Editor’s Note: This content has been excerpted from “Equity Rx: Boston Medical Center's Work to Accelerate Racial Health Justice,” Frontiers of Health Services Management, vol. 39, no. 2, by Kate Walsh. It has been edited down for length. The full article received the 2024 Dean Conley Award and Walsh will be recognized during the Congress on Healthcare Leadership.
Daily, doctors type up prescriptions and send their ailing patients to the pharmacy. But for healthcare systems serving majority Black, Hispanic, Latino, Indigenous and Asian populations from disinvested communities, the cure for what ails cannot be found at a pharmacy. Despite decades of advancements in clinical care, health inequities persist across the nation.
For us at Boston Medical Center, New England's largest safety-net hospital and the primary teaching affiliate for the Boston University School of Medicine, these disparities are deeply troubling. About two-thirds of our patient population identify with a marginalized racial or ethnic group. They are also frequently entrenched in racist systems that impede wealth creation. More than 60% of our patient population receives public insurance; approximately half have a household income below the federal poverty level. We see the health impact on our patients as they struggle with low-wage jobs, food deserts and substandard housing.
For decades, all of us at BMC have taken pride in our leading work to “think beyond the pill bottle” by instead prescribing solutions to address the upstream drivers of poor health, from nourishing food to stable housing. Since its first prescription in 2001, our Preventive Food Pantry has grown to provide healthy groceries to 7,500 patients and their families each month. And because housing instability is a driver of adverse health outcomes, we began coordinating with community partners to help medically complex families obtain housing in 2016, an initiative that has reduced rates of poor health in children.
Building on these innovations, we have continued to lead. We prioritized economic mobility by helping patients collect tax refunds and open 529 college savings plan accounts at the doctor's office. We embarked on multi-institutional job creation and training projects that create pathways to career ladders. While these initiatives improved many lives, the horrific events that spurred America's reckoning on race in 2020, coupled with COVID-19's disproportionate devastation on the nation's communities of color, revealed that our actions were not delivering equitable care fast enough.
At the height of the pandemic in Boston, Black residents were 1.6 times more likely than white residents to die from COVID-19; Latino residents bore more than double the burden of infections than non-Latinos. Looking at health data beyond the pandemic, we found Boston's communities of color had health outcomes consistently 1.5 to 3 times worse than their non-Latino/a–white counterparts in Boston. Even when controlling for economic status, racial differences persist in outcomes such as pregnancy-related deaths, premature cancer mortality and mental health.
Uncovering these statistics in a city renowned for its healthcare and research institutions—at an institution with a long-standing commitment to exceptional care without exception—we realized our efforts to improve health for all patients were insufficient. Helping patients maintain their health is core to every hospital's mission, and to do that job it is essential to rethink how health systems address race.
At BMC, we believe health system leaders must hold themselves accountable, uncover the racism entrenched in societal systems and healthcare policies, and shift efforts from simply filling gaps to eliminating them. We need to be explicit about what it will take to meet the needs of the moment. Transforming healthcare in such a profound, fundamental manner requires humility to investigate and question what we think we know, focus to give this work sustained priority, and resources to fund the necessary restructuring of operations.
Unfortunately, the hospitals that serve Black, Indigenous and people of color populations also tend to be the least resourced. Like BMC, they are safety-net hospitals serving primarily Medicaid or uninsured patients whose reimbursement rates are much lower than the rates for commercially insured patients. Nevertheless, safety-net hospitals need to make the additional investments that are required to deliver equitable care. Building a budget that can sustainably fund an equitable healthcare system must be a priority. This work can take many forms such as assuming more risk, fundraising through philanthropy and grants to propel innovation, and advocating with public and private payers for reimbursement models that support the investment needed to reduce inequities.
To transform the care at BMC, we sharply focused our lens on race and ethnicity across the health system. We created multidisciplinary working groups to interrogate clinical operations; identify high-inequity clinical areas; explore the impact of health-related social needs; and investigate how racism factors into our research, education and workplace culture.
The result of this work is our Health Equity Accelerator, a transformative approach to target the root causes of race-based health disparities, promote and sustain economic mobility, and end health inequities. The accelerator is a new kind of prescription, one that is not handed to our patients but instead handed internally to all leaders, staff members, nurses, physicians and researchers throughout the health system.
Learn more about Boston Medical Center’s Health Equity Accelerator.
Kate Walsh is past president/CEO of Boston Medical Center Health System.