Session Summary: Health | Unequal Treatment

Brian Lowery: We can’t talk about health without talking about COVID, and how the disparities in health outcomes have been stark. There’s been a lot of conversation, both about differences in rates of infection and also differences in mortality. Can you give us a sense of the magnitude of those differences?

Toyin Ajayi: This has been deeply well-reported across every part of this country: when you adjust for age and for comorbidities such as underlying medical risk factors, Black and brown people are sometimes three to six times more likely to die of coronavirus than white counterparts, across the entire country and throughout the experience of this COVID pandemic. It’s profound and it’s impossible to ignore.

Brian Lowery: When I hear about these disparities, there’s often discussion about how they might be driven by biological differences. I was recently in a professional chat where someone pointed to racial differences in lifespan as the biggest indicator of racism in this country. Then someone else responded that we should ask questions and explore other reasons for these disparities. Why do you think there’s such interest in finding nonracial explanations for these types of disparities?

Toyin Ajayi: It’s really uncomfortable to recognize what the data show us and have shown us over and over and over again, which is that race as a social construct does not independently confer increased biological risk for poor health outcomes in the ways that we’re seeing those outcomes exist. But racism as a mechanism by which social construct transmits risk factors and prejudice and bias is a powerful and potent independent risk factor for these disparities.

Saying that out loud and unpacking it and then reckoning with what it means is really hard. So there is this desperate bid to find some other reason to make it so. Call it “socioeconomic status,” call it “behavioral changes,” call it “comorbidities,” which is a sanitized version of the sort of upstream sequelae of all of these problems that we’re talking about. It’s very hard to look ourselves in the mirror as a society and recognize that we have created a construct — out of nowhere — that we have then given the power to determine who lives and dies in our country.

Brian Lowery: One of the things that strikes me most is a study that found that kids who come in with long-bone breaks are less likely to get pain care if they are children of color. This is the work that you take on. What are the things that are most striking to you? When you want people to understand in a clear, profound way the depth of the problem, how do you convey it to them?

Toyin Ajayi: There are so many ways to tackle this. That very poignant example that you cite is reflected in the data over and over again. It’s a reflection of individual bias. Sometimes it’s implicit: people don’t even know that they have these fixed beliefs that they ascribe to a certain race which lead them to behave and treat people disparately. We believe that Black kids have a higher tolerance for pain than white kids. We believe that they are more likely to behave badly or disrespectfully and, therefore, we’re not surprised that they are more likely to be censured in school. Those are the sorts of things that underpin the ways that people have formed attachments to this construct of race and act on the basis of that.

But I’m also really compelled by data and evidence even further upstream that shows us how this construct has been fabricated. Dr. Camara Jones, a family physician, epidemiologist, and a brilliant thinker who is prolific in this space, did a study where she looked at people who identify as Hispanic, but who present as white and who are perceived by the outside world to have a different identity than the one they believe of themselves and that their heritage would reflect versus people who are identified as Hispanic by the outside world. What she found was that your health outcomes and your health experiences are much more correlated with how the rest of the world sees you, irrespective of what your ethnicity and lineage are. If you take that example and really sit with it, how can you not believe, therefore, that the construct of race and the way that people behave and the way that our society treats groups of people based on their race in itself is a risk factor and a driver of health outcomes? You can’t fail to see that’s what’s held within those data.

Brian Lowery: You have already pointed to a number of things that could drive these disparities — for example, implicit bias in the way people are perceived. What do you think are the biggest drivers of racial disparities in medical outcomes? What would you point to as the biggest issues?

Toyin Ajayi: It goes further upstream. By the time that we are showing up in the health care system and experiencing implicit bias, we have already accumulated all of the risk factors associated with bias: where we are allowed to buy our homes or to live; the schools that we have access to; the places that we are able to walk through; the way that police have interacted with ourselves, with our family members, with other people in our community. There’s a movement in health care to talk about social determinants of health, and to really start to unpack and recognize the impact of where you live, work, play, go to school; your access to healthy, nutritious food; how much education you receive and what types of education you’re exposed to; and how all of that drives your health outcomes.

What we recognize is that those social determinants also reflect an inherently racist system that disparately assigns and distributes social goods to people, and then those social goods impact health outcomes. It’s really, really important for us to understand that the causal link between racial bias and health outcomes starts way before a person even falls ill. It starts in all of the factors that then predispose them to illness, and then we further perpetuate it when they interact with the health system and they are then disparately treated when they interact with the health system. So I would go way, way, way upstream to the social drivers.

Brian Lowery: When you start talking about going upstream, one of the points people like to make is that individuals make different choices. What you are talking about is the environments we inhabit, not the choices we make. How do you think about personal responsibility in this situation, and what place do you assign it?

Toyin Ajayi: We can talk about it from an intellectual perspective through the studies that have started to try to quantify the cognitive burden of poverty. What does it mean to your ability to make choices when you spend all day negotiating for food and rent and a safe place to sleep at night? Even the idea that we can make informed choices that are looking into the future is a privilege, because many people are truly physiologically depleted by just how hard it is to survive on a day-to-day basis.

But these are also human beings. Let’s talk about human stories. Let’s talk about the choices of a mom raising a few kids on a very fixed income in a low-income community with a Black son whose health and well-being she’s worried for on a daily basis. What choices can she make when she has a choice between trying to get the maximum calories into her family as possible for as few dollars as she can? How does she do this while recognizing that if layoffs are to happen in her job, she’s more likely to be fired? That if she has a financial crisis, she has no rich relatives to call on? That her landlord would look for any excuse to evict her because having a non-Black person in that home increases the property value? What choices are we actually talking about? I would love to see the experiment that controls for all of those things and then offers people choices about how to invest forward into their future, how to make decisions about providing a stable basis for their families, about accumulating wealth and health. I think Black communities would make the same choices as other communities if we had them.

I continue to reject the notion that this is somehow mediated by simply people making bad choices. The choices are constrained from the get-go.

Brian Lowery: People have a hard time understanding the difference between individual choice and the social context that affects individual choices. I always find this a really complicated task to account for leaving people the room for individual agency and responsibility, and simultaneously understanding how one can’t explain group outcomes and group differences as a function of aggregate individual choices. What makes people the same is how people see them, not the choices individuals make. If you see differences in choices at the group level, it has to be driven by social forces, not individual-level choices. I think people really like to think individual choice accounts for these differences. What are we talking about when we talk about these group differences? How are people supposed to live when as a group they are facing these large social forces?

Toyin Ajayi: You also have to wonder: Who’s asking the question and whose narrative is it? This is just humans, especially in such an individualistic society as the U.S. People like to retell their stories as having entirely to do with their own hard work, grit, and determination. That is the American dream. So the folks asking this question themselves believe that they have achieved whatever status and whatever success and whatever health through their own efforts. Therefore, why can’t others pull themselves up by their bootstraps when I did it myself? That narrative takes away the burden of having to recognize and acknowledge our individual privilege, which detracts somehow in people’s minds from the work that they did to get where they got to, and — therefore — undermines the narrative that would allow us to think about what our obligation is to other people and how our choices constrain other people’s choices. It’s a convenient narrative for folks who find themselves in power and with the ability to tell that story.

Brian Lowery: It’s nice to talk about individual responsibility when things have worked out OK for you, right? These are not new problems. These problems have been around as long as this country has been around. Arguably, people have cared more about it recently. What has been done to address these huge disparities?

Toyin Ajayi: Look, we’re talking about it a lot, and we’ve been talking about it for a really long time. This is an area in which, despite a really clear recognition and very compelling evidence of what the drivers are, we’ve not made anywhere near the progress we should have. It is totally unacceptable that we went through this COVID pandemic and basically rediscovered the same stuff we’ve already known. COVID-19, like every other disease category, has disproportionately impacted communities of color, and it didn’t have to be that way. We today in 2021 continue to see that the mortality gap between Black birthing women and white folks — when you adjust for everything: income, educational status — is massive and has not changed.

I see a lot of effort. I see a lot of conversation. But the facts tell us we have not made any progress. In some spaces, that’s not for want of trying. There’s been a lot of effort, particularly by some really incredible scholars and activists in this space, but we as a system collectively have not mobilized behind the notion that health equity is a fundamental challenge that we have to take on in the health care and social systems. We haven’t talked about it. We haven’t done anything yet.

Brian Lowery: I study these broad issues, and the depth and breadth of the issue is really daunting. Can we do anything about these issues before the upstream factors that you talked about are addressed? When we talk about health care at the social level, are we really just talking about better Band-Aids?

Toyin Ajayi: I appreciate the question, as I think about this all the time. I think the answer is “yes, and…”

I will beg your indulgence a little bit as I try to draw an analogy. Just to be clear, I’m not equating the work that we’re doing with this work. I think about the work of Bryan Stevenson and the Equal Justice Initiative as an aspiration for myself and for my colleagues in this space. For those unfamiliar with his work, he started as a lawyer defending Black men who had been wrongfully convicted of murder or who were on death row. He worked one person at a time, using the tools of the legal system, to bring truth to light and to change individual people’s lives. In small but really important and meaningful ways, he’s made a real dent in the problem by changing the arc for individuals.

What he and his team recognized really early on was that, in order to actually change the problem at its root, they had to get way upstream. In that instance that meant exposing and making clear the link between the current mass incarceration of Black and Brown men and how the legacy of slavery and lynching in our society shows up in the judicial system. You make that connection and start to work on that problem by drawing attention, by leveraging resources, by activism, and by starting to mobilize a much broader group of stakeholders around this underlying issue.

You have to do both the practice and the mobilization. I’m a practitioner. I have a tool. I know how to take care of really sick people who’ve been marginalized and neglected by the health care system. I can also mobilize people to do that. I can tell you with confidence that the work that we’re doing to serve low-income, largely communities of color across a number of parts of this country is meaningful. It’s providing tools and resources to folks who’ve had basically the worst of everything that our society has chosen to offer to them, and starting to make justice occur in small places. But success for us also means having these conversations. It means telling the story of how our systems and our societies fundamentally created the problems we’re solving today, and how an overhaul of that underlying infrastructure is necessary for us to change the inexorable cycles of poverty, of injustice, of lack of access to tools and resources all the way through.

So I think the answer is “yes, and…” We’ve got to have these conversations. We’ve got to continue to lobby our policymakers. We’ve got to continue to mobilize resources. We’ve got to ask how we embed anti-racism into all of our structural policies. My hope is that, in generations to come, people like me don’t spend all of our time seeing clinics full of people of color who are sick and hurting because our societal systems created an inevitable set of circumstances that led to their being there. So we have to do both: It’s our obligation to do so. And to be able to carry both at once is, I think, part of what makes this movement actually powerful.

Brian Lowery: I think the metaphor of Bryan Stevenson’s work is apt, because the spaces of health care and criminal justice are where we see, perhaps the most dramatically, the effects of race in this country. We really are talking about people’s lives. Education, economic opportunity, all those things are a part of living a good life, but when you see it in spaces where you’re talking about depriving people of life, it really puts into stark relief the questions that we’re discussing here. I want to talk a little bit more about your organization. What is your organization designed to do and how is it set up?

Toyin Ajayi: I’m really fortunate to be a co-founder of Cityblock Health. We’re set up to be a primary care, behavioral health, and social care provider. We deliver health and social services to people who are largely marginalized in the healthcare system. That marginalization, given the way our system works, tends to be concentrated toward folks who receive health insurance through the Medicaid and Medicare programs: for instance, people who struggle with disabilities, mental health needs, or social challenges, and who are low-income. Our goal is to radically transform the experience of and the outcomes of care for these communities by investing differently in health care. This is typically a fee-for-service system wherein you get paid to do more stuff to people and which favors reactive care. The emergency room visits, the CAT scans, the expensive surgeries are there to fix or attempt to fix problems once they’ve already occurred. We are instead emphasizing what we call a “value-based” model of care that invests upfront in primary care, mental health, and social services in the community to prevent all that stuff from happening in the back end anyway, and aligns our incentives around reducing spend, improving quality, and improving the experience of care for the folks that we serve.

Brian Lowery: You are a for-profit organization, right?

Toyin Ajayi: Yes.

Brian Lowery: There’s a perceived tension between for-profit organizations supporting underserved populations, people of color in particular. There are all sorts of forces that push against positive outcomes for people of color, and people of color often don’t really trust for-profit organizations that may have their best interests at heart. There’s also not a lot of trust in the medical industry in communities of color. Why should people trust your organization?

Toyin Ajayi: Such a great question, and I appreciate it. The counterfactual and the status quo for many communities of color and low-income communities is that health care is provided by nonprofit organizations who have a mission in mind that very much aligns with my mission, but that are reliant on funding streams that are not always sustainable and often are tied to philanthropic resources who require volume-based care, or this fee-for-service engine that I described when providers get paid to do more stuff and see more people. That doesn’t drive trustworthiness, often, nor does it drive sustainability.

I actually came from that world. This is my first-ever foray into a for-profit entity, and it was a deliberate choice. I was tired of feeling like providing care for low-income, marginalized communities was a thing I had to beg for resources to do. I was really interested in trying to understand how we take the tools, the systems, the structures, and the tremendous amount of resources we spend on health care today to create a sustainable business case for investing in these populations. I do believe this case can be made. As much as I wouldn’t have designed it this way, I believe that it’s our obligation to get access to those resources and invest them in these populations, and not have people have to say thank you or be beholden to charitable whims.

That’s not to say that I don’t think that there’s an opportunity to do really important philanthropic work in these communities. It is to say that I believe that we’re missing an opportunity if we don’t take advantage of this lever and of this tool, which is to create a real business case for doing this at scale.

On the question around trust, I think what’s important is your intent and how you are originating into the space. What I find — and what we’re finding with our communities — is folks already know that health care is operated as a business, and that’s because we’ve decided in this country that we’re going to allocate health care through a marketplace with all of the failures which that marketplace continues. But that’s what we’ve decided. That is how health care is administered today, and folks know that.

It’s better actually to be able to be transparent about this and about the fact that our incentives are aligned around our members’ incentives. The people that we care for, they want to stay home and healthy and be in their communities. They want to spend more time with their kids. They don’t want expensive surgeries and hospitalizations for things that we could have helped prevent. They want care that’s responsive to them, and that values and dignifies their experience. And they want a provider who doesn’t get to be in business if the members don’t come back to them. I actually depend on creating an experience of care that is engaging and high-value to the people we serve. That is that is how our business is successful. So that alignment of incentives in many ways is advantageous, transparent, and allows us to really think about what matters to the folks that we’re serving, not as charity cases, but as people who have purchasing power through their attention and their energy, and to funnel resources that align around what their goals are.

Brian Lowery: I do agree that the idea of serving these communities as charities is problematic for a lot of reasons. In the private market, there are investors, especially in the for-profit organization. There’s one way to read this where investors are going to make money off the problem of racism. Racism is producing the problem and is creating the opportunity to profit. How do you think about that?

Toyin Ajayi: I think that is true for our system of racialized capitalism in this country. There is not a single institution that returns to its shareholders and, in some way, does not benefit from the delta between the haves and have-nots, and that delta in many parts contains the legacy of racism. I don’t know what else to say about that.

Brian Lowery: It is crazy to think of it that way, that you have an organization that is designed to redress generations of racial inequity and, in doing so, creates profits on the purposeful inefficiencies. You’re right: That’s how the system is set up. But, in your case, it’s so clear and transparent that that’s what’s happening, because of your interest in serving the community and doing it in a for-profit way. Otherwise, usually it’s just hidden and we don’t see it. There’s something that’s stark about seeing that profit generated as a function of the problem of racism.

Toyin Ajayi: Our organization exists to invest resources in returning value to the patients that we serve, for whom — I’m the first to tell you — so many of problems are sequelae of systemic racism. They’re also sequelae of a whole host of social factors that tie to education, that tie to income, that tie to access to resources upstream of this. Our goal is to impact those positively for the people that we serve. Also, until we as a society collectively get way upstream and start to ask why these problems exist, why these problems disproportionately impact communities of color, there is no way to extract those two things, to separate those two things. There is no way to do that.

Brian Lowery: I appreciate your pragmatism on this. The other thing I want to think about is how the community is involved. Especially in the nonprofit world, there’s been a growing backlash against the Savior Complex, where people from the outside come in and try to fix or serve this community that they’re not directly a part of. You see this most clearly voiced in the backlash to international aid. You also see it in some of the recent local debacles, like in Pittsburgh, where people who really didn’t understand the community they were serving came in and tried to provide vaccines and testing in underserved populations and did a terrible job. How do you think about community involvement in your organization?

Toyin Ajayi: Our business model is tied to our ability to meet people where they are, build trust with them, be able to understand what’s going on for them, intervene with health care services that make a difference to them, and help change their outcomes. We can only do that if we’re able to do the first couple components: find a patient, build a trusted relationship, and understand what’s going on for them.

We think about community involvement on a couple of levels. The first is just making sure that our teams actually reflect the communities that we serve by hiring folks from the communities we serve, and really leveraging their expertise in their community to help us understand what we can and should be doing for the people that we serve. The second layer is around engaging and leveraging community resources where they exist. We often talk and think about these communities as lacking: It’s always from a deficit perspective. We talk about social determinants and social drivers and social challenges, and it’s always the sort of idea that they are so much lacking. What we’ve found is that there’s so much already happening — there’s a ton of power and resiliency in these communities. There are lots of organizations that have been doing work to serve their communities that have the trust of their community members. So we are much better off partnering with them, following their lead, and humbly asking their permission to participate in the ecosystem that they’ve been creating and generating over time. That takes time, intentionality, and some creativity in thinking about how you bring those types of organizations into the value chain so that we’re creating incentives and partnering in a way that’s beneficial to them as well. I certainly wouldn’t say we’ve solved it all in every community, but we certainly understand the value and are learning our way towards that with the support of community partners in every market we operate in.

Brian Lowery: Given what you’re doing in the model, I see that community involvement is a necessity for it to work. I also wonder about accountability. Especially in a for-profit organization, at some point investors demand returns, there’s a desire for growth, there are all these pressures to find more and more efficiencies and increase revenue or profitability. How do you build accountability into your organization? Or DO you build accountability into the organization? What does success produce, and does that change the way the organization operates to the detriment of the people it’s designed to serve?

Toyin Ajayi: This is health care, so we’re accountable to impact and outcomes, to making sure that we meet our members and serve them, and that we are providing a kind of quality care that makes us proud and that exceeds benchmarks in the market. There’s an accountability around the quality of service and the outcomes driven by the service that I think is really helpful. To your point, we don’t always see that throughout the healthcare ecosystem, and I think that’s why I’m so grateful for and really enjoy being on the service provision side. As a health care provider of primary care, mental health, and social care, there are clear benchmarks about what success looks like from a quality perspective. So that’s one piece.

You also alluded to the relationship with investors and their expectations for returns. That’s where we’ve been really thoughtful about who we bring around the table. We have a mission and a mandate to have impact and to create scale. By challenging the status quo and the tacit acceptance that we have as a society that poor and marginalized communities will just get what they get, that it will be subquality, that it will look homogenous, and that it will be inaccessible. The only way to challenge that is by providing care that is the opposite of that: care that’s respectful, that is accessible, that drives quality outcomes, that is tailored and attuned to the needs of the population we’re trying to serve, and that is investing intentionally against those types of outcomes. We have to do it at scale for anybody to sit up and take notice. So we’re much more interested as an organization and as a company in building that scale and having that impact than we are in a quick return. Our investors understand that, that there’s a long game here and there’s a really big opportunity to build something that is impactful at scale.

Brian Lowery: You see a lot of organizations that come into underserved communities and, because there are not a lot of alternatives, they can be extractive. Sometimes that can happen, not because people come in and are necessarily trying to prey on the community. They start an organization, then more and more turn to ‘how do we do a better job?’, but a better job is defined in terms of a better job for the organization. There can be this slippery slope where you end up in an extractive position, although that wasn’t your intent. How do you make sure that doesn’t happen? It sounds like you’re saying that part of it is the investors you have and part of it is the outcomes that you judge the organization on. Is that right?

Toyin Ajayi: That’s right. A big part of this is the alignment around value and value-based outcomes. To give you an outline of how our economics work: It’s very easy where there are not a lot of options to set up shop in a community and provide what you provide, and you get paid irrespective. You open your doors. People come in, because they have no other choice. They may not feel good when they leave. They may not feel like they were treated with respect and dignity. But you’re the only choice. You’re the only shop in town. In many instances that’s how health care has operated for a really long time. That’s what fee for service creates, particularly in communities where there’s scarcity.

What’s important to us about the alignment with value-based outcomes is that we don’t get paid just for providing doses of health care to people. I only get paid if things change for the person that we’re serving. I only get paid if they make different choices, if they are able to access different resources, if they get healthier, if they’re staying home more than being in the hospital. I only get paid if that is true. That means my incentives are to align the care that I provide with what people say they want, and to create a relationship and experience that’s longitudinal and sustained. I care if they come back. I care if they pick up the phone when I call them again. If you get treated badly, you’re not coming or calling back. You’re out and you’re doing something else. There’s an alignment around our reimbursement model that is intentional in really delivering value for people the way that they measure value for themselves.

That’s why, as an example, when we look at satisfaction or net promoter score, that’s a key leading indicator for us. We strive for a Net Promoter Score of 90 among our populations, which is orders of magnitude higher than what you see in health care, where we’re talking in the teens sometimes. That’s a first. To this day, I don’t know of any other health care organization who is primarily serving Medicaid populations and will even tell you what their NPS is, let alone have one that’s on par with some of the shiniest consumer brands out there. That’s because it’s not a “nice to have,” it’s a “must have” for the success of our model.