The disparate effects of the COVID-19 pandemic, ongoing police brutality, and the recent rise in Asian hate crimes have brought health and healthcare disparities to the forefront of public and media attention. However, disparities in health and health care are not new. They have been documented for decades and result from longstanding structural and systemic inequities rooted in Racism and discrimination. Addressing these inequities may help to mitigate the disparate effects of the COVID-19 pandemic and prevent future health disparities from widening. Furthermore, closing health disparities is critical to improving our country’s overall health and lowering unnecessary healthcare costs. This brief introduces health and healthcare disparities, how COVID-19 has affected them, the broader implications, and current federal efforts to advance health equity.
What are disparities in health and health care?
Health and health care disparities are differences in health and health care that result from larger inequities. Health disparities are defined in a variety of ways. A health disparity is defined as “a specific type of health difference that is closely linked with social, economic, and/or environmental disadvantage” and “adversely affects groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity.” Health disparities are defined by the Centers for Disease Control and Prevention (CDC) as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” A health care disparity typically refers to differences in health insurance coverage, access to and use of care, and quality of care between groups. The terms “health inequality” and “inequity” are also used to describe disparities. Racism, defined by the CDC as “structures, policies, practices, and norms that assign value and determine opportunities based on how people look or the color of their skin,” creates conditions that unfairly advantage some and disadvantage others, putting people of color at a higher risk for poor health outcomes.
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Individuals achieving their highest level of health through eliminating disparities in health and health care are referred to as achieving health equity. Health equity is defined as achieving the highest level of health for all people by Healthy People 2020. It requires valuing everyone equally through focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and health and healthcare disparities. The CDC defines health equity as “everyone having the opportunity to achieve his or her full health potential,” and no one is “disadvantaged from achieving this potential due to social position or other socially determined circumstances.”
Disparities in health and health care are caused by various factors within and outside the health care system (Figure 1). Though health care is important, research shows that various factors influence health outcomes, including underlying genetics, health behaviors, social and environmental factors, and access to health care. While there is currently no agreement in the research on the magnitude of each of these factors’ relative contributions to health, studies suggest that health behaviors and social and economic factors, also known as social determinants of health, are the primary drivers of health outcomes and that social and economic factors shape individuals’ health behaviors. Furthermore, Racism hurts mental and physical health, both directly and indirectly, by creating inequities across the social determinants of health.
Figure 1: Social and economic inequities contribute to health disparities.
Disparities in health and health care are frequently viewed through the lens of race and ethnicity, but they exist across a wide range of dimensions. Disparities exist in socioeconomic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation, for example. According to research, disparities exist throughout life, from birth to midlife and among older adults. 1,2 People of color, low-income populations, women, children/adolescents, older adults, people with special health care needs, and people living in rural and inner-city areas are prioritized by federal efforts to reduce disparities. These groups are not mutually exclusive and frequently intersect in interesting ways. Disparities also exist within population subgroups. For example, Hispanics’ health and health care differ depending on their time in the country, primary language, and immigration status. 3,4 Furthermore, data for Asians frequently obscure underlying disparities among subgroups within the Asian population. 5
What is the current state of disparities?
Before the COVID-19 pandemic, people of color and other underserved groups experienced longstanding health disparities. A major recognition of health disparities began nearly two decades ago, with two Surgeon General’s reports published in the early 2000s that documented racial and ethnic disparities in tobacco use and access to mental health care. Despite decades of recognition and documentation of disparities and overall improvements in population health, many disparities have persisted and, in some cases, widened. 6 Recent data from before the COVID-19 pandemic revealed that people of color fared worse than Whites in various health measures, including infant mortality, pregnancy-related deaths, the prevalence of chronic conditions, and overall physical and mental health status (Figure 2). As of 2018, Black people had a four-year lower life expectancy than White people, with Black men having the lowest expectancy. Disparities in other factors are also documented in research. Low-income people, for example, have poorer health than higher-income people7, and lesbian, gay, bisexual, and transgender (LGBT) people face additional health challenges.
Figure 2: People of Color Perform Worse Than Whites on a Wide Range of Health Measures.
There are also longstanding disparities in healthcare delivery. Health coverage expansions under the Affordable Care Act resulted in significant gains across demographics. Despite these gains, people of color and low-income individuals are at a higher risk of being uninsured (Figure 3), contributing to greater barriers to healthcare access. Furthermore, beginning in 2017, coverage gains stalled and began to reverse, reflecting a variety of Trump administration actions, including decreased funding for outreach and enrollment assistance, approval of state waivers to add new eligibility restrictions for Medicaid coverage, and immigration policy changes that increased immigrant families’ fears about participating in Medicaid and CHIP. These losses eroded some of the ACA’s previous coverage gains, particularly among Hispanics, who were already at a higher risk of being uninsured. Coverage losses will likely continue due to the COVID-19 pandemic, as people have lost jobs and income. Aside from disparities in coverage, people of color and those with lower incomes receive lower-quality care. According to recent KFF/The Undefeated survey data, Black adults are more likely than White adults to report negative health care experiences, such as a provider not believing them and refusing a test, treatment, or pain medication they thought they needed.
Figure 3: Longstanding disparities in health coverage exist for people of color.
What impact has the COVID-19 pandemic had on disparities?
Data consistently show that AIAN, Black, and Hispanic people have experienced disproportionate rates of illness and death due to COVID-19 (Figure 4). According to the analysis, AIAN, Black, Native Hawaiian, and Other Pacific Islander (NHOPI), and Hispanic people had more than three times the rate of premature excess deaths per 100,000 people in the US in 2020 as White or Asian people. Higher rates of illness and death among people of color reflect increased risk of virus exposure due to living, working, and transportation situations, increased risk of serious illness if infected due to higher rates of underlying health conditions, and increased barriers to testing and treatment due to existing disparities in health care access.
Figure 4: Because of COVID-19, people of color have had higher rates of infection, hospitalization, and death.
Aside from the virus’s direct health consequences, the pandemic has disproportionately impacted the financial security, mental health, and well-being of people of color, low-income people, LGBT people, and other underserved groups. According to KFF survey data from February 2021, approximately six in ten Hispanic adults (59%) and approximately half of the Black adults (51%) said their household lost a job or income as a result of the pandemic, compared to approximately four in ten White adults (39%) who say the same. Furthermore, adults with a household income of less than $40,000 were three times more likely than those with a household income of $90,000 or more to report having difficulty paying for basic living expenses in the previous three months (55% vs. 19%). Black and Hispanic adults were more likely than White adults to report a lack of confidence in their ability to make their next housing payment and to report food insecurity as of late March 2021.
Despite being disproportionately affected by the pandemic, Black and Hispanic people were less likely than White people to have received a COVID-19 vaccine as of April 2021. Data from multiple states show that Black and Hispanic people receive fewer vaccinations compared to their proportions of cases, deaths, and the total population, resulting in lower vaccination rates compared to their White counterparts. While vaccination rates are increasing across the board, disparities in vaccination rates for Black and Hispanic people remain (Figure 5). These vaccination disparities reflect longstanding inequities that create additional barriers to health care for people of color and other underserved groups. Furthermore, they put people of color at a higher risk of infection and illness and stymie efforts to achieve population-level immunity.
Figure 5: Although vaccination rates are increasing across the board, Black and Hispanic people continue to face disparities.
What are the broader consequences of disparities?
Addressing health and healthcare disparities is critical for social justice and equity and improving the nation’s overall health and economic prosperity. People of color and other underserved groups have higher rates of illness and death across various health conditions, limiting the nation’s overall health. According to research, health disparities are costly. According to the analysis, the disparities amount to approximately $93 billion in excess medical care costs and $42 billion in lost productivity per year, in addition to additional economic losses due to premature deaths. Addressing disparities becomes increasingly important as the population becomes more diverse, with people of color expected to account for more than half of the population by 2050 (Figure 5).
Figure 6: By 2050, people of color are expected to account for more than half of the US population.
The COVID-19 pandemic has exacerbated underlying disparities in health and health care, emphasizing the need to address them. The disparate effects of the COVID-19 pandemic on people of color and other underserved groups may lead to even wider health disparities and increased health risks for the community as a whole, especially if some groups remain at increased risk from COVID-19 due to lower vaccination rates and increased risk of virus exposure. As a result, prioritizing equity in COVID-19 response efforts is critical not only for mitigating the disproportionate effects of the pandemic but also for preventing even larger health disparities in the future.
What are the federal government’s current efforts to address health disparities?
The Biden administration has made racial equity, including health equity, a top priority, as evidenced by several recent agency actions. President Biden immediately issued a series of executive orders and actions aimed at advancing health equity. These included orders outlining equity as a broad priority for the federal government and a component of pandemic response and recovery. To address structural Racism and racial inequities in biomedical research, the National Institutes of Health (NIH) launched the UNITE Initiative in March 2021. The Centers for Disease Control and Prevention (CDC) declared Racism a serious threat to public health in early April 2021, noting that it would lead efforts to confront systems and policies that have resulted in generational injustice, which has given rise to racial and ethnic health disparities. The Office of Minority Health at the Department of Health and Human Services (HHS) is dedicated to the “success, sustainability, and spread of health equity promoting policies, programs, and practices” and has three overarching programmatic priorities for FY2020 and 2021, including assisting states, territories, and tribes in identifying and sustaining health equity-promoting policies, programs, and practices; and expanding the use of community health workers to address health disparities.
The federal government’s COVID-19 response efforts have included a focus on equity. To address the disproportionate and severe impact of COVID-19 on communities of color and underserved populations, President Biden issued an Executive Order to ensure an Equitable Pandemic Response and Recovery in January 2021. The order creates a COVID-19 Health Equity Task Force, directs agencies to improve equity data collection and reporting, and ensures response plans and policies provide equitable resource allocation. It also directs HHS to conduct an outreach campaign to increase vaccine confidence among communities of color and other underserved populations. The COVID-19 relief American Rescue Plan Act, which goes into effect in March 2021, provides new funding to support COVID-19 vaccination and other public health efforts, focusing on improving access to vaccines and resources to protect against and respond to COVID-19 among underserved populations. HHS will invest nearly $10 billion in this funding to expand access to vaccines and better serve communities of color, rural areas, low-income populations, and other underserved communities. This includes $6 billion for community health centers, which, according to data, vaccinate a higher proportion of people of color than overall vaccination efforts.
The administration and Congress have taken various steps to increase healthcare access and enrollment. As previously stated, beginning in 2017, gains in health coverage stalled and began to reverse. The COVID-19 pandemic will likely increase coverage losses as people have lost jobs and income. President Biden issued an Executive Order on Strengthening Medicaid and the Affordable Care Act in January 2021, which established a Special Open Enrollment Period for Health Insurance Marketplaces and directed federal agencies to review policies and practices to ensure access to health coverage. The American Rescue Plan Act also includes provisions to improve access to health care and make it more affordable. These include increases and expansions in eligibility for subsidies to purchase health insurance through the Marketplaces, as well as Medicaid provisions that provide incentives to states that have not yet adopted the ACA Medicaid expansion, as well as a new option for states to extend the length of Medicaid coverage for postpartum women. The administration also increased outreach efforts and restored funding for navigators who assist eligible people in enrolling in health insurance. These actions will benefit people of color and low-income people, in particular, who are more likely to be uninsured. Six out of ten uninsured adults who would become eligible if all remaining states expanded Medicaid are people of color, and more than seven out of ten are low-income adults. Overall, research indicates that Medicaid expansion is associated with reduced racial/ethnic disparities in health coverage and narrowed disparities in health outcomes for Black and Hispanic people, particularly for maternal and infant health measures.
The administration has reversed Trump administration policies that contributed to reduced access to health care and other programs for immigrant families. President Biden issued an Executive Order in February 2021, Restoring Faith in Our Legal Immigration Systems and Strengthening Integration and Inclusion Efforts for New Americans, stating that the federal government should develop welcoming strategies that promote integration, inclusion, and citizenship. The order directed federal agencies to review existing actions to ensure they are consistent with this policy, reduce barriers to access to immigration benefits, and review changes to public charge policies implemented by the Trump Administration, which contributed to decreased access to health care and other programs for immigrant families. Following that, the administration reversed these public charge policy changes. The Department of Homeland Security also stated that all individuals, regardless of immigration status, should receive the COVID-19 vaccines and that, except in the most extraordinary circumstances, enforcement operations will not be conducted at or near healthcare facilities.
The administration has launched several initiatives aimed at addressing maternal health disparities. President Biden proclaimed in April 2021 to recognize the significance of addressing the high rates of Black maternal mortality and morbidity. Furthermore, the Centers for Medicare and Medicaid Services (CMS) has approved several state waivers to extend Medicaid postpartum coverage. This policy will be available as a state option in 2022 under the American Rescue Plan Act. The Human Resources and Services Administration has also announced $12 million in funding for the Rural Maternal and Obstetrics Management Strategies Program, which aims to create models and implement strategies to improve maternal health in rural communities.
To summarize, health and health care disparities for people of color and underserved groups have long been a problem. The COVID-19 pandemic has exacerbated these disparities, emphasizing the need to address them. Health disparities are exacerbated by underlying social and economic inequities rooted in Racism. Addressing disparities is critical for social justice and improving our country’s overall health and economic prosperity. In response to COVID-19 and more broadly, the federal government has identified equity as a priority and launched several initiatives to address disparities. States, local communities, private organizations, and healthcare providers work to reduce health disparities. Prioritizing equity across sectors; providing resources to support equity efforts; increasing data availability; supporting and building on existing community strengths and resources; establishing incentives, accountability, and oversight for equity; and recognizing and addressing Racism as a root cause of disparities is all important steps toward advancing equity.
Health Disparities defined in Healthy People 2020: A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status: gender, age, mental health. cognitive, sensory, or physical disability, sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
Choose a health disparity experienced by a population group in the United States. Use data to support this disparity. Conceptualize the health disparity by applying a social determinant of health framework described in Chapter 4. Figure 4.2.
Explain the health disparity using data through the application of the framework chosen. Use the framework diagram to explain the health disparity.
APA format no longer than 6 pages (including the title and reference page) with associated peer reviewed references.