Racial and ethnic health disparities are deep and pervasive across the US, and especially in Texas—home to the world’s largest medical center and more hospitals than any state. Strong evidence shows that health is about much more than health care. In fact, 80 percent of health outcomes are shaped by nonmedical drivers of health, such as income, education, housing, and access to nutritious foods.

This report identifies how the health system in Texas is advancing health equity by moving upstream to address the nonmedical drivers of health. Through a review of publicly available health disparities data and health equity initiatives, we reflect on progress and promising strategies led by various health system players. We also share insights and recommendations from health leaders on what more it will take to realize the vision of health equity in Texas.

WHY THIS MATTERS

In 2003, the Institute of Medicine, now the National Academy of Medicine, published a landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The report revealed that racial and ethnic health disparities were deep and pervasive in the US, even after controlling for various socioeconomic factors. Twenty years later, little has changed nationally and in Texas to eliminate racial and ethnic health disparities.

KEY TAKEAWAYS

Our review indicates a stark reality of the Texas health landscape today: On the one hand, racial and ethnic disparities in health and the nonmedical drivers of health remain deeply entrenched. On the other hand, players across the health ecosystem are shifting farther upstream from health care. While this shift is promising, its impact is yet to be seen in health outcomes.

• Racial and ethnic health disparities are deep, persistent, and affect all in Texas. On average, infants, mothers, and adults in Texas live in poorer health and lead shorter lives than peers in most states. At the same time, communities of color, particularly Black and Hispanic, face some of the most pervasive disparities. Racial and ethnic health disparities in Texas cost the economy $40.6 billion annually in excess medical spending, lost job productivity, and lost earnings.
• Racial and ethnic health disparities reflect inequities in the nonmedical drivers of health. Texas consistently ranks among the lowest of all states on nonmedical factors such as income, child poverty, adult education, food insecurity, and housing. Communities of color, in particular Black and Hispanic, face some of the greatest challenges, reinforcing the roots of disparities in structural racism.
• Health system players across Texas have made important progress in addressing the nonmedical drivers of health. In the absence of robust state policy action supporting health in Texas, health system players have stepped up over the last two decades to innovate and advance health equity by shifting upstream from health care.

PROMISING PROGRAMS AND STRATEGIES

Our report summarizes promising programs and strategies that a wide range of health system players are implementing, including hospitals, health centers, health payers, health departments, academic institutions, philanthropy, and nonprofits. Two levels of initiatives are highlighted: (1) midstream, addressing individual health-related social needs such as social needs screening, referral, and clinical-community linkages; and (2) upstream, addressing the broader community conditions for health through systems change efforts, such as anchor missions and collective impact.

RECOMMENDATIONS FOR MOVING FORWARD

In-depth interviews with health leaders and experts across Texas provide insight into the ongoing challenges that impede health system efforts toward health equity and what more it will take to realize the vision of health equity in Texas:

• Frame health equity in ways that are inclusive, data-driven, and solutions-oriented: move away from jargon, identify evidence-based solutions, and ground health equity in shared American values.
• Apply a multilevel systems change approach: address the interconnections of nonmedical drivers of health, explore root causes of inequities, and expand Medicaid.
• Authentically engage communities as partners in advancing health equity: move from transactional to transformative partnerships, and value community expertise by adequately supporting and compensating community members.
• Invest in long-term solutions and align financial incentives: reestablish a state office of health equity, leverage philanthropic and hospital community benefit funding, and generate an evidence base for financial investment.