Crystal Narcisse, MD, right, examines patient Sierra Lee in Louisville, Kentucky in 2023. A new report finds that the nation’s health care system is still failing to provide equal treatment to all of its residents, including many people of color.
Photo by Jahi Chikwendiu, courtesy The Washington Post/Getty Images
“With concerted national effort and adequate resources, the health care system can be transformed to deliver high-quality, equitable care to all.”
— Jennifer DeVoe
The U.S. has made some gains in reducing inequities in its health care system over the past two decades, but still has a long way to go to achieve equal care for all of its people, says a major new review.
Released in June by the National Academies of Science, Engineering and Medicine, the report revisits a 2003 landmark NASEM assessment that called out inconsistencies in the way people are served across the U.S. health care system. The new report, “Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All,” concludes that racial and ethnic inequities remain a fundamental flaw of the health care system and are holding back the nation.
However, Congress and federal agencies can work together to address those inequities, said the report committee, which comprised nonprofit and academic leaders.
“Eliminating health care inequities is an achievable and feasible goal,” said Georges Benjamin, MD, co-chair of the committee and APHA’s executive director, in a news release. “This is not a zero-sum game — we are all in this together.”
The report shares myriad findings on the ways the U.S. health care system is failing to meet the needs of all Americans. For example, while they have the nation’s lowest rate of diabetes, white patients are more likely to receive newer, higher-cost drugs and technology during care. Black people with diabetes, who have the second-highest burden of the disease, are hospitalized at more than double the rate of white patients.
Other research shows that compared to white people, populations of color are less likely to have a usual source of primary care, experience longer wait times during emergency visits and are assigned less serious scores during triage. Long-term care facilities that serve populations of color provide fewer clinical services and have lower staffing levels.
Failure to address the nation’s health care inequities comes at a high cost, in terms of both lives and dollars, the report said. For example, from 1999-2020, Black Americans experienced 1.63 million excess deaths, representing more than 80 million years of potential life lost, according to a 2023 study. Accounting for excess premature deaths, lost labor market productivity and additional medical care costs, the U.S. lost $451 billion from racial and ethnic health disparities in 2018 alone, other research has found.
Addressing health inequities improves the quality of care for everyone, APHA member Vincent Guilamo-Ramos, PhD, MSN, MPH, FAAN, told The Nation’s Health. He rejects arguments that working to resolve inequities for one population hurts others.
“It pits us against each other,” said Guilamo-Ramos, a member of the report committee and executive director of the Institute for Policy Solutions at the Johns Hopkins School of Nursing. “What the evidence suggests is that when we actually make investments in those communities, those racial ethnic groups that are furthest from health equity, it actually spills over to benefiting all of us.”
Advancements such as the Affordable Care Act, which expanded health insurance coverage to millions of low-income people, have helped reduce disparities.
But millions of people remain uninsured, particularly among populations of color. About 19% of American Indian and Alaska Native people were uninsured in 2021, according to the U.S. Census Bureau, followed by nearly 18% of Hispanics, 10% of Native Hawaiians and other Pacific Islanders, 10% of Black Americans, 6% of Asian Americans and 6%of white Americans.
Beyond limiting access to care, lack of insurance can determine what care patients receive. A study published in July in JAMA Network Open found that among injured trauma patients, people who were uninsured were withdrawn from life-sustaining therapy earlier than patients with private or Medicaid coverage.
“Congress should establish a pathway to affordable comprehensive health insurance for everyone,” said committee member Margarita Alegria, PhD, chief of the Disparities Research Unit at Massachusetts General Hospital, during a report release event.
A lack of oversight and legal challenges have limited the ACA’s full impact, according to Sara Rosenbaum, JD, another member of the report committee.
“One of the things we find is that a number of the key provisions in the ACA have gone unenforced,” Rosenbaum, who chairs the Department of Health Policy at the George Washington University’s Milken Institute School of Public Health, told The Nation’s Health. “Most crucial in this regard has been Section 1557 of the ACA.”
In May, the U.S. Department of Health and Human Services published a final rule on Section 1557’s protections against discrimination in health care that was scheduled to take effect this summer. The APHA-supported rule would have protected LGBTQ+ people and others against sex or gender identity discrimination in health care, but was blocked in district court in July. Public health advocates condemned the delay.
Policy is not the sole source of unequal treatment in health care settings. Stereotyping, biases and uncertainty on the part of health care providers can also contribute to health inequities, according to the report.
“The first thing to do is to think about how we practice and to recognize that we have unconscious bias,” Guilamo-Ramos said. “We oftentimes are too eager to focus on whatever the standard is, without questioning that perhaps that standard, that guideline, that algorithm — is it really in alignment with the populations that are furthest from the elimination of the inequity?”
The report also called for better collection of data on patient race, ethnicity and preferred language; increased funding for programs proven to improve health care access and quality; investments in research that can identify successful interventions; and increased resources to enforce civil rights statutes and address complaints.
“Many of the tools needed to reach these goals are already available and need to be fully used,” committee co-Chair Jennifer DeVoe, professor and chair of family medicine at Oregon Health and Science University, said in a news release. “And with concerted national effort and adequate resources, the health care system can be transformed to deliver high-quality, equitable care to all.”
For more information on the report, visit www.nas.edu.
- Copyright The Nation’s Health, American Public Health Association
