As health care organizations across the country identify how to improve health outcomes and advance health equity for individuals in their communities, many are also undertaking their own internal equity journey. Building a culture of equity is a critical step to creating lasting change in how organizations understand health equity, see their role in advancing equity for Medicaid enrollees and communities, and ensure an equitable workplace for their employees.

Over the past few years, Virginia’s Medicaid agency, the Department of Medical Assistance Services (DMAS), has taken steps to address equity both internally and externally. In this blog post, Rebecca Dooley, strategic communications manager at DMAS and Mariam Siddiqui, a senior advisor in the Virginia Medicaid Director’s Office, discuss DMAS’ efforts as well as successes and challenges in building a culture of equity. They also shared advice for other state Medicaid agencies considering similar equity work. This blog post is a product of Advancing Health Equity, a national program made possible by the Robert Wood Johnson Foundation that is supporting multi-stakeholder approaches to reduce and eliminate health and health care inequities through payment and care delivery transformation.

Q: How does DMAS define health equity and how did you come to a consensus on this definition?

A: R. Dooley: At DMAS, we talk a lot about the difference between equality and equity. Under equality, we can give all our members the same services but giving everyone the same services is not enough to break through systematic barriers that have been in place for generations. When we’re looking at our member services, health equity means ensuring that we are using initiatives that are strong enough to break through those barriers that have held Virginians back from achieving better health and social outcomes over generations.

M. Siddiqui: We looked at definitions from the Centers for Disease Control and Prevention, the World Health Organization, and others to see what was out there. We wanted to see how they describe equity and how we can intentionally align ourselves with that focus.

Q: How does your internal equity work at DMAS connect to other state-level equity initiatives?

A: R. Dooley: A bill was just passed in Virginia that requires all state agencies to have a strategic plan to address diversity, equity, and inclusion (DEI). That’s really encouraging because it allows us to align the internal work that we’ve been doing with DEI strategic planning in other state agencies to push the overall mission of equity internally that folds into external equity work, as well.

We were one of the first state agencies in Virginia to develop a DEI Council, create a strategic plan, and hire a DEI officer. Our DEI Council has about 30 active staff members who are committed to making our agency a more welcoming and inclusive workplace where everyone can learn from each other and ensure that each person feels valued and respected. The Council recognizes that the agency’s strength lies in its diversity, and its members work to build on that strength to increase internal collaboration and optimize the impact of the agency and its mission throughout the Commonwealth.

When the governor appointed the statewide chief diversity officer, the officer used DMAS as an example for other state agencies in Virginia. Suddenly we had a lot of people coming to us asking, “How did you do this?” Our chief of staff started a state partnership workgroup that meets once a month with other agencies in Virginia to think about how different state agencies can work together and ensure that our DEI strategic planning is aligned. It’s been a unique partnership that has enabled us to talk to people all over the Commonwealth and serve as an example to the rest of Virginia, which is really exciting.

Q: Can you discuss the importance of gaining buy-in and how you’re sustaining interest in your internal equity work?

A: R. Dooley: We found that it was important to get buy-in for the DEI Council, especially because this work is outside the general scope of our jobs. We started the Council in winter 2019. It was spearheaded by our Medicaid director and our chief of staff, so we have the support of agency leadership. It’s powerful when members of our leadership come to our DEI Council meetings and present themselves as neutral parties — no labels involved — to allow difficult and needed conversations to happen.

In addition to getting interest from DMAS’ senior leadership, we also needed to get buy-in from department directors to allow and encourage staff participation. I’ve been asked to present at a variety of different division meetings to talk about the Council, and we’ve gained more members from those presentations. We now have about 70 people calling in to our meetings, which is 10 percent of our agency. The staff is coming to us with ideas and people are getting excited about the initiatives.

As the Council began making changes, such as renewing some human resource (HR) policies, staff started to recognize that change is possible. This gave the Council some credibility and encouraged more people to participate. We also hosted an “Open House” within the first few months of starting the Council. This was an opportunity for staff to come meet the Council, play games, learn about our agency’s diversity and simply get to know each other. Staff who have worked for our agency for many years met some of their colleagues on other teams for the first time at this event. It was a huge success!

M. Siddiqui: As a member who attends the Council meetings, it’s nice to have that safe space where you can still have these serious conversations. We had plenty of those last year when there were a lot of social justice protests happening in Richmond, which is close to us. Those conversations helped the membership grow because people were open to listening to staff reactions to the protests.

Q: What are some of the successes and challenges you’ve experienced in this work?

A: R. Dooley: One big success is our relationship with the HR team. We’ve been able to hand off to HR some of the conversations that we’ve had in the Council. For example, when we started the Council, there were a lot of conversations about equitable pay. Our HR department was able to bring in a third party to do a salary and compensation study for our entire agency. As someone who was personally impacted by that study and was given an opportunity to be paid equally, it really boosted my morale as an employee — and other employees had the same experience. Other agencies and companies are experiencing the same issue in terms of unequal pay, but DMAS decided to do something about it, which was a big deal. The Council has also encouraged our HR team to review and edit all our HR policies with a DEI lens. We’ve seen some changes, especially when it comes to new parents and our infant at work policy, allowing new parents to bring their infants to work. This type of policy gives new parents greater flexibility with parental leave and childcare.

A challenge we’ve experienced is the natural difficulty that can come from trying to connect with others with a diverse set of perspectives. The majority (over 50 percent) of our agency identifies with at least one minority group. While this means we have a real opportunity to celebrate our diversity, we also have a lot of different viewpoints and lived experiences.

Q: How do you see the relationship between your internal DEI work and the broader picture of improving health equity for your members?

A: R. Dooley: Our workforce is diverse and so is our Medicaid program. It’s important to us that our workforce mirrors and understands our membership. We serve 1.8 million Virginians across the Commonwealth and diversity can be a critical way for us to connect with members. Our staff members who work on our external and programmatic work are also the staff who are very committed to doing the internal work. People have the health equity mindset and recognize the importance of doing the work internally so that we can best serve our members.

M. Siddiqui: Medicaid agency staff don’t see our members on a regular basis, so it can be hard to have a one-on-one connection. With this in mind, we created a Member Advisory Council about a year and a half ago and are one of only two state Medicaid agencies to have a council made entirely of Medicaid members or their representatives. We have a dozen member volunteers from across the state who represent various Medicaid-covered groups. Our members provide us great feedback on programs and policy and our leadership has been very involved in that process. One of the many noteworthy contributions from the MAC is an enhanced website with a renewed focus on digital accessibility. We want to continue to have more face-to-face time with our members as we think about both internal and external equity.

Q: What are key takeaways to share with others who are working to bolster their internal equity work as part of their overall equity efforts?

A: M. Siddiqui: There’s no solution in a day, or even in three months. You want to acknowledge small victories and have measurable goals. Showing that you’re moving that needle, even the slightest bit, makes a big difference. You also want a team that has a shared mission and remembers it. And finally, remembering to integrate this into your routine work and make it a priority.

R. Dooley: Having patience, building a good team, and celebrating your small victories. You want people who are committed to the work and people who have differing viewpoints and areas of expertise. At the start of every DEI Council meeting, we talk about some of the most important things we’ve done lately to remind people that what we are doing is making a change. If we work together and we’re patient, this work pays off.