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The History, Evolution, and Impact of Diversity, Equity, and Inclusion and Health Equity in Health Organizations and Systems, Public Health, and Government

The workshop’s first panel reviewed the historical policies, social movements, and evolution of diversity, equity, and inclusion (DEI) and health equity leadership in health care, public health, and government.¹ In introductory remarks, panel moderator and workshop planning committee member Aletha Maybank, chief health equity officer and senior vice president at the American Medical Association, noted that discussions focus on identified health disparities and the effects of social and structural drivers and systems of oppression on health inequities. However, she said, it is also important to examine the efforts of the people responsible for guiding DEI and health equity work within institutions.

In 1985, the Heckler Report was published as the U.S. government’s first effort to investigate health inequities (Heckler, 1985). In response to its stark findings, in 1986 the Secretary of the Department of Health and Human Services launched the Office of Minority Health.² Over the next 25 years, Maybank said, many states and local governments launched their own offices of minority health in their health departments to improve the health of racial and ethnic minority populations. Other events were the Institute of Medicine’s³ release of two sentinel consensus reports: Cross-

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¹ Speaker Jahmal Miller, chief administrative officer at CommonSpirit Health, is listed in the agenda but was unable to participate in the workshop.

² https://www.minorityhealth.hhs.gov/about-office-minority-health (accessed November 16, 2023).

³ As of March 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine continues the consensus studies and convening activities

ing the Quality Chasm: A New Health System for the 21st Century in 2001 (IOM, 2001), which recommended aims for health care improvement to make it safe, efficient, effective, timely, patient centered, and equitable; and Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care in 2003 (IOM, 2003), which documented substantial racial and ethnic disparities in access to services, clinical care, and health outcomes. In subsequent years, the discussion around disparities in health care shifted to focus on equity.

THE EVOLUTION OF EQUITY IN HEALTH CARE: UNEQUAL TREATMENT AT 20

Joseph Betancourt, president of the Commonwealth Fund, commented that while there are clear definitions for chief executive officer, chief operating officer, and chief financial officer, the definition of chief health equity officer remains nebulous and creating the position is more often than not a check-the-box effort. Mostly, he said, chief health equity officers have been doing their work in the face of insurmountable odds, without leadership support or resources, and without being centered in the corridors of power. When Betancourt talks to health system executives, he tries to frame equity issues in terms of quality, safety, cost, and values, and never shies away from calling out racism as part of the problem.

As colleagues of his reported in their seminal book An American Health Dilemma (Byrd et al., 2000), racial and ethnic inequities in health and health care are long-standing and part of the nation’s history and national fabric. “Suffice it to say, there have been countless reports and publications over the years that have helped move this work forward,” Betancourt said, “but ultimately we are here today because this work has been spotty, incremental, and never at the scale that we had wanted or aspired for it to be.”

Inequities in health and health care exist across multiple areas that can be stratified by race, gender, geography, socioeconomic status, and level of education, with social drivers that disproportionately affect vulnerable communities being the principal contributors to these differences, Betancourt said. These social drivers do not exist by accident but have resulted from clear, deliberate policies such as redlining in mortgage lending, transportation and housing policies, and criminal sentencing. These policies, he said, created a damaging set of social drivers that today affect communities of color; yet despite this, these communities are resilient and try their best to thrive every day.

previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to reports issued prior to July 2015.

Access to health care, Betancourt said, plays a huge role in one’s ability to stay healthy, receive quality care, and benefit from preventive measures. So, too, does access to insurance, with minoritized individuals being more likely to be uninsured. While many people get health insurance through their employers, minoritized individuals often work in jobs that do not provide employer-based health insurance, he noted. Unequal Treatment (IOM, 2003), which Congress commissioned in response to articles in the Journal of the American Medical Association and The New England Journal of Medicine, pointed out that racial and ethnic disparities occur across a wide range of health care settings, disease areas, and clinical services, even when controlling for confounders such as socioeconomic status and insurance, he said. This report, Betancourt summarized, concluded that many sources—navigation, communication, stereotyping, mistrust, and racism, for example—contribute to health inequities, with no one suspect and no one solution.

Betancourt argued that the recommendations in the Unequal Treatment report are as germane and needed today as they were 20 years ago. He believes that those recommendations represent unfulfilled promises and potential, but they also serve as a blueprint that many individuals have been trying to execute. This blueprint includes increasing awareness of inequities and the data showing they exist. The way forward, he noted, also requires addressing inequities in systems of care by collecting data, measuring performance, using multidisciplinary teams, investing in community outreach, focusing on workforce diversity, addressing language barriers, communicating effectively with every patient, educating caregivers about existing health inequities, and ensuring that clinical decision-making is evidence-based and not tainted by stereotypes. He added that while health disparities research has thrived over the past 20 years and identified many of the existing problems, there is a need for more work developing solutions to those problems.

The first chapter of the story of the search for solutions to health inequities starts with the release of Unequal Treatment in 2003, Betancourt said. For the next five to eight years, there was a flurry of activity among early adopters and progressive leaders. Health care organizations formed committees and developed basic blueprints heavy on aspiration and light on execution. Betancourt was excited to play a role in catalyzing some of this activity through the Disparities Solution Center and Disparities Leadership Program, which tried to engage health care systems in this work and provide them with actions they could take based on the blueprint that Unequal Treatment proposed.

The second chapter of this story starts with the health care reform conversations beginning to take root, Betancourt said, and during this period, when support for the Affordable Care Act began to gather energy,

three things happened: one positive, the other two being unintended consequences. On the positive side, there were real discussions around the importance of the social drivers of health as well as execution around the concept of population health. “The Affordable Care Act really gave us a much broader look [at] health and tried to operationalize that in ways that were very real,” Betancourt said.

The first unintended consequence was that this broader perspective of health provided a justification for those who rejected the notion of inequities in health care or downplayed their significance. These individuals could now attribute them to social drivers rather than acknowledging shortcomings in health care systems themselves. However, Betancourt said, this is not an either-or situation. “We welcome and absolutely acknowledge the importance of the social drivers, but that does not absolve us of our responsibility within the health care system to make sure that everybody we see, no matter who they are [or] where they are from, gets high-quality care with no . . . disparities,” he said. The second unintended consequence was that discussions about health inequities and social determinants of health took a back seat to health care reform.

The third chapter in this story is the push to value-based payments and purchasing that occurred in the wake of the Affordable Care Act. Betancourt stated that the idea of pivoting from paying for quantity of services to the quality of services, providing team-based care, and monitoring performance enabled the argument that equity is not only a key component of quality, which Crossing the Quality Chasm had stated in 2001, but a high-value target given that inequity is the epitome of low-value care. “These were exciting times as we were building momentum through 2020,” Betancourt said.

In 2020, two seminal events changed the landscape of health equity: the disproportionate impact that the COVID-19 pandemic had on communities of color and the national reckoning on racism that the murder of George Floyd triggered. These events, Betancourt said, highlighted the effect of historical and structural racism, the role of social determinants of health, and disparities in health and health care. Betancourt stated that these two events challenged the nation’s health care system to move from aspiration to execution and that meaningful health system change would require breaking from the previous norms of unclear targets, limited investments and resources, little accountability, and moving to action. During this period, many organizations hired chief health equity officers, Betancourt said.

Betancourt described the third chapter in several ways. First, succeeding requires having someone in charge who can set goals, identify key activities, and set a timeline and milestones. Betancourt added that the person must have the necessary resources and be accountable, along with the organization, for outcomes, and there needs to be transparency in those efforts. “Anything else is not a real approach to health equity,”

Betancourt said. Second, health equity will not result without health care financing and regulations that prioritize equity with carrots and sticks that move equity work from “nice to do” to “need to do with no excuses.” He said that the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, National Committee for Quality Assurance, and others are building an ecosystem for action and accountability but that advocacy around this will be essential going forward.

Focus is essential, Betancourt said, with equity centered in the entire care journey for each individual, from doorstep to bedside and back. The focus, he said, will likely include health care financing regulations and be customized locally for populations and the local political environment.

Betancourt acknowledged there is significant pushback, which was expected, but that is no reason to be discouraged or demoralized. “We need to be energized and more strategic to keep this work moving forward,” he said. Another looming challenge, he added, is the continued corporatization and commercial drivers of health care. While not opposed to the idea of profit as a motivator for capital, investment, and innovation, he said, he is opposed to the increasing imbalance of profit over people that disproportionately affects communities of color. “As we aim to prioritize new and shiny things in health care, we need to understand that this cherry picking and lemon dropping will occur, and the lemons that will be dropped are communities of color,” Betancourt said. “We need to make sure that communities of color and vulnerable communities are not left behind.” He is also concerned about health care providers today regarding the fatigue coming out of the COVID-19 pandemic, the demoralization they are experiencing, and their administrative burdens. The unwinding of Medicaid’s continuous enrollment provision during the COVID-19 Public Health Emergency,⁴ Betancourt said, will also increase inequities, as will the gaming in Medicare Advantage plans.

In conclusion, Betancourt said that progress has occurred over the past 20 years, though primarily among early adopters and principled leaders, with some legislative success. He added that solutions have not scaled up because of a lack of key regulatory and financial drivers and the nation’s unwillingness to deal with issues of race. The past few years have energized movement around health equity, but sustaining these efforts will require putting in place key levers to support integration and execution. He ended his presentation with words of encouragement: “Resistance is strong, but strategy and resolve are stronger, and that defines us as a community.”

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⁴ https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html (accessed November 16, 2023).

BUILDING POWER FOR RACIAL AND HEALTH EQUITY IN CALIFORNIA

Sandra Witt, managing director of power infrastructure at The California Endowment (TCE), said that TCE’s vision for the next decade, informed by input from its community partners, is a California

• with a robust, intergenerational power-building ecosystem for advancing health, justice, and racial equity;
• where historically excluded people have voice, agency, and power in decision-making to close health equity gaps and eliminate structural racism;
• where health destiny is not determined by a person’s zip code but by an intersectional, intergenerational movement of people power driving transformative change in pursuit of health and wellness for all; and
• where most impacted communities are empowered to lead the nation as a beacon for wellness, equity, and justice.

TCE’s power-building framework’s theory of change focuses on supporting power building with a power ecosystem⁵ approach that centers on organizing the people and communities most affected by inequities. Success at establishing a power ecosystem, Witt said, will lead to systems transformation focused on schools, health, justice, and inclusive development. The idea, she explained, is that systems transformation will translate into improved physical and social environments that, over time, will change health status and result in an equitable California.

Witt said that one lesson TCE has learned from the past 10 years of work is that policy wins are important to produce systems change, but implementing policies in a culture without the right orientation does not work well. This lesson has informed TCE’s theory of change, which asserts that a robust, intergenerational power-building ecosystem—one that centers a community organizing approach, includes critical partnerships, and is aligned around a shared analysis of racial justice—is critical to advance health equity and long-term systemic transformation for a racially just California.

TCE’s goal, Witt said, is for California to have a strong, intergenerational power-building ecosystem for advancing health, justice, and racial

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⁵ The power ecosystem approach focuses on community organizing/base building, narrative change, etc. (Presented by Sandra Witt on October 5, 2023, at Exploring Diversity, Equity, Inclusion, and Health Equity Commitments and Approaches by Health Organization C-Suites: A Workshop [Witt et al., 2023]).

equity by giving voice to those most affected by injustice. TCE’s plan to realize that goal includes

• expanding the community-led advancement of systemic changes across the public and private sectors to promote racial equity and racial healing, and eliminate structural racism at local and statewide levels;
• supporting community organizing as a central approach that builds a strong base for advancing transformative changes in political, economic, and cultural power;
• growing a movement that supports the leadership and healing of young people and adults engaged in the fight for health equity and racial justice; and
• building the capacity of grassroots leaders and organizations, and the broader ecosystem, to create enduring narratives that reflect the experiences of people whose lives are most affected by injustice.

Two long-term efforts Witt believes are promising are the Government Alliance on Race and Equity (GARE)⁶ and the Capitol Collaborative on Race and Equity (CCORE).⁷ GARE, a network of governments working to achieve racial equity and advance opportunities for all, has 98 members in 44 cities, 23 counties, and 11 state departments. CCORE, a community of California state government leaders working to integrate racial equity into institutional culture, policies, and practices, has more than 500 participants in state departments, agencies, offices, boards, and commissions. Witt added that though these two initiatives have slightly different approaches, they share model practices such as a racial equity curriculum that builds on the field of practice; peer-to-peer strategizing and problem solving through cohorts; a racial equity tool for policy, practice, program, and budget decisions; and a racial equity action plan with shared and transparent goals and specific objectives.

Witt discussed the outcomes of these efforts, which have included developing racial equity structures that allow a focus on racial equity as part of everyday work rather than as an add-on, establishing racial equity dashboards, and launching a state-level racial equity commission. Witt also mentioned other outcomes, including expanding budgets and staffing dedicated to advancing racial equity work; increasing the engagement of executives in this work; instituting public accountability for racial equity to increase public engagement; and using American Rescue Plan

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⁶ https://www.racialequityalliance.org/ (accessed December 21, 2023).

⁷ https://stateofequity.phi.org/ccore/ (accessed December 21, 2023).

Act⁸ funds to expand efforts for public participation and ensure that those experiencing racial disparities are embedded in government processes.

Witt stressed that this work is difficult and requires people to participate as their true selves. While it is easy to tell people what to do, it is harder to walk the talk and examine one’s own actions. Witt said, succeeding with its power-building framework and ecosystem approach is contingent on TCE doing its own necessary work to interrogate how it shows up for its partners and whether it is perpetuating the inequities it wants to eliminate. Witt added that this self-examination, along with input from its partners regarding actions it was not taking, prompted TCE to start on its own journey toward advancing racial justice. One comment was that TCE was not being explicit enough about race, which led TCE’s board approval of creating a director for racial equity practice and culture and increasing staff to support this work going forward.

TCE’s internal leadership council developed a framework comprising five elements for a thriving anti-racist health foundation. The five elements, Witt explained, include starting a board learning journey, building staff leadership and a deeper anti-racist capacity, operationalizing a racial equity framework that translates principles and values into durable practices, establishing a healing-informed practice to metabolize White body supremacy, and engaging in learning and self-study to identify the right role to take in systems transformation—mutually reinforcing, interdependent capacities designed to create the conditions for transformation at an individual, organizational, and institutional level. A core element to this framework, Witt said, is building embodied leadership to prevent the harm that comes with anti-racist work and withstand the discomfort, deflection, and defensiveness that can impede true and lasting anti-racist practice and culture.

Cognitive learning and analysis are an important part of developing an anti-racist organization, Witt said. In that respect, TCE’s partners have provided trainings, and its staff members are engaging in their own learning about the history of systemic racism rooted in anti-Blackness, Native erasure, and root cause analysis. TCE is also establishing a practice of somatic abolitionism⁹ to develop the skills needed to stay in this learning mode.

Witt acknowledged that shifting an institution’s culture, practices, and impact is challenging, lifelong work. For example, this work is rarely resourced in a robust manner, and chief equity officers often face isola-

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⁸ https://www.whitehouse.gov/briefing-room/legislation/2021/01/20/president-biden-announces-american-rescue-plan/ (accessed November 13, 2023).

⁹ Somatic abolitionism is an embodied anti-racist practice and process of culture building. https://www.shelburneprimrose.com/resources/somatic-abolitionism-as-anti-body-to-the-white-body-supremacy-virus (accessed February 2, 2024).

tion and backlash in their roles. Another challenge is the continuous emergence of DEI approaches that focus on attempting to change only the way people think versus changing institutional processes and practices. Witt said that White individuals often get centered in this work in ways that harm minoritized individuals. Some of the enabling factors for racial equity journeys include developing public or external accountability, growing the numbers of racial justice practitioners and leaders within institutions, staff organizing to move anti-racism work forward, having executive leadership on board with these efforts, increasing the use of racial equity frameworks and tools, and building the container to process and metabolize the discomfort (somatic abolitionism) that comes from doing anti-racist work, Witt said.

Witt concluded by saying that TCE has much work to do to realize the future of a racially just California for which it is fighting and that, given the current political climate, the hate and division afflicting the nation, and the recent Supreme Court decision on affirmative action, moving forward will require taking bold steps and standing in solidarity with the communities most affected by injustice. “This is not the time to pull back,” Witt said. “This is the time to lean into this space as we cannot get to health equity without racial equity…we cannot be neutral on matters of race because that is the equivalent of being complicit in racial and health injustice.”

DISCUSSION

Maybank asked the panelists for their thoughts on how this work will evolve. Betancourt said racism is part of the nation’s fabric and that there is no one-size-fits-all solution. “What we need to center more than anything else is how to save lives and improve health equity,” he said. “Ultimately, we need the courage to do what is right to achieve change that is built for the environment that we are in and that gets the job done.” The movement needed to produce change will require being explicit about racism and its history, but it will also require giving one another the grace and space to approach this in different ways as long as values and hearts are aligned and efforts are centered on eliminating disparities in health and health care, he added.

Witt noted the importance of having data to support movement toward anti-racism and cultivate conversations with the community. She also cited the need to value communities’ lived experiences and the barriers that people in these communities face to accessing equitable health care. Part of TCE’s evolution has been to realize that power imbalances create these inequities, and that racism is a way to embed and maintain those power imbalances.

Yvette Calderon, dean and vice president for equity in clinical care and professor of emergency medicine at the Icahn School of Medicine at Mount Sinai and Mount Sinai Health System, asked how to move forward with diversifying the health care workforce in the face of the Supreme Court decision on affirmative action. Betancourt said he believes the health care system must not allow that decision to have a chilling effect on this work, citing California as an example of how to deal with this effectively. “I think there are going to be many ways to figure out workarounds,” Betancourt said, noting that the departments of education and justice have released promising guidance. “I am confident that leaders can sort out a way to still build diverse classes, to still understand that lived experience in race matters,” he added. Witt said that TCE’s legal counsel is working with colleagues at other philanthropic foundations to develop guardrails that could help with this situation.

Calderon also asked the panelists to comment on the financial issues that health systems, particularly those caring for marginalized populations, face in trying to do this work. Betancourt acknowledged that hospitals and health care systems serving vulnerable communities have not received the financial support they need. He also said that many health care organizations use their community benefit and not-for-profit status in ways that do not leverage their resources to address real community needs. “If health care systems are to have nonprofit status, in my view, they should absolutely be able to guarantee equal outcomes for their patients,” Betancourt said.

Reginald Tucker-Seeley, vice president of health equity at ZERO Prostate Cancer, asked the panelists to outline steps that people working on DEI and health equity efforts can take to address internal-facing issues and get their organization’s house in order while also working on external issues that affect health disparities. Both Betancourt and Witt said that addressing both internal issues and the social determinants of health is essential to achieving health equity. Witt noted the importance of being clear about values and focusing actions in a manner that reflects those values. At TCE, she explained, the chief equity officer is focused on internal issues, with the organization-at-large addressing external issues. Both she and Maybank stressed the importance of supporting and caring for those doing this work, given the emotional burden that comes with working on these issues.