On a universal level, every action, procedure, or decision involved in healthcare should optimize the possible outcomes that can be achieved as a result of care. This means that in an ideal world, people with equivalent conditions requiring healthcare would receive the same treatment, regardless of geography, family background, affluence, race, or gender, and their care would lead to the best possible outcomes.
According to the Robert Wood Johnson Foundation, "Factors such as our race, ethnicity and socioeconomic status should not play a role in how healthy we are or how long we live. Unfortunately, for many of us, they do…" (RWJF, n.d.). This article focuses on disparities in healthcare, efforts to understand them and why they occur, as well as ways the healthcare industry and specific providers are working to address and limit the effects of them.
Some organizations delineate health disparities from healthcare disparities.
For example, the University of Michigan offers that health disparities are "differences among population groups (that is, ethnicity, gender, income) in the incidence, prevalence and outcomes of health conditions, diseases, and related complications of diseases," while healthcare disparities are "differences among population groups in the availability, accessibility, and quality of healthcare services aimed at prevention, treatment, and management of diseases and their complications, including screening, diagnostic, treatment, management, and rehabilitation services" (University of Michigan Library, N.D.). Another definition comes from Healthy People, which is a broad, long-term agenda for improving the entire country's health that "is the product of an exhaustive collaborative process among the U.S. Department of Health and Human Services (HHS) and other federal agencies, public stakeholders, and the advisory committee" (healthypeople.gov, N.D.). This effort focuses on health disparities and defines them as "a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage" (healthypeople.gov, N.D.). The Centers for Disease Control and Prevention (CDC) clearly endorses the U.S. healthcare industry's responsibility in addressing healthcare disparities, referring to them as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. Populations can be defined by factors such as race or ethnicity, gender, education or income, disability, geographic location (e.g., rural or urban), or sexual orientation" (CDC, 2020). The keyword in that last definition is 'preventable.'
The conditions that drive disparities in health and healthcare are numerous and come from within and outside the healthcare system.
According to the Kaiser Family Foundation, "health outcomes are driven by multiple factors, including underlying genetics, health behaviors, social and environmental factors, and access to health care. While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviors and social and economic factors, often referred to as social determinants of health, are the primary drivers of health outcomes and that social and economic factors shape individuals' health behaviors. Moreover, racism negatively affects mental and physical health both directly and by creating inequities across the social determinants of health" (KFF, 2021).
A more complete vision is to accept that sources of disparity include "socioeconomic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation. Research also suggests that disparities occur across the life course, from birth, through mid-life, and among older adults" (KFF, 2021). Other ways that race and ethnicity can interact with various categories to create disparities is in the difference in health and healthcare for immigrant groups related to length of time in the country, primary language used for communication, immigration status, etc.
VeryWellHealth offers that "like many aspects of public health, the root causes of health disparities are complex."
Health is influenced by so many factors that it can be difficult to pinpoint just why a gap between two groups is so wide" (Correll, 2020). Another way to look at the causes of health disparities is to think about health inequities, which are "differences in how resources are distributed among different groups. These resources could be tangible, like in the case of physical parks where kids can exercise safely, or intangible opportunities, such as being able to see a doctor when ill" (Correll, 2020). Here are some of the major health inequities in the United States that contribute to healthcare disparities:
Income Inequality – "While top incomes skyrocketed between 1980 and 2015, real wages for low-income individuals fell, making it increasingly difficult for poor people in the United States to afford basic medical care or engage in healthy behaviors. This, in turn, makes it harder to stay healthy or treat and manage health conditions" (Correll, 2020).
Systemic Discrimination – Discrimination can be so deeply embedded in standard cultural practices to an unconscious extent that they are unquestioned and taken for granted. Lasting damage occurs when "these forces are the result of past inequities that still affect communities today" (Correll, 2020). VeryWellHealth gives the example of "mid-20th-century discriminatory housing practices… [which] forced many minority families into neighborhoods without nearby access to community resources, like public transportation, quality education, or job opportunities—all of which affect a family's financial stability and, therefore, long-term health" (Correll, 2020).
Environmental Factors – At the same time that people can make personal choices that positively affect their health outcomes, "many of those choices are shaped, influenced, or made for us by the environment we're in." This environment is subject to "physical, chemical, and biological forces that can impact our health, and they can be a driving force behind health disparities" (Correll, 2020). These factors can extend from environmental pollution and poor access to healthy food to the lack of adequate water supply and plumbing facilities—situations that "make it harder for kids to learn and adults to work, exacerbating the effects of poverty on people's health and well-being" (Correll, 2020).
Improving health equity is one of the priorities of the current Administration, which has promulgated executive orders and other actions targeting this important goal.
Not only is addressing healthcare disparities very important in terms of social justice and equity, but it is clearly related to the overall state of health in the United States and to national economic prosperity.
The Kaiser Family Foundation offers that "people of color and other underserved groups experience higher rates of illness and death across a wide range of health conditions, limiting the overall health of the nation.
With impending demographic change, including a near future when people of color are expected to make up over half of the U.S. population, ensuring the health of a majority of the American people is going to be a vital concern.
Health disparities have an impact that beyond just the affected individuals.
These ill effects can extend to "children, whole communities, and society at large. Health disparities are often self-perpetuating" (Correll, 2020). VeryWellHealth offers a common scenario of parents who are too unwell to work and then become low-income. If unemployed, they may have limited access to healthcare insurance, leading to a vicious cycle of getting sicker and remaining jobless. Getting out of a spiral like this is extremely difficult (Correll, 2020). Intergenerational impacts are easy to foresee, especially when mothers and their children are involved. Chronic stress during a pregnancy, like that connected to unemployment or financial issues, can lead to preterm deliveries, serious health issues later in life, and dangerous pregnancy complications (Correll, 2020.) VeryWellHealth cites a study "in North Carolina that estimated that the state could save $225 million a year if disparities in diabetes could be eliminated," as well as "another report estimated that reducing health disparities on a national scale could have saved the United States nearly $230 billion between 2003-2006" (Correll, 2020).
In multiple ways, existing healthcare disparities have increased the impact of the COVID-19 pandemic and made it more important than ever to achieve progress against them.
Many public health experts worry that "disparate impacts of the COVID-19 pandemic for people of color and other underserved groups may lead to even further widening of health disparities and greater health risks for the community as a whole" (KFF, 2021). Healthcare disparities are at work in many cases as "some groups remain at increased risk from COVID-19 due to lower vaccination rates and/or increased risk of exposure to the virus" (KFF, 2021).
In some of its efforts to combat COVID-19, the Federal Government is simultaneously targeting health inequities, beginning with a January 2021 Executive Order "to address the disproportionate and severe impact of COVID-19 on communities of color and underserved populations" (KFF, 2021). One of its components is the creation of the COVID-19 Health Equity Task Force, which requires Federal agencies to "strengthen equity data collection and reporting and ensure response plans and policies provide for equitable allocation of resources… [and] directs HHS to conduct an outreach campaign focused on building vaccine confidence among communities of color and other underserved populations" (KFF, 2021). Additional measures provide funding to support COVID-19 vaccination and other public health efforts among underserved populations, as well as focus on rural areas, low-income populations, and community health centers. Other measures are aimed at the uninsured, immigrant families, and improving maternal health (KFF, 2021).
Making headway against the wide range of healthcare outcomes is not something to be achieved easily.
VeryWellHealth reminds us that the "causes [of healthcare disparities] are often multi-layered… [and that] solutions would need to address not only the root cause of a given disparity but also the context that made it possible in the first place" (Correll, 2020). That's why the Healthy People initiative mentioned earlier targets "the environmental conditions and circumstances that affect and shape how healthy we are" (Correll, 2020). These social determinants of health have a major effect on our behavior and the choices we are able to make in support of living healthfully. The following five Healthy People objectives are a roadmap for the effort to address social determinants of health and reduce healthcare disparities:
Improving economic stability
Economic stability is reliant on such components as food security, income, housing, and employment. When any of these factors are unstable, health issues are a big risk. Some of the solutions available are housing assistance, public health measures like vaccinations, and job programs and unemployment assistance.
Ensuring quality education
A quality education is built on literacy, early childhood education programs, and high school completion. Benefits that also translate into better health include decreased criminality, lower numbers of teen births, improved economic performance, and averted healthcare costs.
Addressing issues within a social and community context
Some issues like incarceration can disrupt families and affect access to life necessities like education, employment, and housing—they have an impact on the health of individuals as well as their larger community. For example, policy changes are needed to "address sentencing laws that disproportionately impact certain Black communities as a means to reduce… disparities" (Correll, 2021).
Expanding healthcare access and health literacy
People need to have access to healthcare when sick, as well as preventive care when well. The Affordable Care Act ensures coverage for preventive care and also requires "medical and public health professionals to address health literacy by ensuring everyone can obtain, understand, and communicate information essential to health decisions" (Correll, 2021). Even so, many people in the United States still lack health insurance and access to healthcare, as well as a basic understanding of what is involved in care.
Improving the built environment
Where someone lives has a significant impact on their health, in terms of healthy food access, security, crime prevention, etc. Obesity and other health disparities can be a significant community health problem when healthy food options are not readily available. One solution is to encourage partnerships between "local governments, food retailers (such as grocery stores), and communities… [to] help bring more affordable and healthier food options to areas where such foods are scarce" (Correll, 2020).
A great place for healthcare organizations to start is through education. It's important that your leaders, managers, and employees understand your commitment to health equity and how they can contribute. Several topics to begin your educational journey include:
The ongoing challenge of healthcare disparities
The public knowledge of healthcare disparities is probably greater than it has ever been, given the uneven impact of the COVID-19 pandemic. However, the Kaiser Family Foundation reminds us that "health and health care disparities are not new. They have been documented for decades and reflect longstanding structural and systemic inequities rooted in racism and discrimination" (KFF, 2021). In addition to improving countless human lives and allowing many more people to access their potential,
This being said, progress on addressing healthcare disparities is happening slowly. According to the American Medical Association, "Recent studies have shown that despite the improvements in the overall health of the country, racial and ethnic minorities experience a lower quality of health care—they are less likely to receive routine medical care and face higher rates of morbidity and mortality than nonminorities" (AMA, N.D.). Clearly, the effort to reduce healthcare disparities is one that is just beginning. People's lives and their health depend on it.