Health disparities in Missouri are ubiquitous — they are seen among the rural and urban, Black and white, marginalized and mainstream. Embracing fair and just opportunities for health, and intervening on health disparities, is both right and necessary — through the payment systems, and for hospitals to deliver on their community-supporting missions.

Many of the foundational elements for gathering, analyzing and addressing inequities or barriers to care are core to the community health needs assessment process required by not-for-profit hospitals to validate their tax-exempt status. With refined data sets, a better understanding of the impacts of social determinants on a patient’s health outcomes and new strategies to address inequities, hospitals have an opportunity to leverage their CHNA process to create health equity within their communities.

Hospitals across Missouri are at different phases of health equity engagement. This resource is a tool for all hospitals to advance their health equity journeys. It offers consensus-driven standard definitions of several key concepts surrounding health equity and provides case studies from leaders in Missouri. Finally, it offers guidance on measuring health disparities, systems to engage with communities on collaborative approaches to health equity promotion and the important role of anchor institutions.

This health equity-centered resource is a working product of the Health Equity Committee of the Missouri Hospital Association. Formed by the MHA Board of Trustees in February 2021, the committee is comprised of 14 health care system leaders with expertise in community health. Committee members represent a diverse cross-section of Missouri’s communities and hospitals.

The poor health outcomes common with advancing age often are determined far upstream — in childhood. They are compounded or moderated by individuals’ unique experiences throughout the sociobiologic cycle of health during one’s life course.⁴ A child’s access to prenatal care, well-child exams, love, nurturing, nutrition, safe housing, healthy built environments, high-quality child care and primary education shares a known and pronounced association with how well and how long individuals live in adulthood. As Frederick Douglass prophetically stated in 1855, “It is easier to build strong children than to repair broken men.”⁵

Health equity is not exclusively confined to racialized concepts of disparity for minoritized communities. However, race commonly is used to typify powerful examples of disparities (Figure 1).

Today, Black mothers in Missouri die at triple the rate of their white neighbors during the year following childbirth, while new mothers with Medicaid are eight times as likely to die following childbirth compared to their neighbors with private health insurance.⁶

Seminal research has quantified a graded dose-response between the number of adverse experiences a child has before age 18, and premature morbidity and mortality.⁷ Today, adverse childhood experiences remain ubiquitous, costly and unevenly distributed. Sixty-one percent of adults report having had at least one adverse experience in childhood, and the burden associated with ACEs costs an estimated $56 billion per year. More than 50% of individuals identifying as Asian report having experienced no ACEs compared to just 28.8% of individuals identifying as American Indian or Alaska Native.⁸ As a result and driven by chronic exposure to toxic stress and trauma, in addition to historical displacement and divestment of marginalized communities, health disparity remains highly pronounced for socially vulnerable, indigenous and minoritized populations across social, economic, behavioral and physical health outcomes in Missouri.

Inequity drives significant disparities. For example, residents of the Ville Neighborhood in North St. Louis City — 97% of whom are Black — can expect to live 27 fewer years than their neighbors living just 10 miles southwest in the St. Louis County neighborhood of Webster Groves where only 1% of residents are Black.⁹

Further evidence of care differentials abound, resulting in disproportionate rates of uncontrolled diabetes and lower extremity amputations for residents of rural, low-income and communities of color.¹⁰ The disparities are compounded as the cost of care results in higher rates of medical debt. Nearly one in three Black and Brown adults in Missouri have had their medical bills turned over to debt collection agencies, which can have devastating effects on opportunities for upward mobility. This is more than double the rate of medical debt in collections for their white neighbors.¹¹

Additionally, emerging research surrounding implicit biases among physicians finds that a staggering portion of medical students and residents believe in racialized myths about the thickness of Black peoples’ skin and their pain tolerance being higher relative to white patients.¹²

Although much work remains to create a system that delivers health equity, there are many promising aspects of investments in this area. New research reveals a strong association between labor force retention and the extent to which organizations embrace diversity, equity, inclusion and belonging.¹⁴ In addition, health equity is a concept that enjoys bipartisan support, as demonstrated by growth in the contemporary societal interest of this and associated concepts (Figure 2). In a 2021 poll of likely voters in Missouri, 64% of respondents across both aisles felt that addressing inequity in health care is very important, while another 20% felt it was somewhat important.¹⁵

As the committee considered its scope of work and how it might best support health care institutions across the state, two terms were identified for initial definition: health equity and anchor institution. A shared definition of health equity provides a baseline for discussion, planning and measuring progress, both in individual institutions and as a statewide effort. A shared definition of anchor institution provides common language for exploring the possible roles that different types of health care institutions might play in advancing health equity in their communities.

What is Health Equity?

Taken independently, health is defined as “the condition of being sound in body, mind or spirit,” while equity is “justice according to natural law or right.”¹⁶ Taken together:

“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health, such as poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

— Robert Wood Johnson Foundation¹⁷

A variety of definitions for health equity exist in the surrounding literature. The Centers for Disease Control and Prevention, as an example, defines health equity as being “achieved when every person has the opportunity to ‘attain his or her full health potential’ and no one is ‘disadvantaged from achieving this potential because of social position or other socially determined circumstances.’”¹⁸

While most of the competing definitions of health equity from authorities in the space are highly similar, nuances exist, and the importance of developing consensus around concepts as simple as defining aspirational terms cannot be overstated. For example, missing from the CDC’s definition are the adjectives “fair” and “just” to describe the shared subject “opportunity.” Unfortunately, opportunities are not fair and just by default.

For example, under the Emergency Medical Treatment and Labor Act of 1986, everyone has an equal opportunity to seek emergency care in hospital emergency departments; however, the amount of out-of-pocket costs associated with that care varies widely based on patients’ access to health insurance. Additionally, the binary use of “his” and “her” pronouns in the CDC’s definition would be seen as noninclusive to individuals from minoritized gender identity groups.

By contrast, the RWJF definition acknowledges a fair and just opportunity for everyone, without exclusion. It also indirectly acknowledges individual choice, in that being “as healthy as possible” will carry different meanings for different individuals based on personal preferences and genetics. It also underscores the need to remediate the pernicious effects of SDOH to fully achieve health equity. It is for these reasons that after careful consideration of competing definitions of health equity in the literature, and decomposing the subtle nuances conveyed by each, that the MHA Health Equity Committee selected the RWJF interpretation as the consensus-based standard definition of health equity from which to use as the foundation of future work.

What are Social Determinants of Health?

Again taken independently, social is defined as “of or relating to human society, the interaction of the individual and the group, or the welfare of human beings as members of society,” while determinant is “an element that identifies or determines the nature of something, or that fixes or conditions an outcome.”¹⁹ Taken together, SDOH are:

“The nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.”

— World Health Organization²⁰

What is an Anchor Institution?

Beginning again with the root derivation of the term, anchor is defined as “a reliable or principal support: mainstay,” while an institution is “an established organization or corporation (such as a bank or university) especially of a public character.” Institutions also can refer to significant societal practices, relationships and organizations, or something firmly associated with a place.²³ Taken as a whole:

“Anchor institutions are large, usually nonprofit organizations tethered to their communities, like universities, medical centers or local government entities. They are deeply rooted economic engines in the communities they serve, holding significant social capital. They are often trusted leaders in the communities, well positioned to help lead multisector work aimed at eliminating health disparities. By leveraging their economic power, good will and human resources, anchor institutions can make significant advancements in the promotion of health equity.”

— National Academies of Science, Engineering and Medicine²⁴

Importantly, efforts aimed at establishing an anchor institution model should begin with a deep evaluation of data surrounding health disparities faced by various population segments within the primary service area. The MHA Health Equity Committee’s public-facing health equity dashboards are rich sources of data on health and social outcomes for populations across Missouri’s counties and ZIP codes.

Secondly, the importance of engaging early and often with the community served cannot be overstated. Community-based stakeholders such as the business community, nonprofit community-based organizations such as the faith-based community, and critically, residents of the community all can help prevent the risk of unintended consequences. For example, hospital campus renovation projects that encroach on occupied housing units unintentionally can produce a chilling effect of gentrification in the form of property taxes that are prohibitive to existing homeowners in the surrounding community. These and other unintended consequences largely can be averted by engaging with and listening to the voices of the community.

The Healthcare Anchor Network offers the following potential strategies for achieving health equity.

Inclusive Local Hiring & Workforce Development

Outside In: Strategies to Foster External Workforce Solutions — Prepare local residents for high-quality, high-demand front-line jobs that are connected to job pipelines.
Inside Up: Approaches to Cultivate Existing Staff into New Roles — Connect front-line workers to pathways for career advancement.

Inclusive Local Sourcing

Creating Connections: Connect existing local, diverse vendors to contracting opportunities within your institution.
Building Capacity: Build up the ability of the local business community to meet health system supply chain needs.

Place-Based Investing

Local Investment: Designate a percentage of investable assets for local development.
Upstream Community Benefit: Use discretionary operating dollars to address disparities.

Questions to ask might include:

• Do we believe that it’s important for everyone to have a fair and just opportunity to be as healthy as possible?
• What are the consequences of people not having an opportunity to be as healthy as possible?
• Why is it important to us?
• What might it produce for our hospital and community if everyone had a fair and just opportunity to be as healthy as possible?
• Have you seen situations where people haven’t had this opportunity?
• What caused them to not have this opportunity?
• What might have helped?
• How might a commitment to this statement affect our work?
• How might it influence our interactions with patients?

Then move to the more expanded definition:

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health, such as poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.

Questions to ask might include:

• As we read this expanded definition of health equity, are there aspects of this definition that provide language or context that reflect our experience?
• What questions does it raise for us — personally, organizationally and as a community?
• What pieces of this definition might be useful for us as an organization/department/system?
• In what ways might this perspective on health equity influence our work?

If your institution has not already identified itself as an anchor institution or is just beginning to consider how to leverage its role, the Committee recommends beginning with a conversation about the strategies that anchor institutions employ to address the broader social issues that affect health and health equity. It is not necessary to formally identify as an anchor institution to participate in advancing health equity.

The process might begin with an inventory of the ways your institution already is involved in one or more of the following efforts.

Questions to explore about inclusive Local Hiring & Workforce Development might include:

• Have we optimized our local hiring and workforce development efforts to produce a diverse and inclusive workforce?
• How might we deepen our commitment to that effort? With whom might we partner?

Questions to explore about Inclusive Local Sourcing might include:

• Do we source locally?
• How much do we source locally?
• Could we do more?
• Do our local sources represent a diverse group of suppliers?
• What might be needed to expand the number and diversity of our local sources?
• With whom might we partner?

Questions to explore about Place-Based Investing might include:

• What is our level of investment locally?
• What kinds of organizations do we support?
• How are those organizations involved in addressing health disparities?
• Are there organizations that are influencing health disparities beyond the health care system — e.g., housing, jobs, food access, education?
• How might we support their efforts?
• Are there investments in property or other specific tangible items that would address the social issues that impact health?

This guidance document focused on the key concepts of health equity, SDOH and anchor institutions and is the first of a series of resources from the MHA Health Equity Committee aimed at expediting the elimination of health disparities in Missouri. Additional resources are forthcoming, including recommended milestones for hospitals in 2023, in addition to the development of secure, hospital-specific health equity dashboards that will be designed to complement and enrich the data that currently are available in the Committee’s public-facing health equity dashboards. These health equity resources and more are available on www.MHAnet.com.

Working together, and with community stakeholders and policymakers from across the state, Missouri’s hospitals can catalyze fair and just opportunities for health.