One of the multiple issues exposed by the coronavirus pandemic has been the depth of inequality in U.S. health care outcomes. Massachusetts is not an exception. According to The Atlantic’s 2021 COVID Tracking Project, in Massachusetts Hispanic and Latinx communities make up about 12% of the overall population but 28% of its identified cases of COVID-19. The Black community accounts for 7% of the state, but 11% of its hospitalizations.

Nationwide, as observed by the New England Journal of Medicine, “when exposed to the same virus, Black, Latinx, and Indigenous Americans have more severe disease and higher mortality than white Americans.”

This is health inequity. People get sicker and die younger along racial and demographic lines. In particular, Black and Hispanic people tend to end up with poorer health than their white counterparts. They are less likely to have insurance and more likely to have difficulty navigating insurance benefits to find the help they need, sometimes due to a language barrier. They also tend to have worse outcomes even when they do see a doctor.

Health equity before COVID-19

Addressing health inequity requires looking at far more than just the health care system. Policymakers, public officials, business stakeholders, and health care leaders need to look at just about every aspect of a community’s life. Health is not just about what happens inside the hospital.

Marty Martinez, chief of health and human services, city of Boston

“We’ve seen the disproportionate impact that COVID has had on Black and brown Bostonians,” says Marty Martinez, the chief of health and human services for the city of Boston. “The details are where you really see the inequities, and that gives you some sense of why we see this.”

“For example,” he says, “If Black and brown Bostonians are more likely to be hospitalized … it’s about higher rates of comorbidities, whether it’s diabetes, whether it’s heart disease, whether it’s obesity. It’s about looking at what has created higher rates of those comorbidities in communities of color.”

This idea of health as a holistic model, taking into account all aspects of a patient’s life, is called “social determinants of health.” It is one of the most difficult issues for policymakers to get their hands around because it is simultaneously vast and personal.

Dr. Crystal Cené, physician, University of North Carolina School of Medicine

“When you think of what contributes to someone’s overall health status … only 15% is due to health care,” says Dr. Crystal Cené, a physician at University of North Carolina School of Medicine. “The large part of what contributes to someone’s health relates to factors that are outside of the health system.”

A social determinant applies to how people live their lives, and the way that their environment makes it easier or harder to make good health decisions. This can include access to traditional health care infrastructure, such as a patient’s relationship to their doctor. It can also include the quality of food available to a neighborhood, the quality of housing, and local pollution.

If a neighborhood has poor public safety, it will be harder for residents to get exercise and stay fit. When local jobs are meager, people will struggle to afford better lifestyle choices. All of these things can shape someone’s health long before they set foot in a doctor’s office and influence how healthy they remain after seeking treatment.

The COVID-19 effect

To say that COVID-19 exposed this issue would be a misstatement. Doctors and community leaders have spent generations pushing back on the significant, often vast, disparities in health between white communities and communities of color. However, the disproportionate COVID-19 death rates among American Indian, Alaska Native, Black, Hispanic, and Latinx people have made the connection between the amount of pre-existing conditions in these communities, which contribute to likelihood of COVID-19 mortality, more apparent and urgent.

To address inequity in terms of COVID-19, policymakers must first address the problem of health inequity on a larger scale.

“It can seem overwhelming but, just like every complex problem, you have to break it down into smaller pieces. You have to think about: How does one piece effect other pieces.”

— Dr. Crystal Cené, physician, University of North Carolina School of Medicine

Community-specific solutions

Instead of looking at what people should do, experts say that change needs to start with community-specific solutions.

Photo by CHRIS ADUAMAFrederica M. Williams, president, Whittier Street Health

“The way you focus on equity is making a consistent and committed focus on the issues,” says Frederica M. Williams, president of the Whittier Street Health Center in Roxbury, “and by creating programs that meet the needs of the population you’re targeting.”

This theme is echoed by policymakers and physicians alike. Addressing social determinants that lead to poor health care outcomes starts by engaging with communities themselves and learning their needs firsthand. From there, doctors and policymakers can begin to build specific solutions. In some cases that might mean filling in a food desert (an area that lacks access to healthy, fresh food) that has contributed to childhood obesity. In other cases that might mean halting illegal evictions so that people can have a safe place to recuperate, or enforcing building codes so that local pollution doesn’t harm residents’ lungs.

The solutions to health inequity are varied, as every community’s needs will be different.

Karen Voci, former president of the Harvard Pilgrim Health Care Foundation, understands these nuances intimately. Established in 1980, The Harvard Pilgrim Health Care Foundation provides tools, training, and leadership to help build healthy communities throughout Connecticut, Maine, Massachusetts, and New Hampshire. Since its inception, the foundation has awarded $155 million in funds and resources throughout the four states.

For over a decade, a significant portion of these funds have supported fresh food growers in communities where health disparities are prevalent — from urban food deserts to rural towns where the nearest supermarket is 20 miles away and the gas station convenience store serves as the primary source for food.

“Everyone knows that healthy food is fundamental to good health. New England’s local produce is delicious and abundant, but too many families throughout our region still can’t afford it. Small groups and philanthropy can’t be the default food system for these communities. Health care institutions, with other key sectors, need to step up and make the investments in local, healthy food retail — just as they have started to do with healthy housing.”

—Karen Voci, president, Harvard Pilgrim Health Care Foundation

Access to the health care system itself also remains deeply divided based on race and wealth. Basic statistics such as the gap between how many Hispanic, Black, and white Americans have health insurance remain, and patients of color are still far more likely than white patients to rely on the emergency room as their primary source of care.

Equity in care is an issue rooted as much in economics, infrastructure, and culture as medicine, and it has always existed.

“It was there,” says Williams. “If there’s a silver lining to all of this, it’s that I didn’t have to explain that to you anymore … Now people understand it.”

Updated November 2022:

Point32Health health plans Harvard Pilgrim Health Care and Tufts Health Plan are the first in New England and among the first nationally to achieve full NCQA Health Equity Accreditation. Learn more about our commitment to reducing disparities and improving care so all we serve can reach their full health potential: read the press release.