This report is one section of of Healthy People, Healthy States: Promising Practices to Address Health Disparities. See the full resource guide.
High-quality data and an intentional data strategy are foundational to identifying disparities and unmet needs, shaping policies to improve the health of all residents, and selecting and monitoring progress toward goals. States are modifying data collection, analysis, and interpretation approaches to effectively capture and address differences in health outcomes by population (including geographic, demographic, and socioeconomic variability). Some are carefully improving data collection processes, tools, and analytics to adequately collect and disaggregate data by demographic, socioeconomic, geographic, and other variables on a more granular level than before. Other states are analyzing data already available to them to take first passes at informing policy and to begin getting feedback from various partners and interested parties. As with all data strategies, awareness of data gaps and potential misinterpretations should be built into this approach to effectively guide policy and programming. Regardless, most experts note that striking the right balance between securing data quality and determining when data are complete enough to advance policymaking can be challenging — suggesting a continuous quality improvement approach. States are simultaneously working to improve quality of data collection and analysis and using available data to begin shaping the policy landscape.
Improving Data Quality and Transparency to Capture Health Disparities
Standardized assessment tools and data stratification approaches improve the accuracy of identifying health disparities. National efforts to standardize are useful to inform state approaches. For example, in the health care arena, states are leveraging National Committee for Quality Assurance (NCQA) HEDIS measures and requiring Medicaid and commercial health plans to report stratified HEDIS measures.4 In the public health arena, states are increasingly using tools such as the Centers for Disease Control and Prevention’s (CDC’s) Social Vulnerability Index to help identify at-risk communities in need of targeted response. States are also investing in data dashboards or portals to improve transparency. Dashboards and portals centralize data in an accessible format, often in the form of maps and charts, which allow end users to identify disparities by zip code or investigate health disparity data trends. This strategy creates transparency and opportunity for feedback and engagement in the quality improvement process. Utah‘s chief information officer notes the state is using “customer” feedback data to improve processes rather than having state employees “sit around in a room and think to themselves how to improve.”5
State examples provided below detail some of these approaches.
Indiana
Indiana is working to “remove barriers to access and opportunity for all Hoosiers” through the Indiana Equity Data Portal. This data portal was developed in response to Governor Eric J. Holcomb’s priorities for the Office of the Chief of Equity, Inclusion, and Opportunity Officer and was developed collaboratively with the Management Performance Hub and the departments of Health, Family Social Services Administration Child Services, State Police, Corrections, Education, Higher Education, and Workforce Development. The portal includes data on equity related to state efforts in health, public safety, social services, education, workforce, and others. Data collected since February 2020 can be viewed cumulatively or by month for the whole state and point-in-time by county. The table below displays included metrics.
| Indiana Equity Data Portal Metrics | |
| Dashboard | Metrics |
| Health | COVID-19 cases and deaths Infant mortality Births and preterm births Rate of pregnant people not receiving early prenatal care |
| Public safety | Arrests Re-arrests Recidivism |
| Social services | Health and wellness (in the past 12 months) Not enough money for food Utilities shut off Fear of not having stable housing Problems getting child care Cost prevented seeing a doctor Transportation prevented seeing a doctor Need help reading hospital materials Fear of being hurt in home Actively seeking work (last four weeks) Not regularly exercising Children entering Department of Child Services care Children currently in the care of the Department of Child Services |
| Education | High school graduation rate Educational attainment |
| Workforce | Unemployment rate Unemployment insurance claimants Workforce-ready grant-funded enrollments Median household income |
Utah
Informed by Utah Governor Spencer J. Cox’s One Utah Roadmap and the urgent need for data-informed COVID-19 response, the Utah Department of Health and Human Services (DHHS) Office of Health Equity (OHE) prioritized a suite of data collection, analysis, and reporting initiatives. OHE developed uniform data collection standards for race and ethnicity information reportable to DHHS, including a primer on the importance of standardizing, collecting, and reporting race and ethnicity information and how the information could be used by policymakers. OHE packaged the standards in easy-to-follow instructions for providers and community-based organizations.
Minnesota
Minnesota addressed vaccine access inequities through investment in equity data infrastructure to better prioritize resources. The state created the Minnesota Electronic Health Record COVID Consortium, comprised of health system partners to aggregate data from their electronic health records to paint a picture of COVID-19-related statistics statewide. Those data provided 93.4 percent of race/ethnicity and 98.9 percent of geographical data on vaccination uptake, along with data on infections and hospitalizations, and were broken down by race, ethnicity, need for interpreter services, and other variables. The state created a Vaccine Equity Metric by combining immunization uptake data with CDC’s Social Vulnerability Index (SVI), a tool to prioritize the most disadvantaged communities in emergency response planning, to guide the vaccine equity strategy. A sample report shows the analysis of combined SVI and demographic data. Implementation relied on partnerships with COVID community coordinators, diverse media vendors, and community-based organizations, as well as Medicaid managed care plans to prioritize outreach to identified communities. Through this approach, managed care partners reported a greater percentage of outreach to their eligible members living in the most disadvantaged areas (SVI quartile 1).
Tennessee
Tennessee is developing an Interstate Hospital Discharge Data Exchange Project to better describe the health needs of Tennessee’s rural populations and inform interstate exchange of services. The project was developed to address gaps in the state’s discharge data, recognizing that many patients living near the border of Tennessee and another state have the option to go to a hospital that is in either state. When patients opt to get care outside Tennessee, the Tennessee hospital discharge dataset is incomplete. Tennessee intends to use this information to help identify and alleviate health inequities, especially for rural populations, which are disproportionally impacted by this data gap, by improving public health programming, locating areas of disease prevalence, and determining community needs accurately. This is a collaboration between Tennessee’s Office of Healthcare Statistics, along with Connecticut, Georgia, Kentucky, New Hampshire, North Carolina, Mississippi, South Carolina, and Virginia to exchange hospital discharge data for patients from 2011 to 2020. The exchange began for some states in January 2023 and will be used to gather data for Tennessee residents who sought medical treatment at out-of-state hospitals and provide data about the reciprocal states’ residents who were treated in Tennessee.
North Dakota
North Dakota’s Community Engagement (CE) Unit Strategic Plan seeks to “improve data collecting and tracking processes for health equity initiatives” by December 31, 2023.6 To achieve this, the state is collecting data to identify population and demographic needs, redesigning survey questions so they are health equity-based, and partnering with the health department’s statistics and performance team to help implement these changes.7 The plan includes steps to integrate community-based feedback on collected data.8 North Dakota will be able to better work with communities to ensure that their health needs are accurately identified and addressed.9
South Carolina
South Carolina’s Department of Health and Environmental Control (DHEC) established an Office of Diversity, Equity, and Inclusion (DEI) under the authority of the director of public health, with a focus on strengthening partnerships and increasing awareness of community-driven work to eliminate health disparities. A key pillar of that effort is to improve actionable, community-level public health data, including through the state’s Live Healthy South Carolina dashboard and current tracking of disparities in health outcomes data. The dashboard provides county-level health data to promote a healthy life for all in South Carolina. The agency also initiated Community Data Walks as an interactive approach for communities to discuss local-level data reflecting gaps in health through a health equity lens.
Social Drivers of Health and Health Disparities: Using Data to Capture the Intersect and Inform Policy
Disparities in health outcomes are largely attributable to differences in conditions in which people live, play, work, and worship, otherwise known as the social drivers of health (SDOH).10 As data availability and analyses mature, states are determining the intersect among SDOH, demographic, and geographic data and developing more specific intervention approaches based on disaggregated data. Data quality and data-sharing issues are challenging, but state SDOH policy priorities are helping accelerate cross-sector data sharing, adoption of technologies that foster information exchange, and best practices that facilitate exchange while preserving privacy.
To better identify and address health disparities, states are collecting SDOH data through a variety of sources, including community health needs assessments and community health improvement plans, managed care organization assessment tools, health care provider screening tools, social service provider assessment tools, and others.
Innovations in state Medicaid programs provide a good signal for state health policy direction and related data strategy needs. A recent scan of state Medicaid programs shows that 35 (of 47 reporting) states are including disparity initiatives in their Medicaid programs and 32 states are including specific health disparities outcome metrics. Of the 47 reporting states, 35 states have incorporated SDOH requirements into their Medicaid managed care (MCO) contracts,11 and several have moved to enhanced reporting using SDOH metrics in predictive analytics.12 Additionally, numerous states across the country (including Arizona, California, Colorado, Hawaii, Kentucky, Louisiana, Minnesota, Nevada, Ohio, Oregon, Tennessee, Virginia, Washington, West Virginia, and Wisconsin) are integrating strategies to address health disparities in MCO contracts — either directly through incentives or through training, hiring practices, and reporting.13 Some states are specifically requiring MCOs to achieve the NCQA Health Equity Accreditation, a new measurement framework for Medicaid.
Relatedly, SDOH approaches rely on timely information exchange among health and social sectors. State health information exchanges and closed-loop referral platforms to drive whole-person care approaches are proliferating to meet this challenge (for example, in Arizona). A full analysis of these technological advances is beyond the scope of this resource, but they are pivotal in connecting socioeconomically disadvantaged people to needed services and supports and foster collaboration among systems to sustain whole-person care approaches.
State examples highlight different SDOH and equity data approaches. [See also the Profiles of Pioneering Models section for detailed state examples.]
Iowa
Iowa’s Department of Health and Human Services developed the Social Determinants of Health (SDOH) Dashboard in 2021. Thirteen measures embedded in the annual Medicaid Health Risk Assessment are used to gather the self-identified needs of Medicaid members. Access to transportation, material needs, stress, oral health care, and health confidence are among the list of measures. Data are disaggregated by race, age, gender, and county of residence. As a sample use case, these survey data were used to identify gaps in education about the state’s extensive dental benefit, providing outreach to members on its availability and eliminating misunderstandings.
Arizona
Arizona Health Care Cost Containment System (AHCCCS) revamped its AHCCCS Health Equity Committee, which is tasked with understanding health disparities and developing strategies to ensure health equity for all AHCCCS (Medicaid) members. The committee’s scope is identifying health disparities within AHCCCS eligible and AHCCCS members through utilization and quality improvement data. In addition, AHCCCS addresses SDOH through its Complete Care initiative, Targeted Investments (TI) Program, and American Indian Health Program. The state’s Medicaid 1115 demonstration waiver application was approved in October 2022 and includes a variety of approaches to addressing SDOH and intersecting health disparities. As part of the renewal request, Arizona included a Targeted Investments 2.0 (TI 2.0) proposal and a housing and health opportunities (H2O) approach. Targeted Investments incentivizes providers to integrate physical and behavioral health. TI 2.0 extends the provider incentive funding to further integration efforts, including a range of initiatives aimed at addressing SDOH. The TI 2.0 initiative builds on years of state investment in addressing homelessness and housing instability — as a priority SDOH intervention — by strengthening outreach to vulnerable Medicaid members, enhancing access to services that support a member’s success in housing (tenancy supports), and reimbursing for transitional housing approaches.
Ohio
Ohio has developed the InnovateOhio Platform, which combines data systems, allows data sharing, and creates “a common and standard digital platform promoting mobility and accessibility for the benefit of state agencies and programs” under executive order by the governor. A key priority is BroadbandOhio, which works to address disparities related to internet access across the state. In addition to improving digital literacy and economic participation, expanding broadband is also cited as necessary to increasing access to telehealth services, especially for patients living in rural areas. DataOhio, one of many initiatives advanced through this platform, provides publicly accessible datasets to help inform policymaking across the state. Implementation and evaluation thereof requires both state and local-level data collection.
Connecticut
The Connecticut Housing Engagement and Support Services (CHESS) program combines Medicaid health coverage with a range of housing services for people experiencing homelessness and chronic health issues. Beacon Health Options, the state’s contracted Administrative Services Organization for behavioral health, developed an algorithm to determine need and eligibility using Medicaid and the Homeless Management Information System. Several iterations of the algorithm revealed a strategy to reduce race and ethnicity bias and improve equitable access. Improvements were linked to the addition of the number of lifetime days spent in shelter to a diagnosis-based comorbidity index that predicts those most likely to become seriously ill or die in the coming year.
Tennessee
Tennessee leveraged its 2021 re-procurement process for Medicaid Managed Care partners to advance data-driven community investment. As part of this application process, MCOs were required to submit a data-informed plan outlining how they would use funds to reinvest in the communities they serve. TennCare’s Medicaid contract includes requirements for Medicaid Managed Care partners to demonstrate how they address SDOH using data-driven methods. Medicaid Managed care partners are also required to be NCQA health equity accredited to promote use of data in addressing social needs among TennCare populations.
References
Below, you will find references for this section of Healthy People, Healthy States: Promising Practices to Address Health Disparities. Find more references for this resource guide.
- Reynolds, Andy. “Stratified Measures: How HEDIS Can Enhance Health Equity.” NCQA, 2022. ncqa.org/blog/stratified-measures-how-hedis-can-enhance-health-equity/.
- Pattison-Gordon, Jule, and Editorial Staff. “Digital States Survey 2022: Resident-Focused and Data-Driven.” GovTech, 2022. govtech.com/computing/digital-states-survey-2022-resident-focused-and-data-driven.
- Community Engagement Unit. “Community Engagement Unit Strategic Plan: 2020–2024.” North Dakota Department of Health and Human Services, 2023. hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/Community%20Engagement/Community_Engagement_Strategic_Plan_3-17-2023.pdf.
- Community Engagement Unit. “Community Engagement Unit Strategic Plan: 2020–2024.” North Dakota Department of Health and Human Services, 2023. hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/Community%20Engagement/Community_Engagement_Strategic_Plan_3-17-2023.pdf.
- Community Engagement Unit. “Community Engagement Unit Strategic Plan: 2020–2024.” North Dakota Department of Health and Human Services, 2023. hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/Community%20Engagement/Community_Engagement_Strategic_Plan_3-17-2023.pdf.
- Community Engagement Unit. “Community Engagement Unit Strategic Plan: 2020–2024.” North Dakota Department of Health and Human Services, 2023. hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/Community%20Engagement/Community_Engagement_Strategic_Plan_3-17-2023.pdf.
- U.S. Department of Health and Human Services. “Social Determinants of Health.” Social Determinants of Health-Healthy People 2030. health.gov/healthypeople/priority-areas/social-determinants-health.
- “States Reporting Social Determinant of Health Related Policies Required in Medicaid Managed Care Contracts.” Kaiser Family Foundation, 2021. kff.org/other/state-indicator/states-reporting-social-determinant-of-health-related-policies-required-in-medicaid-managed-care-contracts/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D%3B+https%3A%2F%2F; Guth, Madeline and Samantha Artiga. “Medicaid and Racial Health Equity.” Kaiser Family Foundation, 2022. kff.org/medicaid/issue-brief/medicaid-and-racial-health-equity/.
- Dutton, Melinda J., Naomi Newman, Mandy Ferguson, Zerrin Cetin. “In Pursuit of Whole-Person Health: An Update on DOH Initiatives in Medicaid Managed Care Contracts.” Manatt, 2022. manatt.com/insights/newsletters/health-highlights/in-pursuit-of-whole-person-health-an-update-on-doh.
- Dutton, Melinda J., Naomi Newman, Mandy Ferguson, Zerrin Cetin. “In Pursuit of Whole-Person Health: An Update on DOH Initiatives in Medicaid Managed Care Contracts.” Manatt, 2022. manatt.com/insights/newsletters/health-highlights/in-pursuit-of-whole-person-health-an-update-on-doh.
