Addressing Racial and Ethnic Health and Health Care Inequities: The Imperative to Achieve Equity Brian D. Smedley, Ph.D. Vice President & Director Health Policy Institute Joint Center for Political and Economic Studies September 18, 2009

Health reform debates in Congress have focused the nation`s attention on the need to improve health-care quality, contain spiraling health-care costs, and expand health insurance coverage. Largely absent from the debate, however, has been discussion of the need to eliminate racial and ethnic health and health care inequities. Arguably, we can`t achieve the broader goals of health reform without attending to equity issues.

Many racial and ethnic minorities experience poorer health relative to national averages from birth to death, in the form of higher infant mortality, higher rates of disease and disability, and shortened life expectancy. Health inequities carry a significant human and economic toll and therefore have important consequences for all Americans. Health inequities impair the ability of minority Americans to participate fully in the workforce, thereby hampering the nation`s efforts to recover from the current economic downturn and compete internationally. Because many people of color are disproportionately burdened with unmet health care needs, these inequities also limit our ability to contain health care costs and improve overall health care quality. And by the year 2042, about half of all Americans will be people of color, which means that their health status increasingly defines the nation`s health. It is therefore important that policymakers view the goal of achieving equity in health and health care not as a `special interest,` but rather as an important central objective of any health reform legislation.

America`s Health Rankings affords an opportunity to examine health and health care inequities, and provides a forum for discussion of solutions. This commentary will review the extent and causes of health inequities, and offer solutions focusing on the four components of health addressed in America`s Health Rankings-behaviors, community and environment, public and health policy, and clinical care.

The Extent of Health and Health Care Inequities

While the nation has made progress in lengthening and improving the quality of life, racial and ethnic health inequities are stubbornly persistent, and in some cases are increasing. These inequities begin early in the life span and exact a toll throughout the life-course. For example:

• While the life expectancy gap between the African Americans and whites has narrowed slightly in the last two decades, African Americans still can expect to live 6-10 fewer years than whites, and face higher rates of illness and mortality.
• The prevalence of diabetes among American Indians and Alaska Natives is more than twice that for all adults in the United States;
• Among African Americans, the age-adjusted death rate for cancer is approximately 25 percent higher than for white Americans;
• Although infant mortality decreased among all races during the 1980-2000 time period, the black-white gap in infant mortality widened; and

In terms of lives, this gap is staggering: A recent analysis of 1991 to 2000 mortality data concluded that had mortality rates of African Americans been equivalent to that of whites during this time period, over 880,000 deaths would have been averted.

People of color also experience significant disparities relative to whites in both access to care and in the quality and outcomes of care received. The National Healthcare Disparities Report (NHDR), prepared and released annually by the U.S. Agency for Healthcare Research and Quality, find persistent problems with access to health care for minority Americans relative to whites. Latinos experienced the greatest access problems of all ethnic groups; they received equivalent care as whites in only 17 percent of the measures, while the remaining access measures were overwhelmingly poorer for Latinos (83 percent). With regard to health care quality, minority groups again faired poorly relative to whites: African Americans and Latinos received poorer quality care than whites on 73 percent and 77 percent of measures, respectively, and Asian Americans and American Indians received poorer care on 32 percent and 41percent of measures, respectively.

Eliminating Health and Health Care Inequality

Health and health care inequities are complex problems rooted in systemic racial and ethnic inequality that is embedded in multiple institutions. Their elimination will require a long-term commitment and investment to address multiple problems, involving many public and private stakeholders. Four components of health identified in America`s Health Rankings offer an important framework for intervention.

Research clearly demonstrates that good health behaviors-such as eating nutritious foods, having an active lifestyle, and avoiding risky behaviors such as drug and alcohol use and unprotected sexual intercourse-are important to prevent illness and extend life. Some racial and ethnic minorities are at risk for poor health behaviors, which are often reinforced by community conditions (e.g., having limited food options in the community) and social norms. Several educational strategies, however, can help improve awareness of healthful behaviors, and community-based primary prevention (discussed below) can create conditions in which healthy lifestyles are easier to maintain.

Promote Patient Education and Health Literacy. Several major health systems are developing and assessing the efficacy of patient education programs, such as health literacy and navigation programs, and are replicating effective strategies. Patient education programs commonly seek to help patients understand how to best access health care services and participate fully in treatment plans. Such efforts are most effective when designed in partnership with target populations and when language, culture and other concerns faced by communities of color are fully addressed.

Promote the Use of Lay Health Navigators. Health departments and systems can support the training of and reimbursement for community health workers, sometimes also known as `lay health navigators` or promotores, who can serve as a liaison between health care institutions and their patients. Community health workers are trained members of medically underserved communities who work to improve community health outcomes. Several community health worker models train individuals to teach disease prevention, conduct simple assessments of health problems and help their neighbors access appropriate health and human resources.

Health inequities are largely the by-product of socioeconomic inequality and community-level conditions that shape health. Several policy approaches can improve these social determinants of health in ways that provide broad returns to society. These include efforts to:

• Create incentives for better food resources and options in underserved communities (e.g., grocery chains, `farmers` markets`). Several local jurisdictions have established public-private partnerships to bring supermarkets to underserved areas. For example, Pennsylvania`s `Fresh Food Financing Initiative` supports the development of supermarkets and other food retailers in urban and rural communities that lack adequate access to supermarkets.
• Develop community-level interventions for health behavior promotion (e.g., smoking cessation, exercise). Such programs are often vital for low-income communities and communities of color, which have fewer community resources for exercise (e.g., safe public parks and recreation centers), effective nutrition and reduction of individual health risks (e.g., low-income urban communities have more public advertisement of tobacco products and greater availability of alcohol).
• Address environmental injustice (e.g., by aggressive monitoring and enforcement of environmental degradation laws). Racial and ethnic minority communities are disproportionately affected by the presence of toxic waste dumps, and industrial and occupational hazards. Through legal and regulatory strategies, state and federal agencies can reduce environmental health risks and monitor whether and how communities are affected by governmental or commercial activity.

Public policies across a range of sectors-including education, housing, transportation, criminal justice-have important implications for population health. Policymakers should therefore assess the potential health consequences of policies, particularly regarding vulnerable populations. In addition, mechanisms exist to strengthen the voices of a range of community stakeholders to assess community health care needs and encourage a better distribution of health care resources.

Addressing Health and Equity in All Policies. As noted above, health inequities are driven largely by social and economic inequality and unhealthful living conditions. Developing strategies to address these conditions requires an understanding of how policies, practices, and programs regarding transportation, housing, education, employment, the environment and other sectors shape health and health inequities. Health Impact Assessments (HIA) can help policymakers understand how policies and projects in a range of sectors influence health, and to consider options to enhance health and/or mitigate potential negative health influences. HIA is being used in a number of jurisdictions around the country, and brings public health issues to the attention of policymakers in areas that fall outside of traditional public health arenas, such as transportation or land use.

Promote Community-Based Health Care Planning. Community health planning is a process in which members of the community identify their needs and assist policymakers in planning, implementing, and evaluating the effectiveness of public health care systems. Community health planning seeks to strengthen communities to play a greater role in their own health, actively involving residents in the planning, evaluation and implementation of health activities in their communities. Some states, such as New York, are examining strategies to reinvigorate HSAs and to include disparities reduction efforts as part of the mission of these planning agencies.

Clinical care for racial and ethnic minorities is, on average, inferior to that received by whites, as noted above. But several strategies can improve the quality of care for minorities. These strategies have the potential to improve the accountability of health care systems to patients and employers, and reduce health care costs and improve quality for all patients by encouraging greater use of evidence-based guidelines and by rewarding the provision of cost-effective primary care.

Collect and Monitor Data on Disparities. State and federal contracts and policies are increasingly requiring all public and private health systems to collect data on patients` race, ethnicity, gender, primary language and educational level, and to monitor for inequality in access to needed services and in the quality of care received. Currently, federal and state data collection efforts with regard to health care disparities are inconsistent. Federal and state governments should utilize their leverage as regulators, payers and plan purchasers to encourage all health systems to collect and report data using consistent standards.

Adopt Cultural and Linguistic Standards. To ensure truly accessible health care, health care systems must also be responsive to patients` cultural and linguistic needs. The federal Cultural and Linguistic Access Standards (CLAS) identify over a dozen benchmarks that have been widely accepted and increasingly adopted by health systems and providers. CLAS standards are intended to improve the cultural competence of health systems and increase the likelihood that patients of color will have access to satisfactory health care. In addition, some jurisdictions are requiring cultural competency training for all health care professionals as a condition of licensure. As of 2005, for example, New Jersey required that all physicians practicing in the state must attain minimal cultural competency training as a condition of licensure.

Encourage Attention to Disparities in Quality Improvement. Health care quality improvement efforts, such as pay-for-performance or performance measurement, are gaining increasing attention. But they can unintentionally deepen health care access and quality gaps. Because underserved communities are typically sicker and face greater barriers to treatment compliance, performance measurement can inadvertently dampen provider enthusiasm for treating low-income communities or communities of color. Quality improvement efforts should take into account the challenges and needs of underserved communities and reward efforts that reduce disparities and improve patient outcomes relative to baseline measures. Some quality improvement measures adjust for patient case mix or emphasize disparities reduction efforts, to avoid unfairly penalizing providers while holding them and health systems accountable for improvements in health outcomes.

Conclusion

Health and health care access and quality are more often compromised for racial and ethnic minorities than for whites. These disparities have a long history in the United States and are both a symptom of broader structural inequality and a mechanism by which disadvantage persists. Moreover, they carry a significant human and economic toll. Addressing these inequities requires comprehensive strategies that span community-based primary prevention to clinical services, a long-term commitment and investment of resources, and a focus on addressing equity in all federal programs and in all elements of health reform legislation. To fail to do so ignores the reality of important demographic changes that are happening in the United States, and fails to appreciate the necessity of attending to equity as a necessary step to help achieve the goals of expanding insurance coverage, improving the quality of health care, and containing costs.

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Ibid.
Ibid.
Woolf SH, Johnson RE, Fryer GE, Rust G, and Satcher D. 2004. The health impact of resolving racial disparities: An analysis of US mortality data. American Journal of Public Health, 94(12): 2078-2081.
National Healthcare Disparities Report, 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhdr06/nhdr06.htm, accessed June 28, 2007.
National Healthcare Disparities Report, 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhdr06/nhdr06.htm, accessed June 28, 2007.