In terms of both health and health care, America is an unequal nation. There are well-documented differences in health between whites and racial and ethnic minorities—for example, in life expectancy. There are also demonstrable differences in health care provided to people of different races and ethnicities—for example, in screening rates for cancers.
Despite these gaps, awareness of racial and ethnic health disparities remains low among the general public, including racial and ethnic minorities, according to an article in the October 2011 issue of Health Affairs by Jennifer K. Benz and colleagues from the NORC at the University of Chicago. This thematic issue of the journal, “Agenda For Fighting Disparities,” was produced with a grant from the Aetna Foundation. It examines the state of health and health care disparities in the nation and examines steps that show promise in closing the gaps.
In conjunction with the Robert Wood Johnson Foundation, Health Affairs has also published a Health Policy Brief, “Achieving Equity In Health,” to accompany the October issue.
Extent of the Problem
Roughly 6 in 10 (59 percent) of Americans say they are aware of overall racial and ethnic disparities in health, up from 55 percent a decade earlier, according to a recent survey whose results are reported by Benz and coauthors. Yet the public is far less aware of disparities in particular disease conditions. Only 54 percent of African Americans are aware of disparities in the rate of HIV/AIDS between African Americans and whites, and only 21 percent of Hispanics or Latinos are aware of those disparities between their group and whites. These findings show that much work remains to be done to increase awareness and mobilize action.
Other articles in this issue of Health Affairs examine different facets of the problem:
- Howard K. Koh, assistant secretary for health, and colleagues at the U.S. Department of Health and Human Services (HHS) describe the agency’s Action Plan to Reduce Racial and Ethnic Health Disparities. The nation’s most comprehensive federal commitment to reducing disparities to date, the plan will advance five major goals: transforming health care; strengthening the infrastructure and workforce of the nation’s health and human services; advancing Americans’ health and well-being; promoting scientific knowledge and innovation; and upholding the accountability of HHS for making demonstrable progress. They also identify opportunities to address health disparities through the Affordable Care Act of 2010 (ACA).
- Safety-net hospitals and community health centers are poised to play a critical role in the care of racial and ethnic minorities under new provisions set forth in the Affordable Care Act. Yet some aspects of the health reform law could disrupt these providers’ historical role and harm their financial viability. An analysis by Dennis P. Andrulis of the Texas Health Institute and the University of Texas School of Public Health and Nadia J. Siddiqui of the Texas Health Institute assesses the dangers, including the possibility that increased competition for newly insured Medicaid patients could take business from safety-net clinics and hospitals.
Social and Environmental Factors That Contribute to Health Disparities
- The health care that people receive makes only a minimal contribution to their overall health; social determinants such as education, income, and social environments—factors outside of the health care system—are far more important. Steven H. Woolf of Virginia Commonwealth University’s Center on Human Needs and Paula Braveman of the Center on Social Disparities in Health at the University of California, San Francisco, write in this issue of Health Affairs that greater attention needs to be focused on the root causes of the disparities. Strengthening schools, reducing unemployment, stabilizing the economy, and restoring neighborhoods will advance the health of millions, they say. By contrast, current moves to scale back social and economic programs to reduce government spending might expose Americans to even greater illness and raise health care costs.
- Thomas LaVeist and colleagues from the Johns Hopkins Bloomberg School of Public Health, emphasize the importance of “place” over race in contributing to health or illness. They report on their study of a racially integrated low-income neighborhood in Baltimore, Maryland, and find that disparities in hypertension, diabetes, smoking, and other factors either vanished or substantially narrowed. “When social factors and medical care are equalized, racial disparities are minimized,” the authors write. The authors suggest that policy makers may be able to mitigate the impact of place on health disparities by helping to build healthy and safe communities.
- Significant differences exist in mortality between rural and urban populations, according to a new study by Janice Probst and colleagues from the University of South Carolina Arnold School of Public Health. The study indicates an increased risk of death among rural whites and minorities, compared to urban whites and blacks, and suggests that the higher risk is related to such characteristics as low education, level of income, and lack of private health insurance. The authors suggest that public health agencies routinely monitor rural minority populations and that resources be put toward improving the accessibility of health insurance for these populations.
- Researchers are just beginning to learn how cumulative risks in the environment may build up and contribute to minorities’ poorer health. Margaret Hicken of the University of Michigan and colleagues examined the medical literature, and report in this issue of Health Affairs on the emerging evidence of links among stress, lead exposure, and the higher rates of high blood pressure in blacks than in whites. The authors say federal and state agencies and research institutions should develop strategic plans to learn more about these connections and apply the broader findings to policies to improve health disparities.
- Fifty-four million people in the United States currently live with disabilities, notes author Lisa I. Iezzoni of Massachusetts General Hospital, who says that eliminating health and health care disparities in this population should be a national priority. The number of people with disabilities is set to grow substantially in the next 30 years as the baby-boom generation ages and children and young adults face complications related to overweight and obesity. People with disabilities confront disparities in their use of preventive and other health services, and health care professionals often get little training in how to care for people with disabilities.
Narrowing the Gaps in Health Disparities
- J. Emilio Carrillo of NewYork-Presbyterian Hospital, and colleagues, report on early evidence of success from a network of “medical homes” in a mostly Hispanic region of New York City. The coordinated care offered by the medical homes in the Washington Heights-Inwood community helped keep residents healthier and prevented trips to the hospital’s emergency department for crisis care.
- Thomas D. Sequist of the Harvard Medical School and Brigham and Women’s Hospital and coauthors report on how the Indian Health Service has started to address health disparities affecting American Indians and Alaska Natives. The service is using culturally tailored disease prevention and management programs, as well as technologies such as telemedicine.
- Interpreter services offered to patients with limited English skills can improve the quality of care—yet many health care providers still do not provide these services because of the perceived high cost. Elizabeth A. Jacobs of the University of Wisconsin School of Medicine and Public Health and her colleagues calculated the costs incurred by a group of California hospitals that formed a network to offer interpretation services using teleconference or video technology. The authors found that the service cost just $25 per patient encounter—a small price to pay to help physicians better communicate with their patients with limited English skills.
- Henry Pollack of the New York University School of Medicine and coauthors analyzed the results of a pilot program for Asian Americans in New York City that offered education outreach, free screening, vaccination and low- or no-cost treatment for Asian Americans. The program screened almost 9,000 people at-risk for hepatitis B and identified 1,365 infected individuals who were provided with follow-up care to prevent complications of this chronic infection. The pilot, the largest citywide program of its kind, could be used as a prototype “for addressing hepatitis B disparities across the United States,” the authors conclude.