$125,000
National Academy of Sciences
District Of Columbia
National Institute on Drug Abuse (NIDA)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
The Institute of Medicine’s (IOM, 2003) [Now the National Academy of Medicine as one of the National Academies of Sciences, Engineering, and Medicine, NASEM] groundbreaking report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” documented differences in the quality of healthcare services received by people from racial and ethnic minority groups, highlighting the roles that racial stratification and social inequities play in health outcomes. Published almost 20 years after the landmark Malone-Heckler report, Unequal Treatment provided compelling models and evidence demonstrating how the health care system operates on multiple levels to create, sustain, and increase racial and ethnic health disparities – emphasizing the contributions of factors beyond the control of the individual patient. Reviewing evidence from the 2003 report and data generated subsequently, NASEM will convene an ad hoc expert committee to examine the current state of racial and ethnic disparities in U.S. healthcare. Congress commissioned the IOM in 1999 to study the root causes of racial and ethnic health disparities due to the growing concern around people from racial and ethnic minority groups and people experiencing poverty becoming a “permanent health care underclass.” Due to the historical marginalization of these populations in the healthcare system, high rates of being uninsured or underinsured, along with high health care costs driving differential access, utilization and quality of care, the IOM sought to illuminate how and why key factors impacting healthcare access, utilization and quality of care contributed to health disparities. The foci were two levels of the healthcare system that were hypothesized to contribute significantly to racial and ethnic health disparities. They first examined the operation of healthcare systems and the legal and regulatory climate in which health systems function, providing more nuanced explanations that moved beyond attributing health disparities to differential healthcare access. The second focused on understanding discriminatory practices at the patient, clinician, and health system levels – measured by bias, stereotyping, and clinician/patient concordance – as causes of racial and ethnic health disparities. The report provided actionable recommendations for evidenced-based targeted interventions that could be implemented over time to improve quality of care and reduce racial and ethnic healthcare disparities. The major findings from the IOM report reinforced that healthcare system limitations had particularly negative implications for the quality of care received by Black/African American persons and certain Hispanic/Latino persons based on their birthplace or English language fluency. However, most of the available data at the time was available for Black/African American persons and there was limited information in the IOM report on other minoritized populations. Among other findings, the report concluded that: • Minoritized racial and ethnic patients often receive a lower quality of care and less intensity of indicated treatment and diagnostic services across a wide range of procedures and disease areas. • Insurance status is a key predictor of the quality of care that minoritized racial and ethnic groups receive since they are disproportionately represented in the Medicaid and dual-eligible Medicare categories and no health insurance; yet when insurance status is controlled, race and ethnicity remain significant predictors of quality of care. • Within the clinical encounter, minoritized patients may perceive both overt, as well as subtle forms of discrimination when seeking care. Bias, stereotyping, prejudice, and communication barriers on the part of clinicians and other healthcare staff may be contributory factors to racial and ethnic disparities in healthcare. • Limited assistance with professional interpretation services is available to patients with limited English proficiency, which has negative implications for the clinical encounter. • Sociocultural differences between patient and clinician influence communication and clinical decision making; thus, ineffective communication during the medical encounter may lead to patient dissatisfaction, non-adherence, poorer health outcomes, and subsequently, racial and ethnic disparities in healthcare. • A significant body of literature defines and supports the importance of cross-cultural education in the training of health professionals. Despite several approaches and various opportunities for integration, curricula in this area have been implemented to a modest degree in undergraduate, graduate, and continuing education of health professions. • Medical graduates who identify with an underrepresented minority group made up about 14% in 2019-2020, with 7% being African American, 6% Latino/a and 1% American Indian or Alaska Native and Native Hawaiian or Pacific Islander. The 22% of medical graduates who identify as Asians, include Southeast Asians who are also underrepresented. • More information is needed on the potential impacts of medical care delivered in the context of cultural and linguistic concordance between clinicians and their patients. These would include efforts to evaluate the role of physicians from underrepresented populations and that of international medical graduates and minoritized racial and ethnic populations, and specifically the extent to which this contributes to healthcare disparities. Along with identifying key areas of healthcare that create and sustain racial and ethnic disparities, the IOM report identified areas needed for further research and suggested several intervention strategies to eliminate disparities in quality of care and improve population health. These recommendations included: • Develop a better understanding of the relative contribution of patient, clinician, and institutional characteristics to healthcare disparities. • Further illuminate clinical decision-making, heuristics applied in diagnostic evaluation, and how patients' race, ethnicity, gender, English language fluency, and social class may influence these decisions. • Assess the relative contributions of clinician biases, stereotyping, prejudice, and uncertainty in producing racial and ethnic disparities in diagnosis, treatment, and outcomes of care. • Investigate the roles of non-physician healthcare professionals, including nurses, physician assistants, occupational and rehabilitation therapists, mental health professionals (including psychologists, social workers, and marital and family therapists), pharmacists, allied health professionals, as well as medical assistants, administrative, and laboratory staff in contributing to healthcare disparities. • Due to a paucity of research, assess healthcare disparities among Asian American, Native Hawaiian and Pacific Islander, American Indian and Alaska Native, and Hispanic or Latino populations and their subpopulations. • Assess the potential impacts of medical care delivered in the context of cultural and linguistic concordance between clinicians and their patients. These would include efforts to evaluate the role of physicians from underrepresented populations and that of international medical graduates and minoritized racial and ethnic populations, and specifically the extent to which this contributes to decreasing healthcare disparities. • Develop and test the utility of healthcare improvement of patient-based measures of (1) trust in clinicians and systems and (2) exposure to discriminatory practices by clinicians or systems. • Develop methods for monitoring progress toward reducing and ultimately eliminating racial and ethnic disparities in healthcare. • Understand the relationship between healthcare disparities and the health gap between racial and ethnic minority and White patients stratified by educational attainment. While the IOM report provided the foundational evidence base necessary for subsequent studies to address how healthcare related factors significantly contribute to disparities in healthcare quality for minoritized racial and ethnic persons and the approaches needed to address them, health disparities persist and, in many conditions, continue to widen. It has been 20 years since the publication of the IOM report, and factors outside of the control of the individual continue to play a significant role in disparate health outcomes. Needed is an understanding of the aspects of healthcare quality identified in the IOM report which have shown improvement, promise, or worsened. For example, a significant advancement in health care is the Patient Protection and Affordable Care Act of 2010 (ACA) which has increased insurance coverage for 20 million U.S. residents, reduced the insurance gap across all racial and ethnic groups in the U.S. and completely eliminated the disparity for Asian Americans, Native Hawaiians and Pacific Islanders, but not for other racial groups. 4 Unfortunately, there remains a considerable segment of the population that lacks access to healthcare due to lack of health insurance. The lack of insurance is most notable for Latino/Hispanic populations 18 to 64 years of age. Further, even among insured populations, numerous adverse social determinants of health—such as lack of transportation and paid sick leave—may impede access to care for marginalized groups. In addition, demographic shifts in the population and public health emergencies such as the COVID-19 pandemic have exacerbated racial and ethnic health disparities in all aspects of healthcare and health outcomes. These factors must be taken into consideration when assessing the current disparities landscape. Advancing the work of the previous IOM report will include a review of the state of racial and ethnic disparities in quality of care, access, and utilization, and expand to examine community and population level factors that operate to influence healthcare disparities. Current evidence suggests that the digital divide has hampered the potential of health information technology to expand access to healthcare for socioeconomically disadvantaged groups and racial and ethnic minority persons. 5 For example, in a study that assessed geographic and racial and ethnic disparities in access to care, Mantri & Mitchell (2021) found that with the shift to virtual care due to the COVID-19 pandemic, visits among Black/African American individuals was cut in half relative to pre-pandemic utilization. 6 Other research has also found that the COVID-19 pandemic has had an adverse impact on healthcare utilization due to limited telemedicine adoption7 and increased racial inequities in the quality and intensity of care. 8 Thus, it is important that healthcare systems emphasize access to high quality of care for all, strengthen preventive health care approaches, address social needs as part of healthcare delivery, and diversify the healthcare workforce to more closely reflect the demographic composition of the patient population.