Over the past half-century, understanding of health and health care disparities in the United States — including underlying social, clinical, and system-level contributors — has increased. Yet disparities persist. Eliminating health disparities will require a movement away from disparities as the focus of research and toward a research agenda centered on achieving racial equity by dismantling structural racism.The Socioeconomic Status and Health Chartbook, published by the National Center for Health Statistics in 1998, added an important dimension to the understanding of the basis of health disparities. The report explored for the first time the associations between health and socioeconomic status and between race and health for a broad range of outcomes. Like the Heckler report, the Chartbook led to a wellspring of new research. In 2000, the Minority Health and Health Disparities Research and Education Act established the National Center on Minority Health and Health Disparities, along with a dedicated research budget to explore strategies for advancing health equity.
Researchers turned next to drivers of health disparities within the health care system — chief among them unequal access. The IOM issued a six-volume series documenting the effects of lack of insurance on access to various types of care, from preventive services to care for chronic or potentially fatal illnesses, such as cancer and renal failure. The reports tied disproportionately low rates of health insurance among minority populations to low availability of community-wide health care services — and, in turn, to health disparities. These reports illuminated the way in which a community’s health status could be linked to its residents’ insurance status.Congress also tasked the IOM with studying racial and ethnic disparities in quality of care, evaluating potential sources of these disparities, and recommending interventions. The resulting 2003 report, Unequal Treatment, explored the continuum of services from hospital-based care to rehabilitation and long-term, home-based, and outpatient care. One finding captured headlines: “Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.” The report documented disparities in most clinical interventions — from basic interventions, such as pain management, to complex ones, such as cardiac revascularization. Although Unequal Treatment acknowledged the influence of socioeconomic factors on health outcomes, it did not explore specific linkages between socioeconomic status and health care or recommend solutions that integrated social and health care–related factors.
Another IOM report published around the same time, Promoting Health, did highlight the role that integrated social and behavioral interventions could play in improving health and reducing disparities. This idea began to shift researchers’ and policymakers’ focus to the community as the natural heart of strategies for reducing health disparities. In 2010, for example, HHS launched the Communities Putting Prevention to Work program, which partnered with 50 communities to reduce rates of obesity and tobacco use.
Twenty-five years after the Heckler report, researchers had made substantial progress in collecting and stratifying data on the basis of demographic dimensions, in understanding the relationship of socioeconomic status and inequitable health care access and quality with health outcomes, and in recognizing the necessity of structural change to achieve health equity.
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