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After ranking Missouri’s state health system performance the fourth-worst in the country last year (despite numerous improvements in some areas), a New York-based policy foundation released a new scorecard for the 50 states and Washington, D.C. this week, assessing state health systems for performance equity among racial and ethnic groups.
Missouri’s scores documented dramatic health and health care inequality among racial and ethnic groups living in the Show-Me State. Even in states with stronger health systems, Commonwealth Fund physicians and scientists found that health equity in terms of race and ethnicity “does not exist in any state within the U.S.”
Per the Missouri Hospital Association, “health equity” is a term meaning “everyone has a fair and just opportunity to be as healthy as possible.”
Commonwealth found only six states had above-average equity performance for all racial and ethnic groups, for which data were available: Massachusetts, Connecticut, Rhode Island, New York, Hawaii and Oregon.
“There’s little doubt that the pandemic has exacerbated these inequities and other weaknesses in our health care system,” Dr. David Blumenthal, Commonwealth Fund president, told reporters earlier this week. Data used in the scorecard generally reflects 2019 and 2020 realities, Blumenthal said.
How did Missouri score?
Commonwealth listed each state’s racial and ethnic groups as a percentile score, with 100 being best, 1 being worst, and 50 serving as a median for all racial and ethnic groups in the United States. They also ranked the groups, when compared to the same groups in other states, where they could gather data.
In Missouri, white people’s experience of overall state health system performance scored at the 58th percentile. That’s above the nationwide average percentile of 50 for all people, but not a high performance for this racial group. Missouri ranked 43rd out of 51 states plus D.C., when compared to other states’ white communities. White people make up more than 4.7 million Missourians, or 79 percent of the state population.
No other Missouri racial or ethnic group ranked above the national average.
Black communities in Missouri scored at the 9th percentile, ranking 36 in overall health system performance out of 38 states where Commonwealth was able to gather data. Missouri has more than 679,000 Black individuals living in the state, 11 percent of the population.
Missouri’s Hispanic/Latino community scored at the 32nd percentile, ranking 24th out of the 42 states, in terms of overall health system performance, where Commonwealth was able to gather data on Hispanic communities. People from this ethnic group, who may be of any race, made up 4 percent of Missourians, or 260,000 people.
Commonwealth was not able to gather much data on Asian American, Native Hawaiian and Pacific Islander communities in Missouri, which include about 132,000 individuals. But the policy foundation found this group’s Missouri population ranked 23 out of 30 states on health care access and 37 out of 41 states on health care quality.
No percentile score or state-ranking data was available for Missouri’s Native American community, which numbers about 21,000 people — a tiny fraction of Missouri’s 6.1 million residents, according to the census.
Can Medicaid expansion create more equity?
Commonwealth officials said that states like Missouri, which have recently expanded Medicaid under the Affordable Care Act in order to extend health coverage to low-income people, may see greater use of health services — including preventative care — as the program becomes available.
“Coverage is a necessary but not sufficient condition for achieving health equity,” Blumenthal said, “and it’s a very important step.” The 12 states that haven’t expanded Medicaid show evidence of equity issues, Commonwealth officials said.
As the News-Leader reported earlier, some 275,000 Missourians are expected to be able to enroll in Medicaid under the program’s expansion, in addition to 880,000 already enrolled last year. State government began processing applications this fall. Adults younger than 65 with household incomes up to 138 percent of the federal poverty line — for individuals, those earning less than $17,774 per year — are eligible.
“Many” disparities among Missouri’s racial and ethnic groups could be bridged through Medicaid expansion, but other factors are at work, said Missouri Hospital Association President Jon Doolittle, in comments relayed by a spokesperson. Meanwhile, Missouri is only beginning its “expansion journey,” Doolittle said, with roughly 14,000 new enrollees so far.
“Inequity is not limited to differences for outcomes along race and ethnicity,” Doolittle said. “Refugees, immigrants, the poor, rural Missourians and persons of color all experience structural challenges to better health.”
Doolittle called on government and community organizations to team up with hospitals in “partnership” to address the state’s disparities: “Health improvement requires we move upstream of the clinical setting to identify where these challenges exist and mitigate the causes of disparity and inequity.”
MHA started a standing committee to work on equity issues earlier this year, and last month unveiled its own health equity dashboard. The online portal allows MHA membership and the public to explore issues surrounding health equity. For example, it shows that in Greene County, about 24 percent of Hispanic individuals lack health insurance. In the Black community, roughly 28 percent lack insurance. Among Greene County white residents, the uninsured rate is roughly 15 percent.
“Delayed and deferred care worsen overall health,” Doolittle said.
State health department promotes Deloitte data collection effort
On Friday, Missouri Department of Health and Senior Services officials issued a written statement in response to News-Leader questions sent the previous day about health equity, Missouri lifestyle and culture as it relates to health, and Medicaid expansion.
“Advancing health equity in Missouri is a high priority at DHSS and among all public health partners in the state, and advancing health equity requires better data,” officials said.
“Due to COVID-19, we have been utilizing our contract with Deloitte (an international consulting firm) to better understand the makeup of Missourians at a more granular level. The beauty of the work that they have been doing with us is that while the data and segmentation is helpful for us to mitigate COVID-19 at the community level, the information being provided will also help us advance health equity in all areas of public health as we move beyond COVID-19. Whether it’s substance use, food insecurity or chronic disease management, our hope is that the right messaging, strategy and outreach for the individual can create better health access and as a result, better health outcomes.”
‘Culturally competent care’ needed, says nonprofit health strategy chief
Kristy Klein Davis, chief of strategy for the Missouri Foundation for Health, said the new Commonwealth study highlights a lack of public funding for public health, among other issues. She noted that in 2019, Missouri ranked 41st in the nation for public health funding by state and federal sources, with per capita spending only two-thirds of the national average.
Davis said an important issue to consider with health equity is access to care. “Where and how can people get their health care? Are they getting it from doctors that they feel like they can trust? Is it available at hours that work for them? Do they have to travel pretty far, or can they get it easily?”
She called for “culturally competent care,” meaning that doctors and other providers need to understand patient experiences and avoid making assumptions about a patient or their life based on where they live or what they look like: “Helping make sure that our physicians, our nurses, our front office and other staff are all ready to welcome new patients and treat them as the individuals that they are, as they’re seeking that health care.”
As people have access to better choices about their health, they tend to choose better options, Davis said. “It’s not about telling people to make different choices. It’s about making different choices available to people.”
She added that equity issues aren’t “only an urban issue” or “only a rural issue” in Missouri: “These are things that we all face, as Missourians.”
Reach News-Leader reporter Gregory Holman by emailing [email protected]. Please consider subscribing to support vital local journalism.