Achieving equality: healthcare governance in transition.

INTRODUCTION Healthcare is not immune to the deeply rooted inequalities in American society. To this day, racial and ethnic differences exist in the quality and outcomes of healthcare that cannot be attributed to socioeconomic or other healthcare access factors. Lawyers committed to social justice have long dedicated energy and attention to these continued disparities. As a lawyer litigating against segregation in healthcare facilities noted in 1966, "The treatment accorded Negroes by Southern medical facilities. .. reflects a striking contradiction between law and practice."' Past efforts to achieve equality in healthcare through civil rights litigation, education and local organizing have been effective to a degree, but have lost their influence in the current healthcare environment. In a renewed effort to achieve racial and ethnic equality in healthcare, some advocates are turning to quality as an indirect route to attaining this goal. The quality approach requires changing the traditional healthcare framework by incorporating new methods for achieving quality into every level of the system, including the patient level, the clinical level, the healthcare organization level and the governance level. 2 Drastically changing the framework of the healthcare system is not easy. There are barriers in the traditional framework that work against. appreciation to Jeanne Cavanaugh for her research and editing. The authors would also like to thank the many people interviewed in connection with this Article. Special thanks to our friend and colleague Eva Cohen. innovation. To overcome these barriers, some organizations have implemented programs that realign relationships among the levels of government, increase use of networks and link public agencies and private organizations. Two exemplary projects that have succeeded in overcoming the barriers to change are the Health Disparities Collaboratives and quality-based programs instituted within certain physician-led managed care systems. Their stories demonstrate a "fit" between the provision of high quality equitable care and the creation of a revised governance framework that allows these new quality approaches to take hold. This Article begins with a discussion of traditional approaches to eliminating racial disparities in healthcare and lays out their limitations. It then describes two exemplary projects within healthcare institutions that are reducing racial and ethnic disparities by using a disease management approach. The Article proposes how these exemplary projects can be viewed as a model for embedding quality into the healthcare system. Finally, the Article lays out a timely opportunity for actors in the healthcare system to buy into the quality-based …