Commonwealth Fund Report Details Pervasive Racial and Ethnic Disparities in US Health Care, Outcomes

Persistent racial and ethnic disparities both in and across US states are fueled by unequal access to high-quality care, according to the Commonwealth Fund 2024 State Health Disparities Report. The findings emphasize the need for US health care leaders and policymakers to make advancing health equity a top priority.

With this report, the organization aimed to highlight how policy decisions influence health outcomes and to inspire the necessary changes to enhance the health of all communities nationwide. Only factoring in how well a state performs on average can mask the realities of inequity, according to the authors.

The investigators performed a deep dive into these disparities, assessing health and health care differences within and between states for Black, White, Hispanic, American Indian and Alaska Native (AIAN), and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations. They collected data encompassing 25 indicators of health system performance with a focus on access to care, health outcomes, and the quality and use of health care services across racial and ethnic groups. Every state was given a system performance "score" in each racial and ethnic group.

“Profound racial and ethnic disparities in health, well-being, and life expectancy have long been the norm in the United States,” the report stated. “These disparities are especially stark for Black and AIAN people, who live fewer years, on average, than white and Hispanic people and are more likely to die from treatable conditions, more likely to die during or after pregnancy and suffer serious pregnancy-related complications, more likely to lose children in infancy, and are at higher risk for many chronic health conditions, from diabetes to hypertension.”

Furthermore, the COVID-19 pandemic exacerbated these inequities, leading to a disproportionate impact on Black, Hispanic, and AIAN communities and resulting in a sharper decline in their average life expectancy since 2020.

In addressing the various factors that contribute to these health disparities, the investigators acknowledged decades of policy decisions at the federal, state, and local levels have perpetuated economic suppression, educational disparities, and housing segregation. While efforts to expand health care coverage through initiatives like the Affordable Care Act (ACA) have narrowed racial and ethnic disparities to some extent, significant gaps remain, particularly in states that have not expanded Medicaid eligibility.

Racial and ethnic disparities in health and health care were present across all states, according to the findings. While certain states like Massachusetts, Rhode Island, and Connecticut exhibited relatively high overall health system performance, significant disparities persist within these states across racial and ethnic groups. Variations in health outcomes, access to health care, and quality of care, along with disparities evident in premature mortality rates, uninsured rates, and utilization of primary care services, were among the key findings.

Health Outcomes, Care Access Disparities, and Quality Concerns

Significant disparities in health outcomes were seen among different racial and ethnic groups, with Black and AIAN individuals experiencing lower life expectancies and higher rates of premature mortality compared with White and Hispanic populations. These disparities are particularly pronounced in states with high concentrations of these communities, highlighting regional variations in health outcomes.

Access to health care also remains a major concern, with disparities in insurance coverage persisting across racial and ethnic lines. According to the report, Hispanic individuals, in particular, face the highest uninsured rates and encounter significant barriers to accessing high-quality care.

Disparities in the quality of care and utilization of health care services were observed, with White populations generally receiving better quality care compared with Black, Hispanic, AIAN, and AANHPI communities. Primary care plays a critical role in delivering high-value services, yet disparities in access continue, leading to higher rates of emergency department visits and hospitalizations among marginalized groups.

Evaluating Regional Disparities

Both Black and White residents in southern and south-central States states such as Arkansas, Mississippi, Louisiana, Tennessee, Kentucky, and Missouri exhibited higher rates of preventable mortality compared with other parts of the country. The report also found AIAN populations in the northern plains and southwestern states experienced the highest rates of premature mortality.

In southwestern and mountain states like New Mexico, Arizona, Colorado, Oklahoma, Texas, and Wyoming, Hispanic residents experienced higher premature mortality rates compared with other regions, where this group has rates closer to White residents.

Disparities in Mortality Rates for Treatable Conditions

The investigators found significant disparities in mortality rates for conditions considered treatable, such as breast cancer and infant/maternal mortality.

For example, Black women are more likely to be diagnosed with breast cancer at later stages, leading to higher age-adjusted death rates compared with other racial groups. Additionally, infant and maternal mortality rates are highest among Black and AIAN residents in most areas of the US.

Policy Recommendations

"Leaders at the federal, state, and local levels could consider evaluating existing and emerging laws and regulations for their implications for the health of people of color," the investigators wrote. "And they could pursue reforms to remedy the longstanding disparities described in this report."

The report outlined several policy recommendations aimed at bridging the gap in health care disparities and promoting equity across racial and ethnic groups in the United States.

Here is a summary of the key policy changes proposed in 4 main areas:

1. Changes to ensuring universal, affordable, and equitable health coverage:

• Extend enhanced marketplace premium subsidies permanently.
• Encourage the 10 states yet to expand Medicaid to do so, or allow Medicaid-eligible individuals in these states to enroll in zero-premium marketplace plans.
• Reduce deductibles and out-of-pocket costs for marketplace insurance plans.
• Lower immigration-related barriers to coverage for certain groups of undocumented, low-income immigrant adults and children.
• Promote equitable treatment of enrollees in commercial insurance plans by requiring insurers to collect and report information on race and ethnicity, meet ACA requirements for including essential community providers in their networks, and obtain health equity accreditation.

2. Strengthening primary care and improving service delivery:

• Reimburse primary care providers based on the value of care they deliver to patients.
• Offer financial incentives to providers who serve in medically underserved communities.
• Expand training for community health workers and incorporate them into multidisciplinary care teams.
• Diversify the health workforce by strengthening pipelines into the health professions for people of color and modernize medical licensing to allow professionals to practice across state lines.

3. Reducing inequitable administrative burdens:

• Create a longer period of continuous Medicaid eligibility to reduce disruptions in coverage.
• Implement an auto-enrollment mechanism for Medicaid or subsidized marketplace coverage.
• Simplify rules for quality reporting, care management, utilization review, and prior authorization programs to reduce administrative burdens on patients and providers.

4. Investing in social services:

• Expand economic support for lower-income families through programs like unemployment compensation, Earned Income Tax Credit, child tax credit, childcare, food security, and targeted wealth-building programs.
• Increase investment in affordable housing, public transportation, early childhood development, and affordable higher education.

"To monitor trends in disparities and promote accountability, policymakers and health system leaders can support the ongoing development and use of standardized, equity-focused measures across all regulatory and performance-reporting agencies and institutions," the investigators concluded. "Such metrics can be used to track whether states, health systems, and health plans are reducing racial disparities in clinical outcomes, insurance coverage, access to clinicians, and other areas."

Reference

Radley DC, Shah A, Collins SR, Powe NR, and Zephyrin LC. Advancing racial equity in US health care: The Commonwealth Fund 2024 State Health Disparities Report. Commonwealth Fund. April 2024. https://doi.org/10.26099/vw02-fa96