Health Affairs, 24, no. 2 (2005): 313-315 doi: 10.1377/hlthaff.24.2.313 © 2005 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Foreword

A Tale Of Two Cities

But while the story of public health and medical achievement in the United States is truly a remarkable one, it also includes a metaphorical tale of two cities. Although public health and medical progress have proved beneficial for many, the evidence also indicates that Americans of color are less likely to reap the benefits of these remarkable achievements. And although there are demonstrated correlations between racial/ethnic background and socioeconomic status, poverty alone cannot explain some of the gaps in health and health care that exist between minorities and the white population.

A sampling of data from different research studies illuminates this contention: (1) The infant mortality rate for black babies remains nearly two-and-one-half times higher than for whites; although rates have decreased for both population groups, the gap remains largely unchanged compared with three decades ago. (2) The life expectancy for black men and women in the United States remains at nearly one decade fewer years of life compared with their white counterparts. (3) Rates of deaths attributable to heart disease, stroke, and prostate and breast cancer remain much higher in black populations. (4) Diabetes disease rates are more than 30 percent higher among Native Americans and Hispanics than among whites. (5) A landmark 2002 synthesis by the Institute of Medicine (IOM), Unequal Treatment, revealed that black and Hispanic Americans receive a lower quality of health care than their white counterparts, even when other factors, such as insurance status and income level, are controlled for.

These differences in health status and treatment have stubbornly persisted for decades, despite the efforts of many to address the complicated factors that contribute to them. The IOM’s 2002 report represented a call to action for policy-makers and organizations to act with greater immediacy on these issues. However, although the report was a catalyst for unprecedented activity on the disparities front, little clarity has been achieved as to who is doing what to eliminate gaps in health status and treatment and whether anyone has major progress to report. On one level, many remain unaware that the related but distinct problems of health and health care disparities even exist. On another level, decisionmakers feel compelled by the evidence of the extent to which disparities exist and are now urgently seeking solutions. However, devising a solution requires the high-priority attention of decisionmakers, particularly those who are interested in improving the U.S. health care system overall.

Solving this national embarrassment will not be easy. At the outset, it must be clear that the strategies for eliminating disparities in health care and health status will, by necessity, be different. Unequal Treatment focused on racial and ethnic disparities in health care. Yet millions of Americans, many of them racial and ethnic minorities, lack access to health care. Moreover, it is widely known that less than one-quarter of our health status is attributable to health care; rather, our health—or lack thereof—is primarily determined by social factors such as unhealthy practices, poverty, unemployment and underemployment, racism and discrimination, housing, transportation, and other neighborhood environmental conditions.

Any effort to reduce and eliminate disparities in health must be comprehensive to be effective. It must include strategies that address the "triple whammy" confronting communities of color in the United States: (1) disproportionately low levels of access to health care, (2) relatively lower levels of health care quality when such care is made available, and (3) the adverse social and economic conditions faced by people of color in their own communities.

The authors of this foreword, and the organizations we represent, have collaborated to support this special issue of Health Affairs. The papers contained within, in the aggregate, represent essential elements of a national blueprint to reduce and eliminate health disparities in the United States: a better understanding of the roles that race, class, and inequity play in contributing to disparities; opportunities for policy intervention; and tools for closing the disparities gap.

The matter of health and health care disparities is too complex to be addressed in a single issue of Health Affairs or any other journal. However, we agree on five points to be underscored:

1. There is a compelling need for the development and implementation of long-range, coherent, and coordinated strategies—and the resources to follow—to reduce and eliminate racial and ethnic disparities in health. These strategies must be developed and advocated by policymakers, health professionals, business leaders, and civic and community leaders.
   
2. The collection and reporting of data by race and ethnicity, to ensure that systems can target health and health care disparities and devise solutions to address them, is a critical first step in understanding the depth of the problem, as well as gauging progress over time, and should be undertaken by federal, state, and local health agencies, as well as private-sector health plans.
   
3. The findings of the congressionally commissioned Unequal Treatment report provide an excellent draft blueprint for addressing disparities in health care: improving health care providers’ awareness of the problem, strengthening culturally competent health care approaches, and improving the diversity of the health workforce.
   
4. Further research and study about community-based approaches to advance health promotion and disease prevention in communities wracked by poverty, racism, and other adverse environmental conditions is critical.
   
5. Finally, we need leadership on this issue—from government, funders, and organizations that represent health care constituents—to ensure that the many ongoing efforts to reduce racial and ethnic disparities in care move forward in a coordinated, thoughtful fashion. In this way, the individual worthwhile efforts of many will have greater staying power.
   

This issue of Health Affairs provides the ingredients necessary to launch a meaningful national dialogue on eliminating health and health care disparities. To be meaningful, the dialogue must intensely and broadly engage diverse stakeholders—immediately and into the next decade. The status quo of disparities in health and health care is simply unacceptable. We must—and we can—do better.

Editor's Notes

 
Risa Lavizzo-Mourey is President and Chief Executive Officer of The Robert Wood Johnson Foundation. William C. Richardson is President and Chief Executive Officer of the W.K. Kellogg Foundation. Robert K. Ross is President and Chief Executive Officer of The California Endowment. John W. Rowe is Chairman and Chief Executive Officer of Aetna.

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