June 16, 2020: Recommendations to members of the minority health strike force

Subject: Recommendations for the eradication of health inequities and systemic racism in Ohio to ensure that all Ohioans lead healthy, productive lives.

The mission of The Center for Community Solutions is to improve health, social and economic conditions through nonpartisan research, policy analysis, communication and advocacy. None of these conditions will improve if we don’t make fighting racism and supporting racial equity a key part of our work. Community Solutions sees the consequences of historical and present-day racism in every issue that we work on and write about.

We have laid out the recommendations below based upon the racial disparities and inequities that are evident in our research and writing. These include disparities in health and life expectancy; infant and maternal mortality; and criminal justice policy.

Community Solutions’ research looked at life expectancy at the census-tract level and found that in Ohio, not everyone has an equal opportunity to live a long and healthy life. Lack of access to fresh foods, environmental hazards such as lead and pollution, under-funded schools and the lack of high-quality employment opportunities are all factors that negatively impact health in many areas across the state. In areas where a higher percentage of the population is Black, life expectancy tends to be lower. As our cities continue to be racially segregated, we see stark disparities in life expectancy between neighborhoods. Many cities around the state have majority white neighborhoods with life expectancies that are more than 20 years higher than nearby majority Black neighborhoods.
Ohio should continue to support and enhance its investments in remediation and abatement of lead-contaminated homes. Included in this should be a renewal of the Health Services Initiative through Ohio’s Children’s Health Insurance Program; maintaining the resources for local efforts in Cleveland and Toledo; and full consideration of the Ohio Lead Free Kids Coalition Action Plan.
Ohio should ensure that every adult and child who is eligible for health insurance through Medicaid has access to that coverage. Decreased support from the federal government for insurance navigators, combined with critical flaws in Ohio’s eligibility system, means the state must ensure that Medicaid is easily accessible to those who are eligible. Since 2014, there have been significant increases in health coverage rates among communities of color.[1] We don’t want to see these coverage gains reversed.
The state should require Ohio medical schools to adopt the National Standards for Culturally and Linguistically Appropriate Services (CLAS), as developed by the United States Department of Health and Human Services Office of Minority Health, as a mandatory component of curriculum.
Per the recommendation of the National Governor’s Association, it is critical to support additional federal funding for Medicaid by increasing the Federal Medical Assistance Percentage (FMAP) and maintain that level until the national unemployment rate falls below 5 percent.[2] The maintenance-of-effort (MOE) provision in the HEROES Act should be supported. We know that the economic recovery from the ongoing pandemic will not be a short-term issue. FMAP is a critical tool to ensure health coverage is maintained and budgets for other services, like education and workforce training, are not further eroded.
Black women die because of pregnancy complications at a higher rate, two to three times the rate, of white women. The odds that a Black or African-American mother will give birth to a baby with a low birth weight is nearly twice as high than of non-Hispanic white mothers, even when controlling for other factors. In our study of more than 800,000 Ohio birth records, African-American women with four-year college degrees had significantly higher rates of poor birth outcomes than white women with only a high school diploma. Other states are seeing significant reductions in infant and maternal mortality by instituting many of the recommendations included below.
The state needs to further target resources to reduce infant mortality to the most at-risk communities and ensure that strategies align with the needs of the people they’re serving
Ohio should routinely track the rate of maternal morbidity, along with maternal mortality rates. Maternal morbidity – any disease related to pregnancy or child birth - occurs 100 times more frequently than maternal deaths[3] and is an indicator of something that has gone wrong as a result of pregnancy and childbirth. Maternal morbidity is often referred to as a “near miss” of a death. Black and Hispanic women have higher rates of morbidity. The Centers for Disease Control and Prevention has identified a list of 21 indicators and corresponding International Classification of Diseases, or ICD, codes used to identify delivery hospitalizations with severe maternal morbidity.
Ohio should join the Alliance for Innovation on Maternal Health (AIM) initiative to reduce maternal mortality and morbidity through the adoption of a set of clinical steps – called patient safety bundles -- that have been shown to reduce harmful outcomes for moms and babies.[4] Safety bundles are steps that have been researched and are shown to reduce negative outcomes from many routine causes of maternal mortality and morbidity such as high blood pressure and hemorrhage. There is also a specific safety bundle focused on reducing peripartum racial/ethnic disparities.
In late 2019, the Ohio Department of Health released “A Report on Pregnancy-Associated Deaths in Ohio 2008-2016.” This report finds that Black women were two and half times more likely to die of a pregnancy-related death than white women over the same period. This report included recommendations to reduce maternal mortality and all of those recommendations should be implemented, focusing on those that reduce racial disparities in outcomes, including:
* Providing education to obstetrics staff on peripartum racial and ethnic disparities and their root causes. This could be done through incorporating implicit bias training into medical education and/or existing trainings.
* Health systems should work to develop a way for patients and/or their families to report inequitable care including a mechanism for a timely and tailored response.
Any state-level health-related commission, council or the equivalent, notably the Pregnancy Associated Mortality Review (PAMR) committee, should be required to include members from diverse backgrounds and be racially diverse. Members should also include both medical professionals and community stakeholders.
Support insurance reimbursement, including through Medicaid, for all members of a birth support team, including midwives and doulas.[5] Women of color experience higher rates of maternal mortality and morbidity, but we know that these outcomes can be mitigated by the support of culturally competent birth support staff.[6]
The Ohio Department of Health should look into the disparities between populations regarding cesarean sections performed and develop policies which lower unnecessary surgical intervention. Nationally, the C-section rate is 31.9 percent, though Black mothers receive C-sections at the highest rate, demographically, at 4 percent. These rates are higher than the federally recommended level of 23.9 percent and carry with them an increased risk of infection, hemorrhage, blood clots and other, serious injury to the mother and child. The Ohio Departments of Medicaid and Health should work on a quality improvement project with the appropriate medical boards and trade associations to impact and decrease our high rates.
Social drivers of health continue to add cost to Ohio Medicaid, and perpetuate the poor, racially-disparate health outcomes we see both inside and outside of the program.
Inside the program, the state’s re-procurement of managed care needs to incorporate metrics tied to value-based payments that account for the successful case management of non-medical needs. Importantly, this has to ensure community-based organizations embedded in communities participate in this system so enrollees are able to receive culturally-appropriate services in settings of their choice versus large, high-cost institutions.
Additionally, the state needs to re-examine its commitments in a number of areas which create the conditions for these outcomes, including a look at systemic factors like housing, transportation, broadband access, quality education, child care, food access and income.
A series of policy decisions and failures throughout the course of our country’s history have led to overrepresentation of people with mental health and substance use disorders in the criminal justice system. This is doubly true for Black people living with a mental health and/or substance use disorders, since individuals of color are disproportionately arrested and incarcerated compared to their white counterparts. Moving toward a system focused on diversion and crisis de-escalation is beneficial and leads to reduced arrest rates, incarceration and inappropriate emergency department use. At the same time, a system focused on diversion can help individuals obtain needed treatment and reduce racial inequities behind bars.
Ohio should work toward a criminal justice system that responds appropriately to the issue at hand. This should start with a focus on diverting people with mental health and/or substance use disorders - who are largely non-violent - into treatment and support services instead of the criminal justice system.
Ohio should require that ALL emergency responders engage in at least one crisis intervention team training to respond to individuals in crisis.
Law enforcement agencies across the state should work with county ADAMHS boards, the state and the federal government to secure grants to add clinical social workers or caseworkers to a department’s crisis intervention response team permanently.Thank you for your consideration. Please contact us via our Director of Public Policy, Tara Britton, with any questions, tbritton@communitysolutions.com.