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Public Health

Vetted resources and information on current public health events.

What are Health Disparities?

Health Disparities

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.

Populations Most Impacted by Health Disparities
  • BIPOC people
  • women
  • children
  • persons with diabilities
  • LGTBQIA+ people
  • homeless people
  • incarcerated individuals

Health Equity

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.

Barriers to Health Equity
  • poverty
  • poor housing
  • unsafe or unhealthy environments
  • lack of access to good jobs
  • quality education
  • comprehensive, high quality health care

Social Determinants of Health

Social Determinants of Health

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:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable health services of decent quality

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.

Factors Affecting Health Equity

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.

  • Social and community context (including discrimination and racism)
  • Healthcare access and use
  • Neighborhood and physical environment
  • Workplace conditions
  • Education
  • Income and wealth gaps

Designated Priority Populations

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:

  • The delivery of healthcare within inner cities and rural areas
  • Healthcare for priority populations
    • low income populations
    • racial/ethnic minorities
    • women
    • children/adolescents
    • elderly
    • individuals with special healthcare needs

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:

  • members of under-served BIPOC communities
  • members of religious minorities
  •  LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex, or other) persons
  • persons with disabilities
  • persons who live in rural areas
  • persons otherwise adversely affected by persistent poverty or inequality

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.

Health & Healthcare Disparities in the U.S.

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.

Current Status of U.S. Health & Healthcare Disparities
Health Insurance Coverage

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.

Accessing to and Receiving Care

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.

  • The KFF/The Undefeated 2020 Survey on Race and Health, found that one in five Black adults and one in five Hispanic adults report being treated unfairly treatment due to their race or ethnicity while getting health care for themselves or a family member in the past year.
  • Nearly one-quarter (24%) of Hispanic adults and over one in three (34%) potentially undocumented Hispanic adults reported that it was very or somewhat difficult to find a doctor who explains this in a way that is easy to understand in a 2021 KFF survey.
  • Other KFF survey data from 2022 found that nearly one in ten (9%) of nonelderly adult women who visited a health care provider in the past two years said they experienced discrimination because of their age, gender, race, sexual orientation, religion, or some other personal characteristic during a health care visit.
  • KFF data also showed that LGBT+ people were more likely than their non-LGBT+ counterparts to report certain negative experiences while getting health care, including a doctor not believing they were telling the truth, suggesting they are personally to blame for a health problem, assuming something about them without asking, and/or dismissing their concerns.
  • The 2023 KFF/The Washington Post Trans Survey found that trans adults were more likely to report having difficulty finding affordable health care or a provider who treated them with dignity and respect compared to cisgender adults.

Ongoing Health Issues (Disease, Life Expectancy, etc)

People of color and other underserved groups face ongoing disparities in health.

  • For example, at birth, AIAN and Black people had shorter life expectancies compared to White people as of 2021, and AIAN, Hispanic, and Black people experienced larger declines in life expectancy than White people between 2019 and 2021, reflecting the impacts of COVID-19
  • As of 2021, Black infants were more than two times as likely to die as White infants, and AIAN infants were nearly twice as likely to die as White infants.
  • Black and AIAN women also had the highest rates of maternal mortality across groups.
  • Rates of chronic disease and cancer also vary by race and ethnicity. Although Black people did not have higher cancer incidence rates than White people overall and across most types of cancer, they were more likely to die from cancer in 2019.
  • Research shows that people living in areas with high concentrations of poverty are at increased risk of poorer health outcomes over the course of their lives.
  • KFF analysis also found that LGBT+ people were more likely to report being in fair or poor health and having an ongoing health condition that requires ongoing monitoring, medical care, or medication compared to non-LGBT+ people despite being a younger population.

COVID-19 Pandemic Toll

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.

  • Cumulative age-adjusted data showed that AIAN and Hispanic people have had a higher risk for COVID-19 infection and AIAN, Hispanic, and Black people have had a higher risk for hospitalization and death due to COVID-19.
  • Beyond these direct health impacts, the pandemic has negatively impacted the mental health, well-being, and social and economic factors that drive health for people of color and other underserved groups, including LGBT+ people.

Mental Health and Substance Abuse

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.

  • Drug overdose death rates were highest among AIAN and Black people as of 2021.
  • Alcohol-induced death rates increased substantially during the pandemic, with rates increasing the fastest among people of color and people living in rural areas.
  • From 2019 to 2021, many people of color experienced a larger growth in suicide death rates compared to their White counterparts. Additionally, self-harm and suicidal ideation has increased faster among adolescent females compared to their male peers.
  • Findings from a 2023 KFF/The Washington Post survey found that more trans adults reported struggling with serious mental health issues compared to cisgender adults and were six times as likely as cisgender adults to have engaged in self-harm in the previous year (17% vs. 3%).
  • There are also substantial disparities in mental health, including suicidality, among LGBT+ youth compared to their non-LGBT+ peers.
The Future of Health & Healthcare Disparities in the U.S.

As we look to the future there are several key issues that will significantly impact health and healthcare disparities in the future.

End of the COVID-19 PHE

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.

Overturning Roe v. Wade

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.

  • These changes may disproportionately impact women of color, as they are more likely to obtain abortions, have more limited access to health care, and face underlying inequities that would make it more difficult to travel out of state for an abortion compared to their White counterparts.
  • Restricted access to abortions may widen the already stark racial disparities in maternal and infant health, as some groups of color are at higher risk of dying from pregnancy-related reasons and during infancy and are more likely to experience birth risks and adverse birth outcomes compared to White people.
  • It may also have negative economic consequences associated with the direct costs of raising children and impacts on educational and employment opportunities.
  • Further, women from underserved communities may be at increased risk for criminalization in a post-Roe environment, as prior to the ruling, there were already cases of women being criminalized for their miscarriages, stillbirths, or infant death, many of whom were low-income or women of color.

End of Medicaid Continuous Enrollment

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.

  • KFF estimates that between 5 and 14 million people could lose Medicaid coverage, including many who newly gained coverage during the pandemic.
  • Other research shows that Hispanic and Black people are likely to be disproportionately impacted by the expiration of the continuous enrollment provision.
  • Moreover, some groups, such as individuals with limited English proficiency and people with disabilities may face increased challenges in completing the Medicaid renewal process increasing their risk of coverage loss even if they remain eligible for coverage.
  • OCR has reminded states of their obligations under federal civil rights laws to take reasonable steps to provide meaningful language access for individuals with limited English proficiency and ensure effective communication with individuals with disabilities to prevent lapses in coverage amid the unwinding of the continuous enrollment provision.
  • CMS issued guidance that provides a roadmap for states to streamline processes and implement strategies to reduce the number of people who lose coverage even though they remain eligible.

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.

Access to Care for LGBTQIA+

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.

Immigration Policies

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 Abuse Concerns

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.

  • For example, people of color have experienced larger increases in drug overdose death rates than White people, resulting in the death rate for Black people newly surpassing that of White people by 2020.
  • Further, Black and Asian people have reported negative mental health impacts due to heightened anti-Black and anti-Asian racism and violence in recent years.
  • Research has documented the negative health impacts, including negative impacts on mental health and well-being, of exposure to violence, including police and violence.
  • Research shows African American and AIAN men and women, and Latino men are at increased risk of being killed by police compared to their White peers.
  • Black and Hispanic adults also are more likely than White adults to worry about gun violence according to 2023 KFF survey data.
  • Other KFF analysis shows that firearm death rates increased sharply among Black and Hispanic youth during the pandemic driven primarily by gun assaults and suicide by firearm.
  • Research further shows that repeated and chronic exposure to racism and discrimination is associated with negative physical and mental health outcomes, including premature aging and associated health risks, referred to as “weathering,” as well as higher mortality.
Barriers to Mental Health Care

Despite growing mental health concerns, people of color continue to face disproportionate barriers to accessing mental health care.

  • Research suggests that structural inequities may contribute to disparities in use of mental health care, including lack of health insurance coverage and financial and logistical barriers to accessing care, stemming from broader inequities in social and economic factors.
  • Lack of a diverse mental health care workforce, the absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health may also contribute to limited mental health treatment among people of color. 
  • Amid the pandemic, many states implemented telehealth behavioral health services to expand access to behavioral health care, and most states intend to keep these services.
  • States are also adopting strategies to address workforce shortages in behavioral health. As states seek to expand access to behavioral health care, it will be important to ensure that services address the cultural and linguistic needs of diverse populations.
  • Further, in 2022, the federal government mandated the suicide and crisis lifeline number that provides a single three-digit number (988) to access a network of over 200 local and state-funded crisis centers. The 988 number is expected to improve the delivery of mental health crisis care; however, it is unknown how well it will address the needs of people of color and other under-served populations.