Many factors cause disparities in who has access to healthcare, as well as the quality of the care they receive. Health disparities facing St. Louis are not unique to the city but are intensified by two primary factors: division between the city and county, and extreme racial segregation. Having two separate governments operating in the same municipal area means that multiple initiatives may be formed to tackle the same problems, but never communicate or share resources. While some services – such as the sewer district and certain medical centers – are shared, many more function independently, necessitating that organizations communicate and comply with two sets of legislatures and regulations.
To learn more about and address the specific issues facing St. Louis, Washington University ProSPER worked with the Union of Concerned Scientists to host a panel with public health experts, community leaders, and county officials. Speakers included Angela Brown, acting CEO of the St. Louis Regional Health Commission, Dr. Bettina Drake, Associate Director of Community Outreach and Engagement at the Siteman Cancer Center, Jessica Holmes, Principal Strategist for Alignment, Innovation, and Growth for the St. Louis Integrated Health Network, Dr. Will Ross, Associate Dean of Diversity at the Washington University School of Medicine in St. Louis, and Dr. Spring Schmidt, the current Acting Director of the St. Louis County Public Health Department.
The impact of racial segregation on health outcomes
St. Louis City has been ranked as the 10th most segregated city in the United States while the metropolitan area is the 6th most segregated. An example of this is the Delmar Divide. North of Delmar Boulevard the population is more than 98% African American, while south of Delmar, the population is more than 70% white. Additionally, south of Delmar Boulevard the median income increases by $30,000, the number of residents with bachelor’s degrees by 60%, and the median home value by $250,000. This is not the only location in St. Louis where such a stark contrast can be seen, and these socioeconomic disparities have significant impacts on the health of residents.
Evidence of this segregation is reflected in cancer rate differences and outcomes in north St. Louis. Eight zip codes close to Coldwater Creek were found to have higher rates of breast cancer and leukemia and these rates were highest among African American women. Furthermore, African American women were more likely to be diagnosed with later stages of breast cancer and have a mortality rate 10% higher than the total population. These women were more likely to delay diagnosis and treatment due to cost, which results in greater numbers of late-stage diagnoses and higher mortality.
Challenges to equitable access
To address this and other issues, the Missouri Department of Social Services in partnership with the St. Louis Regional Health Commission have funded Gateway to Better Health, a pilot program to “provide uninsured adults a bridge in care until they are able to enroll in health insurance coverage options available through the Affordable Care Act.” The program was implemented in 2012 and serves as a means of providing healthcare access to over 60,000 residents. Although the program helps many in the St. Louis area, the panelists agreed that it is a stop-gap measure incapable of adequately addressing the needs of the region.
These needs may grow in the near future due to funding cuts to the Medicaid Disproportionate Share Hospital Program (DSH). This program provides funds to hospitals that provide care to a large number of uninsured and Medicaid insured individuals to offset the corresponding costs. DSH is federally funded and expected to be cut by $4 billion this year and an additional $8 billion over the next five years, justified in part by the Medicaid expansion in the Affordable Care Act. Missouri hospitals expected to lose over $157 million in funding last year alone which could have a devastating impact on the amount of services they are able to provide to low-income and un- or underinsured individuals. As Missouri is one of 13 states that has not accepted the Medicaid expansion, it will be disproportionately affected by these budget cuts.
Hope for progress & action to reduce disparities
While there are many challenges to fixing health care disparities in the St. Louis region, some progress is being made. The St. Louis Integrated Health Commission is working to bring together resources in the county, city, and from private organizations and reduce some of the inefficiencies and missed populations caused by lack of communication. There has also been an increase in the use of community health workers, community members who may not have medical training but are a key resource in helping people navigate the healthcare system, especially for the specific needs of at-risk populations. More research is being done to address racial disparities in healthcare access and outcomes. There is still a long way to go and many problems to resolve, but we can all do our part to support the organizations and people on the front lines of these issues and by contacting our legislatures about fixing some of the systemic issues that drive health disparities. Having public conversations about the issues and hurdles we face is one step toward addressing disparities within the system and supporting the initiatives and healthcare workers who are working toward health equity.