The federal government needs to do more to address the persistent racial and ethnic gaps plaguing the U.S. health-care system, declares a new report by the National Academies of Sciences, Engineering, and Medicine.

These pervasive inequities are documented in the report:

• Diabetes is most prevalent in American Indian and Alaska Native adults at 13.6%, followed by Black people at 12.1% and Hispanic populations at 11.7%. Asians follow at 9.1% and 6.9% for whites.
• Non-white patients are less likely to receive newer, higher cost drugs and diabetic technologies.
• Black patients with diabetes experience hospitalization rates more than 2.5 higher than those for whites.
• Racially and ethnically minoritized individuals are significantly less likely to have a usual source of primary care and experience longer wait times during ER visits and are assigned lower triage severity scores.
• Long-term care facilities serving predominantly minoritized residents offer fewer clinical services, have fewer staff, and more care deficiency citations.

“Despite spending the most on health care among high-income countries, the U.S. has some of the worst population health outcomes,” the report states. “The system’s inadequacies disproportionately affect minoritized populations, with stark racial and ethnic inequities in life expectancy, maternal and infant mortality, and many chronic diseases.”

Contributing Health Policy Expertise

Stanford Health Policy’s Alyce Adams, PhD, MPP, and Josh Salomon, PhD—both professors of health policy—were advisors for specific parts of the report.

Adams—co-director of the NIDDK-funded DREAMS Center for Diabetes Translation Research—was part of a workshop on Community Health Perspectives, noting that social determinants of health and access to high-quality care continue to be a critical drivers of inequitable health care outcomes.

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In the report, Adams explains that Medicaid expansion and Medicare Part D policy reduced access barriers among people with diabetes living in states with restrictive Medicaid drug coverage policies prior to Part D. However, in some cases, disparities in treatment remained the same or worsened as those with the greatest needs were last to respond to expanded Part D coverage benefits (Adams et al., 2015).

Adams and colleagues are using artificial intelligence (AI) and other tools to simulate interventions and anticipate whether a change in coverage policy will benefit or harm certain populations They are also exploring the use of AI to identify concurrent policies needed locally to complement federal and state policies. However, there are concerns that deploying AI within health care systems might perpetuate biases.

Sherri Rose, PhD, professor of health policy and director of the Health Policy Data Science Lab at Stanford, is a national expert in understanding and addressing AI challenges around data representativeness, design and deployment and additional factors that may harm marginalized subgroups. She and colleagues are identifying potential mitigation strategies and focusing on how clinicians and policymakers will use AI-powered algorithms. Input from patients, caregivers, and community partners have informed much of this work and will continue to be central in efforts to design innovative health care interventions.

Salomon, director of the Stanford Prevention Policy Modeling Lab, contributed to all of the committee meetings and discussions as liaison for the NASEM Board on Population Health and Public Health Practice, which co-convened the committee.

“The report presents a sobering diagnosis of persistent inequities in the U.S. health-care system, at the same time it lays out specific, concrete recommendations for policies and actions that can drive progress toward eliminating these inequities,” Salomon said.

Moving Forward

The report recommends multiple actions that Congress, the U.S. Department of Health and Human Services, National Institutes of Health, Centers for Medicare & Medicaid Services, and other agencies should take to remedy inequities in health care. The authors of the report pointed to five key goals:

• Generate accurate and timely data on inequities. The Office of Management and Budget, for example, should more aggressively enforce requirements for routine collection of race, ethnicity, tribal affiliation, and language data by all agencies overseeing federal health care and research programs.
• Equip health care systems and expand effective and sustainable interventions. Congress should increase funding for effective health-care delivery programs to improve access and quality and reduce inequities.
• Invest in research and evidence gathering to better identify interventions that eliminate health-care inequities. One action, they write, is for the NIH and other federal and nonfederal research funders to expand funding for research aimed at addressing health care inequities.
• Ensure adequate resources to enforce existing laws and build systems of accountability. For example, the Office for Civil Rights at HHS is under-resourced, which limits its efforts to enforce civil rights statutes and address the complaints it receives from individuals. Moreover, they write, several ACA provisions that could significantly advance racial and ethnic equity in health care are enforced sporadically or not at all.
• Eliminate inequities in health-care coverage, access and quality. Congress should establish a pathway to affordable, comprehensive health insurance for everyone and establish a pathway to the adoption and implementation of Medicaid payment policies on par with Medicare.

“Eliminating health care inequities is an achievable and feasible goal, and improving the health of individuals in the nation’s most disadvantaged communities improves the quality of care for everyone,” said Georges C. Benjamin, co-chair of the committee that wrote the report, and executive director of the American Public Health Association. “This is not a zero-sum game — we are all in this together.”