A leading voice behind a landmark report on disparities in U.S. health care briefs journalists on the state of the crisis

In 2003, the Institute of Medicine published a seminal report on health disparities, finding that racial and ethnic minorities experienced lower quality health care than their white counterparts in the United States.

At the time, the report did not flag systemic racism as a driving factor in the disparities. Now, though, it’s starkly evident that racism is a public health crisis, said Brian Smedley, who led the team behind the report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” 

“It is clear that racism in many forms is killing people of color and thus has implications for all Americans,” said Smedley, an equity scholar at the Urban Institute. “Racism is a threat to the health and well-being of all of us.”

In a Center for Health Journalism webinar, Smedley described how these health disparities go beyond individuals and their intent, pointing to racism that’s deeply embedded in health systems and structures. He also shared tips on how journalists can write with context and nuance about these health inequities, as well as policies and strategies to address them.

Persistent inequities

Despite the attention that initial report garnered, the nation hasn’t made significant progress when it comes to addressing health disparities, said Smedley, pointing to the 2021 National Healthcare Quality and Disparities Report from the Agency for Healthcare Research and Quality(AHRQ).

From 2000 to 2019, roughly half of the 152 quality measures for African Americans showed improvement while 45% remained unchanged and 7% got worse, according to the report. Other communities of color followed a similar pattern.

Other recent research similarly identifies persistent disparities and pinpoints the role of race. A 2021 report from the Urban Institute found significant differences between Black and white patients when looking at health care safety. For example, Black patients had higher rates of hospital-acquired injuries or illness related to surgical procedures compared to white patients — even in the same hospital and with the same condition. These differences remain even when patients that similar insurance coverage.

“This isolates patient race as a factor in the quality gap,” Smedley said.

Where do disparities come from?

People harbor implicit biases, even if they don’t consciously endorse them, and that includes health care providers. That’s because we rely on mental shortcuts and social categorization, especially in stressful situations with limited resources, Smedley said.

“There is persistent evidence that health care workers are just like the rest of us,” he said. 

A recent study of 40,000 patient electronic health record notes found Black patients were 2.5 times more likely than white patients to have at least one negative descriptor such as “resistant” or “noncompliant,” appear in their chart, even after controlling for differences such as education level.

Physician biases can impact clinical decisions, such as pain recommendations or even how cardiovascular disease is treated.

There are also disparities in how patients of color access clinical procedures and treatments, from lower rates of referral to specialists to Black patients being less likely to receive a kidney at transplant centers throughout the country.

On a broader scale, the country’s health care disparities reflect the legacy of residential segregation and unequal resources, he said. Safety net health systems, where a disproportionate number of people of color are treated, typically lack resources. Conversely, well-off communities are more likely to have more and better health care.

Insurance plays a role, too. The country’s tiered public and private insurance system offers providers varying levels of reimbursements. Those with higher-paying private insurance may find providers more easily while Medicaid beneficiaries might struggle to find clinicians willing to accept the lower payments.

What can be done?    

One important step in addressing health inequities on the structural level is providing universal health care coverage with comprehensive benefits, Smedley said. Hospitals and health systems should receive resources depending upon their need. Pay-for-performance models, by contrast, can effectively punish struggling and already underfunded systems, since many quality benchmarks are harder to hit in sicker and poorer communities.

On an individual level, providers need to stop the inappropriate use of race in making clinical decisions. Diversity, equity, and inclusion training needs to be considered an ongoing lifelong learning skill that’s consistency reinforced, he said.

Improving the pipeline for providers of color can also improve health outcomes. For example, a study of 1.8 million Florida hospital births found that infant mortality dropped by about half when Black physicians delivered Black babies.

“We need to better understand what African American physicians are doing and thinking as they interact with their patients,” he said. 

Loan forgiveness programs for people who work in underserved communities could attract more diverse students and improve health access in underserved communities. Changes to admissions for medical and nursing school could help, too. Schools might deemphasize standardized tests in favor of a whole-file approach, for instance.

Some of the most significant steps, though, come much earlier in one’s educational journey. Residential and school segregation are the root cause behind disparities in academic achievement, in Smedley’s view.

“Separate and unequal schools are just that: separate and unequal,” he said.

Covering the story

Journalists at outlets of all sizes can raise awareness that these disparities persist in their own communities. Data can help, though some measures might require some extra digging.

While many hospitals and health systems collect data on quality, they don’t often publish data that separates the information by race. Journalists can publicly request the data and do their own analysis of where inequities exist. Smedley urged journalists to combine such data with personal stories from people of color to create stories that can spur action – and let patients vote with their feet on where they go for care.

Despite his own bouts of pessimism over the years, Smedley ultimately does believe the country is making progress.

“Over the long haul, we are going to ensure that we are providing the highest quality of care for all patients,” he said. “The toll of health inequities is too significant, too damaging to our nation.”

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Watch the full presentation here: