Health Equity Approach

This project was launched in late 2020, in the wake of a national reckoning on anti-Black racism and a pandemic that has disproportionately harmed historically marginalized communities, including those who are Black, Indigenous and people of color (BIPOC). In June 2020, the Maine Center for Disease Control & Prevention announced that, despite only comprising 1.6% of the state’s population, Black residents represented 24% of all COVID-19 cases in Maine at the time.56 While these harrowing statistics have improved slightly since, as of January 18, 2021, Black and African American Mainers represent at least 5.4% of all documented COVID-19 cases in Maine—more than three times their share of the total population.i The coronavirus pandemic has exposed the ways in which existing policies and structures have failed certain communities, leading to racial disparities in health, safety, and overall well-being. White Mainers are only half as likely to experience unemployment or poverty compared to BIPOC Mainers, a disparity directly linked to health access and outcomes.57 Even prior to the pandemic, Mainers of color were nearly twice as likely as white Mainers to be unable to seek medical care because they could not afford the cost.58 Maine’s potential transition to an SBM would be a significant milestone. With an SBM-FP, the State already has opportunities to invest further resources into enrolling uninsured Mainers, including through more effective outreach and consumer assistance activities—a critical investment towards health equity in the state. DHHS officials have asked us to identify best practices and policy innovations to support the success of an SBM. This transition is a chance to step back and better understand how existing systems may be contributing to inequities and how to avoid repeating missteps in a new model.

While compiling this report, our team grounded equity as a foundational pillar of our work. Prior to identifying and interviewing stakeholders, we conducted background research to better understand communities in Maine, including those who are Black, Indigenous, LGBTQ+, houseless, immigrants, refugees, disabled, migrant and seasonal workers, living in urban or rural areas, and/or newly eligible for MaineCare. We sought expertise and feedback from organizations who currently lead efforts to support these communities in Maine, and we applied a racial equity framework while conducting our analysis and drafting recommendations. While an SBM has the potential to expand health access for Mainers with historically marginalized identities, we heard concerns from stakeholders that its impact may be limited without improving equity coordination across OFI, the Office of MaineCare Services (OMS), and a potential SBM. In the same vein, we believe that there is an opportunity for DHHS to restructure and enhance its equity operations across the Department, which we detail in Recommendation 3 in Broad Recommendations.

Throughout this report, we suggest a number of incremental improvements that DHHS can adopt in the short-term during its potential transition to an SBM. Simultaneously, we share longer-term possibilities—including policy options that are complex and politically challenging—that we hope can help expand the State’s vision and approach to health services. As with other policy considerations, we recognize that DHHS’s choices relating to health equity will need to contend with both immediate and longer-term constraints, and hope that our report strikes a balance to assist state officials in their decision-making. In light of this context, we use targeted universalism, a goal-oriented equity framework, to propose recommendations that would move toward all Mainers having accessible, affordable health care.ii In setting this universal goal, we pursue targeted processes for Mainers who are BIPOC, immigrants, refugees, migrant and seasonal workers, queer, trans, disabled, and/or experiencing homelessness. We articulate our goal through a lens of care, in addition to coverage. Care is a broader term that includes all the ways Mainers might seek to address their health needs, including not only private and public health in-

i We say “at least” noting that over 4,250 positive cases did not report the patient’s race and/or ethnicity. Source: “COVID-19: Maine Data.” Division of Disease Surveillance, Maine Center for Disease Control & Prevention. Accessed January 19, 2021. https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/data. shtml ii Targeted universalism is an equity framework, created by professor and critical race scholar john a. powell, in which “universal goals are established for all groups concerned… (and) the strategies developed to achieve those goals are targeted, based upon how different groups are situated within structures, culture, and across geographies to obtain the universal goal.” powell, john a. Stephen Menendian and Wendy Ake, “Targeted universalism: Policy & Practice.” Haas Institute for a Fair and Inclusive Society, University of California, Berkeley, 2019. https://belonging.berkeley.edu/targeteduniversalism.

surance, but also Free Care or the Maine Mobile Health Program. These programs are critical for migrant and seasonal workers, immigrants and refugees, and those with limited English proficiency, among other groups who are systematically excluded from coverage under certain circumstances. While our recommendations would facilitate increased access to coverage for those who are eligible and interested, they would not replace the need for these sources of care.

This articulation also stems from an acknowledgement that even with coverage, many marginalized populations continue to experience discrimination and stigma in the delivery of health care services, undermining the care they receive. Given that a full examination of the social determinants of health and systems of oppression in Maine is outside of the scope of this report, we approach universal access to affordable health care in this report as a critical economic safety net, rather than as a standalone solution to health inequities in the state.