Dr. Betancourt’s Blueprint for an Equitable Health Care System

JOEL BERVELL: My guest today on this episode of The Dose is Dr. Joseph Betancourt, president of the Commonwealth Fund. It’s a role he stepped into just about one year ago, and it’s a bit of a full-circle story, because as a freshly minted M.D. and researcher deeply invested in health equity matters, Dr. Betancourt was a Commonwealth Fund fellow.

In the intervening years, he was most recently senior vice president for equity and community health at Massachusetts General Hospital and was founding director of the Disparity Solutions Center. He has devoted his career to improving the quality and value of health care for diverse populations. As an associate professor of medicine at Harvard Medical School and a board-certified internist, he has spent much of his career providing primary care to a large Spanish-speaking patient population. And he’s also an Aspen Institute Health Innovators fellow and was named one of Modern Healthcare’s Top 25 diversity leaders in 2022 and in 2023, one of the top 50 clinical health care executives in the United States.

So it’s with great pleasure that I welcome you, Dr. Betancourt, to The Dose. It’s our first real chance to have a conversation about the work that the Commonwealth Fund — that you and I are both so deeply invested in. Thank you so much for being here.

JOSEPH BETANCOURT: Oh, thank you so much for having me. Excited to be part of this conversation.

JOEL BERVELL: So health care in America is highly complex. It’s dramatically divided, and it’s a space where equity is an ideal and hardly a reality. You’ve been on the front lines clinically, and you’ve even created frameworks to address disparities. Why come to the Fund and what’s the impact you most want to have?

JOSEPH BETANCOURT: Well, thanks so much. It’s a great question and it’s really an amazing journey. I’d say that, as you mentioned, the issue of health disparities, of health equity is not an academic pursuit. It’s not a research pursuit of mine. This is a life passion. It comes from my lived experience growing up in a bilingual white culture home from a Puerto Rican family.

I got to see firsthand the impact of race, ethnicity, culture, and class on health care delivery, getting a chance to really aspire and live out the dream, despite a lot of challenges along the way to be a doctor.

It became very clear to me when I was in your shoes as a medical student that, number one, in medical school there weren’t a lot of people who looked like me. Number two, the simple fact that I spoke Spanish made me an asset on clinical rounds. And number three, that people were receiving different quality of care based on personal characteristics like race before we started talking about minority health or health equity.

So that was a springboard really for me, trying to think about ways in which I could improve health care for more than just my patients who I saw, but really with a focus on public health and health policy. As you mentioned, I had a chance to do the Commonwealth Fund/Harvard University Fellowship in Minority Health Policy in 1997. That was a dream come true.

Fundamentally, it was the opportunity, through this new fellowship, to become a leader in health equity. And I would just say that that also served as a launching point for my career in this space. I’ve been on the operator side, I’ve been on the care delivery side, and health care administration at a hospital.

When the opportunity to assume the presidency of the Commonwealth Fund presented itself, it was really incredible. It was awe-inspiring. It was humbling, but it really, I think for me it was a natural progression in my career, the opportunity to go from being on the ground and having a national impact. But now coming to the Fund with over a hundred years of major contributions to health care, major contributions to health equity, a place that touched my life, early in my life, in transformational ways.

A place that has not only a national but an international footprint in all things health care, a place whose mission is affordable, high-quality health care for everyone — all that really aligned perfectly for me and it’s an exciting opportunity and we’re really thrilled about what we’re going to do in the future.

JOEL BERVELL: I’d love to know what’s the impact that you’re wanting to have while at the Commonwealth Fund?

JOSEPH BETANCOURT: We have had impact throughout our hundred years in a lot of different ways. The Commonwealth Fund, which, by the way, was founded by a woman, Anna Harkness. A lot of people don’t know that — really, really important. Made early operational contributions to create the first public health departments, the first medical schools in urban areas, the first public hospitals that led to the Hill-Burton Act that led to the construction of hospitals across the country. That led to a lot of the research that ultimately launched the Affordable Care Act.

So as I think about the future, right now we operate across a series of programs that really focus on three areas, I’d say, maybe with a fourth: coverage. So how do we improve coverage and make it more affordable, accessible; care, how do we make sure it’s equitable and high quality; and cost, how do we make sure that all of this is cost-effective. We do this not only domestically, but we do it internationally.

I would say that equity is embedded in everything we do. Of all of our programs, our health equity program is our largest. But I think what I’ve learned over the course of my career is while I want to lift up our equity work, we really, really need to think about how equity is integrated in all the different areas of our work.

Because in fact, when you think about coverage, when you think about cost, when you think about care, you cannot achieve any of those effectively if you’re not considering equity. And if you’re not considering how these issues impact all people, no matter who they are or where they’re from, and we know we have fallen short on that historically, and even to this day.

JOEL BERVELL: There’s been a huge amount of innovation in health care in the past century. And as you mentioned, the Commonwealth Fund has been around for a little over a hundred years. Is race at the core of the persistent gaps today in health care?

JOSEPH BETANCOURT: There’s no doubt that race has been a major factor in American history. And it not only impacts health care — and we have now thousands of papers that have documented differences in health care quality, health outcomes, based on race — but it impacts all facets of our society. It certainly intersects with other things, like class and gender and sexual orientation.

So I think this is something that over decades, I’d say, people have been trying to better identify and address not only the extent of these disparities or differences, but also strategies to better identify and address them, to do something about them. So, we need to have the courage to talk about them, and race needs to be part of that conversation, absolutely.

JOEL BERVELL: And the Fund supports the work of emerging thinkers and researchers and health care professionals capable of reimagining and implementing meaningful change. How do you identify these emerging leaders?

JOSEPH BETANCOURT: That’s a great question. We have a talented group of program officers across eight programs, two special initiatives that really are focused on identifying key policy and practice issues and windows where change is needed aligned with our mission of affordable, high-quality health care for everyone. While they do that, they are scouring the nation for our nation’s leading thinkers in those spaces, individuals who are doing cutting-edge research.

But what I’m proud to say is I think the Commonwealth Fund in and of itself has evolved over the years to not just look for and connect with the usual suspects — individuals who are prominent, individuals who will publish extensively — but individuals who are up and coming, individuals who are doing cutting-edge research. Quite frankly, with that comes a diversity of lived experiences, a diversity of backgrounds, that adds to the context of our work. And fundamentally, what I like to tell people is that as we’re focused on affordable, high-quality health care for everyone, we need to make sure that we are engaging everyone in the research we do and the policy advocacy we do and the practice work that we do.

So we will be even more deliberate about that in the future. But I’d say that diversity of thinkers, of experience, of researchers, of policymakers that we’ve engaged has been increasing over the years and will continue to increase under my tenure.

JOEL BERVELL: Are there specific areas that you think need elevation at this particular moment?

JOSEPH BETANCOURT: Absolutely. I think we understand that any major health care issue has an equity component and vulnerable populations are always at greater risk when we talk about any major health care issue. So there are several that we are thinking about, we’re talking about. In no particular order, I’ll just kind of run through those. We are undoubtedly seeing a significant pendulum swing, perhaps to an extreme, as it relates to what many are calling the commercial drivers of health and health care or the financial drivers.

This notion that acknowledges, I’d say, that while we do need financial investment to make the health care system more efficient and effective, that financial investment and the return on that financial investment also needs to yield better health care quality and better outcomes for people. That alignment of financial value with value around health care cost, quality, safety is really, really critical.

I guess we’ve seen that pendulum swing such that the commercial drivers have led us to identify research that shows that, and there is, I’d say, signs of a prioritization of financial return above and beyond really yielding value for patients. So these commercial drivers, whether it be private equity’s larger role in health care, whether it be consolidation of large health care systems, we will study that. Our view is that any investment, while certainly appropriate to yield financial returns, should also be required to demonstrate improvements in health outcomes. So that is an issue I think that is on the front page of newspapers, on the minds and tongues of policymakers on the Hill.

I’d say the second, and to some degree related to that, are issues that are really pertinent to the health care workforce. So the health care workforce is no doubt coming out of the pandemic fatigued and burned out, but what I would argue is the health care workforce is also going through another very significant challenge. I’m a primary care provider, so I could speak to this very directly, the increasing demoralization, sense of moral injury, administrative burden that we’re facing.

I was heavily involved on the front lines during the pandemic. It was the worst of times, but also the best of times, because every minute you felt like you were doing something to save lives, and we come out of that to the burdens of bureaucracy. So you come off this challenging time in this incredible high, but back to this business as usual, and I’d say business even worse, that has challenged a lot of us about how well we feel we can care for our patients.

Really finding that meaning in health care and in places like primary care, this is a real crisis, a worsening crisis. The primary care workforce is thin, the primary care workforce is thinning out. People are retiring from that workforce. People are not going into primary care due to some of these challenges around administrative burden and compensation.

I’d say finally, a couple other things that we’re going to stay focused on. Certainly equity. Behavioral health is a major challenge. Climate obviously a major issue. And I don’t think anybody in health care is not discussing artificial intelligence. So, we’re trying to see what role we could play in those areas, but those are some of the pressing areas that we’re thinking about as a foundation.

JOEL BERVELL: So hopefully I’m not overstating this, but I’m alluding to something you mentioned in that answer, and that’s that primary care in this country right now is in crisis. One reason is partly because too few med students are choosing primary care, that we’re becoming more increasingly specialized, and the dwindling primary care capacity of the United States is a serious concern of places like the National Academy of Medicine, the U.S. Department of Health and Human Services, and they vowed to take action to increase and strengthen primary care.

I’m wondering if you see a roadmap. How do we shift their way of resources and attitudes to focus on well-being rather than disease treatment and this increasing specialization of health care?

JOSEPH BETANCOURT: Yeah, it’s been very predictable. I mean, I’ve been a primary care provider for over 25 years. I’ve seen the landscape change. There’s been really incredible advancements, some that are in many ways a blessing, but in some ways a curse, even the electronic health record.

How I could engage a patient now is incredible with the amount of information I have about where they’ve been, what they’ve done, their results in a moment’s time, incredible innovation, and improvements in quality. But we need to mitigate the administrative burdens, and I think primary care faces that disproportionately compared to other specialties.

The field is definitely evolving. We’re in the middle of a science revolution, a data revolution, and so there’s no doubt that the primary care of old I think will evolve. That being said, I think all research shows that primary care providers really are essential to any society’s quality of care and health outcomes. We look at this internationally, we see it very, very clearly.

The key challenge here in the U.S. is we absolutely underinvest in primary care. I think we absolutely don’t pay appropriately for primary care services, and by that I mean this fee-for-service model just really doesn’t do well by primary care providers in particular. We’re doing a lot along the lines of the recommendations of the National Academy of Medicine report on primary care to address those challenges.

So whether it be strengthening the primary care workforce, moving to value-based payment, increasing our investment in primary care. I mean, all those are things that we’re going to need to do and we’re going to need to do them soon, because as you mentioned, medical students are making decisions today about their future. And it’s going to be tough to train our way out of this in a timely enough way to really catch up.

I think advanced practice practitioners will play a role, will continue to play a role in primary care, and we’re excited about that. But we need to move with expediency because this crisis is getting worse, no doubt.

And I’d say that, as you mentioned, this isn’t just something that’s on our mind, it’s on the mind of legislators on the Hill. It’s on the mind of the National Academy of Medicine. But we need to do more, and we’re going to support that and be partners with other foundations, great foundations like Milbank, the National Academies, and anybody who’ll listen. I mean, I think it’s really critical. And as a primary care doctor, this is personal to me. As a practicing primary care doctor, this is personal to me.

JOEL BERVELL: Absolutely. I actually just finished my internal medicine rotation and exactly what you said, I mean, it is the lifeblood and the heartbeat of medicine. It’s the place where people come when an issue first affects them, and so entirely agree that there needs to be more investment there.

Another issue is insurance eligibility, and there’s a lot of complexity within that, but there’s a constant activity to solve for these problems. There were gains in coverage across most racial and ethnic groups between 2019 and 2022. But it’s not clear that, for all the effort, that we got much closer to solutions that fully closed the gap on disparities for people who’ve been chronically under covered and lack access to even primary health care resources. How do you think about this problem, and the most likely, most efficient ways to fix the coverage gap?

JOSEPH BETANCOURT: I mean, I think we should all be very proud as a nation with what the Affordable Care Act has yielded by way of improvements in coverage. We just saw upwards of 20 million people enroll in the Affordable Care Act, a real demonstration that the American population sees the value of the Affordable Care Act and also sees the importance of coverage. So that’s exciting, and I think that’s been a milestone victory.

I’d say that through the pandemic, we reached the lowest rates of uninsured, primarily due to the fact that with the emergency authorization around Medicaid, we didn’t require people to do their redetermination yearly. And so that led to extended coverage for people, which again yielded historic rates of uninsured just within the last couple of years.

So, I’d say a couple things. First, we need to continue to drive on coverage both through the Affordable Care Act and through being more thoughtful about the way we manage redeterminations. Our incredible team that does work on coverage, particularly in I’d say areas of Medicare, Medicaid, commercial insurance, the Affordable Care Act, is working on all of these things and thinking about ways in which we can make this easier and not make it so challenging for people to reenroll. I’d say that’s one.

I’d say second, we clearly also understand that an insurance card does not affordable, accessible access to care make, and so just having insurance doesn’t mean that people are able to see a provider when they need them and they could afford it. We’ve gone a long way to make care more affordable and accessible, but certainly coming out of the pandemic, we have capacity challenges around the country where even in places like Boston where I practice medicine, the wait times to see a primary care provider could be months if you could see one at all.

Some large systems have said, “We’re not taking any more primary care patients,” so we need to drive deeper. Now its coverage is critical, but it is about affordability. It is about accessibility. And again, as I mentioned earlier, these things always disproportionately impact communities of color and vulnerable populations so that they are the canary in the coal mine. They are the ones that are most impacted.

So our ability to address these issues will absolutely help, not eliminate, but close some of the disparities gaps we see. Coverage does matter, and it does help eliminate disparities. It doesn’t eliminate them completely.

JOEL BERVELL: You’ve been talking about some really complex health care issues that are occurring right now in our country. What is the work of the Fund in attempting to influence the agenda setting in health care, especially when it comes to policymaking arenas in Congress, and in places beyond as well?

JOSEPH BETANCOURT: We have a long history of real significant engagement with policymakers at the federal and even at the state level. Our teams focused on health care coverage, access, and tracking. Medicare, Medicaid really, really engage leaders in those spaces in very significant ways by determining what research is needed, trying to identify researchers, and leveraging our own subject matter expertise to answer some of those pressing questions, to provide proposed solutions in those spaces.

I would say above and beyond those spaces, we do a lot by way of delivery system reform and thinking about primary care. I’ve been heavily engaged in those discussions. I’ve been engaged in discussions, quite frankly, around private equity and health care. Even at the White House this year, around climate this year, we’ve done a lot by way of, let’s say health equity this year with significant engagements at the federal side and at the state side.

So, this builds on a long history of us building those relationships. I’m pleased to say that we are a trusted source of information. We’re nonpartisan. Our goal is to provide information that’s timely that drives towards our mission, and we’ll continue to do that, but that’s done by people in our team who are committed, dedicated, smart, strategic, and I think that’s the real benefit and strength of our team.

JOEL BERVELL: Absolutely. I am one of a few Black medical students at my medical school, was also one of the first few Black medical students. So it’s hard for me not to think about the various institutional challenges that seem to be shifting slowly and the efforts from professionals of color to accelerate expanding pathways to encourage, recruit, and train more people of color who can provide competent care.

But at the same time, there’s been legislation that’s been introduced that flies in the face of this. Most recently, a bill that was introduced about banning diversity, equity, and inclusion. I’m wondering how do we balance these competing interests of knowing that there’s needed increases in diversity to create access to health care, while at the same time realizing that there are efforts to stifle this?

JOSEPH BETANCOURT: Yeah, sadly, and I think I heard you talk about this in one of your posts, there’s a series of words that have been actively weaponized today, and certainly diversity, equity, and inclusion are among those words. I would argue that what we’ve seen over the last few years with the Supreme Court decision, what we’ve seen with the leveraging of new bills and really trying to restrict this work.

As you mentioned, I think many don’t even understand what they’re trying to undo. I think it’s a weaponization for weaponization’s sake. It’s a politicization of these topics, and I think we need to go back to first principles and really explain what we’re trying to do. Fundamentally, when we think about diversity, all we’re saying is that research definitely and unequivocally states that when you have individuals of different backgrounds, that bring different lived experiences to any situation, that improves decision-making, that improves effectiveness of teams, and health care is absolutely no different.

What I’ve always said throughout my career is when we try to assure that we have those different perspectives in a room, those different lived experiences, different people from different backgrounds in a room and serving as health care providers, it is in no way about changing or lowering standards. It is about finding excellence and promoting that excellence.

So I think when it comes to diversity, we need to think about and be strategic about what we’re framing up and what we’re trying to accomplish and do it in ways that all people could understand. Because I’ll tell you, I’ve worked in a lot of different places of different political persuasions, and I found in my career, I’ve been able to be effective in explaining things in ways that don’t fall into those traps.

When we think about equity, exactly the same thing. Who wouldn’t rally behind the idea that any patient who goes to any health care system around the country should get the highest-quality of care no matter who they are, where they’re from? I don’t have to say equity for us to mean that. People could rally behind that.

When it comes to issues like inclusion, who wouldn’t agree that people want to feel comfortable at work, that they want to feel heard, valued, respected? So that’s I think the challenge in front of us is how we stick to our values, but really try to reel this back to say, we’re not going to get caught up in this kind of woke weaponization, politicization, of what we’re trying to do. We really need to describe what we’re doing in ways that people could rally behind and could deweaponize what we’re seeing today and explain it with clarity. And I think get people to understand this in ways that right now, there’s individuals who are trying to confuse people about these things.

Again, this is not about sacrificing values or approaches, and yes, this also needs to acknowledge that when you have a Supreme Court decision like the one we had, that’s going to lead to some significant barriers. But I’m confident. California’s done it. I think others can do it. We can be creative and thoughtful about ways in which we can still bring those different learned experiences, individuals with different backgrounds, especially those who are underrepresented into the health care professions.

JOEL BERVELL: Absolutely. I resonate so much with what you’re saying, and especially thank you for saying that it’s not about lowering standards, it’s about making sure that we find excellence where it hasn’t been looked for before, because I think that’s so important.

So, I want to talk about tech a little bit, and is tech being aimed at the right targets in health care? I recently completed a rotation in colorectal surgery, and it’s really interesting seeing the innovative ways that technology is being used to better diagnose disease. For example, there’s a new blood test that looks promising that can detect DNA shed into the bloodstream from tumors. It’s a novel way to detect colorectal cancer.

But what about tech investments more broadly in health care? I’ve had one conversation on this podcast about AI solving for racial biases, which seems very promising, but we’re also seeing massive investments without major returns or better outcomes. Does tech have a real role or is there something seductive about thinking tech is going to save us when we should focus elsewhere and on other solutions?

JOSEPH BETANCOURT: I think that there’s no doubt that the science revolution, the tech revolution, genomics, genetic medicine, all this, number one, it’s moving faster than ever. Number two, it absolutely will be promising for the health and well-being of humanity. I believe that.

I think a big challenge will be affordability around all these things, because that’s the one big challenge that we’re facing as we develop these things. I’ll give you one example where tech is phenomenal right now, particularly for people of color, is the new modalities in CRISPR that actually are being used right now to cure sickle cell disease.

I mean, this is unbelievable and an incredible innovation and an example of ways in which tech could be deployed to address a condition that has just decimated individuals of African descent, quite frankly and disproportionately. And so I think there is an example of the promise.

Here’s the challenge. In my career we’ve always seen, and I think across history, we’ve always seen, recent history, that when we have therapeutic digital and other innovations, there’s always a five-to-seven-year lag to them arriving to vulnerable communities and communities of color. I think that lag costs lives, costs money, and I think that’s a real challenge.

I’ve always said that a lot of these virtual and some of these other things that we’re seeing now for years, I’ve said those could actually be best leveraged in communities that are vulnerable and that are most at risk. You could get your largest return on investment by way of health and health outcomes by engaging those communities.

So the key challenge for us going forward is yes, I believe tech will improve the health and well-being of people generally. Yes, I believe we need to be deliberate in thinking about affordability, democratization, and scale. And yes, absolutely, we need to be very, very deliberate around engaging vulnerable communities and communities of color early and making them part of the wins and part of the successes while we guard against, as you’ve mentioned, things like bias and AI.

I mean, I think there’ve been great conversations around AI. I think in the equity space, they’ve been a lot on the defensive side, how do we protect against? You mentioned yourself just now, there are incredible potentials on the positive side for how we could leverage and utilize AI.

So I think that’s the key mix that gets us to a right place. But tech is here. It’s not going away. It’s evolving. I’ve called out a couple of things that are part of that portfolio. And yes, we who care about equity need to be involved in the distribution, development, and scale and democratization of all of them.

JOEL BERVELL: It’s a very exciting to be in medicine. A lot’s changing. Thank you so much, Dr. Betancourt, for being at the forefront of the field, leading us in the right direction and making changes, especially for those that have been most marginalized throughout history. Thank you so much for joining me on The Dose and for your wisdom.

JOSEPH BETANCOURT: Thanks so much. I really, really enjoyed the conversation. Continue doing your great work and we’ll look forward to conversations in the future.

JOEL BERVELL: This episode of The Dose was produced by Jody Becker, Mickey Kapper, and Bethanne Fox. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit TheDose.show. There, you’ll be able to learn more about today’s episode and explore other resources. That’s it for The Dose. I’m Joel Bervell, and thank you for listening.