Upstream reforms, addressing fundamental determinants, such as improving educational levels1
, income redistribution2
, and universal health insurance coverage3
, are essential, but insufficient, to reducing health disparities. Although less marked than in the United States, disparities persist and are increasing in western countries with universal coverage4–6
. These growing disparities reflect, in part, the consequences of the differential diffusion through society of new technologies7,8
. These findings also suggest that ongoing downstream efforts to minimize disparities will remain critical. These downstream efforts, clearly within the purview of healthcare providers, are the focus of this paper.
The widespread and diverse nature of disparities in health and healthcare is well documented9–11
; we do not discuss these in detail. Healthcare disparities, while widespread, however, are neither inevitable nor omnipresent in the United States12,13
. For example, healthcare disparities are observed in some regions of the country but not others14
. Thus, racial disparity in treatment of patients hospitalized with myocardial infarction are small to nonexistent in the Northeast and largest in the South14
. Quality improvement efforts in the Veterans Administration health system15–18
have been followed by improved outcomes and reduced racial disparities across a spectrum of health problems. Racial disparities in quality of care in Medicare managed care plans, at least for some process measures, have decreased over time21
. These findings suggest cautious optimism that disparities may be ameliorated within the context of the current healthcare system.
Based on earlier work9,22–25
, we define healthcare disparities as the mismatch between need and care associated with membership in one socially identifiable and disadvantaged group compared with their non-disadvantaged counterpart. Minimizing healthcare disparities requires that care be organized with the goal of achieving equitable outcomes among socially identifiable groups. Healthcare disparities associated with race or ethnicity, socioeconomic status, gender, culture, literacy, and geography are all examples considered by this definition. We use the term “social risk” to include groups at risk for disparities.
In the United States, the greatest emphasis in health disparities has been placed on racial or ethnic disparities; however, socioeconomic disparities play a significant independent role in compromising population health26,27
. Socioeconomic inequality in the United States may exact the greatest total health burden of all social risk factors; for example, income disparities are associated with a burden approximating 17.2 million Quality Adjusted Life Years (QALYs)28
compared with a burden of 2.3 million QALYs attributable to Black–White disparities29
Two premises underlie our proposals for addressing disparities. First, we view healthcare as a social good, not simply another commodity30
. Viewed from this perspective, the primary goal for healthcare is optimizing health outcomes. Such a view means allocating healthcare resources based primarily on need rather than ability to pay. Conversely, treating healthcare as a commodity results in a paradoxical inverse relationship between health risk and healthcare31,32
, whereby the most care is provided to those best able to pay (often those with less need), and the least care is provided to those at highest social risk. When healthcare is viewed primarily as a commodity, disparities matter little more than disparities in car ownership.
The second premise is that disparities in health outcomes represent a deficit in healthcare quality33
. Available evidence suggests that disparities in process measures may be diminishing relative to disparities in intermediate outcomes21,34
, hence the need to focus on equality in health
outcomes, not just healthcare
. Together, these two premises suggest a framework for tailoring healthcare
to the needs of individuals to optimize health
outcomes, while reducing disparities in those outcomes.
In focusing on need and outcomes, we intentionally avoid the contentious problem of preferences. While respecting personal preferences is a critical goal of patient-centered care, disparities may arise from differences in preferences associated with membership in a group at social risk. However, those preferences may reflect misperceptions of risks associated with more intensive care35
, awareness of higher surgical risks36
, or lower trust in healthcare providers37
, all of which are more common in those at social risk.
We also avoid linking disparities directly to “underuse” or “overuse” of high variation procedures. Wennberg and others have shown there are dramatic regional variations in the use of procedures, but regional variations in utilization by those at social risk do not match overall regional variations14,38
. Further, there is a limited relationship between regional variations and appropriateness or outcomes14,39
. Thus, there is little evidence to support the notion that relative “underuse” of these procedures by those at social risk protects them from adverse outcomes due to “overuse”. The RAND Health Insurance Experiment provides evidence bearing on this question. Experimentally controlled variations in co-payments were associated with variations in utilization, without affecting either the proportion of appropriate care or overall outcomes. However, for those at both social and biomedical risk, higher co-payments were associated both with lower utilization and worse outcomes40
. Such findings reinforce the need to link clinical decision making to the level of social risk (see below).