2021 Hero Racial Disparities Racial Health Disparities

Distinctive community action to address racial disparities in health

The coronavirus pandemic did not create race-based disparities in health. It magnified them to deadly proportions. Across the country, preliminary state data shows communities of color are more likely to experience serious illness from COVID-19. Black Americans are dying from the virus at a rate of nearly two times their share of the U.S. population.

The increased risk is due to a range of factors, including higher rates of underlying chronic illnesses, poorer access to health care, limited availability of testing, distrust of the health care system and bias within it.  

“The coronavirus pandemic shined a light on just how critical issues surrounding disparities really are,” says Allen Karp, executive vice president of health care management and transformation at Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). “There is no more time to waste in addressing these socioeconomic factors that are wreaking havoc on communities across the country.”

In New Jersey, 14 percent of the state’s population is Black, yet Black Americans account for 18 percent of coronavirus cases and 19 percent of deaths. Horizon BCBSNJ already had begun addressing health disparities through a pilot program launched in 2017 in Newark and had planned to scale the program for statewide launch in the spring of 2020. The coronavirus crisis highlighted the urgency to expand the Horizon Neighbors in Health program to more communities across the state, but also required a reworking of many aspects to accommodate for new health and safety protocols. 

Listen to the Health of America podcast on the Neighbors in Health Newark pilot.

With a $25 million investment from funds the company received as a result of the 2017 federal tax reform, Horizon Neighbors in Health will engage members in 70 ZIP codes and will emphasize individual needs with a goal of enrolling 24,000 people who need better health care. Partnering with the state’s three largest health systems, several community groups and a tech company, the program analyzes medical claims data, demographic information and neighborhood characteristics to help identify not only what is making people sick, but also who is most likely to need medical care by focusing on addressing critical elements such as transportation, housing or food insecurity, which often fall outside a traditional care delivery model.

A crucial aspect of the program is the use of a Community Health Worker to interact with members. These are individuals hired directly from the communities where they work, bringing in-depth knowledge of the area as well as shared life experiences. This helps in building trust and understanding — a key component in gaining engagement.

After the first year, the pilot in Newark showed the model was working to improve health. There was a 60 percent increase in accessing behavioral health services among those enrolled and a 24 percent reduction in emergency room visits. Hospital admissions also were down.

“It is a well-documented that socioeconomic factors and where you live can greatly impact your health,” says Karp. “The Horizon Neighbors in Health program takes a non-traditional approach, meets people where they are and addresses their holistic needs.”

The Neighbors in Health Community Health Workers are available to assist members with a variety of services including scheduling and accompanying a member to primary care appointments, wellness and preventative screenings and referrals to specialty care. With the support of Personal Health Assistance at Horizon, they also introduce members to benefits they may not be aware of, including mail-order prescriptions, behavioral health services and telemedicine options. And the Community Health Workers make connections to needed social and community supports such as childcare, education and training, rental assistance and nutrition programs, such as food pantries. In addition to connecting members to needed services, the program is set up to also track utilization and document patient outcomes to ensure appropriate assistance is provided to those in need.

Additional Resources:

  • See our letter to the House Education and Labor Committee on racial disparities exposed by
  • See our letter to the U.S. House Committee on Energy and Commerce on racial inequities.
  • Learn more about the unequal burden of the coronavirus on communities of color.
  • Listen to the Health of America podcast on the Neighbors in Health Newark pilot.

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