What Does Equitable Access to Healthcare Actually Look Like?

Two women-identifying founders are breaking barriers to provide affordable, high-quality, culturally appropriate care for marginalized people—proving that caring for overlooked populations isn’t an afterthought: it’s the future.

By Anna Louie Sussman

Design by Perri Tomkiewicz

In 2018, Ashlee Wisdom was working at an academic medical center during graduate school when she started breaking out in chronic hives. She described one of the departments she worked at as emotionally toxic, especially for Wisdom, a Black woman, and her colleagues of color, evidenced by their high turnover rate. An allergist ran tests but couldn’t find anything wrong with her; she prescribed her Allegra to keep the itching under control.

As a master’s student at New York University School of Global Public Health, Wisdom regularly read papers about the impact of racism on health. It struck her that had she felt as comfortable talking with her white allergist as with her Black ob-gyn, she might have been able to share a fuller picture of her life, including her stressful work environment, which her allergist could have likely deduced was causing the hives. “I thought about my interactions with her and my interactions with my Black gynecologist, and they’re completely different,” Wisdom said. “I share so much more with my Black gynecologist.”

Black women face worse outcomes than white women for a range of health concerns, from maternal mortality to heart disease. These issues, of course, were not merely academic for her; she recalls reading a paper about the social factors that play a role in the racial disparities in health outcomes, and feeling tears stream down her face. She knew firsthand the importance of receiving culturally competent care, so she began working on a potential solution: a website to help women like her navigate the healthcare system and find providers “who understand the lived experiences and the social context of Black women and women of color,” as Wisdom put it. The Health in Her Hue website launched in 2018, and its related app in 2020 with the support of a $10,000 grant from a brand campaign headed by Serena Williams, alongside the non-profit Vital Voices and the shoe brand Stuart Weitzman. Now, the app is poised for a full build-out after Wisdom closed her $1 million pre-seed round last month.

Wisdom, 31, is one of a cohort of female-identifying founders seeking to design a more inclusive healthcare system by meeting the needs of people who have historically been marginalized, excluded, and mistreated by the medical profession. FOLX Health, a digital healthcare platform aimed at the LGBTQIA+ community founded by A.G. Breitenstein, has raised nearly $30 million since its December launch. Meanwhile Dr. Toyin Ajayi, the co-founder, president and chief health officer of Cityblock Health, which serves the Medicaid and lower-income Medicare population, closed a $192 million Series C in March. The funding round put Cityblock’s valuation at over $1 billion, highlighting that caring for overlooked populations isn’t an afterthought: it’s the future.

“I wanted to understand the broader issues of Black women”

Health in Her Hue’s (HIHH) first feature was content, since Wisdom had no engineering training, but she loved to write. “How can I make content more culturally relevant and less academic, bring it to Black women where they are, and build a community around the mission and vision of what I want to ultimately build?” Wisdom asked herself.

The articles about Black women’s health quickly pulled in readers who formed an online community, which mirrored the community forming around Wisdom in real life, as many of her grad school friends and other women of color rallied around her, excited to work with her pro bono and help her build the site. Moreover, the community feature of HIHH gave her a fuller picture of the diverse experiences of Black women. “I really wanted to understand the broader issues of Black women, as opposed to assuming that my one and limited experience as a Black woman would have all the answers,” Wisdom said.

 

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It was this community—both online and off—that, in turn, helped Wisdom make important business decisions. For example, she had planned from the get-go to offer telemedicine, but Dr. Nzinga Harrison, a mentor and HIHH’s clinical advisor, pulled her back. Not only is telemedicine a very capital-intensive feature to add, since it requires licensing, Dr. Harrison noted, but more importantly, that’s not what her users wanted. Specifically, HIHH’s members came to the site looking for providers who look like them—a Black woman ob-gyn, dentist, or primary care provider—so that’s what Wisdom decided to focus on building for them. From the six providers on the directory when she launched, she now has a database of over 800 clinicians. Eventually, Wisdom plans to offer a premium membership experience with customized content, the ability to track symptoms, and live health summits with providers; subsidized or paid for by large employers and insurers who are committed to closing disparate health outcomes.

Even though insurers have had this data on outcomes for years, the pandemic and the racial justice movement have created new momentum to finally address them, she says. “I think the tide is turning now. [Insurance providers] are being more intentional about understanding what the data is saying and looking for solutions that could change things, because they don’t know what to do—especially with ‘hard to reach populations,’” Wisdom says. “They’re looking for solutions, like Health in Her Hue, that are being designed and built by people from the community.”

The Internet is “the place where we find each other”

If Wisdom is helping Black women navigate the healthcare system, A.G. Breitenstein is helping queer and trans people circumvent it, at least for their basic health needs. In December 2020 , she launched FOLX Health, a digital healthcare platform aimed at the LGBTQIA+ community, which offers mail-order subscriptions for hormone replacement therapy, medical care for erectile dysfunction, testing for sexually transmitted infections, and an online library of accessibly written articles on relevant medical topics such as sexual health, estrogen, and testosterone, as well as tips for the friends and loved ones of trans and queer folk on how to be an ally. 

Like Wisdom, Breitenstein knew from personal experience how underserved her community is. A nonbinary lesbian, she had spent a lifetime explaining to confused doctors why she wasn’t on birth control even though she was sexually active. She also saw in her work as an attorney helping homeless LGBT youth how dramatically the health system had failed them. Researching the history of healthcare in the U.S. (Breitenstein majored in history at Yale), she found that the healthcare system had discriminated against queer and trans people from its earliest days, thanks to its deep connection to religion. The country’s first hospitals were often connected to churches; in this context, queer and trans people were seen as abnormal, or problems to be fixed. “For the queer and trans community, [there was] this oppressive judgement about us as a diagnosis, as an illness, as risky,” says Breitenstein. That stigma and marginalization formed “the backdrop for HIV, and just so many marking points in my career,” she adds. 

 

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Several centuries on, the system is still rife with discrimination. A 2020 report by the Center for American Progress found that 25 percent of trans people were refused medical treatment related to their gender transition by health care professionals, and one in 12 LGBTQIA+ people reported doctors using harsh or abusive language towards them. Unsurprisingly, this mistreatment discourages LGBTQIA+ people from seeking necessary medical care.

A former venture capitalist and serial healthcare entrepreneur (she co-founded three healthcare IT companies—Humedica, the Institute for Health Metrics, and PrivaSource—and is the founding director of the Health Law Institute), Breitenstein had watched as digital health companies like Hims and Ro rolled out direct-to-consumer healthcare, with features such as telemedicine and transparent drug pricing. Sitting on her deck one day, gazing at the sea, she thought that someone would eventually build a healthcare platform that began with community in mind. Then came the “dope slap moment of being like, Oh, my own community has literally had one of the single worst experiences” with the healthcare system, she recalls, with outcomes that only worsen when you layer in race-based discrimination.  

She started by creating an online storefront in early 2020 featuring what would become FOLX’s core offerings—hormone replacement therapy, erectile dysfunction medication, and STI testing—to gauge demand (at that point it couldn’t actually sell any drugs or provide medical services.) The response was “instantaneous and pretty overwhelming.” Word traveled fast, she notes, thanks to the existing strength of the online LGBTQIA+ community. Since its inception, the internet has always been “the place where we find each other, we connect, we share information.” After all, she notes slyly, “There was Grindr before there was Tinder, right?”

Insurance companies, providers, and employers determine what gets covered, how it gets delivered, and what quality is. The very last person in that discussion is the patient.

With her track record and connections to VCs, fundraising came easily, but building out FOLX’s infrastructure has been a challenge, even with $29.4 million raised since its December launch. Just months after FOLX launched, the pandemic hit, and telemedicine became a key part of many physicians’ practices. This requires licensing and credentialing at the state level, and unfortunately for her clinicians, “every doctor in America now is trying to get licensed in all 50 states,” gumming up the bureaucracy. FOLX is currently offered in 12 states so far, and the District of Columbia.

FOLX’s model bypasses the incumbent healthcare structure of doctors, health insurers, and hospitals, and relies on a small number of vetted providers, most of whom are themselves queer or trans. Drugs are priced transparently, with subscriptions starting at $59 a month for a maintenance pack of estrogen, and $89 a month for testosterone. Breitenstein understands that not working with insurers prices some people out; to address that, she has also started a fund to provide a year’s worth of hormone replacement therapy (including telehealth visits with trans-centered physicians) for 100 people each year, with 75 percent of grants going to people of color. But she believes cutting out insurers makes FOLX more directly accountable to the people it serves.

“Right now, the way healthcare is financed, the insurance companies, the providers and the employers determine what gets covered, how it gets delivered, what goodness is, and what quality is. The very last person in that discussion is the patient and the very, very, very, very last—if at all considered—are patients in marginalized communities,” she says. “If our only constituent is the person sitting across from us, and their decision to pay us their hard-earned money for the care we deliver, it gives us an absolute unmitigated relationship, to serve them and to be exactly what they need us to be.”

“We’re not advocating for a segregated healthcare system”

Although right now the users of Health in Her Hue’s app and site are clamoring for providers who look like them, Wisdom believes that all clinicians are capable of culturally competent care, if they are willing to put in the work. “We’re not advocating for a segregated healthcare system,” she emphasizes. “We don’t believe that the panacea is that every Black woman, every Black patient has to see a Black doctor.”

To that end, she is in discussions with the American Medical Association and longtime health equity researchers to create licensed training modules on unconscious bias, cultural competency, and racial equity for providers, offered through Health in Her Hue, which she  hopes to have ready by the end of the year. 

Breitenstein has also discussed creating training with medical schools. Currently, she tells me, medical students receive about five hours of training on queer- and trans-sensitive health care provision, in the course of an entire medical school education. This means that most doctors will be out of their depth when it comes to, say, managing a patient’s diabetes while they’re on hormones. In the absence of formal training, FOLX’s clinicians have had to seek out this information themselves, often motivated by either their own lived experience or by being close to a friend or family member who is queer or trans. It is these clinicians, she believes, who will create the atmosphere of trust and care that goes beyond the slick, commodified experience of other direct-to-consumer healthcare platforms, and is especially important to her community, “because they have been so mistreated for so long.”

“Particularly for this community, trust was a crucial aspect of what we’re building,” Breitenstein added. “Having that clinical network, having those clinicians come from the community, reflect the community, understanding blood and bone what our life is like, was an essential aspect for us.”

Anna Louie Sussman is a New York-based journalist with extensive experience reporting on gender, economics, health, and reproduction. She is currently at work on the book “Inconceivable: Reproduction in an Age of Uncertainty,” which looks at the challenges people face in starting and growing their families. It builds off her New York Times Sunday Review cover story, “The End of Babies.”

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