It is estimated that although 75% of health care dollars in the U.S. is spent on preventable conditions, only 3% of America’s health care expenditure is on prevention [58
]. Thus, a renewed emphasis on prevention could have an enormous impact on improving overall health and reducing inequities in health. There are multiple strategies that would enable the American healthcare system to have a greater impact in improving the health of all and reducing inequities in health care. These include ensuring access to care for all, giving greater emphasis to primary care over specialty care, eliminating inequities in the receipt of high quality care, addressing patients’ social risk factors and needs more effectively, and diversifying the healthcare workforce.
3.1. Ensuring Access to Care for All
Providing access to comprehensive preventive screenings and treatment can play a role in reducing and eliminating at least some racial inequities in health. A statewide colorectal cancer (CRC) initiative in the state of Delaware illustrates that a concerted effort can produce striking changes in a relatively short time [59
]. The program began in 2002 and provided reimbursement for a colonoscopy for any uninsured Delaware resident with household income up to 250% of the poverty level. In 2004, a treatment program was added that covered the costs of cancer care for two years for all uninsured residents who were newly diagnosed, if their household income was up to 650% of the poverty level. In that same year a nurse navigator system was added to facilitate access to screening and treatment and special outreach efforts were made to black residents. By 2009, colonoscopy screening rates had increased by 54% for blacks and 29% for whites and the racial gap in screening was eliminated. Similarly, a 34% decline in CRC incidence for African Americans and a 26% decline for whites led to the equalization of the incidence rates. The mortality gap was almost eliminated by 2009 with a mortality decline of 42% for blacks and 13% for whites. Moreover, the program produced cost savings. The annual bill for the screening and treatment program was $
7 million but the annual savings from reduced incidence of CRC was $
Initiatives are needed that ensure access to health care for all. Research revealed that the implementation of the Affordable Care Act (ACA) increased insurance coverage for 20 million Americans, reduced the gap between whites and nonwhites for all racial groups in the U.S., and completely eliminated that disparity for Asian Americans, Native Hawaiians and other Pacific Islanders, but not for other racial groups [60
]. Efforts are needed to ensure access to care for the millions of Americans who still lack insurance. In 2017, Senator Bernie Sanders introduced such an initiative. It is called the Medicare for All Act and aims to provide a universal right to decent healthcare for all U.S. residents. A recent analysis of the costs of this program revealed that although it would increase the demand for healthcare services by about 12%, the implementation of the program could realize cost savings of about 19%, which would reduce overall healthcare costs by about 9.6% [61
3.3. Eliminating Inequities in the Receipt of High Quality Care
A 2003 report from the National Academy of Medicine (NAM; formerly, Institute of Medicine) concluded that across virtually every type of therapeutic intervention in the U.S., ranging from high technology procedures to the most basic forms of diagnostic and treatment interventions, blacks and other minorities receive fewer procedures and poorer quality medical care than whites [64
]. Strikingly, these differences persisted even after statistical adjustment for variations in health insurance, SES, stage and severity of disease, co-occurring illness, and the type of healthcare facility are taken into account. More recent research documents the persistence of racial inequities in the quality and intensity of care [65
]. For example, among adult first-time kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, disparities in the receipt of live donor kidney transplantation (LDKT) increased from 1995–1999 to 2010–2014 [67
]. In 1995, the cumulative incidence of LDKT at 2 years after appearing on the waiting list was 7.0% among white patients, 3.4% among black patients, 6.8% among Hispanic patients, and 5.1% among Asian patients. In 2014, the cumulative incidence of LDKT was 11.4% among white patients, 2.9% among black patients, 5.9% among Hispanic patients, and 5.6% among Asian patients. From 1995–1999 to 2010–2014, racial disparities in the receipt of LDKT increased (p
< 0.001 for all statistical interaction terms in adjusted models comparing white patients versus black, Hispanic, and Asian patients). Another example pertains to maternal mortality. Racial disparities in in-hospital maternal mortality decreased between 2006 and 2015, but significant disparities remain [68
]. In 2006 the rate of in-hospital death was 248 percent higher for Black women, 50 percent higher for Hispanic women, and 69 percent higher for Asian/Pacific Islander women than for White women. In 2015, the rate for Blacks was 193 percent higher and the rate for Hispanics was 31 percent higher than the rate for Whites.
The NAM concluded that implicit bias on the part of healthcare providers was a likely contributor to these observed patterns [64
]. Research reveals that these implicit biases are normal, natural, subtle and often subconscious [69
]. Moreover, they are universal, all humans have them, with even the most well-meaning individual capable of harboring deep-seated biases. These biases are developed naturally through routine social interactions and exposure to culture (media, etc.). Importantly, they guide our expectations and social interactions with others and can become harmful when assumptions and generalizations about a group affect our interactions with an individual. Research also indicates that rapid and unconscious emotional and neural reactions to blacks occur for most Americans within 100 milliseconds, that is, in about one third of the time that it takes for us to blink our eyes (300 to 400 milliseconds) [70
Analyses of data from a large, volunteer and non-representative sample of persons who took the Implicit Association Test (IAT), a widely used test to assess the presence of implicit bias, concluded that about 70 percent of physicians have an implicit preference for whites over blacks, similar to the pattern observed for other professionals and the general population [71
]. Research reveals that higher implicit bias scores among physicians is associated with biased treatment recommendations in the care of black patients [66
], although the pattern is not uniform [72
]. This highlights the importance of research to better understand the conditions under which these biases are most likely to occur.
Implicit biases may affect not only medical decision making but also the quality of communication and nonverbal behavior [66
]. One study found that black patients provided poorer ratings of the quality of the medical encounter (in terms of warmth, friendliness, teamwork and satisfaction) with physicians who were aversive racists (low on explicit bias and high on implicit bias) than with those who were high or low on both explicit and implicit racial bias [73
]. Another study of providers who work in safety net clinics in a major metropolitan area found that provider implicit bias was associated with poorer quality of patient provider communication and lower patient evaluation of the quality of the medical encounter including provider nonverbal behavior [74
]. For example, more implicit bias was associated with less patient-centered dialogue, lower patient positive affect, lower perception of respect from the clinician, less patient liking of the clinician and lower trust and confidence in clinician
Research is needed to identify optimal strategies of raising health providers’ awareness of subtle, unconscious discrimination and providing them with strategies to minimize its occurrence. One British study found that pharmacological intervention can reduce implicit bias. This randomized double blind, parallel group, placebo controlled study evaluated the impact of a single oral dose of propranolol (40 mg) in 36 whites [75
]. Propranolol is a beta blocker that reduces emotional conditioning and amygdala responses to visual emotional stimuli (e.g., facial expressions). The study found that compared to placebo, propranolol eliminated implicit bias and reduced heart rate, but had no effect on explicit bias (measured by feeling thermometer: warmth towards blacks, whites, homosexuals, Muslims, Christians, drug addicts). While pharmacological interventions provide evidence that fundamental biological processes are present with the occurrence of implicit bias, they are not long-term practical solutions for effectively addressing implicit bias in the healthcare encounter.
There is emerging evidence that there are a broad range of social psychological interventions that are likely to reduce implicit bias among providers [76
]. One study of university students documented that non-black adults could be motivated to increase their awareness of racial bias, their concerns about the effects of such bias and their willingness to implement strategies to reduce such bias [77
]. These researchers viewed implicit biases as deeply engrained habits that can be replaced by learning multiple new prejudice-reducing strategies including stereotype replacement, counter-stereotype imaging, individuation, perspective taking and increasing interracial contact. The study found that these strategies reduced bias in participants and that this effect remained evident three months later. Future research is needed to assess the extent to which these changes in implicit prejudice are associated with the actual reduction of discriminatory behavior and the extent to which these programs can be effectively implemented on a large scale among healthcare providers.
Although implicit bias is likely the most common form of bias among healthcare providers, explicit bias also persists in society and efforts are needed to minimize its occurrence as well. Relatedly, there is also growing concern about the need to address structural competence among healthcare providers [78
]. The term structural competence refers to increasing awareness among providers of the ways in which racism is embedded in our culture and institutions and shapes not only behavior at the individual level but also the ways in which policies, and procedures in medical and other social institutions, have initiated and sustain racial inequality. Accordingly, effectively addressing implicit bias requires identifying and dismantling its institutional legacies and social consequences. This will require changes not only in the individual behavior of providers but also policy changes across multiple domains of healthcare and other social institutions.
3.4. Addressing Patients’ Social Risk Factors and Needs
Another strategy for putting more health into the delivery of health care is for hospitals and other health care providers to be proactively engaged in connecting patients with supportive social services that will help them to improve their health. The Medical Legal Partnership (MLP) is a program that was developed in the Pediatrics department at the Boston Medical Center over three decades ago that addresses the social determinants of health [80
]. MLP enabled primary care providers to refer patients to a new category of specialists: on-site attorneys. The program is premised on the idea that most low-income persons face legal issues that affect their quality of life and their management of disease. For example, all the asthma medications in the world will not enable a child with asthma to breathe symptom free if the underlying poor housing conditions that trigger the asthma in the first place are unaddressed. The addition of lawyers to the medical team facilitates screening families for, and assisting them with, problems that can affect effective care and illness management. The stressors addressed include challenges in the areas of housing, immigration, income support, food, education access, disability and family law. The MLP program is now at hundreds of health care sites in the U.S.
Health Leads (HL) is another innovative program that places undergraduate student volunteers in the waiting rooms of hospital clinics or health centers [81
]. They assess patients’ needs regarding food, housing, heating or other social issues. They then “fill” the prescription for food assistance, employment or housing improvement by connecting patients to local resources through in-person meetings or telephone calls. A study of 1059 low-income families at a pediatric clinic found that the most prevalent needs for families were in employment (25%), housing (14%), child care (13%), health insurance (11%) and food assistance (10%). Within six months of contact with HL desk, half of the families had received help from at least one community resource [81
]. HL is currently in multiple waiting rooms of hospital clinics and health centers across the U.S.
The Nurse-Family Partnership (NFP) program is an innovative early childhood intervention that seeks to address the health and social needs of mothers and their infants within the health care system [82
]. In the NFP, nurses make home visits to low-income, first-time mothers. The visits begin during pregnancy and continue after the baby is born. The visits take a comprehensive view of the mother’s life and seek to improve maternal and child health, as well as address future life opportunities and economic self-sufficiency for the mothers and enable them to provide nurturing and competent childcare [82
]. The care delivered through three RCTs (one in upstate New York with predominantly white women, one in Memphis, Tennessee with predominantly African American women and one in Colorado with predominantly Latinas) have documented that the program has positive effects for both parent and child [18
]. Mothers in the control group received traditional prenatal care so the NFP documented the effects of the additional services provided by the program. For mothers, the NFP led to lower smoking during pregnancy, fewer subsequent pregnancies, increased labor force participation, reduced use of public assistance programs, and lower rates of child abuse and neglect. Among the children, the program led to a reduction in childhood injuries, substance use and juvenile crime [82
]. An evaluation of the three NFP trials estimated that the program saves $
18,054 for each family served [85
The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program uses an inter-professional team (an occupational therapist, a registered nurse, and a handyman) to help low income older individuals with self-care disabilities achieve functional goals they set [86
]. A demonstration project conducted in 2012–2015 revealed that 75 percent of participants had improved their performance of activities of daily living over a five-month period. In an RCT of the program, 79% of participants improved [87
]. There were significant improvements in activities of daily living (ADLs) and independent activities of daily living (IADLs) and reductions in depressive symptoms. The program cost less than $
3000 per participant and provided a 10-fold return on investment via reduced healthcare utilization.
Hospitals are often the largest employer in many communities. Health care systems and other healthcare providers can make effective use of local community resources and strengthen their surrounding communities by providing job training and job opportunities (e.g., as community health workers or medical assistants) in health care to community residents with limited educational attainment that constrains their economic prospects. Such initiatives can help to improve the economic security, stability and health of people in low income communities while simultaneously addressing a growing need for health care workers.
The integration of community health workers (CHW) into the delivery of healthcare is another promising strategy. CHWs are health workers who have received formal but limited training and work to improve community health outside of healthcare facilities. Research over the last 25 years has shown that these workers can improve community health in low-, middle, and high income countries [88
]. Reviews of research in the U.S. indicate that CHW interventions have been effective in improving the control of high blood pressure and reducing cardiovascular risk, enhancing diabetes control, managing HIV infection, and increasing the uptake of cancer screening tests [88
]. A partnership between the National Institutes of Health (NIH) and the Patient-Centered Outcomes Research Institute (PCORI) has funded two pragmatic trials testing care models integrating community health workers into primary care teams to reduce disparities in hypertension control in racial minority and rural populations [89
]. These studies also aim to elucidate and address barriers to implementing these care models in clinics caring for patients from underserved communities.
A panel of the NAM has highlighted the enormous potential of the routine screening of all patients for the social determinants of health, as a part of comprehensively addressing the needs of patients [90
]. It has recommended social and behavioral factors that should be captured in the electronic medical record (EMR). In addition to race/ethnicity and education, it calls for the inclusion of brief indicators of the following factors: financial strain, stress, depression, physical activity, tobacco use, alcohol use, social ties, intimate-partner violence, current residential address and census-tract median income (geocoded). A committee of the National Academies of Sciences, Engineering, and Medicine is currently examining the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes and to address major challenges facing the U.S. health care system, including healthcare disparities [91
]. The committee will make recommendations on how to: (1) expand social needs care services; (2) better coordinate roles for social needs care providers in interprofessional care teams across the continuum of clinical and community health settings; and (3) optimize the effectiveness of social services to improve health and health care. Recommendations may address areas such as integration of services, training and oversight, workforce recruitment and retention, quality improvement, research and dissemination, and governmental and institutional policy for health care delivery and financing.
3.5. Diversifying the Healthcare Workforce
Considerable research suggests that developing a healthcare workforce that is reflective of the racial diversity of the population that it serves is in the best interest of the performance of the entire health care system [92
]. This research indicates that underrepresented minorities (URM) are more likely to work with underserved populations, with URM from the highest SES backgrounds working in under-served areas at higher rates than do white physicians from the lowest SES backgrounds [93
]. Research also indicates that racial concordance between a patient and a clinician has been associated with better patient-provider communication and overall health outcomes, as well as higher levels of patient satisfaction with care and adherence to provider recommendations [92
]. Thus, as the U.S. population becomes increasingly diverse, with the current URM populations becoming the majority of the U.S. population in less than 25 years, ensuring the increasing diversity of health care providers is in the best interest of national health care delivery.
A broad range of affirmative action policies have been implemented in the last 50 years to increase the participation and success of women and minorities in education and occupational contexts. It is insufficiently appreciated that affirmative action was much more effective for women than for minorities. For example, females graduates from medical school (most of them white), increased from 6.9% (n = 524) in 1965-66 to 46.3% (n = 8724) in 2015-16 [94
]. In contrast, black, Latino and Native American graduates have had much smaller increases. For the 1968-69 school year, of the 9,863 first year medical school enrollees in the U.S., 266 (2.7%) were black, three (0.0%) were Native American, 20 (0.2%) were Mexican American and 3 (0.0%) were mainland Puerto Rican [95
]. In 2015, Asians were 19.8% (3701), African Americans were 5.7% (n = 10,610) and Latinos were 4.6% (n = 854) of medical school graduates [96
]. Only 20 (0.1%) American Indian or Alaska Natives and 5 Native Hawaiian and other Pacific Islanders graduated from medical school in 2015. Among URM graduates in 2015, females were the majority. Women made up 65% of black graduates, 53% of Hispanic graduates, 75% of Native American graduates and 60% of Native Hawaiian and other Pacific Islander graduates [96
]. Stunningly, an American Association of Medical Colleges (AAMC) report indicated that in 2014, there were 27 fewer African American males in the first year of Medical School than in 1978 [97
]. In the mid- 1960s, 2.9% of all practicing physicians in the U.S. were black, and in 2012, 3.8% of all practicing physicians were black (5.2% were Hispanic) [98
]. These data highlight that it is not enough just to open the doors of opportunity. Everyone, irrespective of social group and background, must have the ability to walk through those doors.
Although legislation, including the Minority Health and Health Disparities Research and Education Act of 2000 and The Affordable Care Act have included provisions and authorized funding to encourage workforce diversity in the health professions, many of the programs that were established are at risk for elimination with reductions in funding or changes in authorization of funding [99
]. Federal funding should be increased to support the recruitment and retention of students and faculty from URM backgrounds and health professionals—especially physicians—from diverse racial and social class backgrounds, to practice in medically underserved urban and rural areas. This funding can be channeled through the NIH, the Indian Health Service, the Centers for Disease Control Office of Minority Health, and the Health Services and Resources Administration (Title VII and VIII Health Professions Training Grants, National Health Services Corps, Centers of Excellence Program, reauthorization of the Health Careers Opportunity Program (HCOP), the Scholarships for Disadvantaged Students program, Nursing Workforce Diversity Program, and grants to support the Community Health Workforce). These programs should include, but not be limited to, scholarship and loan repayment programs and institutional resources to increase diversity. Programs should include outreach, mentoring, and tutoring at all educational levels—including elementary and high school and college—to encourage URM students to pursue careers in science and health. Federal and state legislation should support the consideration of race, family income, and first generation college graduate status in determining admission to institutions of higher education.