What are health disparities?
According to Unequal Treatment, health disparities are the differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups. Disparities in health care exist even when controlling for gender, condition, age, and socioeconomic status. After decades of improvements in preventive health care and significant declines in disease mortality for many Americans, disparities in health and health care continue to persist in the United States. As such, reducing and ultimately eliminating health disparities remains a focus of national attention.
Racial and ethnic minorities, those with disabilities, women, economically and educationally disadvantaged individuals, and medically underserved people, among others, continue to suffer from a disproportionate burden of disease. The reasons for health disparities appear to be multifactorial, still poorly understood, and complex. Compelling evidence indicates that among minorities, race and ethnicity correlate strongly with health disparities. Minority populations, typically classified as African Americans, Hispanic Americans, Asian Americans, native Hawaiians and Pacific Islanders, American Indians, and Alaska natives, are much more likely to experience poorer health outcomes, decreased life expectancy, higher mortality rates, and premature deaths. These groups are also less likely to be recipients of health care services geared toward health promotion, disease prevention and early detection of disease, and high-quality medical treatments.
The Healthy People 2020 initiative was a set of health promotion and disease prevention objectives for the nation. It endeavored to achieve health equity, eliminate disparities, and improve the health of all groups. Healthy People 2020 defined a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” The Healthy People 2020 initiative has concluded, but planning for Healthy People 2030 is underway and a new set of science-based, 10-year national objectives with the goal of improving the health of all Americans are being crafted.
There are a host of key factors, or determinants, of health disparities. These include but are not limited to insurance status, socioeconomic status, residential and geographic segregation, English as a second language, cultural and racial bias, and stereotyping. , , Racial and ethnic minority groups comprise more than 50% of those uninsured, with some groups (e.g., African Americans, Hispanics, American Indians) representing two to five times the number of uninsured white Americans. In its Racial and Ethnic Disparities in Health Care Updated 2010 report, the American College of Physicians (ACP) discusses the literature regarding the poorer health status of minorities in the United States compared with white Americans. Residential segregation, lack of equal access to quality education, and obstacles to economic opportunity are equally important in determining one’s health status. The ACP report suggests that the most significant variable influencing health disparities is insurance status. Insured Americans are more likely to have access to health care. It is well established that minorities are less likely to have insurance, even when adjusting for work status. Lack of insurance affects an individual’s ability to participate in preventive health care measures and manage chronic disease states. Of minorities eligible for federal and state programs such as Medicaid and the Children’s Health Insurance Program (CHIP), more are eligible for coverage than are enrolled (e.g., because of lack of awareness, language barriers, complex enrollment process). Among uninsured individuals, racial and ethnic minorities are still less likely to have equal access to health care.
The Patient Protection and Affordable Care Act (PPACA) was brought into public law in March 2010, with full implementation occurring in 2014. The goals of the PPACA included increasing insurance quality and affordability, decreasing the number of uninsured Americans, and decreasing the costs of health care. To accomplish these goals, it was determined insurance coverage needed to be expanded and premium rates needed to be adjusted to allow for the largest number of Americans to qualify for federal programs or be able to purchase private insurance plans on the PPACA’s exchange site. Insurers were required to accept all applicants, regardless of preexisting conditions, and cover costs associated with a specific list of conditions. Changing the income requirements expanded Medicaid eligibility, changing the age limit for dependents meant children could remain on their parents’ coverage longer, and creating new protections meant children could qualify for their own policies regardless of their parents’ insurance plans, all of which increased the number of Americans with access to insurance plans. To decrease the costs of health care, additional aspects needed to be addressed. The PPACA requires insurers to charge a premium based on age rather than medical history, and subsidies in the form of refundable tax credits were offered to households and small businesses that purchased policies via the exchange. Health insurance expansions under the PPACA have resulted in a net increase of 16.9 million people gaining insurance between 2013 and 2015, roughly decreasing uninsured rates from 18% to 12%. Race/ethnicity is still a variable among populations with regards to access to care. In 2017 among adults ages 18 to 64, 8.5% of whites, 14.1% of Blacks, 7.6% of Asians, and 27.2% of Hispanics lacked health insurance coverage.
The PPACA has been the largest overhaul in American health care since Medicare and Medicaid in 1965 and therefore has changed many standard operating procedures for hospital systems and private practices alike. Mandates were placed on these entities, requiring them to meet standards in patient care, technology, and reporting systems. With the PPACA decreasing the number of uninsured Americans, this growth of insured patients has strained an already stressed health care model, and clinicians are concerned about their ability to maintain the quality of care with the increase of patient visits.
The Office of Minority Health (OMH) was created by the Department of Health and Human Services (DHHS) in 1986 as a direct response to the landmark 1985 Report of the Secretary ’s Task Force on Black and Minority Health. This report documented health disparities among minorities and placed their disadvantaged health status on the forefront of the U.S. health policy agenda. In conjunction with DHHS, OMH works to improve the health and health care of racial and ethnic minorities. In November 2013 the Centers for Disease Control and Prevention released its second consolidated assessment, Health Disparities and Inequalities Report, United States, 2013, which examines some of the key factors that affect health and lead to health disparities in the United States. This report defines health disparities as differences in health outcomes among groups reflective of social inequalities and calls for innovative intervention strategies that incorporate social and health programs.
In 2003, the Agency for Health Care Research and Quality introduced its first published report with regard to health care equality and health care disparities. The most recent report, the 2017 National Health Care Quality and Disparities Report, was released in September 2018 and combines information on both qualities of health care and health care disparities. Traditionally the National Healthcare Quality and Disparities Report (QDR) has focused on assessing the performance of our health care system and identifying strengths and weaknesses, as well as disparities, along three main axes: access to health care, quality of health care, and priorities of the National Quality Strategy (NQS). In 2010 the NQS was established by a mandate, because of the initiation of the PPACA, with the goal of supporting the general axes of the PPACA and QDR through six priorities: making care safer, focusing on person- and family-centered care, providing effective communication and care coordination, preventing and treating leading causes of morbidity and mortality, caring for the health and well-being of communities, and making quality care more affordable. Data from this report show that for the 2015 to 2016 year, poor people (at or below 100% of the Federal Poverty Level [FPL]) experienced worse access to care compared with high-income people (400% or more of FPL). In total, 15.5% of poor people under the age of 65 were uninsured for the whole year, compared with 4.2% of high-income people. After generally increasing, more recently, the percentage of adults ages 18 to 64 who were uninsured generally decreased. In addition to a general decrease in the number of uninsured adults, there was also an observed decrease in the percentage of uninsured adults from 2010 through 2017 among all three poverty status groups. The greatest decreases in the uninsured rate since 2013, however, were among adults who were poor or near poor.
The quality of health care improvements was assessed by collecting data on the NQS priorities, and it was found that through 2016 the quality of health care improved overall, but the pace of improvement varied by priority area. Despite this improvement, health care quality disparities continued to persist, especially among people in poor households, Hispanics, Blacks, and Alaska natives. Specific disparities to improve include person-centered care, patient safety, healthy living, and effective treatment.
In the United States, health disparities are well documented among minority populations. In essence, health disparities are population-specific differences in the presence of disease, health outcomes, mortality rates, and access to health care. The literature continues to acknowledge that the leading disparities for preventable conditions often exist among racial and ethnic minority populations. , , At present, research has shifted to include transdisciplinary multilevel research on the social determinants of health disparities, community-based participatory research, and public health approaches to eliminating health disparities. The literature states that innovative and creative broad-based approaches are necessary to address the multiple complex factors that result in the disproportionate burden of certain diseases and poorer health outcomes for minority populations. , ,
Health disparities: Scope of the problem
Health disparities in the United States extend beyond race, ethnicity, religion, or veteran status. They extend the bounds of sexual orientation, age, access to medical coverage, geographic location, and health literacy. As health care providers, it is essential to lay aside our own personal biases to establish rapport and deliver effective and equitable health care. Adapting your interview for each patient is a skill that is not easily attained, as you will learn when you begin your clinical rotations. To build your tool belt of history-taking skills, observe the behaviors and interactions of other health care professionals with their patients. As you rotate through each subspecialty, really use your time to sharpen your interviewing skills and develop your rapport building.
Sexual orientation
In medicine, gender is determined by the sex that person was assigned at birth. It enables providers to determine risk factors that person may be subject to based on their genetic makeup. Many medical professionals document sex by the appearance of external genitalia. With the establishment and increased commonality of sex reassignment surgery, this becomes increasingly difficult for providers to identify just based on phenotypic characteristics. Gender is deeply rooted in psychosocial, cultural, and behavioral principles. The gap for standardizing gender classification in the medical domain is still present. For this reason, providers are challenged to determine the factual information. It is overwhelmingly important to avoid biases when questioning patients about their gender, so as not to come across as abrasive or insensitive. Open communication between provider and patient should be encouraged. You may phrase a question such as “I ask all of my patients these questions” or “ What pronouns do you prefer?” or “What gender were you assigned at birth?” Effective communication is proven to improve health outcomes for chronic disease states. We infer that if providers have open communication with this specific population, their health outcomes also improve.
Gender minorities are known to be at increased risk for certain disorders. For example, a study concluded that lesbian, gay, and bisexual persons were at an increased risk for violence, discrimination, post-traumatic stress disorder (PTSD), and depression. Another study looked at the use of tobacco in adolescents who identified themselves as gay, lesbian, or bisexual. These minorities were more likely than their heterosexual counterparts to smoke. Other studies have specifically addressed how to improve outcomes in adolescents who smoke, but there is currently no research that has specifically revealed how to improve the health outcomes of tobacco users in the adolescent gender minority population. Other leading interview questions that may assist you in your determination of sex and gender include, “Have you been attracted to or do you have intimate relationships with persons of the same or opposite sex?” and “Do you contemplate changing your sexual identity, and if so, how would you change it?”
Age
Medicine is an ever-evolving entity, and there have been considerable advances in traditional standards of treatment. With this progress and the drive for offering preventive services, patient outcomes and life expectancy have improved. By the year 2030, it is expected that the adult population over 65 years of age will increase to 71 million people. A substantial health concern in this population is the development of Alzheimer disease. Dementia burdens the economy, families, and the health care system. It is anticipated that by the year 2050, up to 16 million older adults may have Alzheimer disease. It will be the responsibility of health care professionals to screen and educate patients and their families about the preventative measures and progression of this debilitating disease. As a physician assistant (PA), you will screen for other comorbid diseases such as diabetes and hypertension because these conditions increase the risk for the development of Alzheimer disease. Other initiatives that have been implemented through the PPACA include coverage for annual wellness physical examinations and coverage of preventive services, such as colonoscopy and mammography. These services expanded for private paying insurance companies as well as Medicare, so that now even adults who are not eligible for Medicare can obtain the benefits. There were two goals in offering preventive services. The first was to ensure routine follow-up for older adults and the other was to increase compliance with the preventative health maintenance standards of the U.S. Preventive Service Task Force (USPSTF). If you work in a primary care setting, each patient should be screened for the necessary routine health maintenance exams. Polypharmacy is an enormous burden on health care providers and the aging population. A thorough medication evaluation and reconciliation should be performed at each visit. Assessing for any adverse reactions to medications is just as important as monitoring the risk for developing chronic conditions.
Insurance coverage
Per the ACP in Racial and Ethnic Disparities in Health Care updated in 2010, the most significant variable influencing health disparity populations is insurance status. One of the objectives of the PPACA was to limit the number of disparities in the coverage of Hispanic and black ethnicities by expanding coverage for both Medicaid and private insurance. Another objective was to expand coverage in young adults up to the age of 26. The bill, which passed in September 2010, increased the rate of coverage in young adults by nearly 200%. Overall, since the implementation of the PPACA, there has been a decline in the number of uninsured persons overall. Nevertheless, there continues to be a significant discrepancy between the number of uninsured blacks and Hispanics compared with whites. Numerous theories exist to explain the continued lack of coverage. One idea is that the disparity exists because many Hispanics are not covered because their immigrant status does not qualify them for insurance coverage. Nonelderly blacks also have a higher rate of being uninsured for numerous reasons, but the main theme is that it is related to a nonwork status. Blacks also have a higher rate of employment in blue collar jobs, which are less likely to offer appropriate or affordable health insurance. Additionally, this population has a higher rate of poverty than do their white and non-Hispanic counterparts, making it even more difficult to purchase a worthy and inexpensive health insurance policy. Questioning patients about their insurance status and their ability to afford certain medications and diagnostic services should be considered at each visit. As a provider, familiarize yourself with the drugs that are formulary and nonformulary for each type of insurance plan. In addition, research nonprofit organizations or pharmacies in your area that may offer no-cost or low-cost drugs to patients. When you have a deeper understanding of the resources available in your area, you’ll be better able to advocate for your patients.
Geographic location
The Healthy People 2020 initiative has promised to achieve health equity, eliminate disparities, and improve the health of all groups. Its focus is on reducing the effects of chronic disease and improving existing health care services. According to Healthy People 2020, the lack of access to high-quality education, nutritious foods, affordable or reliable public transportation, and safe housing in America was found to be a qualitative factor that has been observed to have had a negative impact on health outcomes. There is also a hindrance to the access of quality health care services for people who live outside of city limits. The PPACA and other governmental alliances, including the National Health Service Corps and Area Health Education Centers, work together with many training programs to place medical providers in these rural areas and to expose students to populations that may have limited health status. At this time, the number of primary care providers available in the United States does not meet the demand for the current population and the anticipated expansion of the population by 2025. The aging population is living longer, which is further burdening the access to primary care for those who already lack appropriate access. The Health Resources and Services Administration has projected that there will be a deficit of around 20,000 primary care physicians by the year 2020. In anticipation of filling this gap, there has been a promotion to recruit more midlevel providers. One possibility to improve this gap is the increase in PAs in these rural communities. The job market for PAs and other midlevel providers is expected to increase by 58% from the year 2010 to the year 2020. One key resource for improving the recruitment of primary care clinicians is Area Health Education Centers (AHEC). These are federally funded entities that are responsible for enlisting new graduates from a variety of disciplines to work in rural settings.
Health literacy
Implementing change and understanding the determinants of disease require a marketable level of literacy. Health literacy refers to the actual understanding of health services needed to make an informed decision on one’s own medical state. The most common groups wherein health literacy is lacking include older adults, men, ethnic minorities, and those of a lower socioeconomic status. It is the provider’s responsibility to analyze each patient’s health status and literacy level to ensure that each patient understands and can make informed decisions regarding medical advice. As of now, most of the current literature regarding health literacy have focused on racial or ethnic minorities, and the effect it has on their health status and health outcomes. Providers should avoid using medical jargon during an interview to ensure the patient understands his or her health concerns. Allowing patients to speak information back to you at the conclusion of the plan and involving the patient in the plan is also imperative. Simply having patients repeat back to you in their own words their medications, treatment plan, and expectations allows you to assess their level of knowledge, which then opens the floor for you to clarify any information that may be misunderstood.
Veteran status
The Veterans Health Study (VHS) was performed in 2009, with over 60,000 randomly selected clients that had served in any branch of the military from October 2001 to June 2008. A review of veteran medical records concluded that about one-third of the participants were smokers, over 40% of female veterans and 4% of male veterans had experienced sexual trauma, and about 13.5% of participants had screened positive for PTSD. The Veterans Administration (VA) will use this information to expand the needed services for veterans and maximize the quality of health care provided.
Clinical applications
Perhaps a simple solution to closing the gap on health disparities involves educating providers. Starting from the foundation and moving upward may prove beneficial, and implementing this type of learning into training programs can help expose students to the real issues they will face in clinical practice.
Participating in interprofessional education (IPE) activities at community resources can broaden the scope of awareness of health disparities for students from a variety of health care professions. These hands-on examples illustrate how the students develop an understanding of health disparities. First, students provide information on health promotion to residents of a senior low-income housing facility. This opportunity allows the students to both practice their patient education strategies and access health literacy differences. The residents also benefit because they learn techniques for a healthier lifestyle. Another example is when students shadow in a clinic that provides services solely for the homeless population. The privilege of having students interact with this disparaged population strengthens their understanding of the specific struggles these patients face. The provider at this clinic shares her extensive experiences about pharmaceutical resources available and how to provide optimal care for those who are uninsured. Finally, students participate in a city-wide annual event performing health screenings for individuals who are homeless or at-risk for becoming homeless. The students aid the attendees in the exploration of community resources, specifically supporting their health and wellness. Through this interaction, the students gain an increased empathy for this community.
A clear understanding that health disparities are all around us will continue to affect the way we practice medicine, no matter the specialty. If we can quickly identify patients whose outcomes are anticipated to be disadvantaged, we as providers can position ourselves to improve health status at an earlier step in the evaluation process. Realizing that health disparities do not just affect those of racial and ethnic minorities will allow us to groom the next generation of health care providers and prepare them once they enter clinical practice. A full comprehension of the issues we face in our health care system will allow it to work more cohesively and effectively toward one common goal—the improvement of patient-centered care. As a student, be inspired to instill in yourself a spirit of cultural awareness, an attitude of empathetic understanding, and a service-led heart in educating and motivating your patients to improve their own health outcomes, no matter their background.
