A Seat at the Table? No. Equity Means Changing the Shape of the Table.

Senior Editor Peter Wehrwein spoke with Vayong Moua, the Director of Racial and Health Equity Advocacy for Blue Cross and Blue Shield of Minnesota (BCBSMN), for this week's episode of the MHE Talks: Improving Patient Access podcast series. Wehrwein and Moua discussed healthcare equity issues, how they relate to access issues, the political determinants of health and killing of George Floyd.

Moua has been at the Minnesota Blues plan since 2005 and in his current position since 2017. Prior to working for the insurer, he worked with several community and state agencies in the areas of policy analysis, multicultural community health issues and interdisciplinary initiatives, including with the American Cancer Society on issues related to tobacco control.

He is a currently a Bush fellow and was chair from 2013 to 2019 of the Cultural and Ethnic Communities Leadership Council, a legislated council to advise the Minnesota Department of Human Services on advancing equity. He was awarded a 2019 Outstanding Refugee Award from the Minnesota Department of Human Service, an award designed to recognize civic engagement, entrepreneurship and leadership shown by members of Minnesota’s refugee community.

Below is an excerpt from the interview with Moua.

Note: The excerpts from the transcript have been edited for clarity and length.

Some biography and what it means to be director of racial and health equity advocacy at Blue Cross and Blue Shield of Minnesota

I came to this country as an infant as a Hmong refugee from Laos. My family was the first Hmong family in Eau Claire, Wisconsin, just across the river (from the Twin Cities).I never imagined myself in this position or this role. At the age of about 15, I was really fascinated with philosophy, and I knew that I wanted to major in that. When I told my parents that you can imagine their response — we didn't cross the Mekong River for you to think deeply about being unemployed! They wanted me to be a doctor or an engineer or something tangible and with prestige, not a racial and health equity advocacy director. But little did they know that it really that it was because of them that I ended up in a role like this. My mother worked in the Eau Claire public health department for 25 years.My father worked in City Hall for 25 years. I am prompted and forged by both civic engagement and public health, I would say.I studied public policy at the University of Wisconsin, Madison. So the combination of philosophy anthropology and public policy set me up on this trajectory.

I am the director of racial and health equity advocacy and to unpack that a little bit. At the heart of that, I would say is to embed racial and health equity analysis principles and priorities into key decision making processes, certainly public policy, but also organizational budgets and strategic plans. We know that so much of what creates these inequities are inequities in decision making. My work is about equity in governance and in key decision-making, and how i8t applies to key issue areas like commercial tobacco control, which has been a huge part of my work, or food security issues or the way we design our communities — transportation, land use, and chronic disease prevention, and, obviously, with COVID -19, all the gross inequities we see there.

So the best description I can offer you is that I work on applying racial and health equity to key issue areas, including preventable chronic disease, and also moving upstream of that into how priorities become priorities.

Health disparities in Minnesota

As you alluded to Minnesota has this high-peaks, low-valleys phenomenon when it comes to racial and health inequities. On average, we are better than average, right? If you look not only at health, but employment, graduation rates, home ownership, income, all the so-called indicators of a quality life and society, Minnesota ranks consistently high — if you're white.

In 2014, the Minnesota Department of Health produced a groundbreaking report called Advancing Health Equity, where it identified structural racism as a root cause of these health inequities. And so I just want to, as I highlight our own study, I want to honor the fact that we've known for a long, long time, and that there's been a lag between what we've known scientifically and what the public has understood and prioritize. And so I want to acknowledge that.

So our study, done in 2018, was in partnership with the University of Minnesota, the School of Medicine and our School of Public Affairs, the Humphrey School of Public Policy. And what we uncovered was that health inequities, preventable health inequities, cost this state $2.26 billion, with a B, billion dollars per year. And this isn't even direct medical costs. This is costs in loss wages, lost time, away from work lost productivity. The study also revealed that the American Indian community experiences diabetes and chronic liver disease at four times the rate of the general population. The Asian Pacific Islander community, diabetes and chronic liver disease at three times the rate, African American community, 1.5 times the rate, Latinx community, 1.2 times. If you look at infant mortality, our African American community has three times the rate as the general population. Our smoking prevalence rate in the American Indian community, in Minnesota is 59%.What's the average among Minnesotans? 14%.

Access, disparity and the political determinants of health

I think structural racism permeates the entire continuum. Even though we know that only 10% of what creates health occurs in a physician's office or in a clinic setting, that doesn't mean it's not significant, either.I think we have to understand that because of the social determinants of health, we see very clearly that health is about upstream decision-making. And that tells me that these inequities are unnatural, right, that they’re human created. And if you can trace whether you're looking at food security and SNAP (Supplemental Nutrition Assistance Program) utilization, or smoking prevalence, or diabetes, or COVID-19, you can trace a lot of these inequities to policymaking bodies, to agenda setting. So I’ve been using the term political determinants of health. And I want to be clear, I don't mean partisan politics. I mean, politics, in terms of power, financial resources, information, social and political capital.

Going beyond a program-by-program response

From my experience across a multitude of issues, from tobacco control to food security to transportation, I've arrived at this epiphany, which is that it’s notpicking one issue over the other. I think we've been throwing programmatic solutions at these problems. You cannot have implicit bias trainings, or a multicultural potluck, or an anti-racism book club to solve this, right? I want to honor the importance of enlightenment of education. But we've been waiting for over 400 years on this racial, equity consciousness and that's not what we can rely on. So I think in the name of policy change, we have to go after the impact of policies and systems. So where I'm putting my energy is in equity integration in governance, and how we prioritize, I don't want to say, regardless of belief, but I want to say, well, you may or may not care about Hmong refugees, but it's the law; you have to disaggregate data, you have to have culturally tailored approaches, you have to fund this.

Tobacco control as a model and making equity analysis the norm

We didn’t just say smoking is bad for your health, you shouldn't do it. We actually increase the price of tobacco, we made it illegal to smoke indoors, and there was a strong public campaign to change social norms. So the same kind of template I think, applies to racial and health equity. So we're trying to embed racial and health equity into how bills (in the Minnesota state legislature are devised), assess how policies are made, the structure of the legislature, creating an equity committee in the legislative process, or maybe equity committee on your board of directors, right, or even on your editorial board — having an equity analysis — and not just a checklist — but a true practice in how you screen and how you assess your priorities. And so I want to just give you the template in which we're trying to match structural solutions to a structural problem, instead of just trying to educate and throw a health fair approach to a structural problem.

Creating a COVID equity director role at the state level; not just a seat at the table but changing the shape of the table

I testified in the House of Representatives in Minnesota on about an equitable COVID vaccine distribution bill, and at the heart of that bill was creation of a COVID equity director role and to have an equity leader on the vaccine distribution advisory team. So you'll notice that we just didn't want to translate a website into Spanish or Somali. We wanted to have a position of power of oversight accountability into all key decision making on the vaccine distribution. And so we went after the sources of power and decision-making, not just a component of a vaccine distributions.

Another example: I served Minnesota on what was called the Cultural and Ethnic Communities Leadership Council, and this council was created in statute. It wasn't created as a token gesture. It advised ourDepartment of Human Services on equity policies. And this is a cross cultural, cross sector Council. And we really function as the equity analysis and the equity impact advisors to our largest state agency.

It’s not just about having a seat at the table. I would say it's actually about redesigning the tables and not filling vacancies into a system that is inherently flawed. So I think where the movement is going is we're trying to influence the way tables and key decisions are designed, not just being a component to be considered as an amenity.

What is Blue Cross and Blue Shield of Minnesota doing?

It has developed its own equity policy to cover our contracting, our procurement, hiring, retention, the way we review policies and our own internal governance. This is fairly new, and I'll be honest, a lot of this has been outside in advocacy and making sure that Blue Cross takes an ecological approach to racial and health equity, not just inside our own four walls.

We want to make sure it's enterprise wide, from how we design our business side and that we're actually applying racial and health equity across that continuum of health.

You can't take on everything wrong. You’ll be boiling the ocean. But what I say is that if you care about lowering healthcare costs, you actually do need to go upstream. You're familiar with the concept of prevention, then you should see racial health inequities and structural racism in the name of prevention,

I'll be the first one to admit that Blue Cross and Blue Shield of Minnesota is on its own journey. And it has a lot of work to do. But there's a lot of conviction. And there's a lot of humility there. And I'm, nobody's pushing my organization harder than I am.

Reflecting on the George Floyd case

This last year has been full of — I don't want to sound petty or bitter —it’s been angst and suffering, a bunch of, I told you so’s. For me, is tragic. But it is no surprise that the murder of George Floyd happening here in Minnesota, and Philando Castile [fatally shot by police officer in a suburb of St. Paul in 2016].

All the inequities that you see in COVID-19, and the murder of George Floyd are deeply connected. Without minimizing the importance of embedding racial justice in our criminal system and in policing, but our community has been suffering slow deaths all along. We saw these gross preventable inequities, again, in cancer, diabetes, chronic disease. And Minnesota, if you've looked at the data, our graduation rates, homeownership — there are these gross inequities, and they don't cut neatly off at the border of a certain sectors. The murder of George Floyd is a visible, visceral, disturbing indication of how inequitable our society is and how Minnesota. Obviously Wisconsin, South Dakota, the United States — they have these issues. But there's something funky and disturbing about the inequities in Minnesota.

So as a racial and health equity advocate, I'm joining forces, building solidarity across cultural communities across sectors to make sure that what we connect the immediate, visceral violence happening in our street to the visceral and preventable inequities happening in schools, in our homes and our neighborhoods — that they all belong to this pattern.