New Report on Ending Unequal Treatment in the U.S. Health Care System

More than twenty years have passed since the Institute of Medicine (now the National Academy of Medicine) published its 2003 landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The central conclusion of the report was that racial and ethnic disparities were a hallmark of the US health care system and that unequal treatment persisted even when controlling for health insurance coverage. That report also found that systemic and structural racism were major drivers and produced measurable adverse effects within the process of health care itself.

Recently, the National Institutes of Health and the Agency for Healthcare Research and Quality requested that the National Academies of Sciences, Engineering, and Medicine (NASEM) convene an expert committee to report on where we stand now: Two decades after the release of Unequal Treatment, do racial and ethnic inequities in health care persist, and if so what can be done to address the problem? This twenty-year update of one of the most important reports on health care equity ever undertaken has been conducted in the wake of far-reaching changes in how health care is organized and delivered, how medical and health professionals are educated and trained, and how health policies influence the accessibility and quality of health care.

The expert committee’s consensus report, Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All, offers a comprehensive, deeply researched, evidence-based review of health and health care inequities within the US health care system. The report explores the barriers that continue to weaken and undermine efforts to achieve more equitable health care, and it presents recommendations for future actions that, taken together, would achieve a more effective and sustained approach to measuring and addressing the problem.

Given the size of this undertaking and the short timeframe for the committee to complete its work (slightly over one year), it is important to note certain limits. First, the committee was expressly tasked with studying equity in health care. Therefore, this report principally focuses on policies and social and structural drivers most relevant to increasing or decreasing inequities in health care. However, at numerous points, it examines how these drivers influence health itself. This contextual approach to health care reflects the fact that the committee’s Statement of Task was to study the structure and function of the health care system and its place within the broader forces shaping individual and population health.

Second, the Committee focused on federal health care programs overseen and administered wholly or principally by the United States Department of Health and Human Services (HHS). Federal programs administered by the Defense Department or the Veterans Administration (VA) were not considered, nor were major regulatory laws governing market behaviors such as competition and consolidation, which are administered by other federal agencies. These laws also bear on the accessibility and quality of health care.

Third, the Committee examined the effects of certain state policies affecting the performance of federal health care programs, as well as (to a limited degree) state policies that directly affect the scope of health care practice (such as licensure). However, it did not undertake a comprehensive review of the vast number of choices states make that shape and drive health care.

This article summarizes the report’s key findings, ongoing impediments to improvement of the US health care system, and suggested strategies for moving forward.

Health Inequity Remains a Defining Characteristic of U.S. Health Care—With Implications for Everyone

Ending Unequal Treatment describes the current health care inequities in the United States. Its principal conclusion is that the nation has made minimal progress over the past two decades in eliminating health and health care inequities. The lack of progress, and in some instances worsening health status, are disproportionately concentrated within racially and ethnically minoritized groups. In this regard, the report presents additional evidence that poor outcomes observed in health care related to race and ethnicity reflect historical and enduring patterns driven by underlying structural and systemic racism in policies and programs.

Ending Unequal Treatment favors the use of the term “health inequities” over “health disparities.” This is a conscious shift in terminology, intended to convey that the clustered and systematic differences seen in minoritized populations often reflect unjust and unfair policies and practices embedded within the US health care system and broader society. Among the report’s most significant conclusions is that the inequities in the US health care system are rooted in a broader context and therefore, achieving health care equity will require a full national commitment to addressing the issue of health inequity. This means increased investments in efforts to ensure that health care is delivered equitably and in initiatives aimed at achieving health equity overall. This in turn, will require the political will to commit significant national financial investments in social welfare programs that aim to end racial and ethnic inequities in health and health care.

Ending Unequal Treatment acknowledges the increasing social and political tension and divisions triggered by efforts to prioritize improvements in health care for racially and ethnically minoritized populations through investments in key social welfare programs and policies on which these populations disproportionately rely. The report argues, however, that even if these investments benefit some Americans, the results benefit all Americans. Indeed, the report explains, while racially and ethnically minoritized populations bear the brunt of health inequities, all individuals, families, and communities across the United States can be impacted by the current deficits in health care delivery and health status. The report highlights the common myth of the “zero sum game,” which holds that focused investment in minoritized groups results in a loss to other groups and that gains by one community means loss to other communities.

Using examples such as access to insurance coverage and emergency department care, the Committee finds evidence that a lack of investment in those most at risk of health inequity has deleterious consequences for US society as a whole. And yet, most health-related policies and broader societal sentiments fail to take this into account, leaving the nation deeply divided and reinforcing the policies and practices that result in health care inequities, despite their spillover consequences for everyone.

Policy And Programmatic Solutions To Eliminate Racial And Ethnic Health Inequities

Despite the limited progress in eliminating health inequities, Ending Unequal Treatment points to several promising strategies for ensuring significant progress and accountability. The report highlights the importance of sustained data collection on racial and ethnic inequities in health care and the need to move away from occasional studies of isolated issues perceived as specific problem areas. To this end, the report recommends that HHS make continual, health care-equity-focused data collection and impact evaluation a routine feature of the health care system.

Additionally, the report calls for similar routine data collection on the racial and ethnic composition of the health care workforce. In this regard, the report draws specific attention to the potential impact of the US Supreme Court decision in Students for Fair Admission v Harvard, which significantly limits the use of race and ethnicity data in undergraduate admissions decision-making. The report argues that where health care is concerned, the need for such evidence remains compelling, given the evidence of positive impact on access and quality of racial and ethnic concordance between patients and health care professionals. Without race and ethnicity data on access to and use of care as well as the characteristics of caregivers, it becomes more difficult to assess the extent of health and health care inequities and ensure that the health care and scientific workforce is sufficiently diverse and adequately prepared to care for an increasingly diverse US population. Nor, without such data, is it possible to mount the strategies needed to measure continuing barriers and progress.

The report emphasizes the important strides achieved through several of the Affordable Care Act’s (ACA) most prominent reforms, including major expansions of insurance coverage, the growth of funding for programs of proven effectiveness such as community health centers and teaching health centers, and establishment of a comprehensive legislative framework for health care and civil rights as part of Section 1557 of the ACA. At the same time, the report points to key shortcomings. Most notably,

• the continuing failure of ten states (whose poorest residents are disproportionately members of minoritized communities) to adopt the ACA’s Medicaid expansion for all low-income working-age adults,
• inequitable Medicaid funding for the US territories that leads to systemwide inadequacy and inequities,
• the failure to fully fund key health care delivery programs of proven effectiveness, such as the Indian Health Service, and
• the failure to provide guaranteed, ongoing funding for educating and training high-value health care professionals such as nurses and physician assistants.

The report notes certain promising developments for reducing ethnic and racial inequities that merit close evaluation and full-scale implementation if determined to be effective. The report devotes considerable time to health care delivery itself. In this regard, the report finds promise in models that integrate social care with clinical care and optimize the use of interprofessional health care teams that can address both medical needs and health-related social needs (HRSN). The report recognizes the potential of federal Medicaid demonstrations authorized by Section 1115 of the Social Security Act that aim to promote a health-related social needs care model in Medicaid and points to early evidence from North Carolina (the first state to implement this type of demonstration) showing positive clinical outcomes, reduced dependence on emergency room care, lower health care expenditures, and an enhanced role for community-based organizations.

To make Medicaid function more equitably, the report recommends two principal reforms: payment parity that puts Medicaid payments for health care services on a par with fee-for-service Medicare; and—given the large role of managed care in Medicaid practice—reforms that strengthen Medicaid managed care plans’ access and provider network requirements.

The report recommends payer investments to promote new models of integrated care: interprofessional health care teams that can assume a broader role in practice and exercise greater leadership in the design and provision of health care, including the use of community health workers and peers for task shifting and addressing the workforce shortage. The report finds compelling evidence of the effectiveness of community health workers and their role in advancing health equity. To this end, the report recommends the incorporation of community health workers and social workers into a reimagined interprofessional team approach and the elimination of state restrictions that prevent health care professionals from operating at the top of their licenses and clinical training. Such restrictions are particularly common where the nursing practice is concerned, with considerable geographic variation despite the preponderance of evidence demonstrating the positive effects on health equity of reforms that remove arbitrary regulatory restrictions on advanced practice by nurses, physician assistants, pharmacists, and other health care professionals.

The report emphasizes reforms that can meaningfully engage communities most affected by racial and ethnic inequities, whose involvement in the design of health care systems is so instrumental to achieving equitable care. To this end, the report recommends that community health centers and hospitals expand their use of community health assessment data and align their approach to practice design with the evidence that such assessments reveal. The report underscores the value of investing in community-engaged research and training clinicians and scientists to undertake such research by ensuring an adequate research infrastructure and programs to develop clinicians and researchers with expertise in health equity, structural racism, and health-related social needs.

The report devotes considerable attention to the research enterprise overseen by the National Institutes of Health. It recommends that the National Institute on Minority Health and Health Disparities (NIMHD) lead agency-wide efforts to prioritize health equity research, while recognizing historical commitments to health equity research by other institutes such as the National Institute of Nursing Research (NINR), as indicated by the proportion of their budgets allocated to research specifically addressing health equity. (In this regard, a notable exemplar is the new NINR strategic plan that prioritizes health equity research and significantly departs from more traditionally based research expenditures and priorities, which have fallen short in generating evidence to eliminate health care and health inequities.) It is worth noting that the institutes that have historically prioritized health equity research typically have less funding to allocate than their counterparts.

Bolstering Systemwide Accountability

Systemwide accountability assumes a critical role in the report. Accountability demands more muscular policies and enforcement by key federal agencies. This includes the HHS Office for Civil Rights; the office’s ability to truly operationalize Section 1557 of the ACA, which prohibits discrimination based on race, color, national origin, age, sex, and disability, requires a level of funding that can enable data collection and evaluation, oversight, training, technical assistance, and support to individuals who must navigate the complexities of a challenging complaint process. Accountability also means transparency in the Section 1557 process for investigating and resolving civil rights complaints, using an accessible website that fosters public confidence in the systemwide civil rights framework for health care.

The report also highlights that the need for greater accountability applies to the nation’s nonprofit hospitals, which enjoy immensely valuable tax-exempt status. Implementing this accountability will require greater oversight of resources for the Internal Revenue Service (IRS) to ensure that tax-exempt hospitals use community health assessment data to shape their community benefit spending priorities, especially investments that align expenditures and care with health and health care needs prioritized by the communities they serve.

The report underlines that accountability extends beyond more impactful federal policy. It also requires that the various health professions ensure that their curricula and training emphasize content, and address an approach to health care, consistent with eliminating health inequities. To this end, the report recommends that the health care professions and their respective state licensing boards adopt a process for initial licensure and renewal that requires demonstrated knowledge and expertise in evidence-based clinical and organizational practice strategies to eliminate health care inequities. These strategies should reflect expertise in multi-level approaches across individual, institutional, and broader societal levels.

Finally, the report stresses the vital need for federal legislative reforms that build on the ACA and guarantee a pathway to insurance coverage for all people in the US. The report concludes that the goal of health equity cannot be met without assuring that everyone has stable, affordable insurance coverage, given the foundational role of continuous and comprehensive health care financing as the starting point for all other reforms.

A Vision For The Future: Achieving Health Equity And Optimal Health For All

To achieve an equitable future of health in the US, an extensive reimagining of the health care system itself is needed. Our current system is overly focused on the provision of sick care with an insufficient emphasis on health promotion and disease prevention, which in turn leads to the unnecessarily high costs and poor outcomes that have long characterized US health care. The current lopsided approach to health care is most strikingly visible in the nation’s systematic underinvestment in primary care and overinvestment in the highest-cost procedures, to the detriment of investments that could maximize the health of all individuals and populations.

Ample evidence suggests that optimizing health for all people will require prioritizing illness prevention and health promotion in health care. This means empowering the health care system to pursue a person-centered care model built on strong relationships between clinicians and patients, one that utilizes an integrated, interprofessional workforce in the design and delivery of the most efficacious care. Such a model is capable of “whole person” strategies instead of disjointed, sporadic responses that emphasize managing and treating specific diseases.

Reaching such a goal will require that health professions training and education programs design their curricula, clinical practicums, and work rotations to instruct the future health care workforce in new health care delivery models. Similarly, emphasis must be placed on ensuring that clinical practices and advanced technologies reduce rather than exacerbate health care inequities.

Ultimately, attaining the goals outlined in Ending Unequal Treatment will require a society-wide embrace of health equity, the deployment of all of the tools society possesses to achieve the goal of equity, and the political commitment to push forward.

Article by Vincent Guilamo-Ramos, Francis K. Amankwah, Kosali Simon, John Ayanian, Margarita Alegrìa, Sara Rosenbaum; Health Affairs