The physical space of the MSK Library is permanently closed to visitors as of Friday, May 17, 2024. Please visit this guide for more information.
The physical space of the MSK Library is permanently closed to visitors as of Friday, May 17, 2024. Please visit this guide for more information.
Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. They are inequitable and directly related to the historical and current unequal distribution of social, political, economic, and environmental resources. Driven by structural racism, discrimination, stigma, and longstanding disenfranchisement, these obstacles overwhelmingly impact communities that are already under-served. Disparities also occur across the life course, from birth, through mid-life, and among older adults.
Health equity is when everyone has the opportunity to be as healthy as possible. It is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.
To achieve health equity, multi-sectoral efforts are needed to address the severe and far-reaching health disparities that plague our nation by expanding access and removing the social and economic obstacles that lead to poor health outcomes.
Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, racism, climate change, and political systems.
The SDOH have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.
The following list provides examples of the social determinants of health, which can influence health equity in positive and negative ways:
SDOH are linked to a lack of opportunity and resources to protect, improve, and maintain health. Taken together, these factors create health inequities— types of health disparities that stem from unfair and unjust systems, policies, and practices, and limit access to the opportunities and resources needed to live the healthiest life possible.
Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDOH account for between 30-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.
Long-standing inequities in six key areas of social determinants of health are interrelated and influence a wide range of health and quality-of-life risks and outcomes. Examining these layered health and social inequities can help us better understand how to promote health equity and improve health outcomes.
Source: KFF, Disparities in Health and Health Care: 5 Key Questions and Answers, April 21, 2023
The Healthcare Research and Quality Act of 1999 (Public Law 106-129) established an Office of Priority Populations within the Agency for Healthcare Research and Quality (AHRQ) to conduct and support research and evaluation, and support demonstration projects with respect to:
On May 18, 2021, AHRQ released an updated Policy on the Inclusion of Priority Populations in Research (NOT-HS-21-015), which expanded the definition of priority populations to include those groups identified in Section 2(a) of Executive Order 13985 ("Advancing Racial Equity and Support for Underserved Communities Through the Federal Government") as members of under-served communities, including:
These groups are not mutually exclusive and often intersect in meaningful ways. Disparities also occur within subgroups of populations. For example, there are differences among Hispanic people in health and health care based on length of time in the country, primary language, and immigration status. Data often also masks underlying disparities among subgroups within the Asian population.
The United States is home to stark and persistent racial disparities in health coverage, chronic health conditions, mental health, and mortality. These disparities are not a result of individual or group behavior but decades of systematic inequality in American economic, housing, and health care systems. Alleviating health disparities will require a deliberate and sustained effort to address social determinants of health, such as poverty, segregation, environmental degradation, and racial discrimination.
Across the country, people in some racial and ethnic minority groups experience higher rates of poor health and disease for a range of health conditions, including diabetes, hypertension, obesity, asthma, heart disease, cancer, and preterm birth, when compared to their White counterparts. For example, the average life expectancy among Black or African American people in the United States is four years lower than that of White people. These disparities sometimes persist even when accounting for other demographic and socioeconomic factors, such as age or income.
Communities can prevent health disparities when community- and faith-based organizations, employers, healthcare systems and providers, public health agencies, and policymakers work together to develop policies, programs, and systems based on a health equity framework and community needs.
Despite large gains in coverage since implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, people of color and other marginalized and underserved groups remain more likely to be uninsured. Racial disparities in coverage persisted as of 2021, with higher uninsured rates for nonelderly American Indian or Alaska Native (AIAN), Hispanic, Black, and Native Hawaiian or Pacific Islander (NHOPI) people compared to their White counterparts.
Other groups also remained at increased risk of being uninsured, including immigrants and people in lower-income families. Many people who are uninsured are eligible for coverage through Medicaid, CHIP, or the ACA Marketplaces but face barriers to enrollment including confusion about eligibility policies, difficulty navigating enrollment processes, and language and literacy problems. Some immigrant families also have immigration-related fears about enrolling themselves or their children in Medicaid or CHIP even if they are eligible. Others remain ineligible because their state did not expand Medicaid, due to their immigration status, or because they have access to an affordable Marketplace plan or offer of employer coverage.
Beyond coverage, people of color and other marginalized and underserved groups continue to experience many disparities in accessing and receiving care. For example, people in rural areas face barriers to accessing care due to low density of providers and longer travel times to care, as well as more limited access to health coverage. There also are inequities in experiences receiving health care across groups.
People of color and other underserved groups face ongoing disparities in health.
The COVID-19 pandemic has taken a disproportionate toll on the health and well-being of people of color and other underserved groups. As such, the pandemic may contribute to worsening health disparities going forward.
According to a 2022 KFF/CNN survey, 90% of the public think there is a mental health crisis in the U.S. today. Over the course of the pandemic, many adults reported symptoms consistent with anxiety and depression. Additionally, drug overdose deaths have sharply increased – largely due to fentanyl – and after a brief period of decline, suicide deaths are once again on the rise. These negative mental health and substance use outcomes have disproportionately affected some populations, particularly communities of color and youth.
As we look to the future there are several key issues that will significantly impact health and healthcare disparities in the future.
In response to the COVID-19 pandemic, the federal government spent billions of dollars in emergency funds to purchase COVID-19 vaccines, including boosters, treatments, and tests to provide free of charge to the public. In addition, Congress enacted legislation that included special requirements for their coverage by both public and private insurers, and the Administration issued guidance and regulations to protect patient access and promote equitable distribution.
The end of the COVID-19 Public Health Emergency (PHE) on May 11, 2023, and the potential depletion of the federally purchased supply of COVID-19 vaccines, treatments, and tests may curtail access to these supplies for some individuals, particularly those who are uninsured. It also will result in new or higher cost-sharing and/or reduced access to these products although these impacts may vary by product and the type of health coverage an individual has.
People who are uninsured or under-insured face the greatest risk of access challenges, including limited access to free vaccines and no coverage for treatment or tests. Since people of color and people with lower incomes are more likely to be uninsured, they may be at a disproportionate risk of facing barriers to accessing COVID-19 vaccines, tests, and treatments once the PHE ends and the federal supply is depleted.
The overturning of Roe v. Wade may exacerbate the already large racial disparities in maternal and infant health. The decision to overturn the longstanding Constitutional right to abortion and elimination of federal standards on abortion access has resulted in growing variation across states in laws protecting or restricting abortion.
The end of the Medicaid continuous enrollment provision may lead to coverage losses and widening disparities. Following the ending of the Medicaid continuous enrollment provision on March 31, 2023, states resumed Medicaid redeterminations.
The extent to which states simplify processes to renew or transition to other coverage and provide outreach and assistance to individuals more likely to face challenges completing renewal processes will impact coverage losses and potential impacts on coverage disparities.
Many states have implemented policies banning or limiting access to gender affirming care, especially for youth, as well as other legal actions that threaten access to care for LGBT+ people.
Policies aimed at limiting access to gender affirming care may have significant negative implications for the health of trans and nonconforming people, particularly young people, including negative mental health impacts, and an increased risk of suicidality.
Additionally, the recent Braidwood case on preventive care access directly affects LGBT+ people in its treatment of Pre-Exposure Prophylaxis (PrEP). It relies, in part, on religious protections arguments to limit access to the drug based on the plaintiff’s claim that it “facilitate[s] and encourage[s] homosexual behavior, prostitution, sexual promiscuity, and intravenous drug use.”
If PrEP use declines as a result of the Braidwood decision, HIV incidence could increase, likely disproportionally impacting people of color and LGBT+ people. Efforts to curtail access to gender affirming care and the Braidwood decision are at odds with the Administration’s stated approach to health equity for LGBT+ people. How such policies play out in the longer term will be determined largely by the courts.
Evolving immigration policies may impact the health and well-being of immigrant families. When the PHE ended on May 11, 2023, Title 42 restrictions that suspended the entry of individuals at the U.S. border to protect public health during the COVID-19 emergency were terminated. It is anticipated that when the authority ends, there will be an increase in immigrant activity at the U.S. border.
The Biden Administration has announced plans to increase security and enforcement at the border to reduce unlawful crossings, expand “legal pathways for orderly migration”, invest additional resources in the border region, and partner with Mexico to implement the aforementioned plans. However, it remains to be seen how shifting policies will impact trends at the border and health and health care in that region.
The future of the Deferred Action for Childhood Arrivals (DACA) program remains uncertain, and its implementation is currently limited subject to court orders. If the DACA program is found to be unlawful in pending court rulings, individuals would lose their DACA status and subsequently their work authorizations.
The loss of status and work authorization may result in loss of employer-based health coverage, leaving people uninsured and unable to qualify for Medicaid, CHIP, or to purchase coverage through the Marketplaces.
Additionally, although the Biden Administration reversed public charge regulations implemented by the Trump Administration as part of an effort to address immigration-related fears that limited immigrant families’ participation in government assistance programs, including Medicaid and CHIP, many families continue to have fears and concerns about enrolling in these programs, contributing to ongoing gaps in coverage for immigrants and children of immigrants.
Growing mental health and substance use concerns and ongoing racism, discrimination, and violence may contribute to health disparities. As previously noted, mental health and substance use concerns have increased since the onset of the pandemic, with some groups particularly affected. These trends may lead to new and widening disparities.
Despite growing mental health concerns, people of color continue to face disproportionate barriers to accessing mental health care.