pubhlth 222a: week 6 - health policy & health equity

health equity

• attainment of the highest level of health for all people

  • everyone has a fair & just opportunity to attain it

health disparities

preventable difference in health outcomes & their causes among groups of people

mental health disparities by sexual orientation & gender identity in the all of us research program

men w/ cisgenger sexual minority identity had higher odds of bipolar disorder

all of us research program

• national cohort study designed to engage 1 million participants from diverse US demographic groups

• includes detailed survey questions about sexual orientation and gender identity

• linkage to electronic health records

healthcare disparities by citizenship

• 1/5 of lawfully present immigrant adults are uninsured

• 1/2 of undocumented immigrant adults are uninsured

undocumented immigrants adults are more likely than lawfully present immigrants adults & naturalized citizen adults to report…

• no usual source of care other than emergency room

• no doctor visit in the past 12 yr

• skipped or postponed care in the past 12 months

CSDH (commision on sodh) conceptual framework (WHO)

structural determinants sdoh inequities —> intermediary determinants sodh

—> impact on equity & well-being

sdoh framework (KFF)

racism & discrimination —> sodh —> health & well-being

WHO vs KFF framework

• WHO shows various interactions, whereas KFF is more of a one way

• KFF lacks policy component

• KFF focuses more on racism and discrimination, but WHO is more ideal

sdoh among ppl of color compared to white ppl

Black and Hispanic people generally fared worse than non-Hispanic white people along the SDOH examined

health & healthcare among ppl of color compared to white ppl

• health care measures coverage, access, use of mental health services, flu vaccine, life expectancy, infant mortality, pregnancy-related mortality, chronic conditions, cancer incidence and mortality

• Black & Hispanic ppl faced worse than white ppl for the majority of measures, except:

  • black people fared better than white people for some cancer screening & incidence measures, but have higher rates of cancer mortality

  • hispanic people have higher life expectancy than white people & far better on cancer incidence and mortality

uninsured rate by race and ethnicity (2010-2021)

• start of 2010, the range is 13%-33% → 20% gap

• by end of 2021, the range is 6%-21% → 15% gap

• overall reducation in uninsured ppl, espcially when aca was implemented and covid-19 coverage extension

commonwealth fund 2026 state health disparities report

• Collected data for 24 indicators of health system performance that focused on health outcomes, access, quality, and use of health services for each US state

• Recommendations:

  • Ensuring universal, affordable, and equitable health coverage

  • Strengthening primary care and improving health care delivery

  • Protecting access to preventive care

  • Address health-related social needs

  • Health AI: Opportunities and risks for equity

Maternal Mortality in the U.S. vs other nations

U.S. has highest maternal mortality rate (23.8%)

pregnancy-related timeline

• preconception care

• prenatal care/pregnancy

  • 26% maternal deaths during pregnancy & 11% maternal death during day of delivery

• postnatal care/postpartum

  • 63% postpartum maternal deaths up to 1 yr

maternal deaths per 100,000 live births, 2000-2023

peaked in 2021 at 33.2

3 preinatal workforce & expansion

• certified nurse-midwife

• certified professional midwife

• doula

• US places a greater emphasis on physician care & hospital births than other high-income countries

• 10% of US births are attended by midwives vs. more than 50% in other OECD countries (Goodman, 2007)

• why lower rates in the US?

  • Scope of practice laws

  • Reimbursement policies 

certified nurse-midwife

• RN and Master’s in nurse-midwifery

• can provide all care for pregnancy & postpartum, annual wellness exams, prescriptions

certified professional-midwife

• Associate’s or BS, does not need to be a nurse

• Can provide care for pregnancy and postpartum, generally provide care for births outside of hospital

doula

• birth vs. postpartum

• Offers nonmedical techniques (e.g., breathing) and emotional support

• Advocates for pregnant person with clinical team

• Does not require medical training

nurse midwife vs licensed midwife

• legal status in 50 vs 33

• limited vs more licensure agency

• yes vs no prescriptive authority

• most private & gov insurance vs varies across states

dr. of medicine, dr of esteopathy, nurse-midwife, & other midwife birth setting

highest in hospital

annual births by practitioner 2007-2017

• 2007: mostly by dr. of medicine

• 2017: less for dr. of medicine & more for dr of ostepathy, nurse-midwife, licensed midwife, & other

midwives & doulas improving birth outcomes + reduce disparities

• suggestive evidence that midwives & doulas improve birth outcomes, and there is substantial unmet demand for their services among pregnant people of color…but rigorous studies documenting impacts on health outcomes are limited

• study finds states w/ midwifery-friendly laws have more midwife-attended briths & better birth outcomes

geographic maternity care desert counties

more common in mid section and eastern side of US

about 14% of the US birthing population is Black compared to….

• 11% of OBGYN

• 6% of Nurse Midwives

• Flexner report (1910) and impacts on historically Black medical schools

diversifying perinatal workforce

• evidence that it enhances decision-making & outcomes

• improve communication, trust, & patient satisfaction

• provide culturally competent care

• increase provider supply in underserved communities

barriers & solution to med school access

• black & hispanic MCAT test takers are less likely to apply to medical school compared to white test takers

• AIAN, asian, black, & hispanic MCAT takers are less likely to enroll in med school compared to white MCAT takers

  • more likely to report that a pre-health advisor negatively impacted decision to enroll in medical school

• recs: provide app fee assistance, eliminate costly secondary apps, & continue virtual interview options

Medicaid Coverage for Pregnant & Postpartum ppl

• Medicaid covers more than 4 in 10 US births

• Eligibility limits are much higher for pregnant people than for other adults in many states, particularly those that have not implemented the ACA’s Medicaid expansion

• After giving birth, Medicaid coverage traditionally only extended for 60 days

• Coverage disruptions are common during the perinatal period

which u.s. state hasn’t implemented the medicaid postpartum coverage extension yet?

arkansas

Medicaid expansion in Arkansas (Steenland et al. 2021)

reduced disparities in coverage continuity but not visits

black maternal health momnibus act

• First introduced in Congress in March 2020, reintroduced in 2023 & in 2026

  • never passed Congress, but some pieces have made their way into enacted legislation

• efforts to improve maternal health, particularly among underserved racial and ethnic groups, veterans, and other underserved populations

• addresses maternal health issues related to COVID-19

• components of the bill:

  • extend postpartum eligibility for WIC

  • initiatives to grow and diversify the maternal health workforce