Executive summary
This is Part 4 in a series investigating health and racial equity in the reorganization of South Carolina’s health care.
Around 2010, a loose community of stakeholders committed to health care reform began gathering, eventually under the name South Carolina Health Coordinating Council (SCHCC). The SCHCC was nurtured by the South Carolina Hospital Association (SCHA). In 2014, the name was changed from SCHCC to the Alliance for a Healthier South Carolina (AHSC). AHSC became the vehicle for health reform based the SCHA’s preferred model, Triple Aim, a process to improve health care by cutting cost and streamlining care. Triple Aim was created by the Institute for Health Improvement (IHI) and involves social determinants of health (SDoH) and addressing health disparities across all economic and social services sectors. Triple Aim became prominent nationally because of its central role in the 2010 Affordable Care Act (ACA), aka “Obamacare.”
In 2016, Triple Aim was infused with social justice, coinciding with a IHI white paper published that year about rooting out institutional racism from health care and elsewhere. An AHSC senior member who was also a SCHA employee, served on an IHI leadership committee that issued a circa 2017 joint declaration declaring health equity a matter of “social justice.” The declaration referenced the 2016 IHI “institutional racism” white paper and also pointed to an AHSC call to action, the document which laid out the group’s purpose. The IHI committee declaration also cited the health equity positions of the World Health Organization (WHO), the United Nations (UN), and the Robert Woods Johnson Foundation (RWJF). All of these play a role in the health care system being implemented today through the South Carolina Department of Public Health (SC DPH).
SC DPH and AHSC are partners in health equity
The focus is on AHSC because it plays a lead role in setting South Carolina’s health equity agenda and our health care policies, an agenda that calls for expansion of government influence in every area of life, as explained in Part 1 of this article series. And because its proposed policies are obsessed with race, racial justice and the belief that America and South Carolina’s institutions are systemically racist, as revealed in Part 3. SC DPH considers AHSC a key partner in our state’s health care and is a “platinum” member of AHSC with a seat on the Board of Directors. But now it is reasonable to believe that our health care system, constructed on health equity and racial equity, as influenced and presented by AHSC, was channeled through the SCHA but with input from many stakeholders and funders of both groups. This report traces its development.
National events at the time of AHSC’s formation
It took shape in the era of Obamacare. South Carolina’s health care transformation to health equity and racial equity began during a time when some of the biggest names behind progressive health models started funding health care transformation nationwide, pushing states toward a version of the 2010 Affordable Care Act (ACA) model. One physician called the ACA “another step toward corporate socialized medicine” in the U.S. Another doctor agreed but went further, calling it “a transitional step to a full government takeover of medicine,” pointing to Obama’s stated preference for a “single-payer, universal health care plan.”
According to a 2020 “State of Health Care in South Carolina” article, South Carolina’s last decade of health care “has been one of mergers and expansions, job growth, expanding coverage under Obamacare….” The article cites the observation of a representative of the Bon Secours St. Francis Health System, an AHSC member, paraphrasing “… implementation and partial repeal of the Affordable Care Act, also known as Obamacare, have been the most important health care changes in the last decade.” It quotes the Bon Secours St. Francis Health System official:
Really, that ushered in a new era of the transition from fee-for-service to a value-based reimbursement model …it has changed health care systems’ approaches to strategic business growth and development.
To many, the gradual path toward South Carolina’s state health care plan may resemble the incremental process to Obamacare. Citizens should be concerned that South Carolina may end up with a system that takes us closer to universal health care. Today, as a result of the ACA, citizens are stuck with insurance premiums that often exceed mortgage payments. One of the incremental routes could be by expanding Medicaid coverage, possibly via something like this South Carolina initiative funded by an Obamacare grant through the South Carolina Healthy Connections Medicaid program. Initiatives begun with philanthropic or federal funds may, at the end of the grant period, be put before a state’s legislature for permanent funding. In this way, state responsibility for health care initiatives expands incrementally.
The Robert Wood Johnson Foundation (RWJF)
The Robert Wood Johnson Foundation (RWJF) is one of the philanthropies that has “worked to advance Obamacare and other left-of-center health system changes” nationwide, according to InfluenceWatch. Reportedly, it was in 2008 that RWJF began to focus on SDoH in health equity as a social justice issue and by May 2023 had spent nearly $1.9 billion on grants. As it happens, 2008 was also the year the World Health Organization’s (WHO) Commission on Social Determinants of Health released an often-cited report framing SDoH as useful for making social justice gains via health equity policies. In South Carolina, RWJF bankrolls progressive initiatives across sectors, including in health care, health education, and research. It funds South Carolina universities and medical services groups, particularly concerning research into SDoH and its adoption as a policy approach.
AHSC co-founding member, AnMed Health, opens its 2020-2021 “Annual Diversity and Health Equity Report” quoting RWJF regarding its broad SDoH vision behind health equity:
Health Equity: Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.
Robert Wood Johnson Foundation, 2017
The following lays out the documents that track the early development of AHSC, including the influences behind the policies that are being advanced today.
The South Carolina Hospital Association (SCHA) birthed AHSC
Although an independent 501c3 non-profit since 2023, since its inception, AHSC was established by the South Carolina Hospital Association (SCHA). On a 2024 Membership outreach page, AHSC Chair Marisette Hasan (a DEI consultant) expressed gratitude for “the leadership and support of the SC Hospital Association as our backbone organization from our inception until May 2023” when AHSC became independent. Before it was a nonprofit, AHSC Executive Director Robertson, identified himself on his LinkedIn profile as a SCHA employee, overseeing AHSC in different capacities from February 2018 and up to its nonprofit status, after which he continued as Executive Director. While at SCHA, among Robertson’s accomplishments through AHSC was taking the lead on “state-wide Hospital DEI” training and “[g]uid[ing] hospitals, state and community leaders in the areas of community health improvement and diversity, equity, and inclusion.” Health equity and racial equity require a system of DEI officers to develop and supervise a carefully crafted social justice programming regimen.
SCHA’s role in AHSC’s approach to health equity
A December 2013 Post and Courier article described SCHCC in terms suggesting it was a loosely organized “volunteer council” that, at that time, had been holding meetings “every few months for more than two years.” It quoted Ana Gallego, “the council’s only staff member.” Gallego now works for RWJF, but her LinkedIn profile shows that, from November 2013 to July 2016, she was with SCHA as “Program Director, Alliance for a Healthier South Carolina” (although back then it was known as SCHCC). Before that, according to her profile, she was SCHA’s “Triple Aim Improvement Coordinator.” The 2013 article also named then SCHCC Chair Graham Adams, CEO of the South Carolina Office of Rural Health and Tony Keck, director of the South Carolina Department of Health and Human Services.
In October 2014 Gallego, under the title of Program Director, SCHCC, authored an article welcoming the South Carolina Nurses Association into SCHCC. The article, which is on page 10, indicated that “the goals of the SCHCC were developed using the Triple Aim Framework.” These include lower cost, better service, and “better health outcomes for the population, and better distribution of such outcomes within the population.” It also called for increased “cultural competence” among health care leaders, advocating diversity, and addressing “the determinants of health.”
An archived SCHA document gave some details of its early involvement with AHSC (then SCHCC). The relationship followed from a 2009 SCHA initiative called “Reengineering,” “which focused its work on the Triple Aim” in pursuit of South Carolina’s health care transformation. According to the document, SCHA found that, because Triple Aim involved multi-sector SDoH, SCHA would need the engagement of non-health sector actors for their efforts to succeed. “Many organizational partners” joined with SCHA and sent representatives to form a board which became SCHCC, eventually AHSC, through a partnership formalized in 2014.
Catalyst for Health
Additional organizations “asked SCHA to provide technical assistance for the development and coordination of their population health programs” so it established “Catalyst for Health” (Catalyst) which uses Triple Aim and was described as “a dedicated macro-integrator to guide and support collective impact-based cross-sector population health improvement initiatives.” The Catalyst team was composed of “Executive Director Rick Foster, MD,” and “Program Director Ana Isabel Gallego, MPH.”
Foster had, in 2012, assumed the position of Senior Advisor for Population and Community Health Improvement at SCHA. From that time forward, he was “actively engaged in leading the development of the Alliance [AHSC] as a statewide health improvement coalition.” That accounts for an archived 2016 document listing AHSC “staff” that included Foster as Chair of the Operations Team and Gallego as Program Director, with the SCHA Catalyst for Health logo nearby.
A 2018 DHEC press release announcing the launch of Live Healthy South Carolina “a comprehensive plan to improve population health,” quoted Rick Foster in his capacity as AHSC Executive Director.
The Triple Aim
Triple Aim is an approach to healthcare management leading to better health outcomes with reduced per capita costs. It was developed by the Institute for Healthcare Improvement (IHI) and became a key part of the Affordable Care Act (ACA) (Obamacare) health care model.
Perhaps Triple Aim began as a logical and thoughtful approach to reducing both costs and medical interventions. It was well received and become a standard for the health care sector. But it became entwined with social justice which some trace to publication of a 2016 IHI white paper outlining a framework to “decrease institutional racism within the organization” and “[m]ake health equity a strategic priority” to reduce health disparities “historically linked to discrimination or exclusion.” One of the co-authors, in a short YouTube clip, called it a “reset” for the Triple Aim. According to the white paper:
The framework stresses the importance of making health equity a strategic priority at every level of an organization, especially at the top. The framework emphasizes a systems view of how we’ve arrived at health inequities, and how they can be mitigated. And it urges us to work both within our walls, dismantling the institutional racism and implicit biases that hold us back; and beyond our walls, creating and nurturing new partnerships in our communities that can make an impact on all the social determinants of health. (emphasis added)
2017 Rick Foster: SCHA employee, AHSC leader, and IHI “Leadership Alliance” member
An undated IHI archived document, likely issued in 2017, lists “Rick Foster, South Carolina Hospital Association” and “Ann Lewis, CareSouth Carolina, Inc.” on the IHI Leadership Alliance, Achieving Health Equity steering committee in fall 2017. The document is a “Call to Action for no tolerance of the social inequities that lead to health disparities” (Call to Action). It included a reference to the IHI 2016 “institutional racism” white paper and points to AHSC’s call to action, along with a handful of initiatives from other groups across the U.S.
The Call to Action statement described health equity as “[f]irst and foremost [a] moral case, which is one of social justice.[v].” In addition to the IHI white paper, it cited a critical race theory-infused Camara Phyllis Jones article on institutional racism, quoting from it, including “[t]here is ample evidence that poverty, unconscious bias, institutional racism, and other forms of discrimination (defined as differential access to goods, services and opportunities of society by race, gender, disabilities, and age)[x], all affect the social and physical environments in which we live. [xi]”. The IHI Call to Action claimed that “everyone has the right to well-being, health, and healthcare” citing positions held by WHO, UN, and Robert Wood Johnson Foundation. The Call to Action reminded readers that “the UN General Assembly’s determination that International Covenant on Economic, Social and Cultural Rights recognition that ‘underlying determinants of health’ include safe drinking water, safe food, adequate nutrition, adequate sanitation, adequate housing, healthy working and environmental conditions, health-related education, and gender equality.[iii]” In this context it again pointed to RWJF and its definition of health equity that “requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and the lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.’[iv]”The statement declared the need for the political will and stakeholder prioritization of “fundamentally addressing and removing the barriers that create health disparities” as necessary in order to “realize the full potential of the IHI Triple Aim.”
A 2019 article on the SCHA website congratulated Foster on receiving the James E. Clyburn Health Care Leader in Public Health Award for his commitment to improving health disparities among “vulnerable populations.” The article noted that Foster was said to be “presently leading a collaborative effort to build a Health and Racial Equity Action Plan for our state.” Presumably, a reference to AHSC’s “Action Plan 2019-2024: Collaborative Strategies for Advancing Health & Racial Equity in South Carolina.” (“Action Plan”) (Archived here) and the subject of Part 3 of this series.
After 13 years with SCHA, Foster left around 2020 and utilized his medical expertise in health equity and racial equity in a position with DHEC (now SC DPH) as a Medical Consultant for Population Health and Community Health Equity. There, his “primary responsibilities” were to lead the South Carolina Pandemic Ethics Advisory Council which, during COVID, which released recommendations on the ethical distribution of medical resources, presumably according to health equity and racial equity considerations. A Furman University page claimed the task force was setting criteria for potentially scarce medical care allocation during emergencies, referencing a Furman philosophy professor and advisory council member. According to an undated web page for the Council, its goal was “[t]o develop recommendations for state institutions regarding the distribution of scarce resources (such as ventilators and medications) during the Covid-19 pandemic,” especially after ethical concerns raised following Hurricane Katrina. An article by The Greenville News regarding “how they’ll decide who gets a bed” (archived here) confirms this and gives some additional information about planning for scarce resource allocation during emergencies.
Credit was given to Foster’s direction of AHSC for “implementing the first-ever SC state health improvement plan under the name Live Healthy SC” in partnership with DHEC (now SC DPH). He was an SCHA employee at the time, leading AHSC. However, Robinson, the current AHSC Executive Director also claims to have “[d]irected the development and implementation of South Carolina’s first state health improvement plan on his LinkedIn.
So significant were Foster’s contributions that, as part of the annual “Live Healthy SC Award Winners,” AHSC presents “The Dr. Rick Foster Leadership Award” to a “champion for health and health equity at a local, regional, or state level.”
The documents have shown the development of AHSC into a vehicle for the SCHA’s health transformation model. The trail leads to the SC DPH. The evidence shows that the model is steeped in social justice and racial equity, one that will take the state toward a socialized health care model and expansion of government. It’s a plan backed by dozens of powerful and well-funded interests. Part 5 will examine “AHSC’s call to action,” the document referenced in Foster’s co-authored declaration from the IHI Leadership Alliance, Achieving Health Equity steering committee. The AHSC’s “call to action” from circa 2015 describes the original outline for South Carolina’s health equity roadmap.
For previous reporting in this series: Part 1, Part 2, Part 3.
The post The Origin of SC’s Racial Equity Health Care Roadmap appeared first on Palmetto State Watch Foundation.