Health disparities

What are health disparities?

According to Unequal Treatment, health disparities are the differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups. Disparities in health care exist even when controlling for gender, condition, age, and socioeconomic status. After decades of improvements in preventive health care and significant declines in disease mortality for many Americans, disparities in health and health care continue to persist in the United States. As such, reducing and ultimately eliminating health disparities remains a focus of national attention.

Racial and ethnic minorities, those with disabilities, women, economically and educationally disadvantaged individuals, and medically underserved people, among others, continue to suffer from a disproportionate burden of disease. The reasons for health disparities appear to be multifactorial, still poorly understood, and complex. Compelling evidence indicates that among minorities, race and ethnicity correlate strongly with health disparities. Minority populations, typically classified as African Americans, Hispanic Americans, Asian Americans, native Hawaiians and Pacific Islanders, American Indians, and Alaska natives, are much more likely to experience poorer health outcomes, decreased life expectancy, higher mortality rates, and premature deaths. These groups are also less likely to be recipients of health care services geared toward health promotion, disease prevention and early detection of disease, and high-quality medical treatments.

The Healthy People 2020 initiative was a set of health promotion and disease prevention objectives for the nation. It endeavored to achieve health equity, eliminate disparities, and improve the health of all groups. Healthy People 2020 defined a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” The Healthy People 2020 initiative has concluded, but planning for Healthy People 2030 is underway and a new set of science-based, 10-year national objectives with the goal of improving the health of all Americans are being crafted.

There are a host of key factors, or determinants, of health disparities. These include but are not limited to insurance status, socioeconomic status, residential and geographic segregation, English as a second language, cultural and racial bias, and stereotyping. ^{, ,} Racial and ethnic minority groups comprise more than 50% of those uninsured, with some groups (e.g., African Americans, Hispanics, American Indians) representing two to five times the number of uninsured white Americans. In its Racial and Ethnic Disparities in Health Care Updated 2010 report, the American College of Physicians (ACP) discusses the literature regarding the poorer health status of minorities in the United States compared with white Americans. Residential segregation, lack of equal access to quality education, and obstacles to economic opportunity are equally important in determining one’s health status. The ACP report suggests that the most significant variable influencing health disparities is insurance status. Insured Americans are more likely to have access to health care. It is well established that minorities are less likely to have insurance, even when adjusting for work status. Lack of insurance affects an individual’s ability to participate in preventive health care measures and manage chronic disease states. Of minorities eligible for federal and state programs such as Medicaid and the Children’s Health Insurance Program (CHIP), more are eligible for coverage than are enrolled (e.g., because of lack of awareness, language barriers, complex enrollment process). Among uninsured individuals, racial and ethnic minorities are still less likely to have equal access to health care.

The Patient Protection and Affordable Care Act (PPACA) was brought into public law in March 2010, with full implementation occurring in 2014. The goals of the PPACA included increasing insurance quality and affordability, decreasing the number of uninsured Americans, and decreasing the costs of health care. To accomplish these goals, it was determined insurance coverage needed to be expanded and premium rates needed to be adjusted to allow for the largest number of Americans to qualify for federal programs or be able to purchase private insurance plans on the PPACA’s exchange site. Insurers were required to accept all applicants, regardless of preexisting conditions, and cover costs associated with a specific list of conditions. Changing the income requirements expanded Medicaid eligibility, changing the age limit for dependents meant children could remain on their parents’ coverage longer, and creating new protections meant children could qualify for their own policies regardless of their parents’ insurance plans, all of which increased the number of Americans with access to insurance plans. To decrease the costs of health care, additional aspects needed to be addressed. The PPACA requires insurers to charge a premium based on age rather than medical history, and subsidies in the form of refundable tax credits were offered to households and small businesses that purchased policies via the exchange. Health insurance expansions under the PPACA have resulted in a net increase of 16.9 million people gaining insurance between 2013 and 2015, roughly decreasing uninsured rates from 18% to 12%. Race/ethnicity is still a variable among populations with regards to access to care. In 2017 among adults ages 18 to 64, 8.5% of whites, 14.1% of Blacks, 7.6% of Asians, and 27.2% of Hispanics lacked health insurance coverage.

The PPACA has been the largest overhaul in American health care since Medicare and Medicaid in 1965 and therefore has changed many standard operating procedures for hospital systems and private practices alike. Mandates were placed on these entities, requiring them to meet standards in patient care, technology, and reporting systems. With the PPACA decreasing the number of uninsured Americans, this growth of insured patients has strained an already stressed health care model, and clinicians are concerned about their ability to maintain the quality of care with the increase of patient visits.

The Office of Minority Health (OMH) was created by the Department of Health and Human Services (DHHS) in 1986 as a direct response to the landmark 1985 Report of the Secretary ’s Task Force on Black and Minority Health. This report documented health disparities among minorities and placed their disadvantaged health status on the forefront of the U.S. health policy agenda. In conjunction with DHHS, OMH works to improve the health and health care of racial and ethnic minorities. In November 2013 the Centers for Disease Control and Prevention released its second consolidated assessment, Health Disparities and Inequalities Report, United States, 2013, which examines some of the key factors that affect health and lead to health disparities in the United States. This report defines health disparities as differences in health outcomes among groups reflective of social inequalities and calls for innovative intervention strategies that incorporate social and health programs.

In 2003, the Agency for Health Care Research and Quality introduced its first published report with regard to health care equality and health care disparities. The most recent report, the 2017 National Health Care Quality and Disparities Report, was released in September 2018 and combines information on both qualities of health care and health care disparities. Traditionally the National Healthcare Quality and Disparities Report (QDR) has focused on assessing the performance of our health care system and identifying strengths and weaknesses, as well as disparities, along three main axes: access to health care, quality of health care, and priorities of the National Quality Strategy (NQS). In 2010 the NQS was established by a mandate, because of the initiation of the PPACA, with the goal of supporting the general axes of the PPACA and QDR through six priorities: making care safer, focusing on person- and family-centered care, providing effective communication and care coordination, preventing and treating leading causes of morbidity and mortality, caring for the health and well-being of communities, and making quality care more affordable. Data from this report show that for the 2015 to 2016 year, poor people (at or below 100% of the Federal Poverty Level [FPL]) experienced worse access to care compared with high-income people (400% or more of FPL). In total, 15.5% of poor people under the age of 65 were uninsured for the whole year, compared with 4.2% of high-income people. After generally increasing, more recently, the percentage of adults ages 18 to 64 who were uninsured generally decreased. In addition to a general decrease in the number of uninsured adults, there was also an observed decrease in the percentage of uninsured adults from 2010 through 2017 among all three poverty status groups. The greatest decreases in the uninsured rate since 2013, however, were among adults who were poor or near poor.

The quality of health care improvements was assessed by collecting data on the NQS priorities, and it was found that through 2016 the quality of health care improved overall, but the pace of improvement varied by priority area. Despite this improvement, health care quality disparities continued to persist, especially among people in poor households, Hispanics, Blacks, and Alaska natives. Specific disparities to improve include person-centered care, patient safety, healthy living, and effective treatment.

In the United States, health disparities are well documented among minority populations. In essence, health disparities are population-specific differences in the presence of disease, health outcomes, mortality rates, and access to health care. The literature continues to acknowledge that the leading disparities for preventable conditions often exist among racial and ethnic minority populations. ^{, ,} At present, research has shifted to include transdisciplinary multilevel research on the social determinants of health disparities, community-based participatory research, and public health approaches to eliminating health disparities. The literature states that innovative and creative broad-based approaches are necessary to address the multiple complex factors that result in the disproportionate burden of certain diseases and poorer health outcomes for minority populations. ^{, ,}

Health disparities: Scope of the problem

Health disparities in the United States extend beyond race, ethnicity, religion, or veteran status. They extend the bounds of sexual orientation, age, access to medical coverage, geographic location, and health literacy. As health care providers, it is essential to lay aside our own personal biases to establish rapport and deliver effective and equitable health care. Adapting your interview for each patient is a skill that is not easily attained, as you will learn when you begin your clinical rotations. To build your tool belt of history-taking skills, observe the behaviors and interactions of other health care professionals with their patients. As you rotate through each subspecialty, really use your time to sharpen your interviewing skills and develop your rapport building.