Episode #103: Rebuilding Trust, A Key Step to Eliminating Healthcare Disparities – with Dr. Mandy Cohen

Welcome to episode #103, Season 4 of Creating a New Healthcare. In this episode we are welcoming back to the podcast Dr. Mandy Cohen, the Secretary for the North Carolina Department of Health & Human Services. Dr. Cohen and her administration have been critical in responding to the current pandemic. Over the past 3 1/2 years, they have also been hard at work, developing and deploying a cutting-edge, state-wide approach to addressing the Social Determinants of Health – a critical national issue whose importance has been magnified by the pandemic.

In this episode, we’ll cover:

  • 3 major lessons that the COVID-19 pandemic has taught us: (1) equity, (2) system-ness and (3) care beyond walls.
  • How Dr. Cohen and the NC DHHS adopted “an equity lens” in deploying targeted programs and policies to create a more equitable healthcare system.
  • The progress in “health opportunity” programs such as the NCCARE360 closed-loop referral program.
  • The central importance of Community Health Workers in building a ‘bridge of trust’ to creating better health.

For me, there were three profound take-aways from this episode:

  1. As we were discussing the importance and necessity of collecting data on racial disparities and inequities in healthcare, Dr. Cohen paraphrased a mutual colleague – Dr. Mark Smith, the founding president and former CEO of the California Health Care Foundation. The lesson she shared is the cautionary note that one should not admire a problem too much at the expense of doing something about it. We should not wait around for perfect or publishable data before taking action. Heeding this advice, she is “full tilt” on deploying resources to assist traditionally marginalized populations – in particular, the Black and Latinx populations.
  2. Governor Roy Cooper has been fiercely promoting the importance of Medicaid expansion – which has become even more critically important due to the stressors of the pandemic on factors such as employment. There are currently 2.2 million people on Medicaid in NC, which accounts for about one-fifth of the entire NC population.  1.5 million of those individuals are children, which accounts for one out of every three children in NC.  If we accepted federal funding and expanded Medicaid in NC, it would provide insurance coverage for another 600,000 people – covering COVID-19 testing, behavioral health treatment, early childhood development programs, life-saving medical care and so on. As Dr. Cohen puts it – the fact that we are one of only twelve states in the entire country that has not yet expanded Medicaid is a “black eye” on the NC commonwealth.
  3. There was another profound ‘aha’ moment that happened during this interview that I don’t think I’ll ever forget. As we were discussing the ‘community health work’ (CHW) program she and her team are deploying, Dr. Cohen punctuated the key role that community health workers serve in the healthcare ecosystem. It’s well known that Community Health Workers serve to provide navigation and coordination of clinical care, and that they assist with social services and social agency. But, from Dr. Cohen’s perspective, their key core function is really about rebuilding trust. It’s about meeting people where they are, and starting to rebuild a bridge that has been broken. She went on to say that we have to acknowledge that we have a “trust deficit” in communities of historically marginalized people. More explicitly, Black and Latinx communities have been left out and let down by our healthcare system. And, some of the current health inequities are likely due to the fact that people don’t seek healthcare because they don’t believe they will be heard, listened to, and appropriately cared for. The “trust deficit” is based on decades of lived and learned negative experiences, and is supported by decades of published research.

Dr. Cohen is a knowledgeable, forward-thinking, empathetic and highly competent public health leader. She has a definite bias to action – deploying programs that achieve measurable positive health outcomes for individuals and communities. Under her leadership, the NC DHHS is keenly focused on addressing the long-standing and systemic ‘dis-trust’ in our healthcare system, which to my mind may be the single most important ‘dis-ease’ we need to tackle if we are to achieve our full potential as a state, and as a nation.

Until next time, be safe and be well.
Zeev Neuwirth, MD