National Academies proposes reimagining health care to fix ‘fundamental flaws’ that underlie inequity

The nation’s longstanding racial and ethnic health inequities will not improve unless Congress steps in to provide affordable health insurance for all and federal agencies start enforcing existing laws against discrimination and improve collection of racial and ethnic data, said the authors of a new report released Wednesday.

Called “Ending Unequal Treatment,” it was issued by the National Academies of Science, Engineering, and Medicine some two decades after the groundbreaking 2003 “Unequal Treatment” report laid bare the fact that people of color experienced the health care system differently and received worse care, regardless of income, social status or education, and that structural racism ran rife throughout health care.

Not much has changed, the new report said. “Twenty years later, it is clear that our nation has not made enough progress,” said Victor J. Dzau, president of the National Academy of Medicine in a statement. “The current system, by its very design, delivers different outcomes for different populations,” the report said.

Racial and ethnic inequities remain “fundamental flaws” in the nation’s health care system, have led to millions of premature deaths of Black, brown and Indigenous Americans, and cost the country hundreds of billions of dollars annually, the authors wrote. They call for the nation’s health care system, which they said remains largely broken for the most marginalized patients, to be reimagined.

Congress, they say, needs to establish a pathway for affordable health insurance for all; reimburse Medicaid providers at the same rate as Medicare providers; and better fund the Indian Health Service.

The report mirrors a 2022 investigation by STAT that found 20 years after Unequal Treatment was released, dishearteningly little progress had been made to end racial health disparities, and many are worse today. A study last year found Black Americans suffered 1.63 million excess deaths and lost more than 80 million years of life in the past 20 years compared to white Americans.

Other specific recommendations for Congress and federal agencies including the Department of Health and Human Services, the National Institutes of Health, and the Office of Management and Budget include:

• Improving the spotty and inconsistent collection of race and ethnicity data of both patients and health care workers by having the Department of Health and Human Services make sure programs under its oversight collect and report this data, with monitoring by the Office of Management and Budget.
• Allocating increased funding to allow health care systems to implement solutions known to improve health equity, such as the use of patient navigators and community health workers, and have HHS agencies set clear, enforceable standards to hold health systems accountable for implementing these solutions.
• Expanding federal research on health inequities, structural racism, health-related social needs, and community-based research. (The report said only a “paucity of resources” had been devoted to health equity research despite the magnitude of the problem.)
• Better funding the Office of Civil Rights in HHS so it can enforce existing but underused laws against discrimination, including section 1557 of the Affordable Care Act, which specifically addresses discrimination.

“Many of the tools needed to reach these goals are already available and need to be fully used,” said committee co-chair Jennifer DeVoe, professor and chair of family medicine at Oregon Health & Science University.

The study was sponsored by the Agency for Healthcare Research and Quality and the National Institutes of Health. It chronicles a long list of racial and ethnic inequities for patients from marginalized groups, from living shorter lives and being more likely to die in childbirth to being less likely to have a regular source of primary care and receiving care from long-term care facilities with less staff and more deficiencies.

Health equity researchers welcomed the new recommendations but some said they do not go far enough. They noted that health inequities are tied not only to the health care system but to larger social problems, such as housing and neighborhood inequality, living in areas that have little fresh food or few safe places to exercise, poverty, inequities in educational opportunities, and other conditions that plague Black and Indigenous Americans more than other groups.

“The recommendations all have merit but they don’t go far enough because they don’t address structural racism as an underlying cause of health disparities,” said Louis Penner, a health disparities researcher and professor emeritus in the department of oncology at Wayne State University.

In a recent book, “Unequal Health,” Penner and three co-authors came to a similar conclusion as the new report: that improving health disparities will not be possible without significant change. But the book focused on changes both within health care and outside of it, arguing that achieving health equity requires addressing the lack of socioeconomic opportunities and inherited wealth faced by many Black Americans, expanding educational opportunities, reducing discrimination in general and within law enforcement, and improving neighborhood and housing quality, among other steps.

“We suggest more extensive and radical solutions,” Penner said in an interview.

A National Academies report issued roughly a year ago went further in urging the federal government to improve health through social changes, such as increased wages, housing vouchers, and more equitable education spending.

Georges C. Benjamin, executive director of the American Public Health Association and the committee’s co-chair, said during a webinar Wednesday that social factors were critical to informing the report’s recommendations.

Another committee member, Ruth Shim, a psychiatrist and associate dean of Diverse and Inclusive Education at the University of California, Davis School of Medicine, said, “Structural and social factors that drive health quality are front and center in this report.”

The report, for example, “describes new models of care that integrate clinical care and social needs,” said Vincent Guilamo-Ramos, executive director of the Institute for Policy Solutions and professor at the Johns Hopkins School of Nursing, and a committee member.

Shim said one thing that had changed markedly in the past two decades is terminology and thinking about what causes inequities. While the Unequal Treatment report suggested that equity would occur if all patients were treated equally regardless of race or ethnicity, Shim said it has become clear that health inequities are often the result of historical disadvantages and that truly equitable health care takes these unfair circumstances into account when making treatment decisions.

A spokesperson from HHS said the Biden Administration had pushed a large number of initiatives to advance health equity, adding “Equity continues to inform our every decision, whether through our new kidney transplant model or historic investment in navigators” to guide patients through the health care system. “There is always more work to be done, but HHS’s actions are already making a real difference for communities of color across the country.”

Wednesday’s report comes amid a national conversation about what it will take to improve health for marginalized communities. At a panel on structural racism in health at Aspen Ideas Health this weekend, Aletha Maybank, the American Medical Association’s chief health equity officer and senior vice president, said it was time to move beyond simply studying inequities. “We have so much data,” she said. “We don’t need more data to know these disparities exist.”

Many speakers said the work today was harder, but even more important, given the pushback against DEI efforts occurring through legal and political battles. Rachel Hardeman, who directs the Center for Antiracism Health Research for Health Equity at the University of Minnesota, said the fight would be long but must be deliberate, despite the urgency of the problem highlighted by the Covid-19 pandemic and the death of George Floyd. “Urgency culture is actually harmful to this work in a lot of ways,” she said.

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.