NASEM Releases New Report Addressing Racial Disparities in Health Care
The U.S. has made little progress in advancing health care equity over the past two decades, and racial and ethnic inequities remain a fundamental flaw of the nation’s health care system, says a new report from the National Academies of Sciences, Engineering, and Medicine.
Despite spending the most on health care among high-income countries, the U.S. has some of the worst population health outcomes, the report states. The U.S. health care system is highly influenced by societal factors, and delivers different outcomes for different populations by its very design. The system’s inadequacies disproportionately affect minoritized populations, with stark racial and ethnic inequities in life expectancy, maternal and infant mortality, and many chronic diseases.
The report documents evidence of numerous and pervasive inequities in U.S. health care. For example, one analysis found that diabetes in the U.S. is most prevalent in American Indian and Alaska Native adults at 13.6%, followed by Black populations at 12.1%, Hispanic populations at 11.7%, Asian populations at 9.1% and White populations at 6.9%. However, non-White patients are less likely to receive newer, higher cost drugs and diabetic technology. Black patients with diabetes experience hospitalization rates more than 2.5 times higher than those for White patients.
More broadly, the report says, racially and ethnically minoritized individuals are significantly less likely to have a usual source of primary care, and during emergency department visits, they experience longer wait times and are assigned less acute triage severity scores. Long-term care facilities serving predominantly racially and ethnically minoritized residents offer fewer clinical services, have lower staffing levels, and have more care deficiency citations.
The report recommends multiple actions that Congress, the U.S. Department of Health and Human Services, National Institutes of Health, Centers for Medicare & Medicaid Services, and other agencies should take to remedy inequities in health care.
“Eliminating health care inequities is an achievable and feasible goal, and improving the health of individuals in the nation’s most disadvantaged communities improves the quality of care for everyone,” said Georges C. Benjamin, co-chair of the committee that wrote the report, and executive director of the American Public Health Association. “This is not a zero-sum game — we are all in this together.”
“When the Institute of Medicine (now named National Academy of Medicine) released its landmark Unequal Treatment report in 2002, we shed light on the fact that your race could determine the quality of the care you receive,” said Victor J. Dzau, president, National Academy of Medicine. “Twenty years later, it is clear that our nation has not made enough progress. There are still major inequities inherent in the health care system. It is imperative that we achieve equitable health for all by committing to pursuing and implementing the goals and actions laid out in this new report.”
Structural inequities are driving unequal health care
There are significant structural differences in services among public and private health insurance payers, which result in unequal access to health care services, the report says. For example, Medicaid enrollees have more limited access to needed medical care than those covered by Medicare or private insurance.
Such inequities disproportionately impact minoritized populations, the report says. However, inequities affect all patients, including populations that are not publicly insured, the report says. Research cited in the report shows these inequities also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity, and costing the United States hundreds of billions of dollars annually.
In the past two decades, progress has been made in generating awareness of inequities, conducting research that documents inequities, passing legislation and creating policies with positive intent to address inequities, and narrowing some gaps in health care inequities for some populations some of the time. However, no sustained trend shows that equity gaps have narrowed year after year for racially and ethnically minoritized groups.
The Affordable Care Act (ACA) expanded health care coverage to millions of individuals with low incomes and has been associated with improved access to the full range of health care services for all racial and ethnic groups, the report says. However, structural limitations and legal challenges to the law have stalled broad implementation of many of the ACA’s provisions, the report says.
Actions needed from Congress, government agencies, funders
The report identifies five goals and recommends multiple implementation actions to comprehensively and systematically intervene at every level of health and health care.
Goal 1: Generate accurate and timely data on inequities. The report urges several implementation actions — for example, at the federal level, the Office of Management and Budget should more aggressively enforce the administration-wide requirement for routine collection of race, ethnicity, tribal affiliation, and language data by all agencies overseeing federal health care and research programs.
Goal 2: Equip health care systems and expand effective and sustainable interventions. Among the recommended implementation actions, Congress should increase funding for effective health care delivery programs shown to improve access and quality and reduce health care inequities.
Goal 3: Invest in research and evidence generation to better identify and widely implement interventions that eliminate health care inequities. As one action to implement this goal, NIH and other federal and nonfederal research funders should expand funding for research aimed at addressing health care inequities, structural racism, and health-related social needs, and at exploring various approaches, strategies, and policies needed to eliminate health care inequities.
Goal 4: Ensure adequate resources to enforce existing laws and build systems of accountability that explicitly focus on eliminating health care inequities and advancing health equity. Many current laws and regulations have been underused, the report notes. For example, the Office for Civil Rights at HHS is under-resourced, limiting its efforts to enforce civil rights statutes and address the complaints it receives from individuals. Moreover, several ACA provisions that could significantly advance racial and ethnic equity in health care are enforced sporadically or not at all. To remedy this, Congress and HHS should ensure adequate resources are available to enable the office to enforce the ACA’s prohibition on discrimination in covered health programs or activities.
Goal 5: Eliminate inequities in health care coverage, access, and quality. To implement this goal, Congress should establish a pathway to affordable, comprehensive health insurance for everyone, the report says. Congress should also establish a pathway to the adoption and implementation of Medicaid payment policies on par with Medicare.
“Many of the tools needed to reach these goals are already available and need to be fully used,” said committee co-chair Jennifer DeVoe, professor and chair of family medicine, Oregon Health & Science University. “And with concerted national effort and adequate resources, the health care system can be transformed to deliver high-quality, equitable care to all.”
The study — undertaken by the Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care — was sponsored by the Agency for Healthcare Research and Quality and the National Institutes of Health. The National Academy of Medicine’s Kellogg Health of the Public Fund provided support for dissemination.
The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, engineering, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.