Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Ending Unequal Treatment Strategies to Achieve Equitable Health Care and Optimal Health for All Georges C. Benjamin, Jennifer E. DeVoe, Francis K. Amankwah, and Sharyl J. Nass, Editors Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care Board on Health Care Services Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPYâUncorrected Proofs Consensus Study Report
NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by the National Institutes of Health and the Agency for Healthcare Research and Quality through a contract between the National Academy of Sciences and the National Institutes of Health (Contract Number: HHSN263201800029I, Task Order Number: 75N98022F00012). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/27820 This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2024 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2024. Ending unequal treatment: Strategies to achieve equitable health care and optimal health for all. Washington, DC: The National Academies Press. https://doi.org/10.17226/27820. PREPUBLICATION COPYâUncorrected Proofs
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPYâUncorrected Proofs
Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the studyâs statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committeeâs deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPYâUncorrected Proofs
COMMITTEE ON UNEQUAL TREATMENT REVISITED: THE CURRENT STATE OF RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE GEORGES C. BENJAMIN (Cochair), Executive Director, American Public Health Association JENNIFER (JEN) E. DEVOE (Cochair), John and Sherrie Saultz Professor and Chair, Department of Family Medicine, Oregon Health & Science University MARGARITA ALEGRIA, Chief of the Disparities Research Unit at Massachusetts General Hospital; Harry G. Lehnert, Jr. and Lucille F. Cyr Lehnert Endowed Chair, Mass General Research Institute; Professor, Departments of Medicine and Psychiatry, Harvard Medical School JOHN ZAVEN AYANIAN, Alice Hamilton Distinguished University Professor of Medicine and Healthcare Policy; Director, Institute for Healthcare Policy and Innovation, University of Michigan ELAINE E. BATCHLOR, Chief Executive Officer, MLK Community Hospital and MLK Community Healthcare DARRELL J. GASKIN, William C. and Nancy F. Richardson Professor in Health Policy; Director, Hopkins Center for Health Disparities Solutions, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health VINCENT GUILAMO-RAMOS, Dean and Bessie Baker Distinguished Professor of the Duke University School of Nursing; Vice Chancellor for Nursing Affairs, Duke University; Director, Center for Latino Adolescent and Family Health, Duke University (through October 2023); Executive Director, Institute for Policy Solutions, Johns Hopkins School of Nursing (from November 2024) VALARIE BLUE BIRD JERNIGAN, Professor of Rural Health and Medicine; Director, Center for Indigenous Health Research and Policy; Oklahoma State University Center for Health Sciences THOMAS A. LAVEIST, Dean and Weatherhead Presidential Chair in Health Equity, School of Public Health and Tropical Medicine, Tulane University MONICA E. PEEK, Ellen H. Block Professor of Health Justice, Section of General Internal Medicine; Associate Director, Chicago Center for Diabetes Translation Research, The University of Chicago Pritzker School of Medicine BRIAN M. RIVERS, Director, Cancer Health Equity Institute; Professor, Community Health and Preventive Medicine, Morehouse School of Medicine v PREPUBLICATION COPYâUncorrected Proofs
SARA ROSENBAUM, Professor Emerita of Health Law and Policy, Milken Institute School of Public Health, George Washington University RUTH S. SHIM, Luke & Grace Kim Professor in Cultural Psychiatry, Department of Psychiatry & Behavioral Sciences; Associate Dean of Diverse and Inclusive Education, University of California, Davis School of Medicine KOSALI I. SIMON, Distinguished Professor and Herman B. Wells Professor; OâNeill Chair and Associate Vice Provost of Health Sciences, OâNeill School of Public and Environmental Affairs, Indiana University Bloomington PAUL C. TANG, Adjunct Professor, Clinical Excellence Research Center, Stanford University REGINALD TUCKER-SEELEY, Vice President of Health Equity, ZEROâThe End of Prostate Cancer (through November 2023); Principal and Owner, Health Equity Strategies and Solutions (from November 2023) CONSUELO HOPKINS WILKINS, Senior Vice President for Health Equity and Inclusive Excellence, Professor of Medicine, Vanderbilt University Medical Center Study Staff FRANCIS AMANKWAH, Responsible Staff Officer CHIDINMA CHUKWURAH, Senior Program Assistant AMIRA DAOUD, Research Associate ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice SHARYL NASS, Senior Director, Board on Health Care Services Board on Population Health and Public Health Practice Liaison JOSHUA A. SALOMON, Professor of Health Policy, Department of Health Policy, School of Medicine, Center for Health Policy, Freeman Spogli Institute for International Studies; Director, Prevention Policy Modeling Lab, Stanford University National Academy of Medicine Fellows ALICIA COHEN, James C. Puffer, M.D./American Board of Family Medicine NAM Fellow; Core Investigator, VA Providence Healthcare System; Assistant Professor of Family Medicine Alpert Medical School, Brown University; Assistant Professor of Health Services, Policy, and Practice, Brown University School of Public Health vi PREPUBLICATION COPYâUncorrected Proofs
TRACY E. MADSEN, American Board of Emergency Medicine NAM Fellow; Associate Professor, Department of Emergency Medicine, Alpert Medical School of Brown University; Associate Professor, Department of Epidemiology, Brown University School of Public Health; Vice Chair of Research, Brown Emergency Medicine Editorial Consultant JOE ALPER vii PREPUBLICATION COPYâUncorrected Proofs
PREPUBLICATION COPYâUncorrected Proofs
Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: ZINZI BAILEY, University of Minnesota JULIE A. BALDWIN, Northern Arizona University ASAF BITTON, Ariadne Labs, Harvard T.H. Chan School of Public Health MARSHALL CHIN, University of Chicago LISA A. COOPER, Johns Hopkins University PATRICK H. DELEON, Uniformed Services University; past President American Psychological Association ALICIA FERNANDEZ, University of California, San Francisco SUSAN T. FISKE, Princeton University ERNEST J. GRANT, Duke University School of Nursing TIMOTHY S. JOST, Washington and Lee University School of Law KAMERON L. MATTHEWS, Cityblock Health ix PREPUBLICATION COPYâUncorrected Proofs
x REVIEWERS LASHAWN MCIVER, American Health Insurance Plans (AHIP) ROBERT L. PHILLIPS, American Board of Family Medicine ERIC T. ROBERTS, University of Pennsylvania, Perelman School of Medicine URMIMALA SARKAR, University of California, San Francisco TIFFANY VEINOT, University of Michigan Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ELLEN W. CLAYTON, Vanderbilt University Medical Center, and JOSÃ A. PAGÃN, New York University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the stan- dards of the National Academies and that all review comments were care- fully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPYâUncorrected Proofs
Acknowledgments This Consensus Study Report would not have been possible without the invaluable contributions from many experts and stakeholders dedicated to eliminating health and health care inequities. The committee would like to thank all the speakers and participants who played a role in the virtual public meetings conducted for this study and the many others who provided valued insight. The public meeting speakers, with their affiliations at the time of their presentations to the committee, are listed in Appendix C. The committee appreciates the sponsors of this study for their gener- ous financial support: Agency for Healthcare Research and Quality and the National Institutes of Health (National Institute on Minority Health and Health Disparities; National Institute of Nursing Research; National Insti- tute of Diabetes and Digestive and Kidney Diseases; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; National Institute of Neurological Disorders and Stroke; National Institute of Allergy and Infectious Diseases; National Institute of Child Health and Human Devel- opment; and National Institute on Aging). The committee would especially like to thank Dr. Richard Valdez (Agency for Healthcare Research and Quality), Dr. Eliseo Perez-Stable (National Institute on Minority Health and Health Disparities), Dr. Monica Webb Hooper (National Institute on Minority Health and Health ÂDisparities), and the persons instrumental in overseeing the initial writ- ing of the study statement of task including Dr. Gniesha Y. Dinwiddie, PhD (National Institute on Minority Health and Health Disparities), Dr. ÂRichard Benson, MD, PhD (National Institute of Neurological Disorders and Stroke), Dr. Tessie October, MD, MPH (National Institute of Child xi PREPUBLICATION COPYâUncorrected Proofs
xii ACKNOWLEDGMENTS Health and Human Development), Dr. Jenna Norton, PhD, MPH (National Institute of Diabetes and Digestive and Kidney Diseases), Dr. Elizabeth Tarlov, PhD, RN (National Institute of Nursing Research), and Dr. Xinzhi Zhang, MD, PhD, FACE (Agency for Healthcare Research and Quality). The committee also thanks the NAM Kellogg Health of the Public Fund for funding the consensus reportâs dissemination. The committee gives special thanks to Kevin ÂFiscella and Mechelle Sanders at University of Rochester, Daniel Dawes at Meharry Medical College, and Josemiguel (José) RodrÃguez at the George ÂWashington University Law School for their contributions to the commissioned papers to inform the committeeâs work. The committee is grateful for the many staff within the National Academies who provided support at various times throughout this project. PREPUBLICATION COPYâUncorrected Proofs
Contents ACRONYMS AND ABBREVIATIONS xvii PREFACE xxv SUMMARY 1 1 UNEQUAL TREATMENT: 20 YEARS AFTER 17 Impact of the 2003 Unequal Treatment Report, 20 The U.S. Health Care System Continues to Perform Poorly, 23 The Economic Burden of Persistent Inequities, 26 Study Charge, 27 Study Approach, 30 Looking Back and Looking Forward, 39 Structure of the Report, 46 References, 47 2 THE HEALTH CARE SYSTEM WITHIN A LARGER SOCIETAL SYSTEM 49 Structural Determinants of Health, 51 Oppression and Structural Racism, 54 Social Determinants of Health (SDOH), 58 NonâHealth Care Sector Partnerships and Community, 66 Societal Commitment to Equity, 67 Chapter Summary, 68 References, 69 xiii PREPUBLICATION COPYâUncorrected Proofs
xiv CONTENTS 3 EVIDENCE OF RACIAL AND ETHNIC INEQUITIES IN HEALTH CARE 79 Inequities in Access to and Use of Health Care, 79 Summary of Evidence of Racial and Ethnic Inequities in Selected Health Conditions, 86 Impact of Place: States and Territories, 101 Intersectionality, 102 Chapter Summary, 106 References, 107 4 HEALTH CARE LAWS AND PAYMENT POLICIES 125 Health Care Laws, 125 The Affordable Care Act (ACA), 126 Key ACA Provisions, 127 Impact of Policies and Legal Interventions, 147 Health Care Equity and the Courts, 154 Chapter Summary, 158 References, 160 5 HEALTH CARE SERVICE DELIVERY 169 Health Care Delivery Models, 170 The Health Care Workforce, 180 The Health Care Environment, 187 Individual Care-Seeking Behavior and Medical Mistrust, 193 Health Literacy, 194 Health Information Technology (HIT), 196 Chapter Summary, 200 References, 201 6 COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 215 Community Environments Influence Health and Health Care, 216 Community Partnerships, 217 Promising Interventions, 218 Approaches to Achieve Indigenous Health Care Equity, 229 Chapter Summary, 237 References, 238 7 DISCOVERY AND EVIDENCE GENERATION 247 Advancing Health Equity Research, 247 Historical and Current Health Equity Research Funding, 248 The Research Workforce, 253 PREPUBLICATION COPYâUncorrected Proofs
CONTENTS xv Health Equity Research Data, 258 Health Equity Research Infrastructure, 263 Moving Health Equity Research from Observations to Interventions, 269 High-Priority Areas for Future Research, 272 Chapter Summary, 272 References, 274 8 ACCOUNTABILITY 281 Accountability Structures and Processes, 283 Health Care Laws and Payment Policies, 284 Health Care Delivery System, 293 Community Centeredness and Engagement, 299 Data and Research Infrastructure, 300 Chapter Summary, 301 References, 303 9 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS 307 Overarching Conclusions, 309 Goals and Recommended Implementation Actions, 310 References, 322 APPENDIXES A Glossary, 323 B Examples of National Academies Consensus Reports Relevant to the Goal of Achieving Equitable Health Care and Optimal Health for All, 329 C Workshop Series Speakers, 331 D Biographical Sketches of Committee Members, 333 PREPUBLICATION COPYâUncorrected Proofs
PREPUBLICATION COPYâUncorrected Proofs
Boxes, Figures, and Tables BOXES 1-1 Summary of Recommendations from the 2003 Unequal Treatment Report, 18 1-2 Statement of Task, 28 1-3 Health, Health Care, and Health Care System, 32 1-4 Inequities Versus Disparities; Inequitable Versus Unequal Treatment, 33 1-5 Key Terms, 36 2-1 Health Care Financing and Insurance Design, 53 2-2 Life-Course Perspectives on Health Inequities, 62 2-3 Select Recommendations from the 2019 National Academies Report, 64 5-1 Racially Concordant Care, 186 6-1 Examples of Community-Based Participatory Research (CBPR) Studies That Successfully Addressed Racial and Ethnic Health Care Inequities, 220 6-2 Integrating Community Members into Health Care Settings, 227 6-3 Selected International Approaches to Achieve Indigenous Health Care Equity, 234 xvii PREPUBLICATION COPYâUncorrected Proofs
xviii BOXES, FIGURES, AND TABLES 7-1 NIH Research Funding Methodology Using NIH RePORTER, 250 7-2 Recommendations from the 2022 National Academies Report Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups, 266 7-3 High-Priority Areas for Future Research, 273 8-1 Select Recent Executive Orders to Advance Health Equity, 286 8-2 Select Draft Bills Related to Health Care Equity, 288 9-1 Recommendations to Ensure That Collection and Reporting of Data Are Representative and Accurate from the 2023 National Academies Report Federal Policy to Advance Racial, Ethnic, And Tribal Health Equity, 319 9-2 Recommendations for Integrating Social Care into Health Care Delivery from the 2019 National Academies Report Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nationâs Health, 320 FIGURES S-1 The system in which health care is organized, financed, delivered, and held accountable to achieve equitable health care and optimal health for all, 3 1-1 Uninsurance by race and ethnicity, 2008â2022, 24 1-2 Life expectancy in the United States by race and ethnicity, 2008â2022, 25 1-3 The system in which health care is organized, financed, delivered, and held accountable to achieve equitable health care and optimal health for all, 43 2-1 The key external societal forces, 50 3-1 Age-adjusted death rate for the 10 leading causes of death in the United States in 2021, 87 3-2 Prevalence of diabetes, 2021, 90 3-3 Age-Adjusted COVID-19 Cases (per 100,000) in the United States by Race and Ethnicity, 93 3-4 Prevalence of ESRD by race and ethnicity, 2001â2021, 94 3-5 Incidence of HIV by race and ethnicity, 2008â2021, 95 3-6 Unintentional mortality by race and ethnicity, 2000â2020, 97 3-7 Maternal mortality rates by race and ethnicity, 2018â2021, 98 3-8 Infant mortality rates by race and ethnicity, 2000â2020, 99 PREPUBLICATION COPYâUncorrected Proofs
BOXES, FIGURES, AND TABLES xix 4-1 Proportion of nonelderly population covered by Medicaid, by race/ ethnicity, 2021, 150 5-1 The composition of interprofessional primary care teams, 173 5-2 NIMHDâs research framework, 179 7-1 NIH Health Equity Funding (Direct Cost), Fiscal Years 2004â2023, 251 7-2 NIMHD Health Equity Funding (Direct Cost), Fiscal Years 2004â2023, 252 7-3 A health equity implementation framework, 271 8-1 Key places in the health care system where accountability is needed and the major actors accountable for accomplishing health care equity goals, 284 TABLES 1-1 The committeeâs assessment on the progress of implementation of the 2003 report recommendations, 21 4-1 Summary of Selected Key Provisions of the ACA and Their Implications for Racial and Ethnic Health Care Inequities, 139 7-1 NIH Institutes/Centers: Direct Costs for Health Equity Related Projects vs. All Topic Projects (2004â2023), 249 7-2 Examples of Health Equity Research Training Programs by Career Stage, 257 8-1 An Example of a Potential Accountability Framework, Recommended for Medicare and Medicaid Innovation, 285 8-2 Examples of HHS agenciesâ published plans, policies, and frame- works to advance health care equity, 289 PREPUBLICATION COPYâUncorrected Proofs
PREPUBLICATION COPYâUncorrected Proofs
Acronyms and Abbreviations ACA Affordable Care Act ACE adverse childhood experience ACO accountable care organization ADHD attention-deficit/hyperactivity disorder ADI area deprivation index AHRQ Agency for Healthcare Research and Quality AIAN American Indian or Alaska Native AI artificial intelligence APRN advanced practice registered nurse ASD autism spectrum disorder CBO community-based organizations CBPR community-based participatory research CDC Centers for Disease Control and Prevention CDO chief diversity officer CHC community health center CHEO chief health equity officer CHIP Child Health Insurance Program CHNA community health needs assessment CHNS Choctaw Nation Healthcare System CHW community health worker CMS Centers for Medicare & Medicaid Services CPG clinical practice guidelines CTC child tax credit CVD cardiovascular disease xxi PREPUBLICATION COPYâUncorrected Proofs
xxii ACRONYMS AND ABBREVIATIONS DACA Deferred Action for Childhood Arrivals DD developmental disability DEIA diversity, equity, inclusion, and accessibility ECC early childhood caries ED emergency department EHB essential health benefits EHR electronic health record EITC Earned Income Tax Credit ESRD end-stage renal disease FDA Food and Drug Administration FPL federal poverty level FQHC federally qualified health center HCP health care provider HHS Department of Health and Human Services HIT health information technology HMD Health and Medicine Division HMO health maintenance organization HRSA Health Resources and Services Administration HRSN health-related social needs ICCO Indigenous communities, collectives, and organizations I/DD intellectual and developmental disabilities IHS Indian Health Service IOM Institute of Medicine IRB institutional review board KKN Ke Ku âuna Na âau LGBTQ lesbian, gay, bisexual, transgender, and queer/questioning MAGI modified adjusted gross income MCO managed care organizations MOUD medications for opioid use disorder NAM National Academy of Medicine NCM nurse case manager NCMHD National Center on Minority Health and Health Disparities NEIHR Network Environments for Indigenous Health Research NHPI Native Hawaiian or Pacific Islander NHQDR National Healthcare Quality and Disparities Report PREPUBLICATION COPYâUncorrected Proofs
ACRONYMS AND ABBREVIATIONS xxiii NIH National Institutes of Health NIMHD National Institute of Minority Health and Health Disparities NP nurse practitioner NSCH National Survey of Childrenâs Health NSSRN National Sample Survey of Registered Nurses OCR Office for Civil Rights OHRP Office of Human Research Protections OMB Office of Management and Budget OMH Office of Minority Health OUD opioid use disorder PA physician assistant PBRN practice-based research network PCC patient-centered care PCP primary care physician PN patient navigator QHP qualifying health plans RCT randomized controlled trial RFRA Religious Freedom Restoration Act RHA Regional Health Authority RN registered nurse SDI social deprivation index SDM shared decision making SDOH social determinants of health SES socioeconomic status SFFA Students for Fair Admissions SUD substance use disorder TLT Transformative Learning Theory UBT unconscious bias training URM underrepresented and minoritized USPSTF U.S. Preventive Services Task Force VA U.S. Department of Veterans Affairs WCCHC Waianae Coast Comprehensive Health Center PREPUBLICATION COPYâUncorrected Proofs
PREPUBLICATION COPYâUncorrected Proofs
Preface Achieving equitable health care and optimal health for all has been a national goal for many years. However, this goal has been elusive. Twenty years ago, Congress tasked the Institute of Medicine (IOM)1 to evaluate the quality of health care received by racially and ethnically minoritized popula- tions in the United States and study why health care disparities existed. This landmark IOM study found that racial and ethnic disparities in health care occurred in the context of broader historical and contemporary social and economic inequalities rooted in the persistent racial and ethnic discrimina- tion in many sectors of U.S. life, including medicine. In this 2003 Unequal Treatment report, the IOM made several recommendations to address these disparities, including the need for additional research to expand the evidence base for further action. In 2023, the Agency for Healthcare Research and Quality and the National Institutes of Health asked the National Academies of Sciences, Engineering, and Medicine to convene a consensus committee to update the Unequal Treatment report and examine the current state of racial and ethnic health care disparities. Our committee accepted the task of iden- tifying the major drivers of health care inequities and assessing whether and what progress has been made to close gaps over the past 20 years. In preparing this report, the committee reflected on major changes in the 1 As of March 2016, the Health and Medicine Division of the National Academies of Sci- ences, Engineering, and Medicine continues the consensus studies and convening activities carried out by the Institute of Medicine (IOM). The IOM name is used to refer to reports issued prior to July 2015. xxv PREPUBLICATION COPYâUncorrected Proofs
xxvi PREFACE health care system since 2003. We reviewed and updated the evidence to better understand how health care inequities have changed over time. We then examined the factors that have reduced inequities and the remaining barriers that have slowed down, inhibited, or reversed progress toward the elimination of health care inequities. We also reviewed the rapidly evolving legal landscape, regulatory environment, and societal factors that influence how the United States organizes, finances, and delivers health care. Health care exists within this larger legal, political, and societal context, with pro- found implications on the ability of the nation to adequately address health care inequities and achieve optimal health for all. The negative repercussions of inequities go beyond individualâs health and specific medical conditions, causing profound differences in life expec- tancy and national economic consequences. One analysis showed that Black populations had over 80 million potential years of life lost compared to their White counterparts. The economic burden of health and health care inequi- ties leads to excess health care expenditures, lost labor market productivity, and increased costs to avoid excess premature death. The economic bur- den of racial and ethnic health inequities in 2018 was $421.1 billion for minoritized population (American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander populations) and $608.7 billion for White populations. Therefore, addressing health and health care inequities could produce significant economic benefits for the nation. Since the original Unequal Treatment report, scientific evidence has advanced such that we know more about effective and actionable practice, policy, and systems solutions. This report summarizes the state of the evi- dence about health care inequities, what we know works or does not work to address them, and where there are evidence and/or implementation gaps. This report concludes with recommendations for how to translate the best science into action toward closing persistent and long-standing health care inequity gaps. Proactive efforts are needed to scale new evidence-based interven- tions and disseminate emerging evidence that demonstrates the potential to reduce inequities. The nation also needs to increase investments in social, economic, policy, and health systemsâ research focused on reducing health care inequities. Achieving and sustaining health care equity is a complex, long-term activity that requires many inter-related strategies and tactics. Thus, this committee includes recommendations that a focused group of actors should implement over a short period and those that may take longer and require broad societal, financial, and political support. This report has recommendations for intervening at the local, regional, and national levels. Many of them will require additional resources or redistributing resources to where they are needed to better align with the science and evidence. Intentional strategies to understand and reduce inequitable outcomes, PREPUBLICATION COPYâUncorrected Proofs
PREFACE xxvii access, and experiences across communities of different races and ethnici- ties, income groups, genders, and neighborhoods are needed. With this in mind, the committee sought to recommend leveraging existing resources or systems as platforms to improve and scale interventions. The United States likes to see itself as the worldâs standard bearer of excellence in health care. Yet when compared to other industrialized nations, we are not the exemplars we believe we are. We rank behind many other high-income countries in how health care systems perform on measures of quality, access, efficiency, equity, outcomes, and life expec- tancy. We have some of the worst inequities in health outcomes based on race, e thnicity, gender, socioeconomic status, sexual orientation, and even zip code. These outcomes persist despite health care expenditures that are twice that of the next closest high-income nation. This report focuses on the persistent inequities that occur in our nation and a way forward, if we can find the will to address them. If we do so, the evidence is clear that it is not a zero-sum game, and everyone benefits. We can and must do better. Georges C. Benjamin, M.D. Jennifer E. DeVoe, M.D., D.Phil. Committee Co-Chairs Committee on Unequal Treatment Revisited PREPUBLICATION COPYâUncorrected Proofs
PREPUBLICATION COPYâUncorrected Proofs
