Editor’s Note: This is the first in a series of posts on health and health care disparities that Health Affairs Blog is publishing in conjunction with the new March/April issue of Health Affairs on Disparities: Expanding The Focus, published with support from The Robert Wood Johnson Foundation. The series will also feature posts from Richard Epstein, Dora Hughes, Tom Miller, and Robin Weinick and Nancy Kressin.
Curiously absent from the debate among presidential candidates is the issue of health and health care inequality. These problems hit some groups hard but affect all of us, and they are ultimately everyone’s business — particularly so for the president and federal government. But public awareness of the problem is low, and political leaders rarely raise the issue without offering more than hand-wringing as a way to solve it.
Our country’s strong market and individualist orientation limits the public’s ability to understand the extent, causes, and consequences of health and health care inequality. The two problems are related but should be distinguished. Health inequality — differences in health status among population groups — tends to be reduced in news media reporting to problems of bad genes or bad behavior, while health care inequality — group differences in access to and quality of health care — only occasionally bursts in to the public’s consciousness with splashy headlines.
Six years ago this month, an Institute of Medicine report, Unequal Treatment, was part of the occasional national conscience-pricking. It concluded, after an exhaustive review of the literature, that many people of color receive lower quality of care than whites, even when presenting with the same health problems and the same health insurance. As the report’s study director, I was pleased to see that Unequal Treatment prompted a sober discussion in health policy, academic, and political circles. But ultimately the report failed to prompt passage of significant new federal legislation or spur the Department of Health and Human Services to adopt its core recommendations.
As a result, little has been done, in my view, to systematically address the problem. To a great extent, health care is still separate and unequal along racial and ethnic lines, as demonstrated by the papers in the March/April 2008 issue of Health Affairs by Darrell Gaskin and his colleagues and by Ashish Jha and colleagues. Some of the most shocking health care gaps — not as well documented when Unequal Treatment was released — are found in mental health care, as Tom McGuire and Jeanne Miranda show, and oral health care, as Susan Fisher-Owens (free access for two weeks) and her colleagues document. And since 1980, the biggest gains in mortality and life expectancy occurred mostly among the best-educated Americans, as Ellen Meara and colleagues discuss.
The costs of inaction are high. People who face health and health care inequality suffer needlessly from poor health and premature death and are at risk for financial ruin. Health inequality stunts the nation’s productivity and economic growth. In the March/April issue, Nicole Lurie and her colleagues explore how these rationales for action play among different health equity stakeholders, such as health care systems, and conclude that the social argument is as important as the economic case.
The lack of federal action leads me to believe that state and local governments are well positioned to tackle the issue as part of broader health care reform efforts. My article in the special Health Affairs issue explores how states can do this, particularly in the context of health insurance expansions, by, for example, creating mechanisms for public and consumer accountability. Other local initiatives — such as the Los Angeles Healthy Kids program documented by Ian Hill and his colleagues — have proven successful in providing insurance coverage for eligible children, even as tight budgets limit their reach.
The impact of residential segregation on health. More important to eliminating health inequality are strategies that address the fundamental social and economic determinants of health. Chief among these is the problem of residential racial and ethnic segregation. Many U.S. cities are as segregated (and in some cases, more so) than Apartheid-era South Africa. Majority-minority communities face a host of health risks, such as poorer nutritional resources, poorer job and educational opportunities, higher levels of crime and violence, fewer and lower-quality health-care facilities, and greater levels of exposure to environmental toxins.
Several papers in the issue show how inequality and segregation matter for health. Dolores Acevedo-Garcia and her colleagues document the impact of neighborhood opportunity on children’s health and development, and they conclude that expanding opportunity should be seen as an important public health intervention. Sarah Gehlert and her colleagues offer an interdisciplinary model — with concrete examples — of how upstream social factors “get under the skin” to produce health inequality. And Len Syme — a pioneer in social determinants research — argues that scholarship can build public understanding of and support for strategies to address inequality to promote the public’s health.
A new focus on the nonmedical determinants of health. This shift among scholars, policymakers, health foundations, and advocates to focusing on social and economic determinants of health is the most important development in efforts to eliminate health inequality. It will receive a big push as a new four-part documentary, “Unnatural Causes,” produced by an award-winning team at the California Newsreel, is aired on many national public television stations this spring and as the Robert Wood Johnson Foundation’s Commission to Build a Healthier America rolls out a series of programs and events that will focus attention on socioeconomic health gradients.
But the nation must do more. A call to action can start with our political leaders, notably those still in the mix for the presidency. Researchers and policy analysts, such as those who’ve contributed to this volume, have already provided more than enough fodder for a robust national dialogue.