The Path to Equitable Health Care

The path to achieving equity for racial and ethnic underserved communities, which are at risk for experiencing health and health care disparities, has not been an easy one. The challenges of these disparities came to national attention in 1985 with the Report of the Secretary's Task Force on Black and Minority Health during President Reagan's administration (often referred to as the Heckler Report; Heckler 1985; Gamble and Stone 2006). In 1989, the American Medical Association (AMA) noted “unjustifiable” differences in treatments provided to African Americans that “must be eliminated” (AMA, 1990). And in 2003, the Institute of Medicine's landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care comprehensively documented continuing, pervasive disparities in our health care system (Smedley et al. 2003).

During this time, we made some progress. We now have federal standards for collecting data on race and ethnicity that allow providers, health plans, and others to determine if there are disparities in their health systems (Affordable Care Act [ACA] 2010). We now also recognize that simply documenting the existence of racial/ethnic disparities is not sufficient; we need to move beyond studying the presence of disparities to studying what works to eliminate them. The research enterprise has refocused on trying to better understand the drivers of disparate care, and disparate outcomes, and has identified contributing factors such as geography, under-resourced providers, segregation, communication barriers, and the role of unconscious bias. This work has been motivated by the hope that by understanding the drivers of disparities, we might more effectively target interventions to eliminate them. However, we keep falling short.

The most recent National Healthcare Disparities Report (NHDR) released by the Agency for Healthcare Research and Quality (2012) found that although overall quality of care is slowly improving in the United States, most disparities experienced by racial/ethnic minorities are not decreasing. More specifically, 50 percent of the measures in the NHDR that track disparities in health care access show no improvement between the years 2002 and 2008, and 40 percent of those measures are getting worse. Latinos, American Indians, and Alaska Natives experience worse access to care than whites on more than 60 percent of the access measures, whereas African Americans experience worse access on slightly more than 30 percent of the access measures. Asian Americans experience worse access to care than non-Latino whites on 17 percent of the access measures. The report found that few disparities in quality of care related to race/ethnicity demonstrated significant improvement. These findings echo previous work by Mead et al. (2008) that examined measures of timeliness, safety, patient centeredness, and effectiveness in health care, and found consistent disparities experienced by these same groups.

Researchers, health care leaders, policy makers, and others have proposed several recommendations to reduce disparities over the last decade. These include increased training of providers to deliver more culturally competent care (Green et al. 2008), embedding disparities measurement into a quality of care framework (Fiscella et al. 2000; Chin and Chien 2006), or, as Massachusetts attempted to do, paying for performance with disparities reduction as a targeted goal (Blustein et al. 2011). Taking a bigger picture approach and stepping outside the health care system boundaries, Derose, Gresenz, and Ringel (2011) proposed a framework that “extends beyond individual factors such as demographics, health insurance status, and health beliefs and suggest addressing disparities through a public health framework to link people to services, ensure availability of health care and a competent public health and health care workforce, and use of the public health infrastructure to develop evidence to inform policies and practices.” They, as do others, assert that addressing health disparities requires the collective effort of both the public and private health care systems. While many of these recommendations have been implemented in health care organizations and there has been substantial effort at the state level (National Conference of State Legislators 2012), the sad reality remains—disparities persist.

Fortunately, the ACA holds promise as a policy lever to drive significant change, with provisions that may improve the health of all Americans and a meaningful promise to narrow disparities. As the single largest federal effort to expand health care coverage in the United States since the creation of Medicare and Medicaid in 1965, the ACA includes provisions to improve access and quality that could have both direct and indirect impact on populations at risk for experiencing disparities in care (Andrulis et al. 2010). Steps that directly address disparities include language in the legislation that calls for collection of race and ethnicity data to stratify quality measure reporting for all federally supported health programs, requirements for cultural competency training of providers, and training and funding to promote workforce diversity. Indirect impacts on disparities can be expected from language that expands Medicaid coverage by raising the national Medicaid minimum eligibility level to 133 percent of the federal poverty level, expansion of coverage offered by small employers through tax credits and penalties, and public health initiatives to address obesity and diabetes.

In the research arena, the legislation dramatically expands research in health disparities and interventions by elevating the National Center on Minority Health and Health Disparities to an Institute and creates the Patient-Centered Outcomes Research Institute (PCORI), which includes an emphasis on addressing disparities among its national priorities for research (http://www.pcori.org). Taken together, these legislative initiatives provide the health services research community with an unprecedented, coordinated set of opportunities to develop, test, and implement ways to advance health care equity. If we do not do this now, then when?

History provides lessons on the importance of timely interventions capturing confluent social, policy and funding streams to address inequities. Brown v. Board of Education of Topeka, a landmark decision of the United States Supreme Court (1954), declared that establishing separate public schools for black and white students was unconstitutional. With this decision, the Supreme Court put an end to the pretense that “separate” could be “equal.” This decision did not address health care specifically, but by calling public attention to issues of racial disparities in education it helped crystallize the larger idea that segregation in public services, including health, was legally indefensible. This was a major contribution to establishing a social milieu that could support larger desegregation efforts. However, 10 years after Brown v. Board of Education, formal segregation in health care was still common. Then came passage of the Civil Rights Act in 1964, Title VI, of which expressly prohibited the provision of federal funds to any organizations or programs that engaged in segregation by race. Although this did not end overt segregation in health care settings, which were mostly privately financed, it was soon followed by the creation of the Medicare and Medicaid programs in 1965, and with them the promise of significant federal dollars going to hospitals. To receive those federal dollars, hospitals could not be segregated and, within a few months, hospitals across the United States integrated their medical staffs, waiting rooms, and patient floors (Smith 2005). To recap, as the social climate became more supportative, as reflected in the Brown v. Board of Education decision, reinforced by establishment of a policy with the Civil Rights Act, and finally the financial incentives brought to bear through the creation of Medicare and Medicaid, there was a major advance in reducing segregation in health care.

Passage of the ACA may turn out to be a similar timely step toward a more equitable health care system. The 1985 Heckler Report, the 1989 AMA report, and the 2003 IOM Reports each reflected, and contributed to, an evolving social milieu that recognizes health and health care disparities as unacceptable or even, to put it bluntly, immoral. Though not Supreme Court decisions, they drew attention to the need to address health disparities and sparked a prolonged period of foundational research and policy experimentation to promote health equity. The quarter century since the Heckler report might largely have been preparatory for a time like today, when the national climate, acknowledged crises in health care and changing realities would open a window of opportunity to make a giant leap toward improving access for everyone, and addressing disparities for communities of color (Kingdon 2010).

The opening of the policy window in the present time led to passage of the ACA, which, like Medicare, is not specifically aimed at reducing disparities, but is expected to have a substantial differential impact on populations at risk for racial/ethnic disparities. At this writing, the “game changing” provision of the ACA is that it will provide coverage to almost 32 million previously uninsured people, many of whom will be racial and ethnic minorities. This alone should have a substantial impact on reducing disparities. However, to fully capture the potential impact of the ACA, some of its many fundamentally experimental provisions (new models of financing, new methods of information discovery and dissemination, new types of care delivery organizations) must also be harnessed to address disparities. As disparities researchers, how do we best align our agendas with this opportunity?

One approach is to harness our improved understanding of the multifactorial nature of disparities to develop multifactorial intervention research projects aimed directly at eliminating disparities and advancing health equity. At this juncture, the health services research community can make important contributions. We need to take the rigor of health services research and apply it to the complex study of what works. For example, will early adopters of health care delivery innovations (e.g., communities that form ACOs) provide a roadmap and, more importantly, the “proof of concept” that comprehensive changes in financing and delivery that link better quality care and better outcomes with financial rewards can be an effective model for improving outcomes in minority populations?

Many of these challenges are associated with having a high proportion of the payer mix that includes Medicaid. As Medicaid payments rates are on average 66 percent of Medicare rates (Kaiser Family Foundation 2008) for primary care services, there is an institutionalized disparity that occurs among providers who care for large proportions of Medicaid patients. However, section 1202 of the ACA calls for parity in payment rates for primary care services between Medicaid and Medicare in 2013 and 2014. As a result, providers who care for large numbers of Medicaid patients will receive significant increases in their revenues. These changes in Medicaid reimbursement rates, coupled with the expansions in Medicaid eligibility mentioned above, may have profound impacts on access to care and quality of services for Medicaid recipients, many of whom are minorities. Health services researchers can provide the evidence base regarding the impact of these policies in alleviating disparities.

A number of studies have shown that disparities are driven, in part, by where individuals get their care highlighting that providers that serve a large number of racial and ethnic vulnerable populations face challenges in providing high-quality care (Reschovsky and O'Malley 2008; Hasnain-Wynia et al. 2010). Vulnerable racial and ethnic groups too often receive care in facilities that are overstretched and under-resourced, often because many of their patients are uninsured. Hopefully, those facilities will see rising revenues with 2014, although there are reasons to worry about whether patients will flee these facilities once they have insurance, and/or that they will be penalized by performance incentive programs that do not account for their challenging circumstances. The potential impacts from these policy changes provide a unique opportunity for disparities researchers to learn more about what works and what does not for eliminating disparities.

Further underscoring the complexity of disparities research are studies that have also shown that where individuals get their care is not necessarily the primary driver of poor health care or poor outcomes. Trivedi, Sequist, and Ayanian (2006) found that although black and Hispanic patients were more likely to receive cardiovascular care in low-volume hospitals, hospital volume did not explain a large proportion of racial difference in postprocedure mortality. Likewise, another study examining variations among Medicare health plans in overall quality and racial disparities found that for each measure, more than 70 percent of a disparity was due to different outcomes for black and white enrollees in the same health plan rather than selection of black enrollees in to lower performing plans (Trivedi et al. 2006). Now that ACA provisions will lead to payment equity between Medicaid and Medicare, the potential impact on resources and quality for providers who care for large proportions of Medicaid patients can have implications for disparities.

Health services researchers can help to elucidate the multiple pathways that contribute to disparities and use this evidence to design multifaceted interventions that could more effectively reduce disparities in care and outcomes. One clear avenue of inquiry that could help propel improvement is by studying models of success to garner the evidence base that shows what works, why, and how best to disseminate this knowledge. The various health policy changes that result from the ACA provide an opportunity to learn more about what does and does not work, particularly for those who have historically not been well served by the health care system.