In his monthly President's Messages, George M. Abraham, MD, MPH, MACP, has been exploring and explaining the many facets of diversity, equity, and inclusion (DEI), while often challenging us to move outside our comfort zone as we consider the underlying principles and their implications for ACP, its members, our profession, and, crucially, our patients.
This month, Dr. Abraham graciously allowed me to address another important facet in our DEI journey—health equity. To start, it is important to highlight the distinction between equality and equity.
In the context of health care, health equality means everyone receives the same standard of care. As internists we pride ourselves on providing high-quality, personalized, evidence-based, patient-centered care. But when health care results in avoidable, systematic differences in health outcomes that adversely affect economically or socially disadvantaged or otherwise marginalized groups, we characterize these as health care disparities or inequalities.
Health equity, however, is not the same as health equality.
In its 2017 report “What Is Health Equity?,” the Robert Wood Johnson Foundation explained, “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” In essence, those with the greatest needs and least resources require more, not the same, effort and resources to equalize opportunities. Inherent to health equity is a moral and ethical imperative to identify and eliminate the underlying causes of health disparities.
But why is health equity so important, and how do disparities manifest in health care outcomes in the U.S.? Our COVID-19 pandemic is illustrative. In September 2020, just months into our now nearly two-year pandemic, colleagues and I published “The Collision of COVID-19 and the U.S. Health System” in Annals of Internal Medicine. We noted that “Prior pandemics disproportionately affected groups that have been marginalized and excluded on the basis of socioeconomics, race, and ethnicity. The COVID-19 pandemic is no exception. Across the United States, deaths from COVID-19 are disproportionately high in African-American, Latinx, and Native American communities.” More than a year later, we now have abundant data on adverse health equity outcomes in the time of COVID-19, when viewed through the lens of race, ethnicity, and age.
In the U.S., the majority of cases and deaths have occurred among non-Hispanic Whites, yet their case and death rates are lower than their population percentage. The excess cases, relative to population size, have occurred in racially and ethnically minoritized groups. This disparity is even more striking when one considers age alongside race and ethnicity. For example, according to a report from the Brookings Institute, “Among those aged 45-54, for example, Black and Hispanic/Latino death rates are at least six times higher than for whites.”
This disparity has only served to accentuate the already existing racial and ethnic disparities in lifespans in the U.S. A recent analysis of the projected impact of COVID-19 on life expectancy published June 24, 2021, by JAMA Network Open, said, “COVID-19 reduced overall 2020 US life expectancy by 1.31 years, from 78.74 years to 77.43 years. The reductions are 3.2 times as large for the Latino population (3.03 years) and twice as large for the Black population (1.90 years) compared with the White.”
Another study of the impact of COVID-19 on life expectancy, published June 24, 2021, by The BMJ, concluded that “Progress since 2010 in reducing the gap in life expectancy in the U.S. between Black and White people was erased in 2018-20; life expectancy in Black men reached its lowest level since 1998 (67.73 years), and the longstanding Hispanic life expectancy advantage almost disappeared.”
We have also seen age-based disparities, with death rates rising rapidly in those ages 65 years and older. Nursing home residents, while only accounting for about 2% of the Medicare population, have accounted for 22% of all COVID-19 cases among Medicare beneficiaries. Nursing home residents were 14 times more likely to be diagnosed with COVID-19 compared to beneficiaries in the community. And Black, Hispanic, and Asian nursing home residents had a higher rate of infection than Whites.
The COVID-19 pandemic has highlighted and exaggerated many other health and health care disparities, including access to telemedicine, to mental health services, and to substance use disorder treatment. But these and other disparities are not new. Since 2003, the Agency for Healthcare Research and Quality (AHRQ) issued the National Healthcare Quality and Disparities Report, covering quality of and access to health care, as well as disparities related to race and ethnicity, income, and other social determinants of health. While the most recent report from 2019 (pre-COVID-19) showed evidence of progress, large gaps remained. They found that “For about 40% of quality measures, Blacks (82 of 202) and American Indians and Alaska Natives (47 of 116) received worse care than Whites. For more than one-third of quality measures, Hispanics (61 of 177) received worse care than Whites.”
As we wrote in Annals of Internal Medicine last June, “The COVID-19 pandemic has further demonstrated that the status quo is unacceptable and strengthens our resolve to help shape a better health care system for all Americans. This pandemic has ripped the seams of the U.S. health care system wide open, thrusting front and center our health care inequities and injustices. The bigger challenge moving forward is how we can take the lessons learned from this time of great suffering and fear to create an equitable and just system of care for all.” ACP believes that the time is now for us to make needed changes, which we described in a landmark series of policy papers in the Annals of Internal Medicine in January 2020. More than ever, ACP believes better is possible.