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How the U.S. can close longstanding racial health equity gaps

Access to insurance, better enforcement and more data will be key to addressing the nation's health equity woes.

The United States knows it has a health equity problem, but according to a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM), the nation isn't making much progress in closing health disparities.

Two decades after the landmark report "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," which NASEM published under its previous moniker, the Institute of Medicine, this latest publication contends that the U.S. needs to improve access to insurance coverage, boost enforcement of institutions limiting health equity and increase data collection and research about health disparities.

"When the Institute of Medicine (now named National Academy of Medicine) released its landmark 'Unequal Treatment' report in 2002, we shed light on the fact that your race could determine the quality of the care you receive," said Victor J. Dzau, president, National Academy of Medicine, in a statement.

"Twenty years later, it is clear that our nation has not made enough progress," Dzau added. "There are still major inequities inherent in the health care system. It is imperative that we achieve equitable health for all by committing to pursuing and implementing the goals and actions laid out in this new report."

U.S. healthcare still defined by health inequity

The NASEM report drew on ample evidence suggesting that health disparities are still the hallmark of the U.S. healthcare system. The U.S. has the worst health disparities compared with 11 other high-income nations, according to data from the Commonwealth Fund and cited in the NASEM report.

Those health disparities are latent across various disease states. Per NASEM, American Indian/Alaska Native (AI/AN) people are more likely than any other race or ethnicity to have diabetes at a rate of 13.6%. Around one in 10 (12.1%) of Black people have diabetes, while 11.7% of Hispanic people and 9.1% of Asian people do, too. White people are the least likely to have diabetes at a rate of 6.9%.

And yet, non-white people are less likely to receive the latest drugs or technologies used to treat diabetes, translating into poorer outcomes. NASEM said Black patients with diabetes see hospitalization rates more than 2.5 times those of white patients.

Racial and ethnic minorities also face barriers in their overall healthcare experiences. Racial/ethnic minorities are less likely to have a usual source of care, NASEM said. Separate data has shown that Black patients see longer emergency department wait times.

These racial and ethnic health disparities are likely the result of institutional inequities, NASEM suggested.

Certain healthcare institutions, like health insurance, have structural differences that can perpetuate health inequities latent in U.S. healthcare for decades. For example, poorer access to care among Medicaid members versus those covered by Medicare or private insurance can perpetuate health disparities.

These health inequities come with a high cost, NASEM added, such as premature deaths, loss of years of life and loss of economic productivity. Some reports estimate that racial health disparities cost the U.S. $451 billion annually. The cost of racial mental health disparities reached around $278 billion between 2016 and 2020, a separate analysis showed.

"Eliminating health care inequities is an achievable and feasible goal, and improving the health of individuals in the nation's most disadvantaged communities improves the quality of care for everyone," said Georges C. Benjamin, co-chair of the committee that wrote the newest NASEM report, and executive director of the American Public Health Association, in a press release. "This is not a zero-sum game -- we are all in this together."

The path to closing health disparities

NASEM outlined five key goals that could help move the needle on racial health disparities.

First, the report authors called for better data about health inequities. For example, the federal Office of Management and Budget should increase enforcement of federal healthcare and research programs required to collect race, ethnicity, tribal affiliation and language data.

Second, Congress should aid health and hospital systems in designing interventions to end health disparities. This means allotting more funding that can support these programs.

NASEM's third goal of investing in more research into effective health inequity interventions can supplement those interventions. This will require more funding for research about health inequities, structural racism and social determinants of health.

Fourth, NASEM called for greater enforcement of existing laws intended to close health disparities. This means providing more funding and resources to the offices tasked with enforcement. For example, greater funding for the Office for Civil Rights at HHS could help it with its oversight responsibilities.

Better HHS funding could also help the department enforce items in the Affordable Care Act.

Finally, NASEM called on Congress to create better pathways for equitable access to health insurance coverage. With the tacit suggestion that the nation's lack of universal health coverage has carved out many of its health inequities, NASEM stated that comprehensive insurance for all would be a key step forward.

"Many of the tools needed to reach these goals are already available and need to be fully used," said committee co-chair Jennifer DeVoe, professor and chair of family medicine, at Oregon Health and Science University. "And with concerted national effort and adequate resources, the health care system can be transformed to deliver high-quality, equitable care to all."

Sara Heath has covered news related to patient engagement and health equity since 2015.

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