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 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 is a set of health promotion and disease prevention objectives for the nation. It endeavors to improve the health of all groups. Healthy People 2020 states if a health outcome is seen in a greater or lesser extent between populations, a disparity exists. Healthy People 2020 emphasizes that the term “disparities” refers to more than mere racial or ethnic disparities. Gender, sexual identity, age, disability, socioeconomic status, and geographic location all play pivotal roles in the achievement of good health. Thus, recognizing the impact of social determinants is crucial to understanding the definition of health disparities.
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, representing for some (e.g., African Americans, Hispanics, American Indians) two to five times that of 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 as compared with white Americans. It also reiterates much of the new literature that calls for structural changes within America’s health care system to meet the needs of America’s multicultural population and recognize the critical role of social determinants of health status and their contributions to health disparities. 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, as well as manage chronic disease states. It is estimated that almost 32% of Native Americans and Alaskan natives are uninsured, with 31% of Hispanics uninsured compared with roughly 11% of whites uninsured. Of minorities enrolled in federal and state programs such as Medicaid and the Children’s Health Insurance Program (CHIP), more are eligible for coverage but are not enrolled (e.g., lack of awareness, language barriers, complex enrollment process). Within 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 the threefold goal of 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 now 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, dependents could remain on their parents’ coverage longer, and 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. After the PPACA was enforced, insurers were required 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.
The PPACA has been the largest overhaul in American health care since Medicare and Medicaid in 1965 and therefore 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 with 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 U.S. health policy agenda. In conjunction with DHHS, OMH works to improve the health and health care of racial and ethnic minorities. On January 14, 2011, the Centers for Disease Control and Prevention released its Health Disparities and Inequalities Report, United States, 2011. This report is the first in an anticipated series of serial, consolidated assessments highlighting health disparities by gender, race and ethnicity, income, education, disability, and additional social determinants of health 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 2015 National Health Care Quality and Disparities Report, was released in April 2016 and combines information on both qualities of health care and health care disparities. The release of this report was special because it also incorporated the 5th Anniversary Update on the National Quality Strategy , which helped readers gain an overall understanding of the nation’s progress in improving health care access, quality, and 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, person- and family-centered care, effective communication and care coordination, prevention and treatment of leading causes of morbidity and mortality, health and well-being of communities, and making quality care more affordable.
Data from this report show that from 2010 to the second quarter of 2015, the percentage of people younger than 65 years of age who were uninsured at the time of report decreased from 17.5% to 10.3%. The age group of 18 to 29 years experienced the largest decline rate, and this drop was seen across all poverty status and racial and ethnic groups. The quality of health care improvements was assessed by collecting data on the NQS priorities, and it was found that through 2013, across these priorities, health care quality improved by 60%. 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 since 2010 include patient safety, effective prevention and treatment, healthy living, and care affordability. Disparities that have shown more difficult to improve include person- and family-centered care and care coordination.
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, or religion. They extend the bounds of sexual orientation, age, and 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. Learning to customize your interview for each patient is a skill that is not easily attained, as you will learn when you begin your clinical rotations. As a student, you should observe other health care professionals as they interact with patients. Emulate behaviors and characteristics of the providers who deliver exceptional care in a nonjudgmental environment. As you rotate through each subspecialty, practice your interviewing skills and develop your rapport building.
How is gender determined? And are gender and sex the same entity? Many training programs and providers of medical care use these terms interchangeably without recognizing the concept that these impressions are fluid and can vary throughout a person’s life. Objectively, the term sex refers to the differences between male or female. Most 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 a provider to identify just based on phenotypic characteristics. Gender is rooted in psychosocial, cultural, and behavioral principles. There are currently no standard documentational or medical criteria for measuring sex and gender. For this reason, it is a challenge for providers to inquire about sex or gender. It is overwhelmingly important to avoid biases when questioning patients about these two titles so as not to come across as abrasive or callous. Therefore, open communication between provider and patient should be encouraged. Effective communication has been proven to improve health outcomes for various chronic disease states. It is inferred that if providers have open communication with this specific population, their health outcomes will improve as well.
Gender minorities are noted to be at an increased risk for certain disorders. For example, a study concluded that lesbian, gay, and bisexual persons were at an increased risk for violence, discrimination, posttraumatic stress disorder, and depression, just to name a few. Just as communication has improved health outcomes for chronic diseases, so too should open communication about the health crises for patients of gender minorities. As of now, there are still no peer-reviewed or accepted tools to classify a patient’s gender. 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 health outcomes in the adolescent gender minority population. Some questions that may assist you in your determination of sex and gender include “What was your determined sex when you were born?” “Have you been attracted to or do you have intimate relationships with persons of the same or opposite sex?” “Do you contemplate changing your sexual identity, and if so, how would you change it?” You can always preface questions such as these by encouraging an open platform and explaining that you ask these questions of all your patients to not single out anyone out.
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 persons. A substantial health concern in this population is the development of Alzheimer disease. This form of dementia places a large burden on 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. The responsibility of health care professionals to screen and educate patients and their families may aide in discovering and preventing the progression of this debilitating disease. An effective technique thus far has been to ensure sufficient communication. Health care providers should also screen for other comorbid diseases such as diabetes and hypertension because these conditions can increase the risk for the development of Alzheimer disease. Other initiatives that have been implemented through the PPACA include the coverage for annual wellness physical examinations and the coverage of preventive services such as colonoscopy and mammography. These services expand for private paying insurance companies as well as Medicare, so that even adults who are not eligible for Medicare obtain the benefits. Two goals of covering preventive services are to ensure routine follow-up for older adults and compliance with the standards of the U.S. Preventive Service Task Force. Each patient should be screened for needed routine health maintenance. This helps to create a complete and thorough medication evaluation to understand the necessary diagnostic studies each patient will need. A routine health follow-up especially for the elderly population will give you the ability to compile a proper medication reconciliation, assess for any adverse reactions to medications, and monitor the risk for developing chronic conditions.
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 age 26 years of age. 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. However, there continues to be a significant discrepancy between the number of uninsured blacks and Hispanics compared with whites. There have been numerous theories to explain the continued lack of coverage. One incongruence might exist because many Hispanics who are not covered are of immigrant status and do not qualify for insurance coverage. Nonelderly blacks have a higher rate of being uninsured for numerous reasons, but it is thought to be related to work status. Blacks have a higher rate of employment in blue collar–type 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, which ultimately makes it even more difficult to purchase a worthy and inexpensive health insurance policy. 17 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, you should become familiar with the drugs that are formulary and nonformulary for each type of insurance plan. This is a tool that you will learn being in a clinical setting that develops after time and exposure to the billing discipline. When you’re able to determine which medications and services are covered, it becomes much easier to be an advocate for your patients.
The Healthy People 2020 initiative has promised to achieve health equity, eliminate disparities, and improve the health of all groups. Its focus is to reduce the effects of chronic disease and to improve 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 a negative impact on health outcomes. There is also a hindrance to the access of quality health care services in persons 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. The aging population is living longer, which is further burdening the system 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. In response, the job market for physician assistants and other midlevel providers is expected to increase by 58% from the year 2010 to the year 2020.
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 most prominent include older adults, men, ethnic minorities, and those of a lower socioeconomic status. It is therefore part of the provider’s responsibility to analyze each patient’s health status and literacy level to ensure that each patient comprehends and is able to comply with recommended medical advice. There is still much research that needs to be focused in this area. As of now, most of the current analyses have focused on healthy literacy in racial or ethnic minorities and the effect it has on their health status and health outcomes. To certify that a patient understands his or her health status, it is important for providers to avoid using medical jargon during an interview. Leaving lines of communication open is also imperative to allow patients to ask questions so they may clarify understanding. Having patients repeat back to you in their own words their medications, treatment plan, and expectations allows you to assess their level of knowledge and any deficiencies that will require you to simplify the information.