Following years of investment in diversity, equity and inclusion initiatives, the healthcare sector is now grappling with the anti-"woke" movement.
After Florida Gov. Ron DeSantis (R) enacted the Stop Wrongs to Our Kids and Employees Act—better known as the Stop WOKE Act—last year, for example, Trinity Health had to add a disclaimer to its workforce trainings on structural racism: No one person is responsible for the history of slavery in America.
The Livonia, Michigan-based health system, which operates 101 hospitals in 27 states, paused internal training in the Sunshine State and undertook a legal review of its professional development curriculum. The health system subsequently altered language pertaining to topics such as white supremacy and the legacy of slavery to ensure that participants do not feel guilty or responsible, as prescribed by the majority-Republican Florida Legislature.
“We had to do that for Florida, and we didn’t have to use that language in other states. We have to adjust ourselves to the region and the local needs,” said LaRonda Chastang, senior vice president of diversity, equity and inclusion at Trinity Health. “Florida is very different than the mid-Atlantic. Michigan is very different than Idaho or Oregon or Idaho or Fresno, California. We have to be very aware of those external forces that impact what we do.”
Trinity Health deploys trainings on unconscious bias and cultural competency to educate employees about people with different backgrounds in an effort to improve care, Chastang said. The health system uses in-person training, focus groups and webinars to discuss how systemic racism and implicit biases can influence its workforce and its patients.
In July 2020, Trinity Health declared racism a public health emergency, alongside scores of other healthcare organizations reckoning with the COVID-19 pandemic and the murder of George Floyd by a Minneapolis police officer.
The health system has always strived to tailor its DEI trainings for different audiences and to avoid combative terminology that may provoke resistance instead of encouraging learning, Chastang said.
"We have always been very mindful of how we bring many people with different backgrounds and experiences into difficult conversations. We want our colleagues to know that even when we disagree, we can disagree respectfully and leave each other whole—that disagreement doesn't equal disrespect," Chastang said. "If a person feels shame in training, it can lead to them rejecting the message and learning that is being shared."
Florida isn’t alone, and neither is Trinity Health. Republican-led legislatures in 17 states including Texas and Kentucky have similarly targeted corporate and government DEI practices, according to a Reuters analysis. Skepticism and even opposition to DEI programs exists internally at healthcare companies, as well, and threatens to roll back progress the industry has made in recent years.
Healthcare companies committed to promoting health equity are navigating a heavily politicized and partisan landscape and actively seeking alternative approaches. Their goal is to sidestep the discord and synchronize interests among healthcare entities to marry high-quality care to a broader social justice movement.
In the wake of backlash, diversity leaders in the healthcare sector are exploring alternative means to address subjects such as structural racism and health equity while attempting to avoid politically charged terminology. Many are focusing on goals specific to the populations they serve and incorporating equity concepts such as quality, safety, value and cost across their operations.
Executives say they have managed to convey messages and lessons about structural racism using different language. However, concerns persist about a chilling effect on health equity. In addition, some leaders fear not directly confronting the role of racism in inequitable health outcomes could yield negative consequences over time.
"This has been the biggest pushback that I've ever seen, and it comes on the heels of the biggest progress we've made. But it's unbalanced. We're still significantly net-positive, and I think we'll remain in that position," said Dr. Joseph Betancourt, president of the Commonwealth Fund and senior vice president for equity and community health at Massachusetts General Hospital in Boston.
Health equity leaders are becoming increasingly flexible in their discussions of structural racism. This includes examining historical contexts and specific policies that disproportionately affect certain populations without invoking buzzwords that provoke political responses. They have also strived to integrate this work into key aspects of their operations such as patient outcome reviews.
The Chartis Group had to modify its DEI programs to conform to restrictive laws, said Duane Reynolds, the consulting company's chief health equity officer. Some companies have opted for alternative language and emphasized terms like “team performance” rather than using the phrase "diversity, equity, and inclusion," for example. While the core message remains intact for now, Reynolds said, states may further limit the scope of these training programs. “States like Florida, if they figure out there’s workarounds, they might put more legislation in place to try and restrict it,” he said.
Health equity leaders have emphasized identifying goals specific to the populations they serve and explaining the precise context and evidence behind equity issues, rather than relying on broad descriptors such as structural racism. For example, instead of "diversity training," they may frame it as "communications training focused on addressing the needs of patients from diverse backgrounds."
“There's no one size fits all,” Betancourt said. “I am a strong believer that in any movement, one needs to make an assessment of what is the right approach to get to the end goal in different environments. And so I think, ultimately, we need to have the courage to do what's right to achieve change in the environment that we're in.”
Terms such as “structural racism” depict broader societal phenomena that individuals may struggle to grasp, said Sarah Gollust, professor of health policy and management at the University of Minnesota. A 2021 RAND Corp. survey revealed varying levels of understanding and acceptance of the concept of systemic racism. More than four in 10 agreed the idea is valid, while just under one-third disagreed. These data underscore the need for more accessible language and communication strategies to help a broader audience understand these concepts, Gollust said.
Yet softening the language risks whitewashing history and failing to address the underlying reasons for structural inequities.
“If we’re not naming structural racism and white supremacy as the root of inequities of health and other life inequities, our solutions cannot be durable and lasting,” Sandra Witt, director of community relations at the California Endowment, said at a National Academies meeting last month.
Shrinking investment, sustained progress
Words are important, but “what matters more than the words are the policies and programs and resources that exist,” Gollust said.
While 2020 witnessed a surge in investment in diversity, equity, and inclusion, many DEI jobs disappeared during the economic downturn that followed. However, political and internal policies have evolved to build an accountability framework that obligates some healthcare companies to incorporate equity into their operations.
For example, the Centers for Medicare and Medicaid Services and accrediting bodies such as the National Committee for Quality Assurance and the Joint Commission now require payers and providers to engage in activities such as stratifying quality data by race and ethnicity, creating health equity strategies to enhance community well-being and improve maternal morbidity rates.
“They can't go totally backward, but they are being less proactive, and less aggressive and even in some instances slowing their investment because they've got to find savings across the organization,” said Abner Mason, CEO of SameSky Health, which provides a health equity platform to health insurance companies.