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Unequal Treatment: 20 Years After

Twenty years after the Institute of Medicine’s¹ 2003 report entitled Unequal Treatment: Confronting Racial Bias and Ethnic Disparities in Health Care, unequal treatment persists, and much work remains to advance health care equity in the United States. Thus, the Agency for Healthcare Research and Quality and the National Institutes of Health (NIH) asked the National Academies of Science, Engineering, and Medicine (National Academies) to create a consensus report that updates Unequal Treatment. This consensus committee was charged with highlighting current drivers of racial and ethnic health care disparities, providing insight into successful and unsuccessful interventions, identifying gaps in the evidence base, proposing strategies to close those gaps, considering ways to scale and spread effective interventions to reduce racial and ethnic disparities in health care, and making recommendations to advance health equity.

Unequal Treatment was mandated by Congress as a follow-up to the 1985 Report on Black and Minority Health, requested by the Secretary of Health and Human Services (HHS). The foundational 2003 report assessed the extent of racial and ethnic differences in health care that are not otherwise attributable to known factors, such as and lack of health insurance and access to care, and explored potential sources of racial and ethnic disparities in health care.

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¹ As of March 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (NASEM) continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to reports issued prior to July 2015.

Based on an extensive and systematic review of the evidence, the 2003 committee concluded that racial and ethnic disparities were widespread and played a central role in certain racially and ethnically minoritized populations receiving inferior care, which was associated with poor health outcomes. The 2003 report also found that a critically important contributing factor was racial and ethnic stereotyping and prejudice by clinicians. Even when unconscious, consistently caused clinicians to misdiagnose and under-treat minoritized individuals. The 2003 report made a series of recommendations for eliminating health and health care disparities (Box 1-1).

IMPACT OF THE 2003 UNEQUAL TREATMENT REPORT

The most significant legacy of the 2003 report is framing the problem of unequal treatment and associated calls for action to address it. That report catalyzed research to better understand the root causes of health care inequities and their effects. Equally important, it was widely read by diverse audiences and established common ground for discussions. Front-page stories and editorials about it appeared in the national and local press. Many health care professional organizations and health care systems began conducting implicit bias training and raising awareness among their workforces that improvements were imperative.

The 2003 report also stimulated considerable research documenting both the persistent patterns and understanding of the drivers of health care inequities; it also triggered efforts to increase the diversity of the health care workforce (Mateo et al., 2024). Thus, from this committee’s assessment of the recommendations from the 2003 report, those that have seen the most progress have been the recommendations on awareness creation for the general population (Table 1-1, recommendation 2-1) and for health care providers (Table 1-1, recommendation 2-2), but these are still far from reaching their full potential. Furthermore, evidence on whether implicit bias training has led to meaningful behavior change is mixed. Table 1-1 summarizes the committee’s assessment on the progress toward implementing the 2003 report’s recommendations. Detailed discussions on implementation status for some specific recommendations are included in relevant chapters.

To move the nation closer to the goal of an equitable health care system to achieve optimal health outcomes for all people, the National Academies ad hoc committees have authored multiple additional consensus reports since 2003. Several themes have emerged in discussions on advancing health care equity (see Appendix B for examples of the reports). Prominent among these themes is the importance of the following:

• Increasing awareness and understanding of health care inequities among actors in the health care ecosystem;
• Standardizing and providing guidance on the collection of data on race, ethnicity, socioeconomic status, acculturation, and language use in all health and health care data systems;
• Increasing diversity in and strengthening the health care workforce through accessible professional education and incorporating culturally competent education and training;
• Adopting alternative payment models to aid payment reform;
• Implementing approaches to address factors that influence health;
• Using data and data systems to their full potential to advance health equity research;

TABLE 1-1 The committee’s assessment on the progress of implementation of the 2003 report recommendations.

• Establishing public-private stakeholder coordination for community-level engagement; and
• Conducting and funding more research to understand and reduce inequities in health and health care.

The committee reviewed these reports, their recommendations, and supporting evidence in depth during its deliberations. Additional details about that process are described later in this chapter.

THE U.S. HEALTH CARE SYSTEM CONTINUES TO PERFORM POORLY

The U.S. health care system fares poorly compared to similarly high-income countries (Schneider et al., 2021) in terms of most performance measures, despite spending at least double the amount of money per person of peer wealthy countries (Schneider et al., 2021). Even after accounting for age, sex, body mass index, income, employment status, education, alcohol consumption, and smoking history, the United States has a significantly higher prevalence of chronic diseases and individuals with multiple chronic diseases compared to Canada, United Kingdom, and other similarly industrialized countries (Hernández et al., 2021). (Chapter 3 offers extensive details about the racial and ethnic inequities across many of these multiple disease categories.) The United States has the largest proportion of people without health insurance among high-income countries (Schneider et al., 2021). The uninsured rate ranges from 8.4 percent (CDC, 2023a) to 9.6 percent (Tolbert, et al., 2023). Nearly 90 percent of U.S. health care spending is on chronic physical and behavioral health conditions, leaving limited funding for disease prevention and health promotion (CDC, 2023b). The poor performance of the nation’s health care system impacts everyone: The United States ranks last among high-income countries in life expectancy at birth, maternal and infant mortality, suicide, and preventable and treatable mortality (OECD, 2023).

The U.S. health care system is not working perfectly for anyone. However, its inadequacy disproportionately affects minoritized populations. Looking at one metric, the percentage of the population that lacks health insurance, rates have remained high across all populations but are highest for minoritized populations. As of 2022, the rate among Hispanic individuals is 20.9 percent; it is 10.4 percent for Black (non-Hispanic Black), 6.4 percent for White (non-Hispanic White), and 6.5 percent for Asian (non-Hispanic Asian) groups. The rate for all others (“Other”) is 8.4 percent (see Figure 1-1).

The inadequacy of the system also impacts life expectancy² and potential years of life lost³ by race and ethnicity. Figure 1-2 shows stark differences. White life expectancy increased from 77.2 years in 2003 to 78.8 years in 2019 before declining to 77.0 years in 2020 and increasing to 77.5 years in 2022. By contrast, Black life expectancy was 72.4 years in 2003 before rising to 74.8 years in 2019, declining to 71.5 years in 2020, and increasing to 72.8 years by 2022. Hispanic life expectancy was not tracked by the U.S. Centers for Disease Control (CDC) until 2006, when it was 80.3 years; it rose to 81.9 years in 2019. In 2020, it dropped to 77.9 years; by 2022, it was

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² The average number of years of life a person who has attained a given age can expect to live.

³ The estimated average time a person would have lived had they not died prematurely.

at 80.0 years, just below its 2006 level. American Indian or Alaska Native (AIAN) life expectancy was reported by CDC beginning in 2019 and is the lowest across all tracked categories; it dropped from 71.8 years in 2019 to 67.1 years in 2020 and only increased to 67.9 years in 2022. Asian life expectancy was also reported by CDC beginning in 2019 and is the highest across all categories. It was 85.6 years in 2019, dropped to 83.6 years in 2020, then increased to 84.5 in 2022. The significant drops in life expectancy for all people in 2020 sounded the alarm of a failing health care system, unable to respond to a public health crisis, but were most drastic for minoritized populations. One recent analysis over a 22-year period also reported that Black populations had over 80 million potential years of life lost compared to their White counterparts (Caraballo et al., 2023).

THE ECONOMIC BURDEN OF PERSISTENT INEQUITIES

The poor performance of the U.S. health care system and negative repercussions of health and health care inequities go far beyond each individual’s health and specific medical conditions, with significant economic consequences for the entire nation. LaVeist and colleagues (2023) estimated the economic burden of racial and ethnic health inequities in the United States. They found that the overall economic burden of heath inequities in 2018 was $1.03 trillion (LaVeist et al., 2023). The economic burden of racial and ethnic health inequities was $421.1 billion for minoritized population (American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander populations). Nearly two-thirds of the estimated economic burden was attributable to premature death with the remaining portion attributable to excess medical care costs and lost labor market productivity. The economic burden for White population was estimated to be $608.7 billion. Minoritized population experienced the highest per-capita economic burden after accounting for population size. Addressing health care inequities will improve personal and population health and could also produce significant economic benefits.

Addressing Inequities Benefits All People

Addressing inequities and improving the health of individuals in the most disadvantaged communities improves the quality of care for everyone and advances population health. This goes beyond the individual and extends to their children, whole communities, and society at large. Parents too sick to work, for example, will earn less money and be less able to provide for their children. Unemployed, low-income families will have more social service needs and be less likely to have access to private health insurance. Their continued inability to afford necessary health care may lead to them becoming sicker, making them even less able to find a new job; getting healthy and keeping their families out of poverty becomes increasingly more difficult.

Some feel that health and health care is a zero-sum game (Norton and Sommers, 2011) and that supporting governmental health care programs would primarily benefit minoritized populations and lead to discrimination and loss for majority populations (Wetts and Willer, 2018). Significant evidence suggests that this is not true for health care and other sectors of society. Implementing interventions for minoritized populations will improve health outcomes for everyone (McGhee, 2022).

Population health and public health approaches can enable targeting health care resources to specific populations in ways that benefit all people. This rationale was advanced in an IOM report on the consequences of

uninsurance (IOM, 2009). That report noted that when community-level uninsurance rates are relatively high, insured people have greater difficulty obtaining needed health care. Because uninsurance and other barriers contributing to health care inequities are concentrated in communities with more minoritized individuals, these barriers are likely to have adverse spillover effects on other individuals in these communities, such as longer waits for care of major trauma and other acute emergencies; delayed diagnosis and treatment leading to greater spread of infectious diseases, such as COVID-19 and influenza; more fragmented systems of chronic disease care; and more instability of all health care providers in the area who rely on consistent rates of insurance coverage in the community to keep their doors open.

Poor health outcomes for minoritized communities contribute to lower-quality care and outcomes for everyone. Because inequitable policies and barriers make it difficult for minoritized populations to regularly access quality health care, they are often only able to access care when disease symptoms have advanced, and emergency department care is frequently their only option (Rust et al., 2008). This limited access can result in overreliance on emergency department care, which is a contributor to emergency department overcrowding (IOM, 2007; Kelen et al., 2021). Overcrowding and subsequent emergency department boarding could lead to poor outcomes for everyone but disproportionately for minoritized patients (IOM, 2007; Liu et al., 2011). Similarly, barriers to accessing health insurance disproportionately impact poor and minoritized populations. Expansions facilitated by the Affordable Care Act (ACA) extended coverage to many uninsured and underinsured individuals and has been associated with improved access to the full range of health care services for all racial and ethnic groups (Wehby and Lyu, 2018). The Medicaid expansions have been particularly beneficial in improving access to health care services and addressing inequities for all people in those states that have participated (Allen et al., 2017; Mazurenko et al., 2018). Inequities still persist across all states. This is true even in those states that have been found to have better health system performance or where health outcomes have improved over time (Radley et al., 2024).

STUDY CHARGE

It has been over 20 years since the Unequal Treatment report, and much work remains to advance U.S. health care equity. Thus, NIH charged the National Academies with conducting a study to highlight the major drivers of health care disparities, provide insight into successful and unsuccessful interventions, identify gaps in the evidence base, propose strategies to close those gaps, consider ways to scale and spread effective interventions to reduce racial and ethnic disparities in health care, and make recommendations to advance health equity (see Box 1-2).

STUDY APPROACH

The National Academies appointed a 17-member multidisciplinary committee. The Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care included experts in health and social policy, social determinants of health (SDOH), social justice, health inequities, minoritized populations, public health, primary care, health economics, health technology, health care services research, health care financing, community-engaged research, health professions education, health law, and ethics (see Appendix E for the biographies of the committee members).

A variety of sources informed the committee’s response to the study charge. First, the committee conducted a review of the literature relevant to the statement of task, focused on peer-reviewed articles, government documents, and white papers published since 2003. The search focused mainly on studies conducted in the United States, but for interventions to reduce health care inequities, the committee was interested in worldwide publications. To supplement the literature review, the committee commissioned three papers, documenting evidence on racial and ethnic inequities in health care measured by access, use, and quality of care; the evolution of U.S. health care and civil rights laws since 2003 that pertain to the study task; and policy initiatives that have been effective for reducing racial and ethnic inequities in health care.

The committee conducted a series of virtual public workshops⁴ to obtain insights on racial and ethnic inequities in health care and current and new approaches to alleviate them. A proceedings summarizing the discussions and highlighting individual participants’ suggestions was published by the National Academies Press in January 2024 (NASEM, 2024). Statements, recommendations, and opinions expressed in the proceedings are those of individual presenters and participants and not endorsed or verified by the committee, and they should not be construed as reflecting any group consensus. Additional input was provided by members of the public, who were given an opportunity to share their relevant experiences, thoughts, and comments for the committee’s consideration through the project website at any time during the study period.

Study Parameters

The committee recognizes that inequities in health care are complex, multifactorial, and interconnected with social and public policies, including structural racism and other social inequities, topics discussed extensively

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⁴ The virtual workshops were held on July 12–13, 2023, August 16–17, 2023, and September 6, 2023.

in consensus reports from National Academies (NASEM, 2019, 2023). Furthermore, the committee recognizes that the most effective interventions for health care inequities may require efforts outside the health care system. Therefore, the committee emphasizes that changes to health care systems and clinical care are essential but will be insufficient to advance racial and ethnic health equity. In addition, the committee acknowledges that certain populations, including immigrants, people with disabilities, and sexual and gender minorities, experience differential and disproportionate effects of inequitable treatment that intersect with and extend beyond their race and ethnicity (NASEM, 2020). For this study and its specific task, the committee did not extensively examine the evidence base related to achieving health equity broadly but focused on racial and ethnic inequities in the health care system, especially in terms of care access, use, and quality. The committee, however, notes areas of overlap between advancing health care and health equity.

Definitions of Key Terms

The terms used in this area of research have evolved over time and will continue to do so as further insights are gained and society and demographics shift. Thus, it is necessary to provide some conceptual clarity for key terms to ensure that the report audiences are starting from the same place in how the committee defines them. The committee chose to use “health” when discussing outcomes and “health care” when discussing the system that delivers care. The committee’s rationale for this approach is summarized in Box 1-3.

The committee made an intentional choice to use “inequities” rather than “disparities” and “inequitable treatment” rather than “unequal treatment.” Box 1-4 presents its reasoning.

Description of Racial and Ethnic Groups

As attitudes toward different cultures and conceptions of race and ethnicity have evolved, so have the terms used to describe various populations. This evolution is perhaps most notable in changes the U.S. Census Bureau has made in the methods and language used to record race and ethnicity. Revisions or additions are made each decade, underscoring the complexity of collecting data on identity and classification and the resulting challenges in comparing demographic data over time. In addition, on March 28, 2024, OMB released revised standards to how the federal government collects data on race and ethnicity that updated those in use by the federal government since 1997. Changes in the revised standards include combining race and ethnicity into one question and adding a category of Middle Eastern

or North African, which was previously in the “White” category. This is discussed in detail in Chapter 7. Box 1-5 summarizes specific racial and ethnic terms and other key definitions and terms used in this report. The committee drew and adapted key terms and definitions from other National Academies⁵ and government agency reports.⁶

“American Indian Alaska Native” (AIAN) is used when discussing individuals or populations having origins in any of the original peoples of North America, South America, and Central America, who maintain tribal affiliation or community attachment. The committee also acknowledges that “Hispanic” is widely used in policy and research discussions when referring to this group. Nonetheless, the committee recognizes that Latin America and the Caribbean are home to many colonial and Indigenous languages and cultures. Therefore, the committee chose to use “Latino/a” unless the data specifically denote Hispanic. The committee acknowledges that the terms “African American” and “Black” are used interchangeably in research and that “non-Hispanic Black” also appears, but it uses “Black” unless the data specifically denote “African American.” The committee acknowledges that “non-Hispanic White” is used in research, but it refers

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⁵ See NASEM. 2023. Federal policy to advance racial, ethnic, and tribal health equity. Washington, DC: The National Academies Press; NASEM. 2023. Advancing antiracism, diversity, equity, and inclusion in STEMM organizations: Beyond broadening participation. Washington, DC: The National Academies Press.

⁶ HHS. 2024. Healthy people 2030 social determinants of health. https://health.gov/healthy-people/priority-areas/social-determinants-health (accessed April 29, 2024); HHS Office of Minority Health. 2024. American Indian/Alaska Native Health. https://minorityhealth.hhs.gov/american-indianalaska-native-health (accessed April 29, 2024). CDC. 2022. What is health equity? https://www.cdc.gov/healthequity/whatis/index.html (accessed April 29, 2024).

to these populations as “White.” Finally, the committee acknowledges that “Asian” is widely used in policy and research discussions but recognizes that it is inadequate to describe the diversity among the populations categorized in this group. Unfortunately, much of the research uses this term and does not include subpopulations. Therefore, the committee chose to use “Asian” except when citing a publication that explicitly captures data on subpopulations.

In addition, rather than referring to “racial and ethnic minorities,” “members of minority groups,” or “underrepresented minorities,” the committee uses “minoritized”⁷, which refers to people from groups that have been historically and systematically socially and economically marginalized or underserved based on their race or ethnicity as a result of racism. The committee wishes to make the distinction that being minoritized is about not the number of people in the population but rather power and equity.

LOOKING BACK AND LOOKING FORWARD

Since 2003, the U.S. health care system has made progress on developing infrastructure to monitor inequities, including numerous performance measures. Mandated by Congress, the federal government now reports on health care quality and inequities experienced by racial and ethnic groups. A growing body of research has documented continuing inequities that marginalized and minoritized populations experience in the health care system. For example, the National Healthcare Disparities Report (NHQDR), published by the Agency for Healthcare Research and Quality (AHRQ) since 2003, has revealed the persistent inequities in health care for marginalized and minoritized populations. These inequities exist across all states and persist even in situations where health outcomes have improved over time (Radley et al., 2024) (see Chapter 3 for detailed discussion on evidence on racial and ethnic inequities in health care).

Federal, state, local, tribal, and territorial governments have made efforts (see Chapter 8) to address these inequities through laws, policies, and programs. For example, executive orders issued in the past few years have sought to strengthen racial equity throughout the federal government, including health care. Multiple federal health agencies, including NIH, CDC, and the Centers for Medicare & Medicaid Services (CMS), have increased their commitment to promoting racial health and health care equity. CDC declared racism a public health threat (CDC, 2023c). These actions, bolstered by

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⁷ This term was also used in the 2023 National Academies report Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity.

extensive evidence, have created a continuing impetus for research aimed at developing and implementing effective interventions to advance racial and ethnic equity and identify strategies to mitigate systemic racism in health care. However, policy statements and research findings have not reduced racial and ethnic health care inequities, and critical laws and policies have not been implemented.

Recommendations 7-1, 7-2, 7-3, and 7-4 of the 2003 report pertained to measuring inequities and monitoring progress toward eliminating them. Many reports, such as the NHQDR, have been created over the past 20 years. However, our committee concluded that the 2003 recommendations calling for data and monitoring have not been fully implemented due to the lack of consistent and comprehensive standards for race and ethnicity data—no standards for which data are to be collected, by whom, and in what settings and who is accountable for data collection, accuracy, and analysis and taking actions based on the findings.

Access to equitable health care remains a significant problem, driven at its core by a continued lack of universal, stable health insurance. An increase in the design and implementation of antiracism and cross-cultural education work in health professional training programs as called for in Recommendation 6-1 of Unequal Treatment spurred little action to address the fundamental social and economic inequities that contribute to inequitable health care.

Looking Back: Why Substantial Progress Has Not Been Made

The past 2 decades have witnessed major policy strides toward greater equity in health care, particularly the ACA in 2010. Setbacks have also occurred, chiefly resulting from judicial developments that weakened some ACA provisions designed to address health care inequities, ended the constitutional right to accessing reproductive health care services, and disrupted efforts to achieve greater educational diversity.

The ACA was informed by evidence documenting where and how discrimination appears in the health care system and the urgent need for far-reaching policy solutions. This evidence demonstrates persistent patterns of inequity and their underlying drivers and an increasing awareness and understanding of how social conditions shape health care inequities. However, in the committee’s deliberations and research, it found that forward motion has yet to yield long-term gains. Most racial and ethnic health care inequities have persisted, and some have worsened. This report documents the lack of clear pathways to translate promising approaches into real and permanent change, which is especially significant because progress on key measures of racial and ethnic equity in health care has stagnated and is sometimes deteriorating.

The committee identified multiple factors contributing to this lack of progress, summarized as follows:

• Policies that fall short of the changes needed or are weakly implemented: The past 2 decades have seen major strides in policy, moving closer to a system of affordable coverage for all. Investments have expanded support for primary care clinics in underserved rural and urban communities. Nonprofit hospitals have been nudged toward greater community accountability. The nation has a landmark civil rights framework for health care. However, owing to the structural limitations of key policy reforms, millions of people remain uninsured and underserved. Primary care workforce shortages have worsened, and access is severely strained. Furthermore, some civil rights reforms have not been implemented, with no accountability or penalty when measures are not obtained.
• Continuing racism in health care and society, at large: Unequal Treatment documented pervasive racism in health care, deeply embedded in the very structure of the system. Since 2003, the nation has gradually acknowledged the problem more explicitly, punctuated by outpourings of societal rage immediately after horrific events, such as the murder of George Floyd. In recent times, many organizations are attempting to measure racism and define its characteristics. Yet, many of the factors, institutions, and structures that produce racism remain in place.
• An overemphasis on treating sickness and incentivizing those who treat sickness: The health care system is designed to treat people who are sick. The sicker someone becomes, the more money the system makes. Payments are designed to incentivize curing disease, not preventing it. The financial gains reaped when people get sick are even greater when health inequities worsen. When sick people (many with preventable illnesses) fill a hospital, the hospital makes more money, but anyone who needs emergency care cannot get it efficiently.
• A complex and fragmented health care system: The system is extraordinarily complex, dominated by fragmentation in care financing and delivery. This presents overwhelming challenges for individuals, families, and communities and provides little or no assistance in navigating these challenges.
• Failure to invest in promising solutions: Extensive documentation points to highly promising models of health care, especially solutions that engage communities and are integrated into community settings. Many of these demonstration programs combine health care and social services essential to addressing underlying

• problems that contribute to poor health, have adapted operations in communities in responsive ways, and are staffed by health care professionals recognized for providing and enabling accessible and culturally competent care. Yet, underfunding of such programs persists, and many have not been able to scale up or achieve sustainability.
• Failure to pursue promising avenues of research: A wealth of evidence documents the inequities across health care settings and over the life course. Yet, the nation has not adequately pursued promising avenues of research that can help identify, scale, and spread solutions.

The effect of these factors has been magnified by a series of shocks to the nation, including an opioid epidemic and the COVID-19 pandemic. The committee predicates its conclusions and recommendations on the conviction that the nation knows how to address the problem of inequitable health care. What is needed is both a firm belief that the situation needs to change and the will to make the right investments.

Looking Forward: A Conceptual Framework to Guide Future Steps

To guide its deliberations, the committee focused on the health care system broadly (including public health and community-partnered care) and developed a conceptual framework to serve as a unifying basis for its approach to the report organization and recommendations for action (see Figure 1-3).

Because the health care system exists within the larger society, the conceptual framework highlights five key societal external forces, each representing a significant influence on equitable health care: structural determinants of health; oppression and structural racism; social determinants of health (SDOH); non–health care sector partnerships; and societal commitment to equity. These key external societal forces act individually, intersect with one another, and constantly interact with the domains in the health care system to pose significant influence on equitable health care.

• Structural determinants of health influence the distribution of HRSNs (social and economic needs that affect individuals’ ability to maintain their health and well-being) across different populations to reinforce or mitigate health care inequities.
• Oppression and structural racism, through historical and continued policies such as residential segregation, systemic oppression, or any form of bias, harm health through multiple pathways. These pathways result in adverse physical, social, behavioral, and economic impacts that directly and indirectly affect the health care system.

• Deprivation of resources and adverse SDOH conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks) disproportionately impact minoritized populations and manifest as unmet HRSNs, which many health care systems are unable to address, further exacerbating inequities in care access, quality, and outcomes.
• The interest of partners outside the health care sector, such as social service agencies, can shape priorities and programs of health care systems, either negatively, by exacerbating inequities and widening inequity gaps, or positively, by unlocking long-term opportunities to advance health care equity.
• Societal commitment to identify and remove barriers and create equitable access to resources to achieve equal opportunities positively impacts health and health care; the lack thereof reinforces health and health care inequities.

Within the health care system, the committee identified four key intersecting domains—each with subdomains—that are critical mechanisms by which the system can reinforce or mitigate health care inequities. All four domains intersect within local communities where health care systems

operate, and care delivery ultimately happens. As discussed throughout this report, community plays a vital role in health and health care; it is a critical determinant of health and can produce mechanisms central to advancing equity.

• Health Care Laws and Payment Policies. Policies to support equitable health care access, quality, and affordability serve as the foundation to remove persistent barriers and ensure that all individuals receive equitable health care services. Factors in this domain include health care reforms, legal, and political environment that have implication for achieving health care equity and optimal health for all.
• Health Care Service Delivery. This domain focuses on delivering of high-quality, culturally sensitive care to all and maximizing the health care system’s potential to eliminate racial and ethnic inequities in health and health care. Factors in this domain include health care delivery models, health care workforce, clinical decision making, implicit bias, integrating health and social care, individual care seeking behavior and medical mistrust, health literacy, and health information technology.
• Discovery and Evidence Generation. Data and research are critical resources needed to implement, evaluate, and enforce strategies to eliminate racial and ethnic health care inequities and advance health equity. Factors in this domain include advancing health equity research, historical and current health equity research funding, the research workforce, health equity research data, health equity research infrastructure, and moving health equity research from observation to interventions.
• Accountability. Goals to create an equitable health care system need to be achieved, and the system needs to remain responsive to the needs of all communities. Legislative oversight needs to ensure that laws have their intended impact and identify actions necessary to improve their performance. In addition, systematic standards and procedures should exist to enable periodic comprehensive reviews of interventions and their implementation.

The ultimate goal is to create an accountable system that achieves health care equity and promotes optimal health outcomes for all individuals regardless of their race, ethnicity, or other demographic factors influencing their ability to receive equitable health care and achieve optimal health. Individual elements of the framework and the role of the variables in each element are discussed in more detail throughout the first half of this report.

Recognizing the Current Legal and Political Environment

The legal and political environment has substantially changed since Unequal Treatment. Over the 2 decades since, Congress has enacted legislation aimed at mitigating the discriminatory impact of policies and laws and establishing new protections against discrimination. These laws have and could have had far-reaching positive effects toward the goals of eliminating health care inequities and achieving health equity. However, these reforms have significant structural limitations. For example, as noted earlier and discussed in detail in Chapter 4, the ACA implemented a comprehensive set of health reforms, including large expansions in health insurance coverage. However, its constitutionality and scope of implementation continue to face multiple legal and political challenges (Jost and Keith, 2020; Keith and McElvain, 2020; Musumeci and Rosenbaum, 2023). These developments have weakened some of its provisions that could help to address health care inequities.

Other recent decisions by the courts could perpetuate and even worsen racial and ethnic inequities in health care. Perhaps most notably for this report, a shifting political, social, legal, and cultural environment since the 2003 report underlies a decision by the Supreme Court in Students for Fair Admissions, Inc. v. President and Fellows of Harvard College.⁸ This decision could severely diminish the ability of federal government, using its constitutional powers under the 14th Amendment and educational institutions bound by Title VI of the 1964 Civil Rights Act, to remedy past and ongoing discrimination by using statistical evidence to fashion broad, race-conscious policies across health care and social welfare programs. Although the decision focuses specifically on undergraduate education, its implications potentially extend to university admissions programs more generally, although its limitations have yet to be tested. Furthermore, because it raises questions about the validity and reliability of government race and ethnicity data more generally, the Harvard ruling may reach more broadly into government and institutional efforts aimed at creating policies to mitigate past and ongoing inequities in a broad range of contexts, including policies aimed at overcoming the effects of racial and ethnic discrimination in health care and social services. These developments could affect the training of health care professionals to meet the needs of the diverse U.S. population and not just current research but future innovation and implementation to advance health and health care equity.

Additionally, the concept of structural racism is understood to include more than private prejudice and actions; it also is found within the laws and policies that order society (Bailey et al., 2021). However, political views differ

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⁸ See https://www.supremecourt.gov/opinions/22pdf/20-1199_hgdj.pdf (accessed April 29, 2024).

on the existence of racism in the nation. The majority of the public does not believe that racism is an issue (Hurst, 2023). Also, less than half of the population recognize the existence of SDOH and their differential impact on health (Carman et al., 2019). These disparate views create barriers to efforts aiming to address racial and ethnic inequities in health care. Furthermore, helping the public to understand how implementing interventions that benefit minoritized populations actually benefit everyone may be challenging in the current legal and political environment.

STRUCTURE OF THE REPORT

Chapter 1 serves as an introduction, outlining the committee’s approach to the study task, presents historical context and an overview of the developments since Unequal Treatment, and introduces the committee’s conceptual framework that underpins its approach to the study task and serves as a unifying basis for its consensus recommendations. Chapter 2 discusses the larger society in which the health care system exists and how key societal external forces interact to contribute to health care inequities. Chapter 3 documents the evidence on racial and ethnic inequities measured by health care access, use, and quality and delves into the intersectionality of race and ethnicity with sexual and gender identity, disability, and immigrant status. Chapter 4 explores the evolution of U.S. health care and civil rights laws as they affect the complexities of health care inequities and discusses developments and shortcomings of some of the most significant policy and law interventions aimed at addressing inequities and advancing health equity. The chapter also discusses health care payment policies. Chapter 5 delves into health care service delivery, discussing topics such as the state of the workforce, different care settings, patient–clinician relationships, and innovative care delivery models. Chapter 6 discusses the central role communities play in creating equitable health care systems and highlights some of the most promising community-based interventions. Chapter 7 discusses discovery and evidence generation, covering evidence to support recommendations regarding the resources and infrastructure needed to advance health and health care equity research. Chapter 8 addresses accountability at various levels, emphasizing the need for a multifaceted approach involving federal lawmakers, agencies, professional entities, and researchers. Chapter 9 presents the report’s overarching conclusions and recommendations for reducing racial and ethnic inequities in health care and advancing health equity. The appendixes provide additional resources, including a glossary; previous relevant National Academies reports; and study committee, staff, and consultants’ biographical information.

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