‘Profound’ racial, ethnic disparities are pervasive in health care, even in top-performing states

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Compared with White patients, members of other racial and ethnic groups generally encounter lower performance by health systems and disparities in outcomes and health care access.

Leaders of the Commonwealth Fund met online to discuss “Advancing Racial Equity in U.S. Health Care: Findings from the Commonwealth Fund 2024 State Health Disparities Report.” The new research compiled 2021 and 2022 data from 25 measures of performance, stratifying it for five racial and ethnic groups, including Black, Hispanic, Native American, Asian and White patients. The report accounted for the COVID-19 pandemic, and it updates the similar health equity scorecard published in 2021 with data from 2018 and 2019.

Three years later, the presentation summarized it: “Racial and ethnic disparities in health and health care are evident in every state, even those with stronger health systems.

“Health system performance is markedly worse for many people of color, particularly Black, Hispanic, and AIAN populations, when compared to White people,” referring to American Indian Alaska Native patients.

The results are not a surprise, but should serve as another call for actions to revise or eliminate conditions that contribute to the discriminatory effects, said Commonwealth Fund President Joseph Betancourt, MD. Those include decades of policy choices and the federal, state and local levels, combined with underinvestment in equity among local health care systems, he said.

“This analysis will give policy makers and health care leaders a critical roadmap to enact targeted policies and make the key investments to eliminate disparities and achieve health equity,” Betancourt said. “Just as deliberate choices have been made that have put us in this situation, we can now be deliberate about promoting high quality, equitable health care for all. This, undoubtedly will create healthier more resilient communities that would ultimately benefit the entire nation.”

Policy actions

The report said achieving health equity requires policy action, said Laurie Zephyrin, MD, Commonwealth senior vice president of advancing health equity.

“This report lays bare the persistent disparities people of color experience in accessing and receiving quality care across the U.S.,” she said. “We must do better – and we can start by rooting out pervasive racial and ethnic bias and inequities in our health care system to ensure everyone gets the care and coverage they need.”

Possible solutions include:

• Ensuring affordable, comprehensive and equitable health insurance coverage for all.
• Strengthening primary care.
• Improving health care quality and deliver.
• Health systems and providers prioritizing and centering equity.
• Investing in social services.
• Improving the collection and analysis of racial and ethnic data to identify gaps.
• Developing equity-focused measures to inform and evaluate policy.

Primary care

The Commonwealth Fund remains committed to primary health care. It is important to understand and measure spending on primary care to understand, spending, gaps in funding, and tracking improvements over time, Zephyrin said.

There are not enough primary care providers in low-income and minoritized communities, and the primary care workforce should reflect the diversity of the community, she said. There are approaches at the federal level, such as the Accountable Care Organization Primary Care Flex Model that the U.S. Centers for Medicare & Medicaid Services announced this month, Zephyrin said.

The report noted Black Medicare beneficiaries are more likely than White beneficiaries to be admitted to a hospital or to seek emergency care for conditions that typically could be managed through good primary care.

Possible solutions include more reimbursement to primary care physicians; financial incentives and loan repayment to physicians working in medically underserved communities; and expanding training for community health workers and incorporating them in multidisciplinary care teams.

Access

For access, there are 10 states that have not expanded Medicaid, and that is a telltale sign of states having access issues, said Sara Collins, PhD, Commonwealth Fund senior scholar and vice president for coverage and access. She cited examples such as Wisconsin and Kansas, which has one of the highest uninsured rates among Black people in the country, she said. Since 2020, Missouri, Nebraska, Oklahoma and Utah have expanded Medicaid; South Dakota and North Carolina did in 2023 and would not be reflected in the report, Collins said.

Comparing health system improvement with addressing social drivers of health, Zephyrin and Betancourt agreed it is not an either-or proposition. Both are important and low-income communities need health care support and programs that improve income, education, housing and food insecurity.

Some findings

The Commonwealth Fund report said “health care experiences for people of color vary widely across states.”

• Massachusetts, Rhode Island and Connecticut stood out for relatively high performance for all racial and ethnic groups, but still showed “considerable disparities” across access, quality of care and health outcomes.
• Deaths before age 75 from health conditions that are preventable and treatable are considered “premature avoidable mortality,” highly correlated with life expectancy. The rate for Black people is worse than for Asian, Hispanic and White people.

“Nationally, Hispanic people generally have lower premature mortality rates compared to Black and white people, despite having higher uninsured rates and worse access to health care than these groups,” the report said. Betancourt said that is the “Hispanic paradox,” with better outcomes in certain areas. He said the Hispanic-Latino population is not monolithic, and state conditions, such as urban or rural locations and investment in social drivers of health, all come into play.

• Preventable mortality rates are higher for both Black and White residents in Arkansas, Mississippi, Louisiana, Tennessee, Kentucky and Missouri, compared with other parts of the country. For AIAN people, rates are highest in the northern plains and southwest. Hispanic patients have higher premature mortality rates in New Mexico, Arizona, Colorado, Oklahoma, Texas and Wyoming.

Presenters included Commonwealth Fund researchers David Radley, PhD, senior scientist for tracking health system performance; Arnav Shah, MPP, senior research associate for programs; and Bethanne Fox, vice president for outreach and strategy.