For the past 40 years, Washington, D.C.-based Grantmakers In Health has been dedicated to helping foundations and funders of all sizes and interests through education, leadership and networking, working with hundreds of philanthropic organizations across the United States. Dr. Cara V. James, president and CEO at GIH, shares how and why her career has focused on minority health and improving health outcomes for vulnerable populations. She also talks about GIH’s strategic plan focused on health equity, social justice, access and quality, community engagement and empowerment, population health and philanthropic growth and impact.
For the past 40 years, Washington, D.C.-based Grantmakers In Health has been dedicated to helping foundations and funders of all sizes and interests through education, leadership and networking, working with hundreds of philanthropic organizations across the United States.
Dr. Cara V. James, president and CEO at GIH, shares how and why her career has focused on minority health and improving health outcomes for vulnerable populations. She also talks about GIH’s strategic plan focused on health equity, social justice, access and quality, community engagement and empowerment, population health and philanthropic growth and impact.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Dr. Cara V. James
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Steven Jackson and Kari Haley:
And this is Off the Charts.
Steven Jackson:
Well, welcome to our show. We are very excited to have Dr. Cara V. James with us. She is the president and CEO of Grantmakers in Health. Welcome, Dr. James.
Cara V. James:
Thank you for having me. It's a pleasure to be here.
Steven Jackson:
We're very appreciative of your time on this podcast. We try to play our role in advancing health equity and educating and inspiring and giving information about something as important as moving the needle when it comes to the space of health equity. So thank you for what you do. So tell us a little bit about yourself and how you got into the realm of health equity and changing the many lives that you've changed so far.
Cara V. James:
That is quite an interesting question, one I have been asked a bit and thought about, and it's hard to say in some respects because my career has always been focused in minority health or improving health outcomes for vulnerable populations going back way, way, way back. This is actually the first job professionally that I've had since college that doesn't have minority health or health equity in the title. But it is really just core to my being. And I think that part of that goes back to just a realization that so many communities and so many people struggle in our communities and in our country. And there are ways in which we can help them. So it's not easy work and as I say, every day it's an uphill battle and sometimes you get a picture of how steep the gradient is, but it really is just core to who I am to help try and improve outcomes for those, particularly those who are released among us and often ignored or underserved.
Kari Haley:
Well, thank you for your great introduction. I think just for our listeners, too, and for our own knowledge, we work in a space clinically, so we're seeing patients, we're both physicians, but you are more focused in the public health space and that's where you've done a lot of your career. So would you be able to explain a little bit more about what is public health for our listeners and what does that mean in terms of health equity?
Cara V. James:
Yeah, so that's a great question, public health and health policy. And I would say I straddled health policy and public health. So I am a health policy researcher by training and have spent my focus in medical sociology and then going into the federal government and working at a foundation. Public health is that intersection of our health system and our communities. Public health has essential functions, but making sure that we're helping to improve the conditions in people's lives to be able to be healthy. That means things like water, it means things like the vaccines and public health education campaigns. It means workforce and getting into the community health workers in so many different aspects of it. It's a challenge because public health is not something that really gets explained well in a 30-second sound bite, which is part of the confusion of our understanding of what it is.
But it is really important and one of the things that we say is when public health works well, we don't see it. It's only when there's something that goes wrong such as the Flint water crisis or an outbreak of HIV in a community or outbreak of the measles or polio in our communities that people really start to see public health. I think we are all much more aware of it as a result of the pandemic and the challenges that we have of a fragmented system that we have federal, state and local areas. But it means that there's a lot of difference in variability. Public health relationship to health equity is critical because when we think about that, those resources, we have communities that don't have some as much public health resources. We think about some of our tribal communities, our rural and frontier communities, as well as some of the cultural services that we look for. And making sure things may be interpreted in other languages or materials may be translated into other languages that we're serving our individuals that have disabilities and making sure that they have access and resources as well.
Those are things that are just how we make sure that our system functions for different people based on the myriad diverse factors that we have is really important and part of the way in which public health ties to it. And also health policy ties to equity because we have policies that get developed, that have different impacts on different communities and on different population groups. So when we think about payment models or things like that, value-based care, it really does impact equity when we think about our provider availability and the workforce that we have, the incentives that they have to treat different patients can contribute to some of the inequities that we see. And I would lastly say, which we also realized with the pandemic from a public health and a health policy perspective, the data, our inability in some cases to have data that allow us to drill down to understand what's happening across different population groups is also one of the ways in which we can magnify some of the inequities that we have by having populations be invisible for some things so we don't see how it's impacting them differently.
Steven Jackson:
Cara, you're obviously very passionate and very effective in what you do and how you do it. And I'm curious because I want to know more about Grantmakers and the crux of the day to day operations and the late nights and long days. I want to hear about that. But I'm curious because I know Dr. Haley and I, we're passionate probably for similar reasons but also probably some different reasons, and maybe that's a result of just lived experience and just having been impacted by whether it's racism or disparities or something that really drives us personally not only to do this podcast, but again stand on the front line in terms of moving the needle as we say. Were there any ahas in your life personally that said, I need to go this route? Because you could have gone on to be a medical doctor or president of the United States, which isn't out of the question, but at the same time you're deeply involved in health equity and I was just wondering was there anything personal? Do you have a personal investment in what you're doing?
Cara V. James:
Yeah, I think, I will say as one of those introverts, we don't always love talking about ourselves in this way, but when I think about my personal journey, you've mentioned med school, so many people who ended up in health policy were on their way to med school and a funny thing happened on the way to the forum. And for me, I was one of those that was pre-med and thinking about that and I took a year and did spinal cord injury research at Georgetown Medical School. And in that lab that I worked in, there was a friend of mine who was doing his neurosurgery residency at Georgetown and he would talk about some of the patients that he saw where he said, if this had happened, if the insurance company had done this, we probably wouldn't be seeing this patient. And it got me thinking about change on a broader level and not necessarily knowing what that was. So, that's partially how I ended up in health policy.
I think in terms of the health equity space, my story is, I've been fortunate but I've also been able to see those around me. I think about one of the people who's been very impactful for me was my maternal grandmother. She lived with us from the time I was six until I went to college. And we unfortunately lost her a couple of years ago. But she was someone who grew up in rural Georgia, never was able to finish high school because of the family needs and things. And I saw how she was treated each time she went into the hospital and I thought about those experiences and the difference that her treatment was, the experience she would have if we were standing there in a suit or standing there with her and talking to the providers and she was sharp as a tack, funny as all outdoors and frequently disrespected in the care that she received and treated as though she was not quite cognizant of some of what was going on. And she could tell you better than I could what was happening in the news for that day.
And so I think about how many other people don't have an advocate or a family member who's there with them and what their experiences are like and want to make sure that that doesn't happen, that we can do better. And thinking about how we make sure that everyone has that fair and just opportunity to be as healthy as possible.
Steven Jackson:
Yeah, excellent. I appreciate you sharing that because that's very meaningful because I feel like there is a personal touch that you would put into the work that you do and those that you impact, they're not just other people, they're not just numbers or cases, but these are people that also again have the right to be healthy and the right to have appropriate access to that health. So thanks for sharing that. Tell us a little bit about Grantmakers in Health.
Kari Haley:
Yeah. Tell us more about the organization.
Cara V. James:
Yeah. So, Grantmakers in Health, we are celebrating our 40th anniversary this year. We are what's called a philanthropy support organization. So we are an educational organization that works with foundations and corporate giving programs across the country to help them as we say, learn, connect, and grow. So learn about important issues related to health or policy or public health, connect with peers who are implementing programs that they could learn from as well as just share ideas and bounce things off of and grow in their philanthropic practice. And we think about their moving more towards trust-based philanthropy and building those partnerships with community, working with them to bring them in at the beginning to hear what their priorities are, help in the co-creation of solutions and implementation of those.
And we do that across a variety of areas and we have with our new strategic plan, five focus areas that include health equity and social justice, access and quality, community engagement and empowerment, population health and philanthropic growth and impact. And across those five areas we view those as the building blocks that you need to achieve our vision of better health for all through better philanthropy. So it doesn't matter if you're focused on oral health, maternal health, access or integrative health or behavioral health. Thinking about who are the populations that are disproportionately affected by this, what does the access and quality look like? Where are those health equity and social justice challenges, and how are you engaging the community and solutions as well as the work that you are doing as a philanthropic entity will help us to improve those outcomes across those areas?
So, we work with more than 200 foundations and corporate giving programs across the country from really large ones that you know to really small ones that you may not have heard of who focus just in a particularly local area. So that's a little bit about us and we do that through education, webinars, issue briefs, surveys, things like that, as well as convenings where we're bringing not only the funders together but other policy makers and others in community and other sectors to help work on these issues because no one sector can solve the challenges that we as a country face alone.
Kari Haley:
And I heard you say the word that we often say on our podcast as well, trust. So can you talk a little bit about some of the strategies that you've used? Because it sounds like you work with a broad spectrum of people and organizations within Grantmakers. What kind of strategies do you deploy for building that trust amongst these different groups?
Cara V. James:
Yeah, so trust is so, so very important and particularly when we're thinking about community, because in some cases trust has not been there because we have done things to communities that have really eroded the trust. So part of that, when we think about building trust in communities, it is making sure that the table, if you will, includes them, and includes them in a way that empowers them to share and tell their stories and to listen to them. I think we often hear from communities that they feel like we as funders, researchers, whatever, we come in, we do stuff, we leave. So how do you make that commitment to community to be there to work with them so that they don't feel like they're just being used? When we think about, in some cases, philanthropy, and we've seen some foundations who've done investigations into their own history and how they came to be and are dealing with some cases racial reckoning.
So we've seen in terms of foundations such as Milbank who've investigated the work and their relationship and the role that they had in the Tuskegee syphilis study, and are working with the descendants of those family members to do some healing and to acknowledge that past and try to move forward in a positive manner. So philanthropy is not perfect and has work to do, but part of that is acknowledging and moving forward in a way that shows a long term commitment, collaboration and partnership and support for the things that communities are focused on.
Steven Jackson:
Well, it goes without saying when there is a lack of trust, then even with the best intentions you can either make it worse or at best not make it any better. And so I think first of all, thank you for telling us about your experience with trust and talking about the importance because like Dr. Haley said, we talk a lot about trust on this podcast, and again, as well intended as we generally are, particularly as physicians, sometimes we're taken as what are you going to do to me? Not about what are you going to do for me or with me? And we often talk about how that need to build trust is there, and we can't afford to ignore that even though we might be, should I put in quotes, "competent or have a lot of letters behind our names," it doesn't equate to just this default trust setting that we all have. You have to build that which is very important.
I'm wondering, have you had any challenges with what you do? Because I know whether in a large organization or just even in society in general when things are quiet, if there aren't any, at least we don't know of any active George Floyd situations right now. Some people say, well why are we talking about health equity right now, especially at the workplace, or some may say, why are we still having these conversations about equity and inclusion and diversity? So I'm just curious, have you run into any challenges or any barriers to what you do as you smile at my questions?
Cara V. James:
I was going to say, I was like this is... Yes. So I have been doing minority health equity, as I like to say, long before it was cool. And it has always been an uphill battle. The work of health equity has never been well-staffed or well resourced. So in that, the expression of doing a lot with a little, that is what so many in the field of health equity have been doing. The pandemic has brought forth great opportunities. And I think also, if I'm honest, challenges. And to back up, I would say I spent eight years working in the federal government from 2012 to 2020 as the director of an office of minority health at the Centers for Medicare and Medicaid Services. That was an office that did not exist before the Affordable Care Act. And as I was working across those eight years, there's change in administration and there was one that I would think most people would probably say was more supportive of efforts to advance health equity and another that, that was not a priority as much for them.
So there were headwinds, but we were still able to get work done. One of the challenges that we have seen as a result of the pandemic, there has been an influx of organizations, people into the field of health equity and not all of them have approached with what I would consider a little cultural humility for those who've been in the space and done the work. And so there's some confusion as people are coming in and saying we need to define health equity when that has been defined, and that's established definitions, the CDC, the World Health Organization, the Robert Wood Johnson Foundation have had definitions of health equity for a very long time.
Steven Jackson:
Long time.
Cara V. James:
So we're reinventing the wheel in some cases, but also we're all in that way having different wheels. And that's creating some of the challenges that we have of a consistent message around what health equity is and what it takes to achieve that. We most definitely are seeing people who are tired of talking about it. I've had some conversations with some leaders who are seeing the work that they started in 2020 being pulled back as their organizations are pivoting a little bit. So that's a challenge as well. And I think that some of the structural inequities that we saw in terms of funding and resources for research programming and so forth that were in existence before the pandemic have persisted during the pandemic. So as one of my tribal colleagues would say, people are calling them to pick their brain, but they call it mining and exploiting, because they're getting their ideas, but they've got the connections to the resources. So those entities are the ones getting funded for the work. And again, that humility of who's been in this space is sometimes ignored.
So I think we have an opportunity to come together. We don't have a consistent roadmap, I think is the other thing, of what it takes for us to really achieve. But I think we also have a window of opportunity that is cracking a little. So we need to figure out both how to prop that window up so that we can continue the work because this is not work that's going to be fixed in, as I say, a 30-, 60-, 90-day plan, or even a one-year or two-year. So we need to commit to the long term and make sure that we have the resources to truly have the impact that we're looking to have and to make that difference, then they're challenges. It's easy.
Kari Haley:
I really appreciate those comments because I think that as we are, as Dr. Jackson was saying, pivoting away or there's nothing big in the headlines necessarily right now, I think it's really easy to turn our attention away to the next thing or the next headline. What are some of the ways, you alluded to it, what are some of the things that you've done personally or that your organization has done to really try to draw back in the attention, or what can other people do to try to hold on to that attention prop, that window up as you said?
Cara V. James:
Yeah, so I think we're seeing a couple of things and I'll talk a little bit about what we're doing and also what I have done when attention has pivoted. And part of what I have done when attention has pivoted is figure out what are the priorities that people are focused on, and the good or bad thing about health equity is they're challenges everywhere. So it almost doesn't matter what the priority is, you can find inequities in those priorities. And how do you continue moving the work when you're in some of those other priorities. The other thing that I think about and we talk about with regards to helping to prop that window up, we need to do a little bit more narrative change work. And there are a number of organizations that are working on that narrative change so that when I think about an effective narrative of changing the conversation about the uninsured as a perception of people who are undeserving or not working and lazy to the uninsured three quarters of whom have somebody working in their household full time, that is a different way that we start to view people.
And when we do that, we start to see the human nature of them and some of the challenges and feel a little bit differently about that, which helps to advance the work that we're doing. And there are examples of that in other spaces as well, but changing that narrative around health equity and around the populations and the challenges that they're facing and helping people to see how our systems are contributing to them in a way. And I think the last thing is that it's important for us to help people see this isn't a zero-sum game. So, that my and my community's benefits don't come at the expense of yours, but that we all benefit when we are having healthy societies-.
Steven Jackson:
That's right.
Cara V. James:
... communities. It helps all of us. And the inequities hurt all of us. It's part of the reason we have such a high cost health system. It's part of the reasons when you look at the fact that we as the U.S. spend more than any other country and health care and our life expectancy is 72nd. That's not a good investment. And that clearly is not benefiting us as a society. So we can do more.
Steven Jackson:
Wow. We have a lot of work to do for sure. And we were hoping that you would fix it by the end of this episode.
Kari Haley:
Twenty-five minutes.
Steven Jackson:
But we're closer, I think we're closer after speaking with Dr. James here. When I think about health equity and even just want to explore this a little bit, when I think about diversity, equity, and inclusion from my vantage point, those are essential principles to know and understand. And from my standpoint, I don't look at them as things or fads or trends. And I think sometimes when, let's just, for lack of better words, we've said it before, when things get quieter then people shift gears or they pivot so to speak, because it's not as popular. We had a lot of big organizations, I won't name any of them, but popular organizations, maybe household items or electronics that we might own. Well, we stand with such and such or dot, dot, dot. There were these big blanketed statements and then it got quiet all of a sudden.
And I would hate to believe that it was just a personal business decision to do that because it's advantageous to the business. Why am I saying all that? I'm saying that because going back to what you said about the changing the narrative, the work that needs to happen there, I still feel like the reason we have diversity, equity, and inclusion departments is because of the state that we're in. In a perfect world, we shouldn't have to have a separate department. It should be embedded in who we are and what we do. And I'm going to offer a solution. I don't know if it's a great one and it's not novel, I didn't create it, but I know that I've been to philanthropic events in the past over the course of many years. And it wasn't until I heard a personal story that it really tugged in my heart personally.
And I say that because, and you brought it up, Cara, is that people don't always understand how the systems or the work at the system level affects individuals. And so if you were to have someone to say, well I had to choose between paying for medicine and paying for food, I chose food. If you heard that story enough times, then people won't look at health equity, I hope they wouldn't look at health equity as a thing or an annoyance that we are still talking about, but wow, my understanding and my getting educated is actually going to impact a few people. And so I just think that's something that just hit me because the power of storytelling goes a long way I think in this space. And so just something to consider. So I'm done. I'm going to go ahead and drop the mic now.
Cara V. James:
No, the power of storytelling is so important and everybody will tell you that story backed up with the data is what drives the change. You can't just have the data and you can't just have the story.
Steven Jackson:
That's right.
Cara V. James:
And when I think about, you mentioned the diversity, equity and inclusion and the departments, one of the things that we have seen is, again, a proliferation of those departments. And one of the things that I wrote about related to this early in the pandemic in July 2020 was how are they set up? Are those departments set up to succeed? Are they set up as a separate department? Does that individual have the resources and the supports that they need to be able to make change? And I think when we talk about diversity, equity, and inclusion and health equity, the diversity, equity and inclusion is really, I think about the internal environment that you're creating.
So in your organization, do you have a diverse staff, diverse representation? Do you have diverse opinions that are being offered? Equity, do you have equitable practices and policies or are those policies favoring one group over another unintentionally in some cases? And that inclusion of does everyone feel like they are valued and included in the environment that you're in? When I think about the health equity from a health systems perspective, that's who you're treating and what's happening there. What are you seeing in that and how are you engaging with them? And again, as we have these conversations, you are absolutely right. It should be standard operating procedure. It should not be special work done by that office for those people over there, but just the way we do business.
And in my ideal world, it may be my pie in the sky, but when we sit down in 20 years and I have just as much gray hair, because no more, I'm not aging or anything. I'll be out of a job because we will have actually, in a generation, really moved to make this standard operating procedure because that's really what we're talking about and what it takes. And those stories of I had to choose between food and medicine, or I had to choose between feeding my kids or feeding myself, that's not something we would have happening in this country and ideally in the world, but in this country in particular when we have so many resources and opportunities. So, that is my hope. But I think that helping people through these conversations, bringing people together, having more synergies around this and showing that much of what we have are shared experiences rather than othering experiences.
We all want our family members to be healthy and thrive in ourselves. We all want our kids to grow and to have opportunities to thrive and to be in safe environments. We all want to be respected when we go to seek health care. And that, that health care is there and of high quality for us and our families. And I think that those are problems that you can't fix in this silo, but we all have to work together. And our workforce, particularly our health workforce, is one of those areas we really need to spend a lot more time on when we talk about how many stories we've seen on burn out of the providers leaving, our long term care workforce and our home health workforce who aren't making a living wage and are qualifying for food stamps, that is a problem.
And when we talk about essential workers, childcare teachers, health providers, EMTs, police, firefighters, if we don't have those people, we don't have a functioning society because none of us can go to work. We're going to be caring for our family members, caring for our kids. We won't be able to make all of that money that we're looking to make. So we have to do better.
Kari Haley:
Well, I really appreciate you taking your time to talk with us and our podcast here. I feel like I have a lot now to reflect on and think about after having this conversation, I need to learn more about health policy. So I want to just pose one question for you as we wrap things up. What would you say to our listeners who want or maybe are now interested in thinking about health policy? How can they get involved? What can they do to help move the needle in the right direction?
Cara V. James:
Oh, that is such a great question because I think health policy can sometimes be overwhelming. Start local, get involved if there are patient boards or community boards through your community health center, through your hospitals, you can start local and work your way up. I think learning about, one of the resources I think is very accessible for people who want to start learning about health policy, is the Kaiser Family Foundation, KFF, they have primers on Medicare, Medicaid, some of those important programs that are critical for people to have access and coverage. They also do women's health, HIV and AIDS. So, so many places. But that's one place you can just start to learn a little bit more and then work your way up. There is policy at every level, getting involved in public health conversations, going to town halls are other ways that people can learn about these issues. And I would say hopefully you guys, as you're thinking about future topics, might have someone come and talk a little bit more about important programs for your communities.
Steven Jackson:
Absolutely. Well-.
Cara V. James:
And we need more providers in health policy, too.
Kari Haley:
Just a plug.
Steven Jackson:
I was going to say, was that a hint or something like that?
Cara V. James:
Hint, hint, because when you think about payment quality, value-based care, no, it takes all of us in the different perspectives because you may not want me who's never practiced making clinical decisions about what we're going to do. So we need all different perspectives in shaping our policies and programs.
Steven Jackson:
And that's another podcast episode. I have a lot to say about that, but I echo Dr. Haley's sentiments. You've given us a lot to think about and I think, again, our listeners have been educated all the more, and again, we are inspired to do our part, whether it's the podcast or a small group or just living the change that we want to see. We all play a role because there's a lot of rolling to do, there's a lot to do. And so thank you so much for what you do for Grantmakers and maybe we'll have you on again.
Kari Haley:
We'll have to do that, I think.
Steven Jackson:
We'll talk about how you fixed it all next time.
Cara V. James:
Thank you. Thank you so much for having me and thank you guys for helping to get the word out. This was great.
Steven Jackson:
You're welcome. Thanks again.
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers, and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.