Bridging The Gap In Health Equity

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Hello and welcome to Louisiana Spotlight.

I'm Kara St. Cyr , your host for tonight's show.

For decades, Louisiana has been at the very bottom of the United States health rankings.

These rankings look at everything from health outcomes such as preventable deaths, rates of chronic disease to health access and cost.

This year, the American health ranking placed Louisiana dead last in overall health.

One of the biggest factors in the state's poor ranking is the disparities and inequities in our state's health care system.

Tonight, we'll look at what these inequities actually look like and the causes for them.

We'll talk with experts and policymakers about what a more equitable system would look like and how to achieve it.

But first, we'll hear from one expert who has spent more than 30 years researching health equity to give us a better understanding of the issue at hand.

I'm Thomas LaVeist and I'm the Dean and Weatherhead presidential chair in Health Equity at the Tulane University School of Public Health and Tropical Medicine.

I've been doing research on health equity for about 30 years.

So in your own words, what is health equity?

Well, the way to think about health equity is, I think, to distinguish it from equality.

So equality means the same.

You give the same to everyone.

Equity means you give to people based on what they need.

So when you think about the way that races are run in track and field, because each of the circles going around the track are a different size, they don't start at the same place.

They stagger the start because it would be inequitable because the inside track so smaller.

Well, health equity is the same kind of concept when you think about the standard of what health should be in the United States.

Different populations are further away from that standard than other populations, right?

So the idea of health equity is to give to each population group what it needs so that each group can meet that standard.

And I mean, when I say group, I'm talking about racial groups.

I'm talking about gender.

I'm talking about economic status.

Talking about geography across all of these different aspects of humanity.

We want people to all meet the standard for what our health should be for a country.

This is affluent as the United States.

Can you give me a real world example of what you mean?

So the United States has the largest health care budget of any country in the world.

Yet if you look at that infant mortality rate, we're about 17th.

So we're not having the same output for the amount of money that we're putting into it as other countries.

But when you look at different groups of people, the United States, some groups are doing far worse.

So you look at the African-American infant mortality rate, it's about double the rate for white Americans, White Americans, if mortality rate is far higher than it should be, much worse than most of Europe.

The Native American population also has very high mortality rates.

So that's the real world example.

So as a country, the rate is too high for everybody, including whites.

But then when you look at other groups, they're even worse.

And so the idea of equity would be we want to get everybody in the country to a standard of where we should be as a country.

And we have to intervene with each of these groups at different levels of intensity in order to get everyone to that standard.

Well, focusing inside the country, I mean, where does Louisiana compare to other states?

Well, I think it's pretty well known that Louisiana typically where among the least healthy states in the country.

Usually we're battling with Mississippi and Texas for who is 50th out of the 50 states.

Of late, we've begun to do a little better here in Louisiana, and we're moving up a bit.

And there's a goal as a large statewide goal, to get us to be 40th of 50 states.

And we I think we will get there eventually.

But we we tend to have pretty high rates of most conditions in this country among states in this country.

When you say most conditions, do you mean like chronic illnesses?

I mean chronic illnesses, but I also mean infectious diseases also.

So high rates of hypertension, stroke, cancer, we're all we're among the highest states in the country in all of those.

But so it's across the board.

It's accidents, injuries, it's firearm use.

It's every every cause of death that you can imagine.

We're not doing as well as we should be doing.

What are the factors that are contributing to health inequities in Louisiana?

I think a lot of it comes down to economics.

We have a very high poverty rate here in Louisiana with the second poorest state in the country.

We don't have the health care resources that some other states have.

You know, we don't really have any of the major national health care chains in the state at all.

And these are all drivers.

So earlier, you mentioned that it's not just African-Americans that are affected by health inequities in our state in particular.

Is that still accurate?

Oh, sure.

Well, African-Americans are a particular problem both in Louisiana and nationally.

But the indigenous Native American population also has very high rates of many conditions as well.

There's, you know, certainly the white population in rural areas have pretty bad health outcomes.

And overall, I'd say the white population in Louisiana is doing as badly or in some cases even worse than the black population in some of the states in the north.

So the disparities are complex and it's not a simple matter of race, but it's also geography.

How does health equity affect other members of the community?

Why should everyone care?

Without a question, health equity affects everyone within the society.

You know, I published a study which showed the economic impact on the total US economy of having people be sicker than they should be.

And we calculated that an estimate of that to be one in a quarter trillion dollars, that's how much of a drag it is on the U.S. economy.

So people are sicker than they should be.

So they're using more health care resources than they otherwise would use.

People are less healthy, so they're less productive at work.

They're missing time from work because they have to care for sick loved ones.

And also people die prematurely.

So we as a as a society, we invest in people and their human capital.

But then we're not able to generate to get the benefit of that investment from their economic output because they die prematurely.

So we are, as a society impacted by this.

So health is wealth is not just a cliche.

We need a healthy workforce to have a healthy economy.

And so every person living in the country is impacted by health inequities because there's so much human capital being wasted.

Like Dr. Livy said, this topic is complex and there are clearly many factors that play into Louisiana's poor health ranking.

We're lucky to have experts and advocates of health equity here with us in studio.

Ashley Shelton is the founder and president of the Power Coalition whose goal is to educate and empower citizens across Louisiana through community organizing and engagement.

Mrs. Davondra Brown is the director of Community Partnership and Health Equity at the Louisiana Department of Health.

And Dr. Shantel Hebert-Magee is the chief medical officer for Medicaid at the Louisiana Department of Health.

Thank you so much for joining us, ladies.

So I'd like to start by getting to know more about the work you all do and how it pertains to health equity.

So I'm going to start with you, Ms.. Shelton.

Let's talk about the Power Coalition and what work have you guys done in terms of health equity?

Yes.

At the Power Coalition, we do a lot of deep listening across the state.

And the whole idea is how are we actually engaging community to understand what their needs are and then how reconnecting that to civic engagement elected officials.

And we also do a lot of data work as well.

And so we have a health equity atlas that, you know, that proves what's happening to people, proves what we understand to know about the human condition here in Louisiana.

And so I think, you know, sometimes we look at data as just these numbers, but what we know is that this is the true, real lived experience of people in our community.

And so, you know, for us, it's about taking that listening, proving it with data and then putting forth policy recommendations that then actually create real solutions for people in community here in Louisiana.

And what about you?

So at the Louisiana Department of Health over Community Partnerships and Health Equity.

So we work internally to make sure that our staff is equipped to do all of the health equity work across the state, make sure that our health care administration system is supported by equitable means, equitable data, and make sure that our processes and our practices are informed by that community.

And we also bring together community partners external to LDH to make sure that we're doing that work and building that capacity in the community and across the state to do equitable health care.

And Dr. Hebert-Magee, you also work at the Department of Health.

I do.

So I serve as the chief medical officer for Medicaid.

My primary responsibility is to review, implement and revise clinical policies to ensure that our Medicaid beneficiaries, which are somewhere around 2 million people, get access to optimal health outcomes and access to care.

Similar to our other distinguished panelist, I work with our stakeholders, including our managed care Health plans to review the quality metrics to ensure that what we are providing is evidence based and it will lead to these optimal health outcomes.

All right.

So going back to you, Ms. Shelton, you mentioned the Health Equity Atlas.

And if you look at the story that we just watch from Dr. Levine, he paints a pretty grim picture of what health equity looks like in Louisiana.

Do you find that the concerns that are listed in this atlas are consistent with what Dr. LaVeist mentioned?

Yes, You know, and I think it's what's real for folks to understand about, you know, all of these numbers where the, you know, the second poorest state in the country, you know, we have high level of levels of poverty.

You know, one of the things that the Atlas did was look at social determinants of health and look at look beyond just, you know, what you know, like what disease or chronic diseases are you dealing with, what you know, what infections or, you know, or things that we see moving in communities.

But this was really you know, this is more about trying to understand that if we actually could address the health disparities from a from a lens of social determinants of health, that we actually could increase our billions of dollars in our economy.

He said trillions.

You know, I'm sure those numbers are consistently growing, but it's it's real money we're leaving on the table and there's no reason for us to be the second poor state in the country.

And we have to start looking at health equity as a real lever for change in our state so that we can get off of the top of every bad list, in the bottom of every good list.

And so we've got a lot of work to do.

But I do feel excited about how in what ways can we actually problem solve to make sure that we have a healthy state and healthy communities?

Dr. Hebert-Magee, do you have anything to add?

Is it consistent?

I think what she stated was spot on.

The reality is that there are a myriad of issues that contribute to the inequities that we see and, you know, the first thing you have to do is uncover.

You have to shed light.

You have to see the dirty laundry in order to clean it.

Right.

And so that's what has happened.

I think COVID has spurred more attention to the matter at a national level because we saw this across communities.

You know, all across the country that have this dichotomy in wealth, in education and access.

And because of that, now we do have key interest and support.

Sometimes there is public will, but there isn't political will.

Sometime there's political will.

But the public don't think that it's a priority.

But there is a time in which everything comes together when the stars align.

And I think we are in that space where people are receptive to the information because sometimes this is a hard pill to swallow if we are being transparent.

You know, some people think that the status quo is okay.

And it's not just those who are in positions of power.

There are people who feel like that's the hand that they were dealt and that their circumstances can't change.

There is hopelessness.

There is despair.

And we saw that during the pandemic where people just felt like there was futility to any opportunity.

And it's so sad because it has truly impacted our children.

And I think that's why it's important to have Power coalition, other groups who are able to be on the ground, who are able to be, you know, at the forefront in that they are cut from the same fabric of the community and they're able to engage people and say, hey, there are opportunities for you to improve your health and wellness so you can truly self-actualize and reach your full potential.

And Power Coalition isn't the only organization or agency that's working to address these issues.

Louisiana Department of Health is doing that as well.

When it comes to health equity and specifically when it comes to access to health care.

What is the Department of Health doing to expand access?

Well, I think my colleague just talked about something that's very important and that's bringing these types of organizations together to work on these types of issues.

Right.

One of the things that Dr. Hebert-Magee just mentioned is our addressing COVID.

That was a huge eye opener for a lot of us, realizing that our constituents it's on the ground, our organizations on the ground, they were the ones with the access to the people.

And when we talk about access, it's not always saying here, here's something for you, here's a handout for you.

Here's something that we think you need.

It's actually connecting to the community and letting them tell you what they need and how they want to receive it.

And that's one of the great things that community organizations and our community partners with LDH, they have that type of access to the community.

They have that type of access to the information so that we can have a uniform kind of information system between community and governmental agencies to know what it is that they want.

So then we can supply it to them in the way that they want it, in the way that they will accept it, and in a humble way.

Right.

And the other thing is connecting the partners together so that we can work on things in a more uniform manner.

And people aren't stumbling over each other.

They're not showing duplicity of services.

We are being fiduciary responsible with the funds that we have, and we're able to do that in a way that the community is able to access it and receive it.

That is what real access looks like and that's what we try to do with the Louisiana Department of Health.

One of the things that came out of that is us starting a health equity consortium across the state to do just that work.

And so we put all of the regions together.

We've been meeting with them now over the last 6 to 7 months, bringing them together to talk about developing health equity plans that are local so they can look at the data, they can look at our state health assessment dashboard that is public knowledge and then say this is what's happening in this zip code.

We want to take that.

It's good stuff, it's good outcomes, and we want to replicate that in this zip code.

Here's some here's a zip code that may need some support.

How can we look across the state to see where there's another area or another zip code that's excelling in it so we can do this information sharing.

Those are the type of access levels and access points that we try to to make sure that we work on and monopolize.

On what the Louisiana Department of Health said something interesting.

I got to speak to this, something that was really key.

And you use the word humility.

And I don't think that there is enough humility when it comes to our interaction with the public.

Oftentimes, it is a unilateral conversation.

We're talking at them.

We're saying this is what you need to do.

And so having advocacy organizations, grassroot organizations, having a conversation in that respect for the individual.

So I couldn't let that point go.

I know.

Or humility.

I'm like, no, no, no.

We've got to hone in on that.

Well, and I think that's important.

You see that with Louisiana Department of Health.

We've made that a priority over the last few years.

You see that in our business plan.

You see that in the efforts that we made with COVID.

And you'll see that with the health equity consortium, as well as our review, advise and inform board, You got to bring people to the table and not only bring them to the table, you have to make sure that their voice is heard and welcomed when they're there.

And that's what we try to do.

And what's interesting about that is that it's it's prioritizing the community and people that are in it rather than prioritizing doctor's offices and clinics and things like that.

And that's not something everybody would think about when they think about health access.

Right.

And chronic illness affects more than 130 million Americans.

These people need continuous access to medical care over the course of a few years or maybe their entire lives.

This presents several challenges for these patients.

They have to find the right medical care, the right doctors and the right support to get through their illness.

We spoke with one person battling a lifelong condition.

Alvin Henry is a sickle cell patient and advocate for others with his condition.

He serves as the president for the Louisiana Sickle Cell Association.

I got to speak with him about what it's like to suffer from a chronic illness.

Hi.

First of all, can you tell me your name and how old you were whenever you were first diagnosed with sickle cell?

I am Alvin Henry Jr.

I'm the business technology director for the Louisiana Department of Wildlife and Fisheries, and I was diagnosed at the age of two years old with sickle cell disease.

So in your own words, can you tell me what sickle cell actually is?

Sure.

So sickle cell was a inherited blood disorder, so you have to be born with it and how it affects two is your red blood cells.

So as everybody knows, your red blood cells are typically round, but with sickle cell, they form a circle shape.

And when they do that, they lose oxygen nutrients and they become very stiff and start circulating every year your veins.

And it causes a multitude of other health issues over the course of your life.

One in which that everybody of goes is pain.

What does that actually feel like?

It's kind of like a stabbing feeling in your joints and or every muscle that you have just contracting and pulling it all at the same time.

So it's like a very terrible muscle cramp that just never stops.

At times when it's severe and get to the point where, you know, I can't walk, I can't speak, it can get very severe where, you know, I need somebody else to to help me.

Is that how you found out you had this or your family?

Yes.

So my family did not know that I had it at birth, because at the time they do not tested for it like they do now.

Sometime between the age of being born and two years old, my mother noticed that something wasn't right.

So she scheduled multiple doctor's appointments and kind of shocked me around town with everybody kind of turning her away, saying that nothing was wrong.

She ended up finding an African American lady in Port Allen, that had a practice and somebody referred her there, she went.

They said, first thing we do is check for sickle cell.

And that's what it ended up being.

And so at the age of two, that's how it's diagnosed.

Do you think you would have been able to get the diagnosis if it weren't for a black doctor or nurse paying attention to you and your symptoms?

No.

I mean, because my mother was a testament to that.

I mean, she visited multiple doctors, multiple E.R.s and hospitals, none of which did a blood test or even brought up the idea of sickle cell.

Do you think that Louisiana provides enough resources for patients like you?

So that's the easy answer.

And that's.

No, it doesn't.

So we have a shortage of doctors, oncologists, hematologists that are willing to treat sickle cell.

And there's a difference there.

We don't have a shortage of oncology hematologists in the state, but those who are willing to treat a patient that has sickle cell are our foreign capital.

So there are areas in this state that does not have a doctor.

You have to travel about an hour away to find a doctor.

What you are you know, you do find a doctor, then it's that relationship that you have as the patient with that doctor.

And that varies with that amount of pain.

It's a lot of pain medicine.

And as you know, this country is going through a large opioid epidemic.

Opioids are the pain medicine that sickle cell patients use to lessen their pain.

It never goes away.

It's just that's what we use to lessen it.

We control they're being put in place right now to shorten or to decrease That opioid epidemic is hurting patients that actually need the medicine.

So I have to jump through hoops just to get the medicine I need to go, you know, to live out my normal life.

And there's other patients out there that are in far worse position.

Just because you see a smile on my face does not mean that I'm not in pain.

I'm in pain every single day.

It's just what level of pain I'm in.

I've had to kind of look to other ways for things.

I've typically stood up for myself, or just because I was in a situation where I was in the mercy of somebody else.

When I had to go to the E.R., the treatment that I experienced in the ER█s is just horrific.

It gets down to the point where you don't feel like you're being treated as a human.

And it's because there's a stigma around sickle cell that those patients are only here for drugs.

They're drug seeking patients.

And it's not the case.

I'm sure there's always a bad apple that's in everything that we do.

But for the most part, sickle cell patients must have pain meds to manage their condition.

And after many years of being on those pain meds, there is dependencies that come along with it.

Dependency and addiction are two different things, but they're treated the same.

So we are seen coming into an E.R.

environment as an addict and we are treated as such.

So how do you deal with that stigma but still get the treatment that you need?

And sometimes it's turning the other cheek and a lot of times it's turning the other cheek way farther than you ever would.

Down to the point where you're almost self degraded by how you're treated by medical providers.

And it's an education that they need to have to understand what's actually happening versus what their perception of what's happening.

You mentioned that there is a stigma that's attached to sickle cell patients, and from my research it's usually linked to race and the fact that this disease is really understudied.

Do you feel like that's accurate?

Yes.

Yes, that's very accurate.

Sickle cell is predominantly black Americans here in the U.S. that they have the disease.

So that's what's presented in medical facilities as the face of sickle cell.

There are other conditions, you know, one that comes to mind just because it's another genetically inherited blood disorder is cystic fibrosis.

The funding comparison for sickle cell to cystic fibrosis is insane.

Sickle cell has three times the number of patients here in the US, and it has a fifth of its research left off of its funding.

But we are not the ones that have cystic fibrosis.

I have tried to look for the non race reasons and I can't find it.

So yes, I do believe it's a factor.

What would you like sickle cell treatment to look like, to just have that holistic a look at a person as a person and not just a patient?

They came in for this one thing.

Let me get them out the door and then on to the next person to have that and facilities that we can actually go to throughout Louisiana.

It's what's needed in this state to kind of to fix that gap and inequality in health care.

What's your initial reaction to Alvin's story?

I think as an African-American person in this state, in the Deep South that I identify, I understand it.

I think that there's so many people, regardless of the condition.

But if you are in pain that, you know, unfortunately, there is this stigma around, are you a drug seeker versus trying to understand, you know, what's happening to you?

And I think that we also, when we look at the data, can see, you know, across many different things, whether it's sickle cell or maternal health or any number of different statistics, that there is this thing about race that is a factor in why we aren't figuring out the solutions and why, you know, why we aren't doing what needs to be done to address what clearly can't be addressed.

But requires, you know, requires folks to, you know, to prioritize it and to put the resources that are necessary so that we can address those disparities.

Mrs. Brown?

I think my first thought is, wow, even without a chronic disease, I have those stories right?

Despite my education and where I've come in social status, I still have those stories dealing with certain medical professionals that you do try to find another reason for it besides race.

And you can't.

So that's unfortunate.

The other thing that I think about is our LDH response, partially to this was the release of the implicit bias standards that went out to medical schools as well as health allied health professional schools.

It's to hopefully have them adopt those implicit bias standards for any trainings that they developed or that they identify to use and to train their staff.

Because what we're seeing is an example of implicit bias.

That's people that have either been taught or learned that people of certain races or skin colors are susceptible, I guess, to addiction or to complain about pain, but they really are in pain.

There have been studies that have shown that does it matter even causing for a race of the physician, even accounting for race of the physician that physicians still believe or medical professionals still believe that black people have a higher threshold to pain.

Those have historically been studies that have been done over and over again.

And we don't know what that is.

We don't know if that's because of the medical profession and their teachings.

We don't know if that's because of the person and their upbringing.

And then that becomes a kind of cohesive group that they all start kind of believing the same thing.

We're not quite sure yet what the reason is, but the numbers still, they they show it.

And so that's what I hear.

I hear that example.

I hear our response and just hope for a better future.

What do you hear?

It's very disheartening.

Suffering is universal.

And I heard a man trying to keep his composure, talking about, you know, the gross inequities that he faced when he was most vulnerable.

When you're suffering, you're at your weakest, and that's when you expect the greatest compassion.

And for people who take an oath, people who are not only health care practitioners, but health care providers from the initial experience, you know, whether you're being transported by EMT or family member, going into the emergency room, into a doctor's office, a person that's suffering, there should just be a natural force that makes you gravitate towards them and want to console them.

So for me, it was just truly disheartening.

Through the packages with Dr. LaVeist and with Alvin, they talk a lot about race, they talk a lot about poverty, but they don't talk a lot about gender.

And I'm curious, how do women experience inequity, health inequity in this state?

I'm going to bring this question to you.

Yeah, you know, it is it is unfortunate because I think that unfortunately, when I talk about policy and when I talk about what's happening in our state, I always remind folks that, you know, every bad policy, every implicit bias and how it plays out, it disproportionately impacts black women and other women of color more than anybody else in this state.

And so when you look at maternal health statistics and who's dying in our state, we know that Louisiana has one of the highest mortality, maternal mortality rates for black women and one of our highest elected officials said if you correct for race, then our numbers are on on par with the rest of the country.

And I think that it speaks to a bias, right.

That is, let's not fix for race.

Let's fix the problem.

And I'm going to ask you this question as well.

I mean, how do women experience health inequity in this state?

Yeah.

So just if you look at our maternal mortality rate, I think here in Louisiana, we're at about 40 people per 100,000.

When you look across the country, we're all under 24 people are women per 100,000.

That's almost double here just in Louisiana.

So we're truly we have a big disparity as it relates to gender here in Louisiana.

I think you see that as a response by some of the policy that has been written over the last couple of years.

So we did have a legislation that came to to create our new LDH Office of Women's Health and Community Health.

So that was hopefully in response to that.

I think you have a response even with rural areas for women particularly.

So you see a combination of that Rural Health Disparities task force that was created by legislation response, our reporting to our Health Equity consortium, which is under our new Office of Women's Health and Community Health.

So I think we're paying attention to it because we see the numbers, we see the disparities, and it's definitely gender biased.

And I would just like to add that that is one of the positive actions being taken, is that there has been legislation to make sure that private insurance covers the cost of a Dula, a midwife, and the midwife has already passed.

The Dula legislation is currently being heard at our state legislature but has already passed positively through committee.

And so we know that folks are trying to do this work and we know in particular that these numbers are, you know, are more pronounced in our rural communities and in particular the Delta.

And so being able to increase access and address those disparities that our rural communities face in terms of access and care.

So a lot to do in the future, but it seems like some good things are happening.

It's possible that we could see better health equity for women in the future.

Yes, but thank you so much for all of your input.

We'll continue this conversation with our final panel.

But first, we'll hear from Dr. Eboni Price-Haywood, who has been tasked with improving the state's healthy rankings through her work at Ochsner█s Healthy State 2030.

Here's what she had to say about the challenges and solutions.

I'm Dr. Eboni Price-Haywood, system medical director for Ochsner█s Healthy State 2030 Initiative, as well as the Ochsner Xavier Institute for Health Equity and Research.

So Healthy State is your program.

You're the medical director.

Can you tell me a little bit about it?

What's your role?

The Healthy State Initiative first announced in November 2020 in response to the longstanding history that we have in Louisiana of poor health outcomes, according to the America Health rankings.

Louisiana has been number 49 or 50th for many, many years, meaning that the overall health of our state is very poor as a large health system.

We felt the responsibility to lead the initiative, to be a catalyst for change, to improve the overall health of the state with the goal of improving our state rankings over a ten year period between 2020 and 2030.

What obstacles have you run into trying to achieve that goal?

The health disparities that we see in the state of Louisiana and the overall poor health is not something that happened overnight.

It took decades and I would argue it took centuries to get us to where we are.

So this is a marathon, not a sprint.

And it's going to take a long time for us to change the dial.

But in order to do that work, we have to recognize that we as a health system cannot do it alone.

We have to do it in collaboration with other entities.

And so we've brought together a group of 35 organizations representing different sectors across different industries, not just health care, with a model of collective action for collective impact.

And that means recognizing that a lot of what drives the poor health outcomes is prior to the folks walking into the hospital system.

It's where you live.

It's where you work.

It's your circumstances that that drive your health outcomes.

And so in order for us to improve the state health rankings overall, we must step outside of the health system and address some of those other issues.

So for our specific inequities that we have in Louisiana, are those common do you see them in other states?

What makes us different?

Poverty is the number one factor that drives the poor health of the state.

Louisiana's a poor state.

We're a rural state.

We're a service industry type state.

A lot of what we experience in Louisiana is actually reflective of major portions of the South.

The phenomenon of the South, honestly, in my opinion, I do believe that there is a legacy related to slavery because of the economics of that system.

So in the state of Louisiana, it's racial ethnic minorities who have a larger proportion of the poor.

It's also the rural parts of the state that have a disproportionate impact of of the poverty being that that is the demographics of the state.

The legacy of the state economically and how things have evolved over time so that those groups who were disadvantaged in the past are still disadvantaged today.

That's why you see the disparities by these different groups, because it's the same structure that's been refurbished.

But the impact is poverty, lack of access, lack education, lack of economic opportunities, which ultimately impacts your overall health and well-being.

So where do we go from here?

What do you what's the solution?

First and foremost, if you don't address policy.

Policy is the overarching structure that determines how all of us behave.

So you have to address that under policy, addressing poverty, workforce development, economic development.

Each of us in our different industries can contribute to the wellness of our state.

Since starting these programs, working in these programs with these students, do you feel optimistic about it?

Do you think that Louisiana can claw its way up to higher rankings?

I'm definitely optimistic.

Let me say, I don't do anything unless I believe it's possible.

But as I've often said, it's a marathon and not a sprint.

I think what we need to do is build up the workforce, build up health advocates to be able to continue to to do what's necessary to move to make that change.

But that takes time.

Optimistic about improving Louisiana's health rankings, but an emphasis on policy.

We're looking to have policymakers and experts who are here with us in studio at LPB.

I'm going to introduce them now, starting with Senator Regina Barrow.

She represents District 15 in East Baton Rouge.

She's a vice chair of the Health and Welfare Committee, chairman of the Select Committee on Women and Children, and has proposed various bills related to health equity.

Jan Moller is the executive director of the Louisiana Budget Project, which monitors and reports on public policy and how it affects Louisiana's low to moderate income families.

And Dr. Shantel Hebert-Magee, who is the chief medical officer for Medicaid at the Louisiana Department of Health.

Thank you so much for joining us.

So as you could see in the program that we just played, Dr. Price-Haywood said that inequities, health inequities, there are systemic issue and you need policy.

Really move the needle forward.

I'm going to start with you here.

You are the vice chair of the Health and Welfare committee.

What are some policies that you and the committee propose to help bridge the gap in health equity?

So one of the policies that instantly came to mind as I was listening to this was just raising minimum wage and that that changes the dynamics huge and drastically.

Right.

Just the rate of pay.

We are one of the few states in the country that still the minimum wage is a federal minimum wage, which is $7.25 an hour.

And so during the pandemic, one of the things that was really highlighted was the inequities as it relates to health care and those people who were on the front line.

And many of those individuals were contracting COVID much quicker.

And unfortunately, not receiving the health care that was needed.

And unfortunately, done a lot quicker.

It really highlighted the inequities that we had in the state and that immediately came to mind because I have been on the Health and Welfare committee since I was elected in 2005, because it is my philosophy that if a person does not feel well, is not receiving the care that they need and having access, then they are unable to do anything else.

Well.

And so we have a lot of work to do in this area.

But again, as the doctor stated, this certainly is a marathon, not a sprint, because we are making small strides to correct some of those issues.

But you've also worked on SB 64, which you kind of mentioned.

It's to create a health equity task force, and that was a result of the pandemic.

There was SB 116.

It created Office of Women's Health and Louisiana Department of Health.

And then there was also SB 113.

Were any of these other bill successful in the legislature?

Yes.

So the Office of Women's Health, which I'm extremely excited about, because it's going to begin to coordinate, is going to be able to prioritize women█s health and making sure that we are beginning to address some of those issues as it relates to women█s health.

But again, I wanted to meet one of our greatest issues is the fact that we are still paying people minimum wage.

And for that bill that you were just talking about with minimum wage that didn't pass.

It did not pass.

But we did get a bill passed just Thursday that would allow state workers, state workers to be paid more than minimum wage.

State workers, just state workers.

So moving on to you, Mr. Moller.

I mean, both Dr. LaVeist and Dr. Price-Haywood, they emphasized poverty and other societal issues that are causing health problems and contributing to an equity in the state and all of that before a patient even walks through the door.

Last year, the Louisiana Budget Project released a census that detailed the severity of our state poverty rates.

And that page really stuck out to me because it was a lot of somber information or sobering, really.

So tell us more about your findings in that report and how it relates to health equity.

Well, yes, the census data is clear, and I think it's probably not a surprise to viewers that Louisiana has chronically high rates of poverty and it's particularly prevalent among children.

You know, and we've had this for a generation, and we always say that the budget project poverty is expensive and it charges interest.

And what we mean by that is children who grow up in poverty in poor economic circumstances, they suffer stress, they suffer.

This can lead to poor health outcomes much later in life.

So the more that we can do through policy to address poverty, particularly children, the better our outcomes will be long term.

If you can if you can make circumstances better for a child, particularly in the youngest years, you can have long term benefits for that child and that family.

The good news is one of the things we learned during the pandemic.

The pandemic, of course, was horrible for so many families in Louisiana.

But we also learned that we can address some of these issues through poverty, through policy.

Senator Barrow's exactly right about the minimum wage.

You know, we can that's the best thing we can do to improve wages, but we can also do things through the tax code, through a child tax credit, for example, that was passed and expanded at the federal level during the pandemic.

Those benefits have since gone back.

During the pandemic, we also expanded food benefits, so families with children had a lot more to eat.

Those benefits have now been rolled back at the legislature this week.

There is going to be legislation to create paid family and medical leave that would allow families.

Moms and dads, to take a little time off to in connection with a newborn or a new adoption or to care for themselves or their family members and still get paid.

This is something people take for granted in much of the rest of the civilized world.

But we don't have that here in America.

We don't have that here in Louisiana.

But these are things we can address through policy to make life a little bit better for families with young children, make them a little bit more economically secure.

And if we do that, then we decrease the chances that they will have, you know, chronic conditions that are the ones that that lead most people to to poor health outcomes.

All right.

Dr. Hebert-Magee, I'm coming to you with this question.

So how does the state monitor health disparities in rural communities?

And are there any new trends you're seeing in rural areas or in areas where hospitals have recently closed?

So we do have, you know, an office that looks at rural health within the Office of Public Health.

And so they definitely monitor the number of hospitals that are open.

Also, the quality of care that's being offered.

We know that, as you mentioned, for more than a decade, we've seen closures in our rural health facilities.

One of the good things of Medicaid expansion is that we had the resources to be able to keep those hospitals open.

The reality is that who live in rural communities are mostly uninsured because they are unemployed and it leads to poverty.

We know in these rural communities they have higher tobacco usage.

They're more likely to be obese.

They have cardiovascular issues and diabetes that are much higher than, you know, the urban areas or urban areas.

So therefore, rurality is an issue.

So we're trying to close that gap.

The first thing is that you have to have the data.

So without data, without that evidence based information, it's hard to move the needle.

So we've been collecting the data and so we want to ensure that we're providing the wraparound services.

Right.

So really, it's just about meeting people where they are.

Correct.

Correct.

All right.

So moving on to you.

I mean, access is not the only issue for rural areas, but here in Baton Rouge, I mean, that's an issue as well.

And it's a much bigger city.

And Mid-City and charity hospitals closed in 2016 and 2013, and that left a gap in access to many parts of your district.

I mean, how have those closures affected those communities?

Well, it was enormous.

I mean, in terms of being able to get to an appointment, you know, I heard all kinds of stories from individuals who had to pay people $45 to bribe to drive them to their doctor's appointment because they didn't want to wait for the bus or they didn't know how the bus system worked.

And so we are beginning to make some improvements in those areas.

But again, it is still a gap because there's still some educational things that need to happen with some of the individuals in our community who don't understand how to process work.

And so we operate in those gaps with the MCO█s and other partners that we have.

Well, I'm curious, for people in your district, were there instances of people just not going to the doctor anymore?

There were there were people, unfortunately, who probably passed because they did not have access to that.

And there are some people who just did not want to have to pay $45 for someone to bring them to a doctor's appointment one way.

Right.

Because $45 on top of however much you pay at the doctor's office.

Yes.

It adds up.

It does.

And when you're talking about driving for the north, Baton Rouge to south Baton Rouge, that could be quite expensive.

Well, I noticed you and Senator Barrow mentioned, I think that for a number of people there was a degree of frustration, a vexation.

The reality is that it shouldn't be that difficult to have someone to see you when you have an urgent issue or there's a high acuity.

I think part of the mistrust that we saw in COVID is because people felt that they were neglected or that they were not considered to be, you know, to get care.

Right.

So, yes, I think there was a certain dehumanizing quality that they experience.

And I can see as health care practitioners doing something day in, day out, sometimes you become desensitized to the issues.

And then with the electronic health record and providers trying to put all of this stuff into a computer, they're not making eye contact with the patient.

And it's the little things, you know, so true that make a huge difference when they know that someone is invested in their care.

So many providers now, they actually have case managers and patient health navigators that call and say, hey, are you going to make your appointment?

You missed your appointment.

How can we make sure that you get here?

Then the person start feeling that someone cares about us.

We become so siloed we don't have a sense of community anymore.

Right.

We're very, you know, just individualized in our thoughts and our processes.

And I think having services actually pick someone up that may be the only person to that person hello today.

Yes, that█s right.

You have elderly people who are sick and shut in.

They don't have anyone checking on them.

You know, they may don't even have food.

And then some of the MCO█s now have meal plans, particularly for people who had surgery recently to ensure that they actually heal better and that their wounds heal.

So I don't want to be tangential, but I do think that your point was very poignant because there are a myriad of reasons why people stop going to the doctor when some of those facilities close, because sometimes it is our facilities that actually see those that are most vulnerable, that treat them with respect.

And some of the other institutions that have traditionally only seen private patients, they don't prioritize them.

They don't treat them with respect.

They're concerned that, oh, they're going to miss this appointment.

They don't really care.

And so it causes them to fall back in at least of some of the issues that, you know, become, you know, more problematic and exacerbates their conditions.

Yeah, it creates a stigma.

What are you going to say to piggyback on that?

I think.

You know, we've had a huge historic change in the way we deliver health care in Louisiana just in the last 15 years.

You know, one of the things we've done really well in Louisiana is reduce the uninsured rate.

We've had historically uninsured rate well above the national average.

We're now below the national average.

So we talk a lot about what Louisiana does wrong.

This is one thing we've done right recently, but it's been a pretty recent change for about 80 years in Louisiana, we had kind of a two tiered health care system where if you had private insurance, there was hospitals and clinics all over the state where private physicians would see you.

And then we had ten state owned charity hospitals that saw everybody else, primarily people without insurance, predominantly black and brown people.

And that was the health care delivery model.

That all changed about 15 years ago.

And then it changed even more when Medicaid expanded.

So we've had a whole new system, and that's been a big transition for families and people to get used to.

And we're only starting to see the effects of that transition.

And there's been a lot of good by that, but there's also been a lot of disruption.

Absolutely.

And I would add to that, you know, I am seeing now more people, especially in my community, because we have this system where you have primary care, you have urgent care, and do you have a E.R.

all on the same ground.

So if you show up for one thing and you think that you have no problem with one area, they can see you, too.

Which area best needs to see you, whether that's urgent care or the E.R.. And I believe that that is really adding value to the health care system, because before people were only showing up when it was an emergency.

Right.

They only showed up to get health care when it was an emergency because of the way the system was set up.

So I begin to believe that we are beginning now to see the benefits of that system in place.

But it's taking time and it's time for people to learn how to access that system.

And again, feeling valued and feeling important makes all the difference.

Well, you mentioned that there were some good things happening with the Medicaid expansion.

Now that pandemic era insurance policy, its it's ending.

And how many Louisiana residents are going to be kicked off.

I mean, how is this going to change?

Well, so let's be clear.

Medicaid expansion is not going away.

What happened during the start of the pandemic is that the federal government gave states more money to fund Medicaid, But in exchange for accepting that money, and every state, including Louisiana, accepted the extra federal money, they couldn't kick anybody off of Medicaid.

So Medicaid is conditioned on income.

If you make too much money, if you make more than 138% of the federal poverty line, you make too much for Medicaid.

But for three years, even if your income shifted above that line, you were still eligible for Medicaid.

So nobody had lost Medicaid coverage in Louisiana.

A lot of people had gained Medicaid coverage.

Maybe they lost their job during the pandemic.

Nobody got kicked off the program for three years.

That ended on April 1st.

So over the next year, the State Department of Health has to go through everybody on Medicaid and determine their income.

It's called the unwinding to see who makes too much money to qualify.

The problem with this is that we know it's going to be hard to reach some people.

Maybe people moved or they changed their number or they just don't answer junk mail.

They think it's junk mail when it comes to their house.

So it's going to be a very complex problem.

The Department of Health is doing everything they can to make sure that people answer these letters, respond to them.

If maybe somebody isn't eligible, maybe they got a new job and they make a little too much.

There are other there's other coverage that's available to them.

But that's going to be a very complex problem.

And our concern is that a lot of people who are still eligible may get kicked off the rolls just because they didn't jump through the right bureaucratic hoop.

The estimates are that as many as 350,000 people aren't going to are going to get kicked off the program over the next year.

So one of the things that policymakers need to do is make sure they do use every tool at their disposal to reach everybody, to make sure everybody has a chance to to stay eligible, if indeed they're still eligible.

Right.

Just making sure no one slips through the cracks.

But Medicaid expansion is not going away.

It is still here.

It is a very good policy.

And I was very happy to see all of the candidates for governor said that they would keep that policy if they're elected.

So I think that policy is here to stay.

Right.

Do you have anything to add?

Yeah, I think one of the things that she mentioned, you know, some of the people who were added to Medicaid or who are sort of receiving Medicaid during the pandemic were a lot of young people, people who were just finishing college thinking they were going to start a job.

And lo and behold, either they were laid off, job was furloughed.

And so we found people who normally would not be part of our Medicaid population who because we had expansion, they were able to go and receive critical services during the pandemic.

And so having Medicaid expansion rooted embedded in Louisiana has helped us to curtail a lot of the deaths we would have seen if we didn't have that in place.

So it made a huge impact.

At the same time, Medicaid is going to always have an influx, going to have women who come in ship, children who come in, who are going to need resources.

And having that provision, it takes one thing off the table and allow for people to get access to care.

More importantly, being well.

So I'm so happy that our governor took the lead in the South and was the first deep southern state to embrace Medicaid expansion.

And now we are moving in the right direction.

So this next question is for everybody to answer.

Okay.

What health equity policies would you like to see implemented in the future?

So certainly, I believe one of the biggest issues and if moving now, so we'll see what happens.

People being able to have paid family leave, that's extremely important so people can afford to be out, take care of themselves, take care of their family members when needed.

Because at the end of the day, if you're not well, if a family member is not well, you're not going to be to do your job well.

So being able to receive that they would be compensated for that.

I think it's going to be a huge benchmark for us to move.

And what about you?

Well, she she said what I was going to say.

We know the policy tools that work higher minimum wage, expanding the earned income tax credit and the child tax credit paid family leave.

Those are the things, you know, universal school lunches.

There are a lot of things that we can do.

They all need to work together.

There's not one single policy that's going to move the needle on health equity.

But if we address poverty in a holistic way, eventually we're going to see better health outcomes.

Yeah, for me, my passion is I really want to see violence addressed as a public health measure.

I think that for so long we have sent people into the criminal justice system without actually addressing the true underlying issues.

We've changed the narrative.

At one point in time, we said that violence struck certain communities and now we see their communities of violence and we act as though the people are perpetrators and not that their circumstances cause them to take drastic measures.

We have to look at it from an educational stance and a healthcare stance, and I really want our policies to be more comprehensive and for us to have that empathy when people present, whether they are a victim or a perpetrator, and how do we divert them from committing or being a victim to this.

Again, that is so, so good.

And I just want to add to that.

Mental health are making.

Mental health is seeing it more as a disease like heart attack or diabetes and really addressing mental health and starting with our children.

We have not done a good job of addressing mental health with children.

And so I want us to really begin to address mental health and to fund mental health properly.

And that's something that I consistently fight for and will continue to fight for.

Thank you so much, all of you, that you've brought up.

No these are all great points and very interesting points.

We█ve just run out of time.

I want to thank Senator Barrow, Mr. Moller, Dr. Hebert-Magee, Ms. Shelton and Ms. Brown for sharing their knowledge on these issues.

So what do you, our viewers, think?

We encourage you to comment on tonight's show by visiting lpb.org/louisianaspotlight and clicking on the Join the Conversation link.

We'd love to hear from you.

Thank you for watching and good night.

For a copy of this program.

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