Health equity has emerged as a critical topic in healthcare and New Hampshire society at large, as health gaps persist. Achieving health equity means ensuring that all individuals, regardless of their backgrounds, have the same opportunities to reach their highest level of health and well-being. To dive deeper into this topic, we had the opportunity to talk with Dr. Marie Ramas, a regional medical director for a national physician-led accountable care organization that supports about 130,000 patients from New Jersey to Maine, and who has a passion for public health and health equity.

As described by Dr. Ramas, health equity involves “creating systems and environments that enable all people to be the best form of themselves.” It emphasizes the importance of individuals having agency over their health and well-being, allowing them to define what wellness means to them personally. This definition highlights the need for healthcare systems to be adaptable and inclusive, considering the diverse needs of the population they serve.

Community Health Centers Help Address Health Disparities

A medical professional and president of the New Hampshire Academy of Family Physicians, Dr. Ramas shared insights on the intricacies of health equity and its implications for communities. Community Health Centers, including Federally Qualified Health Centers (FQHC), play a crucial role in promoting health equity, particularly for underinsured and uninsured populations. These centers are designed to provide comprehensive healthcare services to those who may have limited resources or access to care. 

“It [a community health center] is a way of providing more comprehensive healthcare for under-resourced people. New Hampshire has eleven Community Health Centers and I worked at one in Nashua  serving a largely Latino population.” - Dr. Marie Ramas

Health disparities affect various populations based on factors such as race, socioeconomic status, geographic location, housing, access to food, employment, and social support networks. These social determinants of health all play a significant role in determining a person's overall health and well-being.

For Dr. Ramas, “there are definitely racial disparities and inequities as far as access to care and health outcomes. We also see differences from a socioeconomic standpoint in New Hampshire and between rural and urban settings. For example, living in more isolated rural areas also plays a role in people’s access to efficient health care.”

Key Disparities in Health Outcomes

There are several key disparities in health outcomes related to vulnerable populations and the social determinants of health mentioned above. For example, high exposure to trauma, limited access to mental health services, and housing and food insecurity were noted by Dr. Ramas as key factors affecting everyone’s health, especially children, leading to conditions such as asthma and behavioral health issues.

She added that when it comes to young adults, “we see disparities when it comes to mental health and substance, particularly from a racial standpoint and also in our LGBTQ+ community. There's a disproportionate increase in overdose, mental health crisis, and lack of follow-up within these groups when compared to their white counterparts in the state.” 

As for adults, chronic disease management and high utilization of emergency rooms are the most significant disparities among different population groups. Access to primary care and preventive services remains a challenge for some communities, which contributes to poorer health outcomes in the long run.

Priority Groups Instead of Minorities or Under-Represented Groups:

In discussing these disparities, Dr. Ramas suggested moving away from terms like "minority" or "under-represented" groups and using the term "priority groups" instead. This shift in language acknowledges that these communities are not underrepresented by choice but due to historical and systemic factors. It reinforces the need to prioritize their voices and identify their specific needs.

“Very often, when we think about underrepresented or minority groups, we think about black, indigenous, or persons of color (BIPOC). They're under-represented in how we research, and how we get survey results, so they’re rather misrepresented, and it's not their fault. That’s why I prefer to say priority groups. I want to make sure that we're still prioritizing their voice and identifying their needs.” - Dr. Marie Ramas

The Impact of Health Disparities Goes Beyond Individuals

From a financial standpoint, health disparities also affect our economy. Low levels of health can affect the workforce’s productivity and ability to perform: 

“Physical health is foundational to a person's productivity and ability to experience satisfaction in life. We see that if a person is struggling with their health and well-being, they might call off work more, use more sick days, and tend to not stay in the same workplace for a long time. In addition, there’s a higher use of substances to cope with poor health outcomes and there's a high utilization of emergency rooms, and urgent care as well.” - Dr. Marie Ramas

From an interpersonal standpoint, the lack of health access can make communities less resilient. The 2020 Civic Health Index from the University of New Hampshire’s School of Public Policy indicates that people who don’t feel connected within their community have less likelihood of rebounding from a traumatic event or a big stress on communities.

“If we don't create environments that promote and optimize health and prevention of illness, then people are less resilient and if they are less resilient, that means that they are more likely to suffer from adverse health and mental health outcomes. If - and when - the next pandemic comes, vulnerable communities will have a much harder time rebounding socially as well.” - Dr. Marie Ramas

The disproportionate impact of the COVID-19 pandemic on people of color is a testament to the relationship of health with all the other aspects of our lives. As a member of the American Academy of Family Physicians, Dr. Ramas was able to hear firsthand from colleagues across the world as the novel coronavirus spread:

“One of the bigger frustrations at the beginning of the pandemic was caring for those I call invisible first responders, as most of my patients were non-American-born individuals. These are the people doing housekeeping in the hospital, and doing home health. The folks who are necessary for our communities to maintain rhythm but don't have the luxury of being able to work from home. They were being neglected. They were hiding their symptoms because they had to work to pay bills and to support their family, for instance.” - Dr. Marie Ramas

Moving Away from Performative Health Equity Practices

When it comes to the diversity, equity, inclusion, and belonging work that we've been exploring as a healthcare system over the last few years, there is a tendency to focus on metrics that indicate whether an organization or system is practicing health equity. For Dr. Ramas, this is a rather performative way to address health disparities: “The problem with focusing on metrics is that you are just checking boxes. You may achieve the targets but equity does not become woven into the daily practices of an organization.”

Cultural competency and language access are good examples of this: 

“We have policies that require organizations to have a method of translation and interpreting services, but we don't really talk about the quality of the services or what that may look like. However, the  US [Department of] Health and Human Services has defined standards for healthcare organizations, and there are certifications in CLAS, culturally and linguistically appropriate systems and services. The difficulty is that we're still thinking of aspects that can help drive and reduce disparities and promote health equity as extra or as projects and not as investments into the longevity of our healthcare system.” - Dr. Marie Ramas

“Having a diverse workforce is absolutely imperative”

Representation matters, but again, not just in numbers. For Dr. Ramas, having executive leadership - above middle management - that reflects a diverse spectrum of people, not only by race but by gender, age, and socioeconomic background, not only helps reduce disparities and improve equity and health outcomes but also has proven to be more profitable for organizations everywhere.

“Recruiting, retaining, and nurturing diverse leadership within organizations is fundamental. Something we’ve experienced in different spaces in New Hampshire is understanding how to compensate for the expertise of our historically under-represented communities when we are trying to create new innovative models to support said communities.” - Dr. Marie Ramas

Lastly, Dr. Ramas highlighted the need to provide sufficient staffing and resources for DEI work (Diversity, Equity, and Inclusion work involves efforts and initiatives aimed at promoting and fostering diversity, equity, and inclusion within organizations and communities) within the healthcare system: “Organizations like the Equity Leaders Fellowship support rising BIPOC leaders within the state. Additionally, the New Hampshire Leadership Institute is an organization that provides the historical context within different sectors, from government to housing, to financial, to health - between the policy work that happens within the state.”

High-Quality Primary Care is the Foundation of Health Equity

Lack of access to high-quality primary care is one of the biggest barriers to equitable health:

“The reason I focus on primary care is that the United States has the worst health care outcomes from all of its counterparts in the world. We are one of the only countries that do not have a centralized primary care system for patients and community members. Creating a system that supports and enables primary care and access to prevention is foundational to ensuring health equity.” - Dr. Marie Ramas

New Hampshire’s number of primary care residency programs is growing and, according to Dr. Ramas, the Granite State will likely have four primary care residency programs over the next two years. One in Coös County and another one in Cheshire will add to the existing Family Medicine residency programs in Concord and Portsmouth. This means there will be more opportunities to access high-quality primary care. 

Moreover, initiatives like the State Health Improvement Plan are a significant step forward in addressing health equity in New Hampshire. 

“I’m very excited about our State Health Improvement Plan, as this is the first time in New Hampshire history that we took a public health document and developed it into a multidisciplinary, multi-stakeholder living resource that takes into consideration not only how the professionals identify health wellness and public health, but also how constituents in New Hampshire define what it means to be healthy.” - Dr. Marie Ramas

While challenges persist, there are positive developments in promoting health equity in New Hampshire. From community health clinics to implementing systemic changes, progress is being made to create a more equitable healthcare landscape. As initiatives like the State Health Improvement Plan take shape, there is hope for a future where everyone has the opportunity to reach their highest level of health.

Dr. Marie-Elizabeth Ramas

Dr. Marie-Elizabeth Ramas is a family physician activist with a decade of experience practicing full-scope family medicine with obstetrics in both rural and urban settings. Raised in New Hampshire, she returned in 2016 to practice medicine in Nashua and currently is the medical director for GateHouse Treatment Center. Dr. Ramas is an avid advocate for high-quality, affordable care for all. She focuses on empowering patients to achieve their best health by helping to break down barriers to optimal wellness for communities. Dr. Ramas has held multiple leadership positions in medical specialty associations at both the state and national levels, and she serves on various non-profit boards and committees dedicated to promoting health equity. She is a contributor to both local and national media outlets, including The AAFP Leader Voices Blog. Most recently, she co-founded The Lighthouse NH social media page to help address health and wellness concerns for NH BIPOC communities.