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Necessary Conversations: Understanding Racism as a Barrier to Achieving Health Equity

June 24, 2022

The story of our nation is one of justice and freedom, but the unspoken truth is too many people are shut out of equal opportunities because of the color of their skin. Civil Rights laws and advocacy movements have brought racial inequities to light, but have not solved urgent problems caused by structural racism. This inequity has led to wide-scale poorer health outcomes and shorter life spans.Structural racism refers to the persistence of inequity in communities of color while others benefit from a disproportionately larger share of the nation's resources. There is indisputable evidence that the impacts of this inequity are generational. Structural racism has led to a lack of basic healthcare, education, housing, and other needs for too many in our nation.Authentic conversations about racial inequities are essential, difficult, and urgent. There are many forces that prevent people from talking about racism. Without honest reflections on race and the history of this nation, conversation and narratives often generate unproductive fear, shame, guilt, avoidance, and denial. We need to move past that to a place of healing and action. A book by RWJF's chief science officer, Dr. Alonzo Plough, shows us how. 

Health Equity: Everyone Counts - The Need for Disaggregated Data on Marginalized or Excluded Racial/Ethnic Groups

May 31, 2022

When data are unavailable for a marginalized racial/ethnic group, their needs are rendered invisible when policies are made, resources are allocated, and programs are designed and implemented.Regardless of intentions, the ways in which data are collected, analyzed, and reported may have inequitable consequences. The effects of policies that make data unavailable on excluded or marginalized groups can put those populations at further disadvantage that may reflect systemic racism.This report, produced in partnership with the University of California, San Francisco, should be relevant to those planning, conducting, or funding ethnic/racial data collection, analysis, and/ or reporting, for both federally and privately funded data, in all sectors, not only health.

Parent Engagement Practices Improve Outcomes for Preschool Children

February 8, 2017

Supporting parents' efforts to help their children develop during the preschool years improves a child's school readiness, reduces behavior problems, enhances social skills, and promotes academic success.The IssueChildren begin learning at home before they ever reach the classroom, but many families face barriers to providing high-quality early educational opportunities. There are a number of research-based strategies to bolster parent engagement in ways that improve child outcomes.Key FindingsPrograms that promote positive parenting practices and parent-child relationships can reduce behavioral problems.Promoting home learning activities and effective teaching strategies can foster early learningStrengthening parent-teacher partnerships can boost academic and social-emotional skill development.Emphasizing a child's physical health can aid healthy overall development.ConclusionProviding systematic supports for parent engagement in early childhood has the potential to promote optimal development for all children.

How Accessible and Affordable Were Individual Market Health Plans Before the Affordable Care Act? Depends Where You Lived

January 24, 2017

Before the Affordable Care Act (ACA), the landscape of the individual market looked much different than it does today, particularly for those in less than perfect health. For the most part, what state you lived in determined how easily you could purchase a health plan, the price you would pay, and what the plan would cover. Rules for insurers in the individual market varied from state to state, but in most states, if you had a pre-existing condition, you could be denied coverage, pay more, or have coverage for your pre-existing condition excluded from your health plan. As Congress debates repeal of the ACA and its protections for people with pre-existing conditions, many policymakers have called for greater state flexibility in insurance regulation than currently exists under the ACA. It therefore is helpful to understand the range of consumer protections in the states before the ACA, and why the ACA included the insurance reforms it did. This issue brief summarizes state rules for the individual market on the eve of the Affordable Care Act.

Building a Culture of Health by Creating Opportunities for Boys and Young Men of Color, Executive Summary

October 4, 2016

There is a long list of social, institutional, and economic barriers that prevent too many boys and young men of color from reaching their full potential. They are more likely than their white peers to face risks in their community, in school, and at home that jeopardize their health and life chances. To better understand these barriers that America's young men of color face and promising ways for our nation to overcome them, the Robert Wood Johnson Foundation's Forward Promise initiative—in partnership with the Moriah Group—commissioned seven issue briefs. These briefs, authored by leading researchers in academia and the social sector, examine quality education, suspension and expulsion, childhood trauma, and lack of early career opportunities.

Moving Toward Healing: Trauma and Violence and Boys and Young Men of Color

September 1, 2016

The purpose of this brief is to highlight the great burden that trauma, violence, adversity, and the social determinants  of health impose on the health of boys and men of color. To protect BYMOC from the potential harm inflicted on  them—and to mobilize the resilience and promise these young people hold—providers, leaders and policymakers  must understand the physical, emotional and societal effects of trauma, violence, and adversity. They must also recognize the implicit and explicit racism and stigma faced by BYMOC. Only with this understanding can leaders effect the fundamental transformation to ensure that BYMOC heal, thrive, and realize their fullest potential.

Improving High School Graduation Rates Among Males of Color

September 1, 2016

Young males of color constitute a disproportionately high percentage of our nation's non-high school graduate population. Data from the U.S. Census Bureau's American Community Survey show that in 2012, 7% of all U.S. 16- to 24-year-olds were not enrolled in school and had not earned a high school diploma or equivalency credential. That same year, for the same age group, this rate (called the status dropout rate) was 10.9% for Black males, 15.0% for Hispanic males, and 14.8% for American Indian/ Alaska Native males. For each of these ethnicities, the status dropout rate for females was significantly lower (U.S. Department of Education, National Center for Education Statistics, 2014, Table 219.80). The U.S. Census Bureau data also show a positive correlation between the incidence of young dropouts and levels of family poverty.

Early Childhood Expulsions and Suspensions Undermine Our Nation's Most Promising Agent of Opportunity and Social Justice

September 1, 2016

This brief presents the latest information regarding early childhood expulsions and suspensions with a special emphasis on how continuing gender and race disparities violate the civil rights of many of our youngest learners and contribute to our nation's costly achievement gap by locking our boys and African-American children out of educational opportunities and diminishing the ability of early education to provide the social justice remedy it was designed to produce.

Addressing Trauma Among Gay, Bisexual, and Queer Boys of Color

September 1, 2016

A growing body of research reveals that lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience a disproportionate amount of mental health challenges when compared with those who are heterosexual and cisgender. LGBTQ people, in general, have a higher prevalence of suicidal thoughts, attempts, and completions (Hatzenbuehler, 2011); depression and anxiety (Cochran, Sullivan, & Mays, 2003), and substance use and abuse (Marshal et al., 2008). LGBTQ people are more likely than heterosexual or cisgender people to have histories of childhood sexual abuse (Balsam, Lehavot, Beadnell, & Circo, 2010) and are more likely to be homeless (Rosario, Schrimshaw, & Hunter, 2012).This is true of young LGBTQ people as well. Studies find that young adults under 24 years of age who identify as LGBTQ, have a higher likelihood of depression and suicide than heterosexual youth (Marshal et al., 2013), are more likely to engage in self-harming behaviors (Jiang et al., 2010), and have increased rates of being a victim of bullying (Berlan, Corliss, Field, Goodman, & Austin, 2010) than their heterosexual counterparts.

Telehealth Parity Laws -  Ongoing Reforms Are Expanding the Landscape of Telehealth in the Us Health Care System, but Challenges Remain.

August 15, 2016

Despite the fact that no other developed country even comes close to the United States in annual spending on health care, 20 percent of Americans still live in areas where shortages of physicians and health care specialists exist, and the United States still ranks the lowest overall among eleven industrialized countries on measures of health system efficiency, access to care, equity, and healthy lives. Many believe that the answer to issues of cost and access in the US health system lies in telehealth, which increases access to care, alleviates travel costs and burdens, and allows more convenient treatment and chronic condition monitoring.With the implementation of the Affordable Care Act (ACA), the federal government announced the move toward encouraging and including telehealth services in health care coverage. The ACA, however, only implementedtelehealth at the federal level through Medicare, in selected circumstances; the power to determine which, if any, telehealth services is covered by Medicaid still remains largely within the powers of individual states.Also, states can govern private payer telehealth reimbursement policies. This means that telehealth implementation varies from state to state in terms of what services providers will be reimbursed for delivering, as well as what sort of "parity," defined as "equivalent treatment of analogous services," is expected between in-person health services reimbursements and telehealth reimbursements. This variation affects providers' ability to implement telehealth options, thereby reducing the patients' ability to use these services and become comfortable with the telehealth processes. Consequently, telehealth faces significant obstacles in becoming an accepted and used health care option for individuals, and states and the nation as a whole cannot fully realize the cost savings of telehealth.

Regulation of Health Plan Provider Networks: Narrow Networks Have Changed Considerably under the Affordable Care Act, but the Trajectory of Regulation Remains Unclear

July 28, 2016

Health insurance plans with limited networks of providers are common on the Affordable Care Act's (ACA's) health insurance Marketplaces. Recent studies have found that these "narrow network" plans constituted nearly half of all Marketplace offerings in the first two years of coverage, with one analysis concluding that about 90 percent of all consumers had the option of buying such a plan if they chose.Plans with limited networks are not new and are not confined to the Marketplaces. Yet there is reason to believe that they have grown in prevalence partly because of the ACA. Many of the health law's consumer protections--prohibitions on health status underwriting, increased standardization of benefits, a maximum limit on out-of-pocket spending, and the elimination of annual and lifetime limits on benefits, for example--have foreclosed traditional strategies used by insurers to keep costs in check. Meanwhile, other elements of reform, including online Marketplaces that make it easier for consumers to compare plans based on premiums and a financial assistance framework that links the amount of a person's premium tax credit to the cost of the second cheapest plan available to them at the silver metal tier, explicitly encourage insurers to compete on price. These developments appear to have led many insurers to design Marketplace health plans that combined a comparatively low premium with a more restricted choice of providers.Limited network plans might offer value to consumers. Coverage that pairs a low premium with a network that provides meaningful access to health care might meet the needs of many enrollees, no matter the network's overall size. Negotiations between insurers and providers over network participation might encourage more efficient delivery of care. And the power to contract selectively might allow insurers to create networks comprising a subset of providers who meet raised standards of quality, potentially resulting in higher-value care.But these plans also pose risks. A network can be too narrow, jeopardizing the ability of consumers to obtain needed services in a timely manner. This can happen if the network contains an inadequate mix of provider types. For example, a recent examination by Harvard researchers of the network composition of health plans offered on the federal Marketplace during 2015 found that nearly 15 percent of the sampled plans lacked in-network physicians for at least one specialty. Or a network might have an insufficient number of providers: There might be too few physicians who are taking new patients, who are available for an appointment within a reasonable time, or who speak the same language as the enrollee. Certain network limitations also might have the effect of discouraging enrollment by sicker consumers, potentially skewing the risk pool. Plans that provide limited or inadequate access to in-network providers make it more likely that enrollees will obtain care from out-of-network sources, exposing them to significant expenses and the possibility of surprise medical bills.Surveys show that many consumers are open to trading network breadth for a lower premium. They also suggest that, in practice, large numbers of consumers do not find network designs to be transparent. If the features of a plan's network are inadequately explained or its list of participating providers is inaccurate, it might be impossible for consumers to make an informed decision about whether the plan's combination of network and price is right for them.Consumers' experiences with narrow network plans since the ACA's implementation have defied easy characterization. Surveys of the insured, including those with Marketplace coverage, suggest that the vast majority are satisfied with their plan's choice of doctors. Yet anecdotal complaints about networks have proliferated, and the exclusion by some health plans of high-profile hospitals and care facilities has generated media headlines.In light of these developments, and as part of a larger effort to keep pace with changes to the health insurance markets since passage of the ACA, lawmakers and regulators have devoted significant attention to determining how networks should be regulated to ensure they are adequate and transparent. This work has involved efforts to establish or update standards for evaluating the sufficiency of a plan's network, improve the accuracy of provider directories, and protect enrollees from surprise bills from out-of-network providers. This brief offers an overview of state and federal actions that address the first two categories--network standards and provider directories--with a focus on rules that govern plans sold on the ACA's health insurance Marketplaces.

The Workplace and Health

July 11, 2016

Where people live and work greatly influences their health. To examine workers' perceptions of health related to the workplace and inform the Robert Wood Johnson Foundation's work in creating a Culture of Health in America, the Foundation—with National Public Radio and the Harvard T.H. Chan School of Public Health—conducted a poll of working adults in 2016.Key FindingsResearchers found:Their job affects their overall health for more than four in 10 working adults (28% good impact; 16% bad impact), their stress level (16% good; 43% bad), and family life (32% good; 17% bad).Workers in low-paying jobs face dangerous work situations (45%) compared to those in high-paying jobs (33%), and find work has a bad impact on stress (51%) compared to those in average and high-paying jobs (41%).One in five workers (19%) are "workaholics," working 50 or more hours a week in their main job. They do so because they say it is important to their career (56%); and that their workload makes it hard to take a vacation (49%).Black working adults give their workplace fair or poor ratings (37%) on providing a healthy work environment, compared to Hispanic (26%) and white workers (21%).Women are more likely while working to have cared for a family member who was seriously ill, injured, or disabled (33%), compared to men (24%); blacks more likely (41%) to have done so than whites (28%) or Hispanics (20%).A majority of workers (55%) go to work when sick; including medical workers (60%) and restaurant workers (50%) who go to work when they have a cold or flu.For most workers, the workplace provides a healthy work environment (75%) and offers formal wellness or health improvement programs (51%).