State’s Medicaid program can play a key role
“There has never been any period in American history where the health of Blacks was equal to that of Whites. Disparity is built into the system.”
Harvard science historian Evelynn Hammonds’ clear and direct reflection on the legacy of our health care system sets the frame in a new report published by my office at the Minnesota Department of Human Services, “Building Racial Equity into the Walls of Minnesota Medicaid: A focus on U.S.-born Black Minnesotans.”
Of course, this is not news to many in our community. Dr. Samuel Myers from the University of Minnesota coined the term “Minnesota paradox” to describe how Minnesota can have one of the highest qualities of life for White Minnesotans, while “African Americans are worse off in Minnesota than they are in virtually every other state in the nation.”
We also know that disparities aren’t seen just in health outcomes and that community-wide disparities don’t happen by chance—they are the result of decisions being made about who has access to what.
For Black Minnesotans, the consistent denial of the same opportunities for housing, education, nutrition, healthy neighborhoods, and justice under the law makes the racial health disparities we see in Minnesota less surprising.
Minnesota’s Medicaid program has a key role to play in addressing health disparities among Black Minnesotans, with approximately 41.5% of Black Minnesotans, and 64% of Black Minnesotan children, relying on Medicaid for health care coverage.
This report aims to address these gaps and build racial equity into our Medicaid program by rethinking how policy within the Department of Human Services (DHS) is designed, proposed and considered through intentional community co-creation.
But who is the “community”? Given the distinct current and historical contexts that have contributed to the health of Black communities in the United States, and to focus on specific community strengths and opportunities to build racial equity from their perspective, we focused on U.S.-born Black communities in Minnesota.
We cite data that show notable health disparities between U.S.-born Black/African American people enrolled in Medicaid programs compared with those who immigrated to the United States. Although the average age of enrollees in the two groups was the same, rates of asthma, heart failure/hospitalized heart conditions, and depression were three times higher for U.S.-born Black/African American people.
We met with individuals from the U.S.-born Black community, leaders of community organizations, and those working to advance racial equity in health care for Black Minnesotans, as well as specific DHS divisions involved in the creation and stewardship of policy areas. We incorporated the reflections and recommendations from all these conversations into the report, which highlights three areas of action.
Call to Action: Simplify and support enrollment and re-enrollment
Despite being eligible for Medicaid, many people who would benefit from its coverage aren’t enrolled at all or experience gaps in their coverage. U.S.-born Black Minnesotans enrolled in Medicaid programs often talk about challenges they face in enrolling. One study noted that Black Medicaid enrollees were more likely than White enrollees to go off Medicaid for more than six months.
Those who were off more than six months were less likely to have a regular source of care, more likely to forgo health care for financial reasons, and more likely to report problems paying medical bills.
Our first Call to Action is to improve racial equity by pursuing continuous eligibility policies. This would allow people to maintain their health care regardless of life changes for up to 12 months at a time. Governor Tim Walz’s recent budget proposal includes one specific policy change, 12-month continuous eligibility for children from birth to 19.
The report calls on DHS to go one step further by exploring what would be necessary for six years of continuous eligibility for children on Medicaid up to age 6, and two years of continuous eligibility for all enrollees age 6 and older.
Community members and DHS staff also talked about the value of having navigators (professionals who help people apply, enroll, and manage their paperwork and/or find providers) help people apply for coverage through MNSure. We call on DHS to support navigators and develop and implement a plan to ensure that eligible Black Minnesotans gain and/or maintain Medicaid coverage throughout the year, but, in particular, as the COVID-19 pandemic winds down.
Call to action: Access to culturally relevant care
There is ample evidence that access is a significant barrier for Black community members. A participant in the Community Conversations reflected, “They [medical practitioners] don’t listen to us [Black people] when we explain our problems; Black patients do not receive the same treatment as White patients.” A significant amount of literature validates the lived experience shared by this community member, both in how Black adults and children are the recipients of unequal care.
Community leaders stressed the importance of culture in the health and well-being of community members. Culture was described as the fabric that links an individual to their community through shared beliefs, knowledge, practices, and protections. Loss of culture in the healing space contributes to illness by separating an individual from one of their shared strengths.
To address generations of structural inequity will require sustained intention. Therefore, the report calls on DHS to invest in a dedicated internal structure to provide a direct connection to U.S.-born Black Medicaid enrollees, community-based organizations, and other institutions to inform and co-create policies and programs that elevate strengths and address inequities.
Additionally, the report highlights the need for better data on race, ethnicity, and language that is standardized and disaggregated. While an incomplete and imperfect proxy for culture, this data can serve as an important initial signal and inform conversation and collaboration with communities.
Call to action: Engaging the communities and families Medicaid serves
A shared desire for meaningful engagement and co-creation emerged in all our discussions. Top-down policy solutions have been tried, and yet disparities continue to grow. Community members noted that the pandemic has clearly demonstrated the impact of a fractured trust between state agencies and the U.S.-born Black community. A repair of this trust requires relationships be built over years and gives that community the opportunity to “start a journey of trusting larger agencies that provide resources and services.”
Therefore, DHS should integrate not just community engagement in general, but the longitudinal, culturally specific engagement of enrollees and their families into routine policy, budget, and administrative activities.
This discussion of the impact of structural racism on the health of our communities is not new. More than 100 years ago, W.E.B. Du Bois was pointing out the impact of structural racism and how social drivers of health impacted the opportunity of Black Americans. To meet this moment, it’s time to heed Du Bois’s words from his book, “The Souls of Black Folk”:
“Now is the accepted time, not tomorrow, not some more convenient season. It is today that our best work can be done and not some future day or future year.”
Dr. Nathan T. Chomilo is the medical director for the State of Minnesota’s Medicaid/Medical Assistance & MinnesotaCare programs and practices as a general pediatrician in Brooklyn Center with Park Nicollet. He is a board member of the Minnesota Chapter of the American Academy of Pediatrics and an adjunct assistant professor of pediatrics at the University of Minnesota Medical School. He lives in Minneapolis with his wife and son.