As Oregon moves toward an overhaul of its health care delivery system, it’s crucially important that we take into account the growing diversity of our state. One in five Oregonians is a person of color, and one in ten is a first-generation immigrant or refugee. These different communities have distinct health needs rooted in historical disempowerment and structural inequities, and the advent of coordinated care organizations offers an incredible opportunity to achieve health equity for our state.
The Center for Intercultural Organizing, a nonprofit organization dedicated to advancing immigrant & refugee rights, is cautiously optimistic about the proposed Request for Applications and administrative rules and the potential of CCOs to help improve health for our communities. We offer the following constructive critiques of the draft documents for the state’s consideration, in alignment with our communities’ health equity priorities.
Cultural and linguistic competency: The draft documents repeatedly reference the state’s commitment to making sure CCOs provide culturally and linguistically competent services and communication, from the organizations’ governance structures to the actual care itself. The introduction at 1.2.1 (pgs. 5-6) most notably lays out a commitment to eliminating health disparities and a focus on culturally appropriate care, language that is broad enough to include many different communities.
The challenge here relies in the state’s reliance on “evidence-based practices” as the gold standard for care. For many immigrant & refugee communities, the most culturally-competent care would promote the parallel use of traditional models of healing along with conventionally allopathic medicine; these traditional models might include the use, for example, of shamans or other culturally-situated healers, herbs and other medicines, or other treatments that might not have a defined evidence based for success, but are key for a culturally-appropriate engagement of these communities with the health care system.
We propose that the state include language around health equity which includes culturally-situated healing practices not rooted in an evidence base, but which are key to communities’ successful health outcomes.
Workforce development: The state has committed itself to ensuring a diverse workforce in two respects: increasing the utilization of community health workers, and ensuring that the state promotes a medical workforce that represents a variety of cultural, racial, and ethnic backgrounds. The state has thus prioritized two of the most important ways to facilitate dialogue and trust between underserved communities and health systems: ensuring that the workforce reflects the state’s diversity, and that community health workers are readily available to serve as liaisons between patients and health systems. We ask that the state and new CCOs work with advocates to identify national best practices in workforce diversity and community health worker promotion in the implementation of these standards.
Equity and accountability standards: We applaud the OHA for ensuring that CCOs will be required to work with the Office of Equity and Inclusion in the development of community needs assessments. The expertise of the Office will be well-situated to effect concrete changes in community health moving forward.
At the same time, OHA’s language is far from inclusive in this regard; the list of criteria delineated in A.1.8 specifically identifies race, ethnicity, and a host of other factors, but excludes any mention of immigrants and refugees. Although the health challenges experienced by communities of color and immigrant & refugee communities are similar, but distinct, especially when it comes to culturally competent and appropriate health services. We recommend that the state and CCOs specifically include immigrant & refugee communities in these community needs assessments as an explicit focus, with other underserved communities.
Data collection: CCOs will be required to compile race, ethnicity, and language data (so-called REAL standards). This presents an opportunity to comprehensively track health outcomes for communities of color, immigrants, refugees, and other underserved communities. Often times, the data collected around immigrants & refugees is incomplete; patients might be incorrectly categorized based on their apparent racial or ethnic identity, data about native language might be collected, and identification categories – e.g. “Asian & Pacific Islander” – might aggregate data about a large number of distinct communities thus reducing the utility of that data.
We ask that the state and CCO candidates partner with community-based organizations and advocates to develop culturally-competent and appropriate standards for this data, and that CCOs disaggregate the data they collect about these communities to the most granular level possible.
Transparency and community engagement: The biggest flaw with these documents and the process as proposed is the utter lack of transparency in CCO certification. As written, the current standards don’t allow the public full access to records about who is seeking certification and their plans to improve community health, until after the state has agreed to contract with them. Before that point, only the names of entities seeking certification will be available. This process, seemingly designed to ensure a smooth, quick certification process, cuts the public out of the discussion entirely. Without access to the full application materials – with trade secrets obviously protected – the public will have no opportunity to raise legitimate concerns about the ability of certifying organizations to provide for population health.
The state’s language around community engagement in the development of CCO applications is similarly problematic. Although appendix A encourages applicants to promote community involvement in the application process, there are no real requirements around stakeholder engagement at all during the application phase.
To correct both of these issues, we first propose that the state require some amount of community engagement during the application process. We also suggest that the state allow the public full access to applications to the fullest extent possible without compromising trade secrets, to allow this process to be truly transparent.