BLOOMINGTON, Ind. - The United States has made little progress in advancing healthcare equity over the past two decades, and racial and ethnic inequities remain a fundamental flaw of the nation’s healthcare system according to a new report from the National Academies of Sciences, Engineering, and Medicine.
The report states that despite spending the most on healthcare among high-income countries, the U.S. has some of the worst population health outcomes. The U.S. healthcare 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 study, “Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All,” is an update of a groundbreaking 2003 report that highlighted racial and ethnic disparities in healthcare, and was co-authored by Kosali Simon, a distinguished professor at the Paul H. O’Neill School of Public and Environmental Affairs.
“We’ve made little progress in the past 20 years,” Simon said. “The inequities are driven by the interaction between healthcare and external forces in society. There have been a lot of changes in policies in the past 20 years, and their impacts have varied.”
The report documents evidence of numerous and pervasive inequities in U.S. healthcare. For example, one analysis found that diabetes in the U.S. is most prevalent in American Indian and Alaska Native adults, followed by Black populations, Hispanic populations, Asian populations, and white populations. 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. Among the actions are generating accurate and timely data on inequities; equipping health care systems and expanding effective and sustainable interventions; investing in research and evidence generation to better identify and widely implement interventions that eliminate health care inequities; ensuring adequate resources to enforce existing laws and build systems of accountability that explicitly focus on eliminating health care inequities and advancing health equity; and eliminating inequities in healthcare coverage, access, and quality.
“We’re so much more aware of these inequities than we were 20 years ago,” Simon said. “Yet, when we look at the gaps that persist, we have to ask how the healthcare sector can integrate social determinant frameworks with patient treatment to produce optimal outcomes. Some of the gaps are persistent and have been fairly non-responsive to vast policy changes that have happened, including the Affordable Care Act. Problems of access have been reduced, but there still is so much more that must be addressed.”
The Affordable Care Act expanded healthcare coverage to millions of individuals with low incomes and has been associated with improved access to the full range of healthcare services for all racial and ethnic groups, the report says. However, the report says structural limitations and legal challenges to the law have stalled broad implementation of many of the ACA’s provisions.
“Eliminating healthcare 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.”
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.