Ending Inequities in Health Care
The United States spends more on health care than any other high-income country, yet we have some of the worst population health outcomes. Our health care system is designed in such a way that racial and ethnic disparities are inevitable, and the differences are extreme: the life expectancy difference between white women and black men is over a decade. How can we fix the system to ensure health care equity for all?
A new National Academies report called Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All tackles this question. Building on a 2003 report on racial and ethnic disparities in health care, the new report finds that little progress has been made in closing those equity gaps over the past two decades.
On this episode, host Sara Frueh talks to Georges Benjamin, cochair of the report committee and executive director of the American Public Health Association. They discuss how the health care system creates disparities and how we can fix them.
Resources
Read the National Academies reports on health care inequality:
- Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003)
- Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All (2024)
Transcript
Sara Frueh: Welcome to The Ongoing Transformation, a podcast from Issues in Science and Technology. Issues is a quarterly journal published by the National Academy of Sciences and Arizona State University.
The United States spends more on health care than any other high income country, yet we have some of the worst population health. Racial and ethnic disparities are an enduring feature of American health care, and in fact, our system is currently designed in such a way that disparities are inevitable. How can we fix the system to ensure health care equity for all?
A new National Academy’s report called Ending Unequal Treatment tackles this question. Building on a 2003 report on racial and ethnic disparities in health care, the new report finds that the disparities from over 20 years ago still persist.
I’m Sara Frueh, an editor at Issues. I’m joined by Georges Benjamin, cochair of the Report Committee and executive director of the American Public Health Association. On this episode, we’ll discuss how the health care system creates disparities and how we can fix them. Dr. Benjamin, welcome.
Georges Benjamin: Sara, thank you for having me today.
Frueh: You’ve been a leader in the world of public health for a long time, but for listeners who may not be familiar with you, can you tell us a little bit about yourself and how your work during your career has intersected with the problem of health inequities?
Benjamin: Oh, thank you very much. Actually, I am an internist with the subspecialty of emergency medicine. I trained in the Army Medical Corps for about nine years, and then I went out and practiced in the private sector, having served as the chair of the Community Medicine Department at the City Hospital in Washington, D.C. I was a D.C. health commissioner for a couple years. I served in the fire department as a deputy fire chief to run the emergency medical system for Washington D.C., and then eventually I ended up in Maryland, both as a deputy secretary of health and then the secretary of health for the state. And I’ve now been at the American Public Health Association for about 22 years practicing public health.
You cannot be in an urban setting, for sure, and not see differences in both outcomes and the way people are treated.
Frueh: You mentioned that you worked for a fire department and as a doctor, and I’m wondering if you saw these health inequities and health care inequities up close during that work?
Benjamin: You cannot be in an urban setting, for sure, and not see differences in both outcomes and the way people are treated. When I was at the City Hospital, we would get patients transferred to us who were uninsured. And so, they’d gone to a hospital, and they were seen, usually quite briefly, and then put in an ambulance or sent by car over to the City Hospital, because we were there for the uninsured, for sure, but because we were at City Hospital.
And these people were often in a higher degree of illness, they usually had few resources, and when we took care of them and we discharged them, we knew that they were also going back into their homes, into the community, in really trying conditions. Some were there… didn’t have medication, have money for medications. They often were food insecure. And if they were going back into a violent environment, they were returning, in some cases, to the environment which actually got them in the hospital in the first place.
Frueh: Thank you for that. I want to quickly check in about the study that you recently chaired, pulling back to a more abstract level. What did your study look at and what were you trying to learn about health inequities?
At the end of the day, the biggest challenge is the way the system is fundamentally designed, financed, and delivered, which gives you these inequities.
Benjamin: One of the things that we wanted to do with our study is look back and say, “Okay, what’s happened over the last 20 years since the last time the Academies have looked at health inequities?” 20 years ago when the Academies did the health inequity study, what they discovered was that there are many things in our society that both impede your ability to get health or enable you to be healthy, and we call those the social determinants of health. And on that list of things included racism and discrimination. And of course, there was a great howl when that happened because all the people in the health care world said, “Oh, no, no, no, no. We’re not discriminating against people. We don’t treat people differently.” But the truth of the matter is we do. There are both conscious and unconscious bias.
But what we tried to do now in our study, we took a systems look at health care inequities. And what we basically discovered was that over the last 20 years, not a lot of progress has been made. Doesn’t mean that we haven’t had any progress, but not substantive progress. And more importantly, the way we have designed our system in our country is designed to give us the inequities that we’re getting. So really, in many ways… there are structural racism, there are system issues, there’s obviously bias in the system, for sure, they’re biased with individuals, but at the end of the day, the biggest challenge is the way the system is fundamentally designed, financed, and delivered, which gives you these inequities.
Frueh: Can you say a little bit more about that? How this operates on a system-wide level to create this? How did those systems get in place? What’s perpetuating them? What does that look like on a system-wide level?
Benjamin: We’re the only industrialized country in the world that doesn’t have health insurance coverage for all of its citizens. So, let’s start with that. When the Affordable Care Act was passed, they actually designed a system which got all eligible citizens in the system, and then the Supreme Court said, “Well, it’s okay, but you cannot force every state to cover the Medicaid population.” And so, we have about 10 states in the nation that have not expanded coverage for their Medicaid population. Those people, in many cases, go uninsured. So, we still have 20 plus million people in our country who are uninsured. And we know when we look at the studies that in the states that have expanded Medicaid and the states that have not expanded Medicaid, the states that have expanded Medicaid, the health care status of those populations are much better just because they have access to health insurance coverage.
We’re the only industrialized country in the world that doesn’t have health insurance coverage for all of its citizens.
Another example is the way we pay for providers to take care of people. The provider rate for Medicaid, for Medicare, and for private insurance are different by magnitudes of payment. And increasingly, we’re seeing more and more providers who not only won’t take Medicaid insurance, but they won’t take Medicare insurance. We’ve also now seen more and more, where, as our system has evolved, as costs have gone up, that both people who get their insurance through their job, as well as people who are buying their insurance through the open market, increasingly the out-of-pocket costs, not just the cost of the insurance policy itself, the premium, but the out-of-pocket costs for each encounter are going up more and more. And so the costs to the individual are being shifted. And so increasingly, we’re not only seeing people who are uninsured, but we’re seeing more and more people who are underinsured. And one of the leading causes, and in fact some studies, the leading cause of bankruptcy in this country are health care costs. So, it has an economic implication, it has a health implication.
And then when you add the fact that increasingly in our rural communities, again, many in states where they didn’t expand Medicaid, rural hospitals are closing very quickly. And so we’re now having people who don’t have access to any kind of health clinic in their community, no hospital at all. We also know that increasingly in our country, more and more communities don’t have anyone to take care of women’s health. So, the number and access to OBGYNs is a problem in our country. So, access to care, payment of care, and then this complicated system in which we transfer people from one system to another, it’s really a growing mess that needs to get fixed.
Frueh: It sounds like these problems are very broad and reach a lot of the population in the US, but it also sounds like from your report that these problems disproportionately affect some racial and ethnic groups more than others. What groups did you look at that are bearing the brunt of this health care system?
Benjamin: Yeah. We talk a great deal about minoritized populations, and these are populations that tend to be communities of color—African-American, Hispanic, Native American communities—bear the brunt, but I want to point out that it depends on where you are. So, there are disparities not only between race and ethnicity, but you also have disparities between urban and rural populations. So, you go to the Appalachia, it’s lower income whites who are disproportionately impacted. You’ll see that in the South where you have more poverty, and the communities, regardless of race or ethnicity, you’re seeing these disparities. Although, when you look at people of the same income level, you also see these disparities based on race.
One of the more interesting phenomenas, of course, is even when you have people who have the same insurance coverage, in many situations, people who are African American or who are Hispanic find that their health outcomes are far worse even when they have the same fundamental assets. And then you have to ask yourself, the question is why. And it’s a complicated question, but sometimes it comes down to just access to care, differences in the quality of care received within the health care setting, and in some cases differences in how people seek care based on preconceived notions of what they can get.
Frueh: What are the on the ground impacts of these inequities and care for individuals, for communities, for our nation as a whole?
Why is that in a city 10 square miles that you can’t provide comprehensive, adequate prenatal care services to the women and children in this city?
Benjamin: At the end of the day, it means that we have a population of people with much more heart disease based on race and ethnicity, more lung disease, more kidney disease, more diabetes. You have more amputations and more preventable things that should not happen if people got care early.
You asked me before, what were some of my prior experiences? One of the most interesting things that I had to deal with as a health commissioner was dealing with infant mortality. That’s a child who does not live beyond their first birthday. And in Washington D.C., we have some of the best neonatal services in the country, and yet we have one of the worst infant mortality rates in the nation. Why is that in a city 10 square miles that you can’t provide comprehensive, adequate prenatal care services to the women and children in this city? The fact that in our nation, we still have far too many African American women who are dying disproportionately in childbirth, that’s a problem.
Frueh: You raised the question of, in a city with so many resources, why the maternal mortality rates are so high? And I’m sorry, but I’m going to turn that question back to you. Do you know why there’s this mismatch between the amount of resources we have and the outcomes for these women? What is happening to impede their access to that or otherwise damage the outcomes for patients?
Benjamin: Far too often, we have a mismatch between the providers providing the care and the patients, and the patients’ needs. And then there are issues where we have patients that just don’t communicate well with their providers. And again, that lack of adequate communication where the provider is not listening attentively enough or the patient’s not able to communicate effectively enough with their provider, that physician-patient relationship is so essential to making sure that people have good quality health care. If you are someone who is insured, but your marginal income is such that your doctor’s having to make decisions about which antibiotic they prescribe for you when you get a urinary tract infection when you’re pregnant, that’s a problem, because they may not be able to optimize your care, because you may not be able to afford the prescription that is best suited to take care of the infection that you have. And so, there’s a compromise made there, and that’s not satisfactory.
Frueh: It sounds like this is a very multilayered complicated problem, and I’m wondering how we start to fix it. What did the committee recommend as far as solutions that could finally start to close these equity gaps?
The committee does believe very strongly that it’s fixable, that we have lots of tools, all the tools we really need, to begin to solve this problem.
Benjamin: Well, to start with, the committee does believe very strongly that it’s fixable, that we have lots of tools, all the tools we really need, to begin to solve this problem. Number one, we need to get a system with everyone in and no one out. Secondly, we need to strengthen our oversight and accountability systems. We have something in law that came under the Affordable Care Act called the Community Benefit Assessment that every hospital is supposed to do. They’re supposed to look at the needs of their community and then to wrap some of their programming around the needs of those communities. We think that can be strengthened.
We think that dealing with implicit bias is certainly important. We know that we all bring life experiences to the table that influence how we think about things and how we care for people beyond the science that we know. So, we think that increasing diversity of the workforce, so that we bring a range of people with life experiences to the table, is important. We believe very strongly that we should put more emphasis on primary care and comprehensive care. We felt team care is very important. A lot of evidence that putting care together with teams is important. And by the way, there was another study that the academy did that looked at primary care, which strongly made the case for primary care and team-based care.
We believe that we ought to expand at the national level—realizing that licensing is done at the local level—the ability of providers to practice at their full range of training. During COVID, we expanded both the number of people who gave shots, and within their scope of practice and within their training, and we were able to very rapidly improve the ability to vaccinate people during COVID.
COVID was a terrible experience for all of us. A million people died, and that was a real tragedy, and we had huge disparities, particularly in those communities of color doing COVID. Having said that, we, in effect, covered everybody because we expanded coverage. We paid for the vaccine, we paid for the testing, and we improved access to health care. And then, of course, after the emergency, we went back to the same system we had before, and a lot of those disparities are now reemerging.
Frueh: The first issue you noted about getting everyone into the system and that the committee thought that that was important, did you delve into how exactly we could make that happen, making health care more accessible to all?
We ought to behave and fund what we do: our behavior as well as our values.
Benjamin: We clearly have to work on those 10 states that have not expanded Medicaid. We’ve got to either find both the political and the fiscal leverage to get them there. We continue to encourage them. The Center for Medicare and Medicaid Services, that is the agency that funds Medicare and the Medicaid program at the Department of Health and Human Services, and they are working to try to encourage states to do that, to try to offer them opportunities for waivers, to experiment with new ways to get people covered. But fundamentally expanding the Medicaid program to all the states is absolutely an important first step.
People who have policy chops that I do say health care is a fundamental human right, and we have people who say that, “Well, we don’t necessarily believe that.” Except the minute anybody gets sick, we treat it as a fundamental human right. We don’t let them just lay on the street. We pick them up, we take care of them at an enormous cost. And I argue that isn’t it more efficient for us to do it in a structured, organized system by making sure everybody’s in the system?
And we ought to behave and fund what we do: our behavior as well as our values. And if we can fund this in a way that we get everybody in the system and treat everybody with the respect that they deserve, then we’ll finally get that system up and running. But it’s been challenging. It really has been challenging because the people that are opposed to this find every excuse in the world to avoid expanding the Medicaid program. And by the way, it’s often for… We think about this as an issue around single adults, but in some of these states, the eligibility level, even for women and children, is so low from an income perspective that it’s laughable. So, we need to get everybody in the system.
Frueh: Another thing the committee recommends is strengthening oversight and accountability systems. And I’m wondering if you can say a little bit about that? What do we have now as far as oversight and accountability? And what needs to happen to make those systems stronger and better functioning?
We aren’t really looking at the disparities between the various populations. We don’t fund it as much as we should. We don’t train the researchers that we need to train to do this kind of research.
Benjamin: At every level of government, there are opportunities for us to engage the private sector in ways that hold them accountable for the outcomes that they get. Far too often, we put out rules that say if a hospital has a person that needs to be readmitted, then we will, and it happens far too often, then we will fiscally punish the hospital. But we really don’t work as hard as we could to address this issue of readmission, for example. We know that falls is a big issue. We are really concerned about falls in hospitals, but we haven’t really funded the research to really understand why people fall. It’s a leading cause of morbidity and mortality in the population, and yet the amount of money we spend on this kind of really functional research is really limited. We don’t look at disparity research as aggressively as we should. We aren’t really looking at the disparities between the various populations. We don’t fund it as much as we should. We don’t train the researchers that we need to train to do this kind of research.
And one of the recommendations of our committee was to expand both the diversity of the research pool and build fundamental infrastructure to allow this research to occur, particularly when we want to engage communities. We’ve always had this challenge getting minorities into research studies, but we had a really good response with the vaccine studies during COVID. And one of the reasons we were able to do that is they were able to build upon existing community-based research programs for HIV, AIDS and expand those programs because they were already in the communities, they were engaged, they had competent researchers involved, and they were able to expand those programs for an additional infectious disease, i.e., COVID. And because of the relationships they already had in the community, they were able to get more people in those research studies and show that the vaccine was safe and effective across a variety of populations based on race, ethnicity, age, gender.
And the challenge with this going forward is keeping those research enterprises what I call warm. So, keeping them in place, giving them the infrastructure. What happens far too often is we do a research study, and then we take apart all the infrastructure, and we don’t use that group we put together for anything else, or we let it fall apart, and then we have to rebuild it. And so, one of the things our committee wanted to do was say, “Let’s keep these community-based programs warm. Let’s keep them involved. Let’s keep them engaged. Let’s fund them for other things. Let’s expand their scope in ways that allow them to do the kind of community-based participatory research that we know gives us results.”
And then I think, finally, what we did on the research front was in health and health care, like in a lot of sciences, dissemination is a challenge. For many researchers, publishing that paper is very important, and then you move on to the next thing. And if someone doesn’t read your paper, they don’t know about what you’ve discovered. Well, when we have a lot of programs in medicine that we have done as pilots, we love our pilots, and we do these pilot programs, and then they show their worth, and then we don’t disseminate them aggressively. There really isn’t money to scale them up. Scaling up is very important, and often customizing it, because all communities aren’t the same, is very important. So, the committee recommended very strongly that we find ways to rapidly disseminate things that we find that work, and then, of course, rapidly disseminate things that we’ve discovered don’t work, so that people don’t make the same mistakes over and over again.
Frueh: Can you give some examples of some interventions that do work that you’d like to see scaled up, and some interventions that don’t work, which you keep seeing people using anyway?
We know that improves the care for patients, and yet we haven’t figured out how to fund it adequately to scale it up so that we can do more patients.
Benjamin: Well, I can say that putting together team-based care, and there’s a range of primary care models that we know work. And we keep reinventing the wheel. We keep saying, “Boy, if we put together a pharmacist, and a nurse practitioner, and a primary care clinician, and a social worker, and a team, boy, that’s a wonderful idea, will that improve the care for patients?” And we keep doing that. We know that improves the care for patients, and yet we haven’t figured out how to fund it adequately to scale it up so that we can do more patients. That’s an example.
We know that social determinants for health, those things on the societal side that make a strong difference. We know that food insecurity is a big issue. And every time someone comes in and has some challenges with their weight or is malnourished, we’re very quick to write them a consult to go see a nutritionist, but we don’t address the fact that this person works two jobs and the fact that the community they live in has no access to a full service grocery store that serves fresh, affordable vegetables, for example. And yet we know the health department can work with the Chamber of Commerce and can work with the economic development people in the government to address these, what we call food deserts in communities so that people have more access to affordable nutritious foods.
We know that education is a social determinant. It turns out that the more education that a woman has, the more likely her child is to survive their first year life. That educational level is a surrogate for some other issue, but we know that that correlation does occur, and for every society in which they discover that, all around the country, all around the world, that relationship has held. We know that if a person gets out of high school and gets their high school diploma, that their health is better. So, there’s these social things that we know we can address. And what the committee did was we looked at these societal issues, and we wanted to make sure that they were recognized as important as far as the process.
Frueh: You’ve talked about all these different levels of policy and society that have things they need to work on. Policymakers need to expand access and deal with some of the social determinants of health. The research structures need to have more partnerships with communities. Health systems need to do more team care. Is there anything that individual health care providers, doctors, nurses, other practitioners, can and should be doing around this issue?
If they don’t feel they treated fairly in the health care system yesterday, they’re less likely to trust the system. They’re less likely to come back.
Benjamin: Because we all carry biases to the table, everybody should think about how their offices are constructed, how people are treated in their office. Do they have barriers so that people who come into the office aren’t treated in a disparate manner? One of the issues we always talk about is trust. During COVID, again, there was a lot of issues around trust around vaccines and trust of the health care system. And we often said that, well, we have these historical wrongs that have occurred, like the Tuskegee experiment and things that happened to African Americans during slavery. But while those were certainly in the distant past that what people were really responding to was how they were treated yesterday. Now, if they don’t feel they treated fairly in the health care system yesterday, they’re less likely to trust the system. They’re less likely to come back.
So, that relationship between the provider and their patient expands to the provider and the provider’s office, office staff, the welcoming of those people in that office. And so, there are many things that we can do on the clinical care side of the house to ensure that people are treated like customers. Now, often, people get upset when I say patients are customers. They’re patients, but there is a customer edict that we have to follow where when people come to us for care, that we treat them with respect and dignity, and that our offices and our environment in which we care for them is welcoming, that we treat them with the kind of respect and dignity that they deserve. And I just have to say that, while certainly on the whole our profession does that, there are instances where I’ve seen that not happen, and that’s a challenge. And we do have systems that are just structured to be unwelcoming, and we need to take those systems apart.
Frueh: One last question. Not a lot of progress has been made, as your report says, since 2003 on this issue. And I’m wondering how much optimism do you have, or not have, that we can make real progress on this issue in the 20 years ahead? And if you are hopeful, what is that grounded in?
I believe that the nation is poised for the next phase of health reform.
Benjamin: Well, I’m absolutely hopeful, and I’m hopeful because I think that while we’ve had incremental progress, I think the committee said not enough. And I think now we’re in a position where we kind of understand fundamentally structural racism, discrimination. We’ve looked at the system through our study from a systems perspective. We’ve identified some really key issues that we can address. And I believe that the nation is poised for the next phase of health reform. That next phase of health reform should include expanding coverage to everyone. We can do that through the Affordable Care Act, primarily. We can address payment reform, so we can reduce the cost of the health care system. We’re doing a lot already on prescription drugs.
One thing we can do is try to decrease the variance in reimbursement between the various insurance plans that we have. That means Medicare, Medicaid, and private insurance. By narrowing those gaps, by doing some introspection in our own practices and our own selves so that we can provide the kind of care and welcoming environment that our patients deserve. And I think that we’re in a breakout moment. As we begin to expand access to more research that the next generation of researchers that we need to develop, the systems are in place to do that. We just have to adequately fund them, and I believe that we can and we will.
Frueh: Thank you, Dr. Benjamin, for taking the time to speak with us today, and it’s encouraging to hear your optimism on this issue. To learn more about ending structural inequality in health care, visit our show notes to find links to the report and more of Georges Benjamin’s work.
Please subscribe to The Ongoing Transformation wherever you get your podcasts, and write to us at [email protected]. Thanks to our podcast producer, Kimberly Quach and our audio engineer, Shannon Lynch. I’m Sara Frueh, an editor at Issues. Tune in on November 19th for an interview with Guru Madhavan about engineering and the wonders of often overlooked infrastructure.