Marshall Chin, MD, MPH, Scientific Advisory Council Member
How did your interest in health disparities begin?
Part of it is personal, and part of it is professional. I am a third-generation Chinese American, so it’s my grandparents’ generation that immigrated from Toisan in southern China back in the early 20th century. They came over for economic reasons, and they had large families, so I have a lot of aunts and uncles. Both my parents grew up in Boston’s Chinatown. On my mom’s side, the family made noodles with a machine in the basement of their home, and they sold the noodles to the restaurants in Chinatown. My dad’s side of the family did laundry, so most of my uncles were these blue collar guys that worked in the laundries. I grew up in Concord, Massachusetts, which is a suburb about 20 miles west of Boston. Every Saturday we would go into Chinatown to visit the extended family, so I got to know Chinatown and my family’s story.
Boston’s Chinatown is similar to most Chinatowns, including Chicago’s Chinatown: there are a fair number of people who don’t have a lot of resources and are new to the country. The vast majority of my aunts and uncles were very talented people, but there was a bamboo ceiling because of the discrimination and racism of that era. That always sort of stuck with me.
I was a medical student at the University of California, San Francisco. I did most of my rotations at San Francisco General Hospital, the public county hospital, and the VA hospitals. I remember early on seeing a lot of challenges of the population: teen pregnancy, effects of gang violence, partner violence, housing and food insecurity. This combination of my personal background and what I saw in training made it a mission, a moral imperative, to work on equity.
I sometimes have wondered whether Chinese communities in Chinatowns are not included in equity discussions because of the language barrier.
There’s a variety of reasons why Asian Americans have been too invisible. Some of it is that the data are not collected, or that granular data that divides Asians across different subgroups often are not collected. Some of it is being treated as the other, always being a perpetual foreigner, or even as the model minority myth—it’s another way of making invisible the heterogeneity within the Asian population.
I coauthored a recent editorial in JAMA Network Open about how Asian Americans, Native Hawaiians, and Pacific Islanders are underrepresented, especially in senior leadership. My wife, Naoko Moramatsu, and I also wrote a paper about Asian American invisibility that goes through some of these different issues in more detail.
Can you tell me a bit about your current research?
Monica Peek and I are co-leading a project to evaluate an intervention among 32 federally qualified health centers in California that is designed to improve the way they manage the population of patients. That intervention aligns with current California State Medicaid policy in the direction where that Medicaid program wants to go regarding how care is organized and how care is paid for. We’re doing a mixed method evaluation using a combination of administrative data for clinical performance information, surveys of staff, providers, and patients and qualitative interviews of patients, staff, and leadership. We’re hoping to answer a number of questions: Did the intervention work? What are the facilitators and the barriers to the intervention? Should this policy and this intervention continue in the future?
With the Robert Wood Johnson Foundation health equity program Advancing Health Equity: Leading Care, Payment, and Systems Transformation, we’re working with 12 state teams to try to advance health equity. A team consists of a state Medicaid agency, a Medicaid managed care organization health plan, at least two frontline healthcare delivery organizations, and community-based organizations. What each team is trying to do is align their work around payment and care transformation to address the medical and social needs of patients and communities.
For about a year and a half I’ve been co-chairing the Centers for Medicare and Medicaid Services Health Care Payment Learning and Action Network Health Equity Advisory Team. It has a lot of parallels to the Robert Wood Johnson Foundation project: we’re working with all these different stakeholders on a national level to try to align payment and care transformation in alternative payment models to advance health equity. We’ve come up with three papers so far, one on guiding principles for incorporating equity into alternative payment models, a second paper on adjusting payment for the social risks of patients and communities, and a third one just came out on the topic of health-related social needs—how can healthcare organizations best partner with community-based organizations.
How do you aggregate and analyze the information coming from all these organizations?
It’s a combination of thinking about some things in common and also taking a lot of individual stories because everything is context-specific. You need to have both some of the general themes and case studies. It’s very important to understand how individual organizations or individual states do things that work in their context—what will work in Chicago isn’t what necessarily will work in Tennessee or Alabama. Equity work is a team sport—it’s got to be a team sport to accumulate this knowledge and synthesize this knowledge and have the accumulation of all these stories.
What are you the most proud of in your career?
I’m most proud of being part of this overall health equity team in Chicago and nationally. When I first started, almost all the work was documenting health disparities. While that’s important, it’s different from interventions to try to erase and eliminate and mitigate health inequities. We’re now at a point where we’ve learned about how to improve health equity, and a lot of work I’m mentioning is trying to do things that are sustainable and at scale. All three projects I talked to you about really are at a state level or higher. A lot of academic research tends to be demonstration projects—to see if something will work in a pretty confined area. Now the question is, how can we get big stakeholders like the university healthcare system or the city of Chicago or the state of Illinois or the national Centers for Medicare and Medicaid Services to adopt policies that will improve the chances that we have health equity?
There’s no single magic bullet. It involves thinking about processes by which organizations improve and change, it involves payment, it involves care transformation, it involves specifically trying to create a culture of equity and then addressing issues like structural racism and other systems of oppression. All these things have to occur at the same time over a period of time. I’m proud of being part of these efforts to get us to this point locally and nationally and giving more voice to marginalized populations and communities. It’s been a gradual process, the idea of community-based and community-engaged research and having community at the table for these discussions around equity that involve all these other powerful stakeholders. I’m proud to have helped with that particular process and with training and mentoring the next generation—I’m very proud of my mentees and the contributions they’re all making.
Do you have any fun facts?
The past six or seven years, my wife and I have been training and performing in improv comedy. We’re part of an improv troupe, The Excited State. Recently retired alderman Leslie Hairston used to have an annual Laughter and Local Politics event, so during one of these annual events during the pandemic, I was one of the two standups to perform.
Could you tell me more about how improv helps train people in health equity?
Improv is particularly good for teaching communication skills like observation, listening, being in the moment, and building a relationship. You start wherever the person who’s your scene partner [or your C3EN partner?! Just kidding] is, and you build it from there. In patient care, this translates to truly being there in the moment with your patient, truly listening, truly being with where they are at, and then moving from there, not preaching to people, or imposing your view on others, but really understanding the person in front of you.
The very first exercise that was given when I was a Standup 101 student, the instructor asked us, “How do people perceive you when they first meet you? What do they get right? What do they get wrong?” A good standup has to be able to both read the audience as well as read themselves.
Arts are particularly good for teaching emotional intelligence skills. They’re very experiential and hands-on. Personal storytelling is a powerful way to teach about equity.