Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All (2024)

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3 Evidence of Racial and Ethnic Inequities in Health Care The Unequal Treatment report documented that health care access, use, quality of care, and health outcomes differed significantly by race and ethnicity. These inequities have persisted over the past 2 decades despite attempts to improve health across various conditions for everyone. Inequi- ties in health care also exist among people with multiple minoritized or intersectional statuses, who often experience poorer health outcomes than those with a single minoritized status. This chapter documents the evidence on racial and ethnic inequities in health care settings by access and use of care and discusses inequities in health conditions measured by prevalence, quality of treatment available, and outcomes. The chapter also discusses inequities in health and health care by geographic location, and examples of intersectionality of race and ethnicity with sexual and gender minority, disability, and immigrant status. INEQUITIES IN ACCESS TO AND USE OF HEALTH CARE Inequities in access to care exist across all inpatient and outpatient health care settings, including primary care, specialty care, emergency department (ED) and other hospital-based care, and rehabilitative, long- term, and prison care facilities. As explained in Chapter 1, this report uses the term “inequities” instead of “disparities” (except when citing a publication that explicitly measured disparities). In addition, the commit- tee is aware that health—a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity—and health 79 

80 ENDING UNEQUAL TREATMENT care—the services provided to individuals, families, and communities for the purpose of promoting, maintaining, or restoring health across settings of care—are different but inextricably linked. Further, this report uses “health care system” (activities related to the delivery of care across the continuum of care) to describe the U.S. health care system as a whole and also individual health care systems. Primary Care Primary care is the one of the only sectors of the health care sys- tem shown to improve health and health care equity (NASEM, 2021a; ­Rittenhouse, 2023). The World Health Organization describes the five core functions of primary care as accessibility, continuity, comprehensive- ness, coordination, and person-centered care, each of which are critical to mitigating health care inequities (WHO, 2023). Greater access to primary care has been associated with increased high-value preventative care and chronic disease management (Hostetter et al., 2020; Wilkinson et al., 2021), decreased urgent care and ED visits (Coster et al., 2017), improved life expectancy (Basu et al., 2021), and helps address sociocultural barriers to care (Batista et al., 2018). Although primary care presents a unique oppor- tunity to improve health care equity, challenges exist to providing equitable access to primary care. Racially and ethnically minoritized individuals are significantly less likely to have a usual source of primary care (Levine et al., 2020; NASEM, 2021a). They are also more likely to report a facility or hospital as their usual source of care rather than an individual clinician, which can impede both care continuity and access to guideline-concordant care (Atlas et al., 2009; Shi et al., 2014). Inequities in access to a usual source of primary care result from a num- ber of factors. Lack of insurance and underinsurance, each more prevalent among minoritized populations, are substantial barriers and associated with delayed or foregone care, including lower rates of use of preventive and pri- mary care services (NASEM, 2021a; Tipirneni et al., 2020). Individuals with Medicaid and other public insurance are more likely to experience barriers related to fewer practices accepting their insurance, limited appointment availability, and long wait times (Hsiang et al., 2019; Rittenhouse, 2023). Even among those with commercial insurance, increases in co-payments and other out-of-pocket costs for visits further limits access to and use of primary care in low-income and historically marginalized communities (Ganguli et al., 2020; Rabin et al., 2016). Additional barriers to primary care access among minoritized popula- tions include family and caregiving responsibilities, inability to take off from work to attend appointments (Allen et al., 2017), geographic and transportation issues (Allen et al., 2017; Douthit et al., 2015), lack of access 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 81 to culturally and linguistically appropriate and concordant care (Adakai et al., 2018), lack of comfort and trust with a given provider or the health care system as a whole (Read and Korenda, 2021), and experiences with and fears of future discrimination (Adakai et al., 2018; Allen et al., 2017). Moreover, a significant shortage of primary care professionals exists, with particularly severe shortages in rural and underserved areas (Jabbarpour et al., 2024). Nearly half (47 percent) of the U.S. population lives in a desig- nated primary care Health Professional Shortage Area1 and about 67 percent of these areas are rural (HRSA, 2023). Although access to primary care is generally better in urban areas, neighborhoods predominantly occupied by minoritized populations are still significantly more likely to have a short- age of primary care clinicians compared to other neighborhoods (NASEM, 2021a). Further, the overarching U.S. health care system payment paradigm incentives individual health care systems to invest in high-cost services to treat sickness rather than investing in robust primary care programs that promote optimal health for all. These misaligned incentives further exacer- bate primary care shortages for everyone. More detailed discussions about the payment misalignment are in Chapter 4. Specialty Outpatient Care Research reveals inequitable access to specialty care services (Cai et al., 2021; Krickus et al., 2023; Nguyen et al., 2022a). Specialty outpatient care is often needed for definitive care, such as for cancer, mental health, and specific cardiovascular and neurologic conditions. Administrative data from the Medical Expenditure Panel Survey show widespread inequities in access to outpatient specialty care, with the largest differences between Black and White adults for specialties such as dermatology, otolaryngology, general surgery, orthopedics, and urology (Cai et al., 2021). Disparities also exist between White and Hispanic or Asian/Native Hawaiian or Pacific Islander (NHPI) adults and between White and American Indian and Alaska Native (AIAN) patients across subspecialties (Cai et al., 2021). Outpatient visits to psychiatrists also had statistically significant differences between White and Hispanic, NHPI, and AIAN adults (Cai et al., 2021). Access to outpatient mental health and substance use care is also inequitable (Breslau et al., 2020). End-stage renal disease outcomes, such as initiating home dialysis and increased mortality after liver transplants (Alvarado et al., 2021), also display large inequities in outcomes (Shen et al., 2020), and racial inequity remains in use of outpatient dialysis care (Wang et al., 2023). 1 Health Professional Shortage Areas are geographic areas of populations that lack enough health care providers to meet the health care needs of that population. 

82 ENDING UNEQUAL TREATMENT ED and Hospital-Based Care The presence or lack of hospital and other health care infrastructure is a determinate of access to care and can be a barrier to equitable treatment. This is a persistent problem in some urban communities and a growing problem in rural communities (Eberth et al., 2022). Data on race and eth- nicity-based differences in ED use show that visit rates are higher and more frequent (based on number of visits over a 6-month period) among Black and Latino/a adults compared with White adults (Hanchate et al., 2019a; Parast et al., 2022). Access to emergency care is critical for all patient popu- lations. However, differences in use rates, especially for conditions such as diabetes and hypertension, in which outpatient evaluation and treatment might prevent ED visits (Sripipatana et al., 2019; Taylor et al., 2019), often serve as a surrogate marker for inequities in preventive care and access to outpatient primary and specialty care. Further, lack of preventive and primary care for underserved populations may lead to more expensive care when conditions worsen and become urgent and require emergency depart- ment based or hospital care. Metrics such as assignment of triage severity scores and wait times, which directly affect how quickly patients can access emergency care, differ by race and ethnicity; patients from minoritized groups, often Black popula- tions, have longer wait times and are assigned less acute triage severity scores (Owens et al., 2020; Zhang et al., 2020). Race- and ethnicity-based inequities in transport destinations also exist (Pack et al., 2023). For example, among older patients with Medicare, even when living in the same zip code, Black and Latino/a adults are more likely than White patients to be transported by emergency medical services to a safety net hospital (Hanchate et al., 2019b). Inequities in access to care for time-sensitive conditions, such as stroke, also exist. For example, among patients with acute ischemic stroke, minori- tized groups and women are less likely to receive intravenous thrombolysis, although these inequities vary to some extent by hospital characteristics (Faigle et al., 2017; Kimball et al., 2014). Blood pressure control following hemorrhagic stroke also differs by race group (Koch et al., 2016). Race-based differences in rates of preventable hospitalizations likely result from inequities in ambulatory care for underserved populations. For example, in a national study of hospital discharges, Black patients were significantly younger than White patients at the time of first preventable hospitalization for a range of chronic and acute conditions. This was most notable for uncontrolled dia- betes, in which Black adults were on average 12 years younger than White adults at their first hospitalization (Biello et al., 2010). This is consistent with higher rates of hospital admissions for uncontrolled diabetes and short- and long-term complications from diabetes for Black compared with White adults (Fayfman et al., 2016; Rodriguez and Campbell, 2017). 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 83 Long-Term Care, Skilled Nursing, and Rehabilitation Facilities Long-term care facilities are crucial for promoting the health and well- being of millions of elderly people, but the limited available data point to racial and ethnic inequities. U.S. long-term care facilities remain highly segregated along racial and ethnic lines, often resulting in part from the marked geographic residential segregation that continues to be prevalent across the nation (Fashaw-Walters et al., 2022; Li et al., 2015). Facilities serving predominantly racially and ethnically minoritized residents rely frequently on limited financial resources, offer fewer clinical services, have lower staffing levels, and have more care deficiency citations (Li et al., 2015). These challenges result in inequitable care quality, health outcomes, and quality of life for many racially and ethnically minoritized individuals in such facilities (Mauldin et al., 2021). Similar to long-term care facilities, data are limited on racial and ethnic inequities in U.S. skilled nursing facilities. However, the data have shown that these disparities are characterized by racial and ethnic residential segregation (Rivera-Hernandez et al., 2019a). In addition, resource availability and care outcomes frequently disadvantage racially and ethnically minoritized people (NASEM, 2021b). Researchers found lower-quality care measured by rates of rehospitalization, successful dis- charge to the community, and prevalence of five-star Medicaid ratings in skilled nursing facilities serving large proportions of African American patients (Rivera-Hernandez et al., 2019a). Higher 30-day readmission rates for African American and Hispanic patients also occur for both fee- for-service and Medicare Advantage (MA) patients (Rivera-Hernandez et al., 2019b). Lower access to rehabilitation services for racially and ethnically minoritized patients for both physical and substance use issues has also been documented (Avecedo et al., 2020; Flores et al., 2020; Gorman et al., 2020). For example, research has revealed racial and ethnic disparities in substance use treatment completion across the life course. Often, this is a result of structural and institutional barriers affecting retention (Acevedo et al., 2020). Home-Based Care Momentum has been increasing to shift the locus of health care delivery closer to the community, and millions of older Americans receive in-home health care services and health management. A recent nationally representa- tive survey of noninstitutionalized Medicare beneficiaries found that home health service use was higher for those from minoritized racial and ethnic backgrounds than for non-Latino/a White individuals (Saulsberry, 2023). 

84 ENDING UNEQUAL TREATMENT However, these beneficiaries also relied more on informal and unpaid care- givers, often family members, accounting for more than half of home-based care (Saulsberry, 2023). For home health agencies, data suggest racial and ethnic inequities in both care quality and outcomes. For example, Black and Latino/a patients are less likely than White patients to be served by an agency rated as high quality (Fashaw-Walters et al., 2022). Furthermore, in a sample of post- acute patients who received services from home health agencies, Black and Latino/a individuals were more likely to have a subsequent ED visit, and Black patients were more likely to be rehospitalized (Chase et al., 2020). Similarly, a study found a greater likelihood of being discharged from agency-delivered home health services without functional improvements among Black, Latino/a, and AIAN patients (Fashaw-Walters et al., 2023). Health Care Services in Carceral Settings The U.S. prison system comprises 1.2 million people. Its racial and ethnic demographics do not mirror the U.S. population. Black people make up 13.6 percent of the U.S. population (U.S. Census Bureau, 2023) but 38.7 percent of the incarcerated population (Federal Bureau of Prisons, 2024a). That ratio is 1.3 percent versus 2.7 percent for AIAN people (Federal Bureau of Prisons, 2024a; U.S. Census Bureau, 2023) and 19.1 percent versus 29.5 percent for Hispanic people (Federal Bureau of Prisons, 2024b; U.S. Census Bureau, 2023). Research documents significant limitations and variability in health care access and quality in carceral settings, with an impact on outcomes, including long-term health effects on formerly incarcerated individuals (Puglisi and Wang, 2021). Large segments of this population have complex health care needs, including management of chronic conditions, mitiga- tion of elevated infectious disease risk in jails and prisons, treatment for psychiatric and substance use disorders, and frequent multimorbidity (Jolin et al., 2023; Wildeman and Wang, 2017). The incarcerated population is also aging (Widra, 2023), with a concern for increasing rates of comor- bidities and complex medical conditions that require attention both during the incarceration and upon release. Hepatitis C is an example of a chronic infectious disease in which prevalence rates are higher in incarcerated set- tings than the general population, and treatment is underused, putting indi- viduals with it in prison at risk for cirrhosis and hepatocellular carcinoma (Rich et al., 2016). Health care personnel, equipment, infrastructure, and distribution of pharmaceuticals are limited and under resourced, contributing to delays in care and subpar care (Curran et al., 2023; Puglisi and Wang, 2021). 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 85 Inequities in care were highlighted during the COVID-19 pandemic, when a lack of quarantine and vaccination mandates in short- and long-term carceral settings (Widra, 2021) resulted in high rates of COVID mortality rates and the spread of COVID to communities that inmates returned to postincarceration (LeMasters et al., 2023). Health care received in prisons by individuals from minoritized groups (e.g., Black, Hispanic) is a critical area of research in which data are lacking, though inequities by race in the general population suggest the potential that similar inequities exist in the carceral population. Collection of nationwide data on the health and treat- ment of individuals in prisons is needed (Binswanger, 2019). Veterans Health Administration (VHA) VHA is the largest integrated health care system in the United States. It provides care to over 9 million veterans.2 Equitable care is a major tenet of the VHA.3 The eligibility and care delivery structure help to reduce both financial and non-financial barriers to care, however inequities in health and health care persist.4,5 While work is needed to achieve equitable health care and optimal health for all, there are examples where VHA has narrowed racial and ethnic heath and health care inequities. For example, Black veterans undergoing surgical treatment for early-stage lung cancer in VHA received comparable, if not superior care, to White veterans (Heiden et al., 2022). Another analysis found that Asian, Hispanic, and NHPI vet- erans receiving VHA care had similar or lower all-cause and cause-specific mortality compared with White veterans (Wong et al., 2019). AIAN vet- erans experienced higher adjusted all-cause mortality and Black veterans experienced higher cardiovascular and cancer mortality compared with White veterans. Racial and ethnic disparities among veterans receiving care in VHA, however, were overall fewer than in the general U.S. population (Wong et al., 2019). Moreover, as a single-tier system with low or no cost sharing and an emphasis on primary care, VHA care has also been associated with reduction in racial and ethnic disparities for cost-related medication non- adherence (Gaffney et al., 2020) and vaccination uptake compared to the general U.S. population (Gaffney et al., 2022, 2023; Haderlein et al 2022). 2 See https://www.va.gov/health/aboutvha.asp (accessed March 29, 2024). 3 See https://www.va.gov/healthequity/ (accessed March 29, 2024). 4 See https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/ veterans/2020qdr-chartbook-veterans.pdf (accessed May 6, 2024). 5 See https://www.va.gov/HEALTHEQUITY/docs/NVHER_2021_Report_508_Conformant. pdf (accessed March 29, 2024). 

86 ENDING UNEQUAL TREATMENT SUMMARY OF EVIDENCE OF RACIAL AND ETHNIC INEQUITIES IN SELECTED HEALTH CONDITIONS The racial and ethnic inequities in access and use of care is manifested in the prevalence, treatment, and outcomes of health. To better understand these inequities, the committee commissioned a paper6 to chronicle the progress toward eliminating racial and ethnic inequities in health and health care based in part on the National Healthcare Quality and Disparities Report (NHQDR) and other data sources and published studies since 2003. As part of the commissioned paper, the authors were required to use data from the 2022 NHQDR annual report and other relevant literature to iden- tify trends in racial and ethnic health care inequities over the past 20 years. NHQDR appendixes include the most comprehensive, longitudinal report on progress in addressing U.S. racial and ethnic health care inequities but lack data on people from highly marginalized groups, including incarcer- ated, undocumented, and gender diverse populations. The key findings from the commissioned paper were that progress has been poor and uneven, with some areas showing improvements and others worsening inequities, and that health care outcomes have been uneven and unequal across patient populations over the past 2 decades.7 The next section presents a brief overview of the racial and ethnic ineq- uities in selected health conditions—many of which fall under the top 10 causes of death in the United States (see Figure 3-1)—with the substantial inequities.8 Cardiovascular Disease (CVD), Stroke, and Cardiometabolic Risk Factor Heart disease, particularly coronary disease resulting in myocardial infarctions, is the leading cause of death in the United States, accounting for 695,547 deaths in 2021 (CDC, 2024). CVD mortality rates among Black individuals have shown to be consistently higher in communities with high levels of racial segregation compared with those with low to moderate levels (Kyalwazi et al., 2022). Also, Black populations have the highest age-adjusted rate of CVD, followed by NHPI, White, AIAN, His- panic, and Asian populations (CDC, 2021). Younger Black individuals9 6 The detailed commissioned paper includes the methodology and findings and appears on the project website and the National Academies Press website. 7 Critical gaps exist in the quality measurement landscape; many of the quality metrics used in the NHDQR are process measures with uncertain links to meaningful outcomes. Patient- reported outcomes are also lacking, limiting understanding of how the health care system impacts these important measures. 8 This section is adapted from a study (Fiscella and Sanders, 2023) commissioned by the committee for this report. 9 Younger Black Americans refers to those under the age of 65. 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 87 FIGURE 3-1 Age-adjusted death rate for the 10 leading causes of death in the United States in 2021. SOURCE: National Center for Health Statistics, National Vital Statistics System, Mortality. https://www.cdc.gov/nchs/products/databriefs/db456.htm (2022) have significantly higher CVD mortality compared to their younger White counterparts (Kyalwazi et al., 2022). Differences in CVD prevalence have been reported among disaggre- gated Asian subgroups compared to White populations (Waitzfelder et al., 2023). Also, one study that evaluated the prevalence of coronary artery disease among Asian subgroups found significant variation among Korean, South Asian, and Pacific Islander populations (Gordon et al., 2019). Critical inequities also exist in stroke incidence and mortality. Stroke, the fifth leading cause of death in the United States overall, causes more deaths in women and minoritized populations than in White men, and the mortality rates are markedly higher in the Southeast (Tsao et al., 2023). Numerous studies have documented inequities in stroke incidence across populations (Gardener et al., 2020; Tsao et al., 2023). Despite some data demonstrating that it is likely decreasing in White, Black, and Latino/a individuals (Koton et al., 2014; Tsao et al., 2023), differences in risk by race and ethnicity have persisted (Madsen et al., 2024; Tsao et al., 2023). For example, data from the population-based, surveillance Greater Cincinnati Northern Kentucky Stroke Study have consistently shown higher incidence in Black compared with White adults (Kleindorfer et al., 2010; Madsen et al., 2024). Race-based inequities are more prominent in middle-aged adults compared with the oldest age groups, likely a result of biases in survival to 

88 ENDING UNEQUAL TREATMENT older ages (Howard et al., 2011; Tsao et al., 2023). Data for Hispanic indi- viduals are less robust, although data from the Brain Attack Surveillance in Corpus Christi study indicate that the incidence of ischemic and hemor- rhagic stroke is higher in Mexican American than other Hispanic adults (this difference appears to be decreasing) (Lisabeth et al., 2021). Hypertension is an important modifiable medical risk factor contribut- ing to Black–White inequities in CVD, chronic kidney disease, and stroke (Carnethon et al., 2017). It is more prevalent among Black populations, with research showing racial discrimination substantially contributing to higher blood pressure (Forde et al., 2020) through perceptions, affective response, and potentially epigenetic mechanisms (Forde et al., 2020). In addition, excessive alcohol, select medications, and Life’s Essential 8 factors, such as smoking, physical inactivity, high salt intake, obesity, poor sleep, and stress, are modifiable factors (Tsao et al., 2023). Rates of hospitaliza- tion for acute hypertension from 2017 to 2019 were about 3.5 times higher for Black Medicare beneficiaries at a rate of 369.5 per 100,000 beneficiary- years compared to White beneficiaries at a rate of 104.8. The rates for Hispanic and AIAN beneficiaries were 171.1 and 147.8 respectively. Control of high cholesterol is another modifiable risk factor for CVD and stroke (Yebyo et al., 2019). Time trends show improvement in public awareness of the risks associated with high levels of low-density lipopro- tein, but being unaware and untreated was more common among racially and ethnically minoritized adults and those who had lower educational attainment, lower income, and no health insurance (Sayed et al., 2023). In a national sample, Black men and non-Mexican Hispanic women were less likely than White individuals to receive guideline-concordant statins (Frank et al., 2023; Jacobs et al., 2023). Lacking insurance and a usual source of care contribute to these disparities (Jacobs et al., 2023). Even those with ischemic heart disease or familial hypercholesterolemia have racial and ethnic disparities in cholesterol control (Agarwala et al., 2021; Gu et al., 2018). Other data point to race and ethnicity-based inequities in quality of care and fatality after CVD. For example, quality of heart failure care was generally similar at hospitals with high proportion of Black patients com- pared to other hospitals, although a few inequities persist (Diamond et al., 2023). Hospital treatment of myocardial infarction and heart failure has improved, as have inequities, but disparities persist (Montoy et al., 2022), such as for surgical and structural interventions (e.g., valve repair and devices) (Alkhouli et al., 2019; Cascino et al., 2023). Analysis of within and between hospital disparities suggest that these are likely systemic rather than localized to particular hospitals (Downing et al., 2018). Despite myocardial infarction and cardiac arrest being among the lead- ing causes of death in the United States, disparities in fatality persist (Ariss 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 89 et al., 2022; Larik et al., 2023). Inequities in public awareness of symptoms contribute to treatment delays (Mahajan et al., 2019). Differences in the bystander cardiopulmonary resuscitation, defibrillator usage, and post- resuscitation therapies likely contribute to these inequities in outcomes (Mehta et al., 2022). Age-adjusted mortality attributable to heart failure declined 1999–2011 and then increased from 2011–2017 across all census regions, with the most significant increases in the Midwest and South (Glynn et al., 2021). Accord- ing to the NHQDR, rates for adult hospital admissions for heart failure per 100,000 population worsened by 12 percent 2016–2019 (AHRQ, 2023a). In 2019, rates were significantly worse for Latino/a and Black patients compared to non-Latino/a White patients, yet both of these minoritized groups experienced lower hospital mortality compared with non-Latino/a White patients for reasons that are not clear (Minhas et al., 2022). In addi- tion, more than 75 percent of counties experienced increased hypertension- related CVD death rates from 2010–2019 (Vaughan et al., 2022). The highest rates were among men and Black populations. All racial and ethnic groups had widespread county-level increases (Vaughan et al., 2022). Research has also documented inequities in the quality of stroke care. For example, a systematic review involving studies from 2010 to 2021 examined inequities in access to stroke treatment between minoritized racial groups and White individuals (Ikeme et al., 2022). White patients were esti- mated to use emergency medical services at a higher rate than Black, Asian, and Latino/a patients. White patients more often arrived within 3 hours from the onset of stroke symptoms than Black and Latino/a patients and were more likely to receive thrombolytic therapy than Black, Latino/a, and Asian patients. Rates of use of mechanical thrombectomy were also lower in minoritized populations than in the White population (Ikeme et al., 2022). Other inequities in CVD-related conditions include changes in the pediatric heart transplant allocation system (Zubair et al., 2022), and cardiac reha- bilitation following hospitalization (Thomas et al., 2019). Diabetes Diabetes is the eighth leading cause of death in the United States accounting for 103,294 deaths in 2021 (CDC, 2024). It is estimated that 11.3 percent, accounting for about 29.7 million people, had diagnosed diabetes. The prevalence is highest among AIAN adults aged 18 and above at 13.6 percent, followed by Black populations at 12.1, Hispanic popula- tions at 11.7, Asian populations at 9.1 and White populations at 6.9 (CDC, 2023b) (see Figure 3-2 for the prevalence by race and ethnicity in 2021). As discussed in Chapter 1, Asian is a large and diverse population that are often grouped into a racial and ethnic group. Significant differences in 

90 ENDING UNEQUAL TREATMENT FIGURE 3-2 Prevalence of diabetes, 2021. SOURCE: Data for this table was obtained from https://www.cdc.gov/diabetes/data/ statistics-report/appendix.html#tabs-1-3 prevalence have been observed among subgroups of the Asian population (Bancks et al., 2021; CDC, 2023b). NHQDR reports show minimal improvement in the quality of care from 2008–2019. There was no appreciable improvement in terms of receiving four recommended services—two or more hemoglobin A1c measurements, dilated eye examination, foot examination, and flu vaccination—in the past year, with Hispanic individuals having lower rates than White individuals (AHRQ, 2023a). Similarly, Black and Hispanic patients had worse control of blood sugar levels than White patients. Several studies suggest that non- White patients are less likely to receive newer, higher-cost, noninsulin drugs (Eberly et al., 2021; Lamprea-Montealegre et al., 2022; Le et al., 2023a) and diabetic technology, including continuous glucose monitors and insulin pumps (Agarwal et al., 2021). These inequities translate to inequities in outcomes. NHQDR shows a worsening of adult hospital admissions for diabetes short-term complica- tions from 2016–2019. Black patients had hospitalization rates more than 2.5 times higher than for White patients (AHRQ, 2023a). Similarly, admis- sions for diabetes complications for Black children and adolescents were 1.7 times higher than for White children and adolescents. Lower extremity amputations among all adult groups also worsened except for Asian and Pacific Islander individuals (AHRQ, 2023a). 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 91 Cancer Cancer is the second leading U.S. cause of death, accounting for 605,213 deaths in 2021 (CDC, 2024), with inequities occurring across the cancer continuum, from prevention to treatment to end-of-life care. Inequities also exist based on cancer type, detection, survival, and well-being. Inequities in uptake of cancer-preventing vaccines also exist among racial and ethnic groups. Members of racial and ethnic minoritized groups, for example, are less likely to be aware of the human papillomavirus vaccine than White individuals (Le et al., 2023b). Screening rates for cancer are generally lower among members of minoritized groups than among White people, with the largest inequities seen for colorectal and lung cancer (Rutter et al., 2021; Sosa et al., 2021). The NHQDR shows improvement between 2000 and 2018 in earlier diag- noses of breast, cervical, and colorectal cancer. However, compared to their White counterparts, women from minoritized populations are diagnosed with these cancers at more advanced states. Follow-up on abnormal screen- ing findings, including lung nodules, is also often worse for minoritized populations (Fuzzell et al., 2021; Steiling et al., 2023). These inequities likely contribute to delayed diagnosis (Nicot-Cartsonis et al., 2022; Primm et al., 2023). Community social determinants, including insurance and care access, contribute to cancer diagnosis delays (Giaquinto et al., 2022; Kucera et al., 2023). A systematic review reported that residing in segregated Black areas was associated with higher rates of later-stage diagnosis of breast and lung cancers, higher mortality rates and lower survival rates from both cancers, and higher cumulative cancer risks associated with exposure to ambient air toxins (Landrine et al., 2017). Research has shown that among individuals with early-stage lung can- cer, Black patients are less likely to receive curative surgery (Evans et al., 2021). Racial and ethnic inequities also exist in access to newer immuno- therapy and targeted treatments (Amin et al., 2023; Chang et al., 2023) despite research showing that minoritized patients benefit as much or more from these modalities (Gupta et al., 2022). Racial inequities in postcancer reconstructive surgery have decreased, but differences persist (Hang and Henk, 2020; Jonczyk et al., 2023). Disparities extend into survivorship, with less surveillance and lower quality of life for minoritized patients (Rincon et al., 2020). Racially and ethnically minoritized populations receive worse care, including less palliative care and hospice, more aggressive treatment, more avoidable hospitalizations, and more admissions to intensive care units (Fischer et al., 2023; Mullins et al., 2021; Parajuli et al., 2020). Finan- cial toxicity from treatment for advanced cancer has disparate impact among minoritized populations, (Rotter et al., 2019) affecting quality of life 

92 ENDING UNEQUAL TREATMENT (Arastu et al., 2020). Among Medicare beneficiaries with advanced cancer, inequities in hospice appear to have narrowed, although variations in these inequities by age, cancer, and place persist (DeGroote et al., 2022; Estrada et al., 2021; Mullins et al., 2021; Samuel-Ryals et al., 2021). AIAN people have the highest cancer mortality rates, followed closely by Black people (Siegel et al., 2023). The mortality rate in AIAN and Black men is two times that in Asian men and 18 percent higher than in White men. Black–White disparities in overall cancer mortality has declined from 33 percent in 1993 to 12 percent in 2020 (Siegel et al., 2023), driven by greater declines in smoking-related cancers related to a decrease in smoking initiation among Black adolescents from the late 1970s to the early 1990s (Siegel et al., 2023). COVID-19 COVID-19 was the third leading cause of death in 2021 in the United States, with the emergence of unprecedented racial and ethnic inequities in mortality (CDC, 2024). In April 2020, Hispanic, AIAN, and Black popula- tions had a higher incidence of COVID-19 cases compared to their White and Asian counterparts. By the end of 2020, rates increased for all racial and ethnic groups, with AIAN and Hispanic populations experiencing the greatest inequities and Black and Asian populations having the low- est incidence. In January 2022, as the Omicron variant became dominant, incidence increased drastically for all racial and ethnic groups, with AIAN and Hispanic populations facing the greatest inequities. Rates among Black, White, and Asian populations were similar (Hill and Artiga, 2022) (see Figure 3-3 for COVID-19 incedence). During the early phases of the pandemic, racial and ethnic inequities in COVID-19-related knowledge emerged (Jones et al., 2020). Differ- ences in beliefs hindered engagement in protective COVID-19 behaviors (Smail et al., 2021). Equity-focused strategies, including addressing mis- information and disinformation on social media, addressing mistrust for health care, and mitigating structural barriers through community engage- ment, were implemented slowly (Dada et al., 2022). Racial and ethnic inequities in access to COVID-19 testing (Asabor et al., 2022; Dalva-Baird et al., 2021); and access to telehealth arose (Jewett et al., 2022). Whereas more than half of White patients used video telehealth, most minoritized patients were less likely to use it (Buis et al., 2023; Chen et al., 2022; ­Jewett et al., 2022; Rodriguez et al, 2021). Inequities in racial and ethnic age-adjusted proportionate monthly COVID-19 hospitalizations peaked during summer 2020. The peak monthly adjusted disparity among Hispanic compared to White patients was more than ninefold higher in the West and Midwest, more than sixfold 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 93 FIGURE 3-3 Age-Adjusted COVID-19 Cases (per 100,000) in the United States by Race and Ethnicity. NOTES: Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. AIAN refers to American Indian/Alaska Native. Age-adjusted rates standardized to 2019 U.S. Census Bureau population estimates. SOURCE: Hill and Artiga, 2022. higher in the South, and threefold higher in the Northeast (Romano et al., 2021). Black and Asian or NHPI individuals were more likely to have a COVID-19-associated hospitalization, intensive care unit admis- sion, or in-hospital death compared with White individuals during the first year of the pandemic (Acosta et al., 2021). These inequities reflect racial and ethnic differences in household composition, access to care, SDOH, and existing comorbidity (Karmakar et al., 2021). The development and rollout of COVID-19 vaccines were accompanied by racial and ethnic inequities in vaccine receipt (Nguyen et al., 2022b) accen- tuated by experiences of discrimination and structural barriers (Hernandez et al., 2022; Montiel Ishino et al., 2023), yielding inequities by state (Siegel et al., 2022). Primary care offered a means to address the vaccine concerns of minoritized patients (Ha et al., 2022; Kern et al., 2023). For older patients, vaccination rates were lowest among AIAN individuals (Fast et al., 2021). Yet, despite higher rates of infections among minoritized groups (Jones et al., 2021), inequities emerged in treatment, including for monoclonal antibody therapies, remdesivir, and dexamethasone (Wiltz et al., 2022) and oral anti- virals (Boehmer et al., 2022). For example, from April to July 2022, Black patients were prescribed Paxlovid 36 percent less often than White patients, AIAN and NHPI patients 23 percent less often, and Asian patients 19 percent less often. Latino/a patients were prescribed Paxlovid 30 percent less often than non-Hispanic patients. These inequities were generally higher for those at high risk for severe COVID-19, including those who were older than 50 or immunocompromised (Boehmer et al., 2022). 

94 ENDING UNEQUAL TREATMENT FIGURE 3-4 Prevalence of ESRD by race and ethnicity, 2001–2021. SOURCE: Figure was obtained from 2023 United States Renal Data System Annual Report: https://usrds-adr.niddk.nih.gov/2023/end-stage-renal-disease/1-incidence- prevalence-patient-characteristics-and-treatment-modalities (accessed March 29, 2024). Chronic Kidney Disease Chronic kidney disease affects 1 in 7 individuals (NIDDK, 2023a), with substantial racial inequities in both chronic kidney disease and end-stage renal disease (ESRD).10 Hispanic individuals of all ages are more likely to have ESRD caused by diabetes than White or Black individuals whereas Black individuals in all age groups are more likely to have ESRD caused by hypertension than White or Hispanic individuals (NIDDK, 2023b). Fur- thermore, the prevalence among Black individuals is over four times as high as among White individuals (NIDDK, 2023b). Moreover, the prevalence of ESRD among Hispanic and AIAN individuals was more than twice as high compared to White individuals (see Figure 3-4 for the prevalence of ESRD by race and ethnicity). The use of a correction factor for Black race for estimated glomerular filtration rate (eGFR)—a measure of chronic kidney disease, acute kidney injury, and ESRD—is no longer supported by the field (Uppal et al., 2022). The National Kidney Foundation and American Society of Nephrology convened a task force to reassess including race in testing for and diag- nosing kidney disease, highlighting the importance of excluding the race correction factor from the eGFR calculation because it led to undertreating 10 This is defined as permanent loss of renal function requiring dialysis or transplant. See https://www.cms.gov/medicare/coordination-benefits-recovery/overview/end-stage-renal- disease-esrd (accessed March 29, 2024). 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 95 Black individuals and delayed referral to kidney transplants (Delgado et al., 2022; Zelnick et al., 2021). Inequities in wait time in referral and evalu- ation for kidney transplants are also prevalent among AIAN populations (Keddis et al., 2018). HIV A highly effective antiretroviral therapy, combined with AIDS activism that fostered a person-centered approach to HIV prevention and treat- ment, has dramatically slowed the HIV epidemic in the United States (see Figure 3-5 incidence of HIV by racial and ethnic group). NHQDR data document that new infections among adolescents and adults decreased from 2008–2020 for all groups except NHPI populations, which barely changed, and AIAN people, whose rates worsened (AHRQ, 2023a). Relative to White individuals, new infection rates in 2020 were sig- nificantly worse among all racial and ethnic groups except Asian individu- als, with Black individuals having the highest rates (AHRQ, 2023a). Rates of HIV status awareness was also slightly lower among these groups, with the lowest among AIAN populations (AHRQ, 2023a). Compared to White FIGURE 3-5 Incidence of HIV by race and ethnicity, 2008–2021. SOURCE: Data for this graph was obtained from https://gis.cdc.gov/grasp/nchhstp atlas/tables.html. 

96 ENDING UNEQUAL TREATMENT individuals, rates of HIV viral suppression were also significantly lower and worsened among NHPI populations from 2017–2020. Early diagnosis, immediate treatment, and access to high-quality care have been successful in reducing HIV-related deaths, but targeted efforts are needed to address persistent racial and ethnic inequities in infections, care, and mortality (Bosh et al., 2020). The evidence shows multiple barriers to HIV preventive medication, yielding inequities in access, particularly in the Southern United States (Kamitani et al., 2020; Zhang et al., 2019). Some of the largest reductions in overall mortality and inequities in absolute mortality have been for HIV-related deaths (Bosh et al., 2020). However, large relative inequities for Black and smaller inequities for AIAN, NHPI, and Hispanic individuals persist despite effective preventive and therapeutic treatment. This underscores the need for systems of care to address these large inequities and end the HIV pandemic. Unintentional Injuries and Substance Use Disorders Unintentional injuries, including falls, and substance use disorders (SUDs) impact all racial and ethnic groups, yet racial inequities persist across the U.S. population. Unintentional injury mortality was the fourth leading cause of death (CDC, 2024). AIAN populations have the highest rate of deaths from overdoses and motor vehicle accidents (Kerr et al., 2021). The NHQDR notes the large increase in opioid overdose deaths from 1999–2020, with the highest rates for AIAN, Black, and White indi- viduals (AHRQ, 2023b). Other unintentional injuries11 had a general rise, with AIAN men experiencing the highest rates. Rates varied by state, with no AIAN–White inequity observed in New York and Texas (Kerr et al., 2021). From 2000 to 2020, AIAN individuals experienced the highest rates of unintentional injury compared to all other racial and ethnic groups except from 2018 to 2019 (see Figure 3-6). Racial and ethnic differences in receiving of medications for o ­ pioid use disorder (MOUD) after a critical OUD event among patients with Medicare disability were substantial and did not change over time ­ (­Barnett et al., 2023). Similar racial inequities appear among people with ­Medicaid and commercial insurance (Dunphy et al., 2022; Kilaru et al., 2020). MOUD rates are low and unequal by race after overdose (Kilaru et al., 2020), hospitalization (Holland et al., 2023; Priest et al., 2022), and pregnancy (Grella et al., 2023; Henkhaus et al., 2022). 11 Other unintentional injuries include other land and water transport injuries, falls, ex- posure to mechanical forces, accidental drowning, exposure to smoke and fire, contact with animals and plants, exposure to forces of nature. 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 97 FIGURE 3-6 Unintentional mortality by race and ethnicity, 2000–2020. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Mental Health Racial and ethnic inequities exist in suicide, suicide ideation, and receipt of services. Suicide trends have declined among White populations since 2018 but have increased among minoritized populations (Karaye, 2022). Moreover, between 2008 and 2017, increases in reported suicidal ideation were largest among White and smallest among Black individuals (Twenge et al., 2019). A systematic review found that exposure to racism is associ- ated with increased risk of suicide and development of mental disorders (Rudes and Fantuzzi, 2022). For youth aged 15–24, suicide rates were highest among AIAN and White youth compared to Black, Asian or NHPI, and Latino/a youth in 2019 (Ramchand et al., 2021). Among adults receiving antidepressants, discontinuation during the first 30 days of treatment was significantly more common among Latino/a than non-Latino/a individuals and those with fewer than 12 years of education or low family income (Olfson et al., 2006). Another study found that the use of any outpatient mental health service was more than twice as high for White as for Black or Latino/a individuals (Olfson et al., 2023). Similar racial disparities and lack of improvement are seen for treatment of post- stroke depression, with Black and Hispanic patients less likely to receive treatment than non-Hispanic patients (Dong et al., 2022). 

98 ENDING UNEQUAL TREATMENT FIGURE 3-7 Maternal mortality rates by race and ethnicity, 2018–2021. NOTE: This analysis included data for only three racial and ethnic groups. SOURCE: Hoyert et al., 2023. Maternal Health The United States has the highest maternal and infant mortality rates among peer countries, partly the result of worsening maternal health care (Gunja, 2022; Main et al., 2020). Maternal mortality has been increas- ing for all racial and ethnic groups, but rates have been disproportionally higher for racially and ethnically minoritized populations (Hoyert, 2023; Wang et al., 2023). For example, one analysis reported that the maternal mortality rates per 100,000 live births in 2018 were 37.3 for Black, 14.9 for White, and 11.8 for Hispanic people. In 2021 the rate for Black people at 69.9, was 2.6 times higher compared to that of White people at 26.6, and 2.5 times higher compared to the rate for Hispanic people at 28.0. Although research on AIAN populations is scant, they are “two times more likely to die of pregnancy-related causes” than their White counterparts.12 Also, significant racial and ethnic inequities exist in maternal morbid- ity and other maternal health outcomes (Fink et al., 2023). For example, rates of severe postpartum hemorrhage increased among all racial and ethnic groups, with higher rates for Black, Hispanic, and Asian/Pacific Islander populations (Gyamfi-Bannerman et al., 2018). Also, from 2020 to 2022, Black and Asian/Pacific Islander populations had the highest average 12 See https://www.cdc.gov/hearher/aian/disparities.html (accessed April 29, 2024). 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 99 Cesarean section birth rate at 36.6 percent and 33.0 percent, respectively (March of Dimes, 2024). A national study using electronic health record data to assess hypertension among women of reproductive age showed that Black women had a higher prevalence but lower hypertension control than White women (Weng et al., 2023). Structural racism, discrimination, and SDOH all affect maternal health, quality of care, and birth outcomes. A systematic review of barriers to high- quality prenatal and postpartum care underscored the role of structural barriers, including delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation, childcare hurdles, and legal system concerns. For individuals who accessed care, experiences of dismissal, discrimination, and disrespect that were related to race, insurance status, age, substance use, and language were common (Bellerose et al., 2022). Child Health and Development Racial and ethnic inequities exist in child health and development, and this continues across the life-course as discussed in Chapter 2. In fact, infant mortality rates from 2000 to 2020 was highest among Black infants (see Figure 3-8). A multidisciplinary scientific work group convened by the March of Dimes concluded that racism is a highly plausible, major FIGURE 3-8 Infant mortality rates by race and ethnicity, 2000–2020. SOURCE: Data for this figure was obtained from CDC Wonder https://wonder.cdc. gov/controller/datarequest/D76;jsessionid=7B16033334B112A99CD324B7762B. 

100 ENDING UNEQUAL TREATMENT upstream contributor to this disparity through multiple pathways and biological mechanisms, such as chronic stress, environmental exposures (Braveman et al., 2021). Structural racism impacts the health of children from racially and minoritized populations in part through greater early life adversity and toxic stress, with a lasting impact on development. One study found that higher segregation reduced upward mobility for Black children from house- holds across the income distribution and White children from low-income households (Chyn et al., 2022). Segregation reduced academic achievement while increasing incarceration and teenage birth rates. Exploration of mech- anisms shows that segregation reduces government spending, weakens sup- port for anti-poverty policies, and increases racially conservative attitudes for White residents. In another study, children exposed to socioeconomic deprivation had the worst health, including more internalizing and exter- nalizing mental health problems, lower cognitive performance, and adverse physical health (Xiao et al., 2023). Furthermore, inequities have been reported in conditions including treatment for appendicitis and diagnosis and treatment for attention-deficit/ hyperactivity disorder (ADHD). A retrospective analysis of data between 2001 and 2018 for children less than 18 years admitted for appendicitis who underwent appendectomy showed a steady decline in complications (Mpody et al., 2021). However, Black children consistently had higher rates of complications and perforation, resulting in significantly higher hospital costs (Mpody et al., 2021). Additionally, a multisite sample of more than 4,000 children found that even after controlling for socio­ demographic factors, ADHD symptoms, and other potential comorbid mental health symptoms African-American and Latino/a children, compared with White children, were less likely to receive an attention-deficit/hyperactivity ­disorder (ADHD) diagnosis or medication (Coker et al., 2016). Oral Health Child tooth decay or early childhood caries (ECCs) is particularly problematic among minoritized children living in poverty. The national prevalence of ECCs among children 5 years and younger 2017–2018 was 32, 23, 20, and 13 percent for Mexican American, Asian, Black, and White children, respectively, and children living in poverty have a prevalence of 25 percent (Kotha et al., 2022). Among children aged 6–9, AIAN children were more likely to have untreated dental caries at a rate of 55 percent, compared to Black children who were at a rate of 23 percent. Black children were closely followed by Mexican American and White children at rates of 18 and 12 percent, respectively (Phipps et al., 2023). Food insecurity is associated with caries (Sabbagh et al., 2023), and that relationship is 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 101 attenuated with participation in the Women, Infants, and Children program (Sanjeevi et al., 2023). Inequities in oral health are seen across the lifespan (Henshaw et al., 2018; NIH, 2021). The NHQDR shows that AIAN, Asian, Black, and Latino/a individuals all had lower rates of dental care than White individu- als (AHRQ, 2023a). Untreated dental caries among Black children decreased by 45 percent overall from 2001–2004 to 2015–2018 but remained signifi- cantly more likely than among White children (AHRQ, 2023a). Lack of dental coverage and experiences of discrimination contribute to inequities in dental care use (Singhal and Jackson, 2022). IMPACT OF PLACE: STATES AND TERRITORIES Racial and ethnic inequities persist., and they are pervasive across all states. when health outcomes have improved, inequities remain (Radley et al., 2024). State policies, such as expansion of Medicaid, physician work- force policies, including number of primary care providers, state support for infrastructure, state public health programs, and investment in com- munity programs, affect racial and ethnic inequities in care. States with the smallest inequities in health include Massachusetts, Hawaii, the D ­ istrict of C ­ olumbia, Minnesota, Rhode Island, New Hampshire, C ­ alifornia, ­Maryland, C ­ onnecticut, Virginia, and Pennsylvania (Radley et al., 2023). States with the largest inequities include Mississippi, Wyoming, ­Tennessee, South Carolina, West Virginia, North Dakota, Arkansas, Oklahoma, Alaska, and South Dakota (Radley et al., 2023). Addressing the health care needs of individuals in U.S. territories pres- ents particular challenges given high rates of poverty and limited territorial resources and fundamental differences in Medicaid payments (Hall et al., 2019). Federal statute caps funding, and federal matching rates are fixed (Hall et al., 2019). In contrast, federal Medicaid funding for states has no cap, and the federal share varies based on states’ per capita income (Hall et al., 2019). Thus, federal law establishes disparate Medicaid funding, and benefit coverage and delivery systems vary between territories, with only Guam offering long-term services, and Guam, American Samoa, and the Northern Mariana Islands providing nearly all services through a single public hospital (Hall et al., 2019). Puerto Rico is the only territory to oper- ate a managed care delivery system. However, all the territories have been challenged by low provider reimbursement, provider shortages, and poor infrastructure, with worse access to specialty care and mental health ser- vices (Hall et al., 2019). Guam, Puerto Rico, and U.S. Virgin Islands have expanded their Medicaid programs under ACA (Hall et al., 2019). Data are scarce regarding the quality of care in U.S. territories. Puerto Rico is the largest, home to more than 3.2 million with a median household 

102 ENDING UNEQUAL TREATMENT income that is less than one-third of the U.S. median; 42.7 percent of its people live below the federal poverty level (Center for Puerto Rican S­ tudies, 2023). An analysis of 2011 Medicare Advantage enrollees showed that those who were Latino/a in Puerto Rico received worse care compared with Latino/a enrollees in the mainland (Rivera-Hernandez et al., 2016). An analysis of Medicare Advantage data from 2006 to 2016 found that plans in Puerto Rico received lower payments than those in the 50 U.S. states and District of Columbia, and this gap widened after ACA (Rivera-Hernandez et al., 2016). INTERSECTIONALITY Although the evidence for widespread health inequities is robust, data generally only consider differences by one demographic category, such as race and ethnicity. However, individuals belong to multiple demographic groups, such as sex and gender, race and ethnicity, socioeconomic status, and sexual orientation. Extensive literature has demonstrated inequities experienced by individuals with multiple marginalized identities related to gender and race and that many inequities differ in important ways by these intersecting systems of oppression. How such identities shape experiences of the health care system also vary by care setting, disease condition, and geography. The literature notes that the overlapping axes of marginalization are challenging to consider in isolation, as experiences attributed to one belonging to one group may be actually influenced by other dimensions of identity (Crenshaw, 1997). Sexual and Gender Minority Health Care Patients who identify as both racial and sexual or gender minori- ties face a range of health-related disparities and barriers to care related to factors such as a greater burden of poverty, safety concerns, and lack of access to gender-affirming care (Wilson et al., 2022). For example, Black men and transgender women who have male sexual partners experi- ence barriers to obtaining testing for HIV and pre-exposure prophylaxis (Lelutiu-Weinberger et al., 2020). Furthermore, among men who have sex with men, HIV infection rates are higher for Black individuals than other racial or ethnic groups (CDC, 2022). Individuals who identify as sexual and/or gender minorities and are from minoritized racial groups also have worse mental health outcomes than others who identify as sexual minori- ties (Gattamorta et al., 2019) and describe negative experiences when being treated for mental health conditions (Holley et al., 2016). One study of U.S. women indicated that having a female partner pre- dicted a lower rate of cervical cancer screening compared to women with male partners and that this difference varied across racial groups (Agenor 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 103 et al., 2014). In another women’s health study, Black lesbian women had lower rates of human papillomavirus vaccine initiation compared with Black bisexual women, White lesbian and bisexual women, and Black or White heterosexual individuals (Agenor et al., 2018). Substance use pat- terns also vary between homosexual and heterosexual women (Lee and Tan, 2022). Men from minoritized racial and ethnic groups who also reported having male sexual partners have been found to be a vulnerable population with regard to many aspects of health, including housing, food insecurity, substance use, and sexually transmitted infections (Kipke et al., 2020). An individual’s entire identity (capturing all of their lived experiences) should be taken into account when delivering needed care, and all indi- viduals should be given the opportunity to have trusting relationships with health care providers. At the population level, intersectionality needs to be integrated into any interventions designed to address and eliminate inequi- ties in the health care system. Health Care for Individuals with Disabilities Approximately 1 in 6 children and adolescents aged 3–17 have a devel- opmental disorder disability (Cogswell et al., 2022). In 2019, AIAN children had the highest childhood disability13 rate at 5.9 percent followed by children of multiple racial groups at 5.2 percent, Black children at 5.1 percent, and Hispanic and White children at 4.3 percent. Asian and NHPI children had the lowest rates at 2.3 percent and 3.2 percent, respectively (U.S. Census Bureau, 2021). Analysis from the 2016 National Survey of Children’s Health (NSCH) data revealed varying prevalence rates of developmental disabilities (DD) and autism spectrum disorder (ASD) among children of different racial/ethnic groups (Magaña and Vanegas, 2021). For DD, rates ranged from 2.8 percent for Asian American children to 7.5 percent for Black American children. Latino/a and White children’s prevalence of DD were 4.3 and 4.7 percent, respectively. ASD prevalence ranged from 1.3 percent for Asian American children to 2.8 percent for Black American children. Latino/a, and White children’s prevalence of ASD was 2.4 and 2.6 percent, respectively. Racially and ethnically minoritized children with special health care needs face greater inequities in health and health care compared to racially and ethnically minoritized children or children with special needs individually at the local, state, and national levels (Akobirshoev et al., 2020). For example, Black and 13 The American Community Survey considers those with disabilities to have one or more of the following: seeing, hearing, concentrating or remembering (ages 5 and above), walking or climbing stairs (ages 5 and above), dressing or bathing (ages 5 and above), or doing errands alone such as buying groceries or going to the doctor (ages 15 and above). 

104 ENDING UNEQUAL TREATMENT Latino/a children were more likely to have unmet medical and dental needs, worse oral and physical health, and experience financial barriers to paying for medical costs. Similar inequities exist in the prevalence of adults living with disabilities (KFF, 2022). Individuals living with disabilities have poorer health-related quality of life compared with people without a disability. Research documented that people living with disabilities experience higher risks and rates of diseases, morbidity, and mortality (Weil, 2022). However, they were not recognized or designated by the federal government as a population expe- riencing health disparities until NIH did so in September 2023 (NIMHD, 2023). Adults with disabilities experience notably inferior health outcomes compared to the general population, which is further pronounced among those from minoritized populations (NIMHD, 2023). Access barriers to health care for racially and ethnically minoritized individuals with I/DD exist (Li et al., 2021). For Black and Latino/a adults with I/DD, prevalent barriers included a reluctance or mistrust of doctors, an aversion to using medical services, and uncertainty about where to seek care. White adults with I/DD identified location and insurance-related issues as their primary obstacles. All groups highlighted financial constraints as a common reason for delaying or forgoing care. Policies and interventions are needed that are aimed at enhancing health care access for racially and ethnically minoritized populations with I/DD, with a primary focus on building trust between patients and health care providers. The pronounced health care inequities experienced by racially and ethnically minoritized populations with dis- abilities highlights systemic economic barriers affecting both communities. People with I/DD from minoritized racial and ethnic backgrounds encounter heightened exposure to adverse social determinants of health, resulting in limited access to quality health care and unfavorable health outcomes (Magaña et al., 2022). Immigrant Health Care In 2022, the U.S. foreign-born population reached a record 46.6 mil- lion, or 14.2 percent of the U.S. population (Camarota and Zeigler, 2022), with an expected growth of 78 million by 2065 (Budiman, 2020). Accessing and navigating the U.S. health care system has been cited as a barrier for immigrant populations (KFF, 2023). Lack of linguistic and cul- tural concordance with HCPs has contributed to and exacerbated adverse experiences in health care, negative interactions with HCPs, and increased distrust of the U.S. health care system (Omenka et al., 2020). COVID-19 disproportionately impacted immigrant populations as a result of a par- ticular vulnerability in housing, utilities, and food insecurity, language and 

EVIDENCE OF RACIAL AND ETHNIC INEQUITIES 105 cultural barriers limiting access to health care and legal systems, and a higher likelihood of employment as essential workers (Kiester and Vasquez- Merino, 2021). When considering the intersectionality of race, ethnicity, and immigra- tion status, studies show complex and varied associations related to the immigrant health paradox for racially and ethnically minoritized popu- lations. For example, a study with first-, second-, and third-generation Arab American immigrants found no significant differences in diabetes, hypertension, or heart disease outcomes (Abuelezam et al., 2019). Another study examining racial and ethnic health inequities and inequities by immigration status in diabetes outcomes, using data from 16 waves of the National Health Interview Survey, showed that foreign-born Asian adults had significantly higher odds of diabetes compared to U.S.-born Asian adults. In contrast, foreign-born Black, Latino/a, and White adults had a lower odds ratio compared to their U.S.-born counterparts (Engelman and Ye, 2019). Compared to U.S.-born populations, the complexity of health out- comes in immigrant populations reflect the heterogeneity of health within them and the impact of living in the United States and interacting with its structures and systems. Among Black immigrants, who have lower odds for diabetes than their U.S.-born counterparts overall, living in the United States for more than 15 years was significantly associated with increased diabetes risk, which was higher than that for U.S.-born Black adults (Engelman and Ye, 2019). Latino/a immigrants in the United States for more than 15 years also showed higher diabetes risk than recent Latino/a immigrants (Engelman and Ye, 2019), labeled as a risk of accul- turation. A longitudinal study found that U.S.-born Latino/a adults and foreign-born Latino/a adults who had been in the United States on average for 36 years did not significantly differ in functional limitations, depres- sive symptoms, metabolic dysregulation, and C-reactive protein (Boen and Hummer, 2019). Both Latino/a and Black adults experienced higher levels of disability, depressive risk, and adverse physiological health outcomes as they aged (Boen and Hummer, 2019). These findings point to negative and long-term health effects of U.S. social and structural contexts on these populations. Some scholars have posited racialized legal status as a SDOH to explain how the racialized nature of anti-immigration sentiment and policies has contributed to inequities in health outcomes for both foreign-born and U.S.-born minoritized racial and ethnic populations. Immigration status is one example of a racialized legal status that has direct health effects, such as an increase in mental health disorders in children in immigrant families, and spillover effects on other members in racially and ethnically minoritized communities who face discrimination, stigma related to legal status, and 

106 ENDING UNEQUAL TREATMENT unjust treatment by enforcement systems (Asad and Clair, 2018). An anti- immigrant climate, in the context of structural racism, leads to the codified exclusion of racially and ethnically minoritized populations in federal and state policies and public benefits, racial and ethnic profiling in immigration enforcement and criminalization, and labor exploitation and neighborhood disinvestment (Misra et al., 2021). Empirical evidence has shown the associations between inclusionary and exclusionary policies on immigrant health. States with more inclusive policies had Latino/a noncitizens with higher levels of health insurance coverage (Young et al., 2019). The gap in Medicaid coverage between U.S. and foreign-born populations is highest in states with more exclusive Medicaid eligibility rules for immigrants and lower immigrant popula- tions (Zhu and Xu, 2015). The effects of exclusion are seen even when considering non–health care policies. For working-age immigrant adults, living in states with more restrictive policy climates was associated with a lower likelihood of health care provider visits (Dondero and Altman, 2020). Although exclusion at the policy level exacerbates the anti-immigrant climate and rhetoric associated with adverse health and health care out- comes, policies aiming to address and mitigate the effects of undocumented status and increase inclusion have shown promise in improving health for immigrants. The Deferred Action for Childhood Arrivals program (DACA)14 is one policy associated with positive health outcomes (Giuntella et al., 2021; Manalo-Pedro and Sudhinaraset, 2022). CHAPTER SUMMARY Racially and ethnically minoritized populations continue to receive inferior access to health care, with no significant and sustained improve- ments in these inequities since 2003. They also continue to experience higher rates of disease morbidity and mortality and receive poorer-quality health care. Inequities and poor outcomes are compounded among such individuals who are also members of other minoritized groups. Based on the materials in this chapter, the committee offers the follow- ing conclusions: Conclusion 3.1. Available data show that racial and ethnic inequities in health care access and use exist across the continuum of care. Conclusion 3.2. Available data show that racially and ethnically minoritized populations generally have worse outcomes compared to their counterparts in White non-Hispanic comparator groups. 14 See https://www.uscis.gov/DACA (accessed March 29, 2024). 

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