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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Proceedings of a Workshop

WORKSHOP OVERVIEW1

At the request of the National Institutes of Health (NIH), a 17-mem-ber ad hoc committee was appointed by the National Academies of Sciences, Engineering, and Medicine (the National Academies) to examine the current state of racial and ethnic health care disparities in the United States, highlight the major drivers of health care inequities, provide insight into successful and unsuccessful interventions, identify gaps in the evidence base and propose strategies to close those gaps, consider ways to scale and spread effective interventions to reduce racial and ethnic inequities in health care, and make recommendations to advance health equity. This work builds on the consensus report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care2 (NASEM, 2003).

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1 The workshop was organized by the National Academies’ ad hoc Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care as part of the committee’s information-gathering process. This Proceedings of a Workshop was prepared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop series. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not endorsed or verified by the National Academies or the Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Healthcare, and they should not be construed as reflecting any group consensus.

2 The webcast recording can be found at https://www.nationalacademies.org/event/02-01-2023/unequal-treatment-revisited-the-current-state-of-racial-and-ethnic-disparities-in-healthcare-meeting-1 (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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The committee conducted a series of virtual public workshops on July 12–13, 2023, August 16–17, 2023, and September 6, 2023, to obtain insight on racial and ethnic disparities in health care and current and new approaches to alleviate racial and ethnic inequities. The first workshop3 featured presentations and discussions on major developments over the past two decades relevant to the current state of such inequities; discussed their impact on patients, families, and communities; assessed the roles of clinicians and health care leaders in contributing to or mitigating inequities; and explored what could be done differently in communities to advance health care equity. The second workshop4 discussed innovative and promising approaches aimed at addressing racial and ethnic inequities in health care, the promises and realities of U.S. civil rights policy as it relates to health care, data and measurement needs to advance health equity research, and opportunities for future research. The third workshop5 featured a panel of federal agency leaders who discussed federal efforts and initiatives aimed at reducing racial and ethnic inequities in health care access, use, and quality.

This Proceedings of a Workshop summarizes the presentations and discussions from the three virtual workshops6 and highlights individual participants’ suggestions to advance racial and ethnic health care equity. These suggestions are discussed throughout the proceedings and summarized in Box 1. Appendixes A and B provide the Consensus Study Statement of Task, which guided the organization of these workshops, and the workshop agendas, respectively.

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3 Recorded webcast is archived online at https://www.nationalacademies.org/event/39910_07-2023_unequal-treatment-revisited-a-workshop-series-part-1 (accessed on November 22, 2023).

4 Recorded webcast is archived online at https://www.nationalacademies.org/event/40178_08-2023_unequal-treatment-revisited-a-workshop-series-part-2 (accessed on November 22, 2023).

5 Recorded webcast is archived online at https://www.nationalacademies.org/event/40362_09-2023_unequal-treatment-revisited-a-workshop-series-part-3 (accessed November 22, 2023).

6 This is not the final deliverable from the committee. Its consensus report is due in summer 2024. As part of the study contractual arrangements, the committee is required to produce a proceedings that summarizes the presentations and discussions at its public workshops and a final consensus report that contains its recommendations to reduce racial and ethnic disparities in health care with a focus on advancing health equity. More information about the committee membership and its work can be found at https://www.nationalacademies.org/our-work/unequal-treatment-revisited-the-current-state-of-racial-and-ethnic-disparities-in-healthcare#sectionCommittee (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×
Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

LEARNINGS FROM THE PAST TWO DECADES

David Williams, the Florence & Laura Normal professor of public health, chair of the department of social and behavioral sciences, and professor of African and African American studies and sociology at Harvard University, said that many professional organizations acted upon the recommendations in the 2003 Unequal Treatment report and started conducting implicit bias training and raising awareness among their workforces that improvements were impera-

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

tive. Williams noted that the report also stimulated research documenting the persistent patterns of inequity and providing insights into the drivers of those inequities. Twenty years later, studies have documented the health care inequities that marginalized and minoritized people continue to experience. However, Williams added that investigators have done less work to develop effective interventions to address these inequities.

He shared the findings from an analysis that reviewed 221 studies documenting harmful consequences of inequities in emergency medicine and found

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

that only six evaluated an intervention to reduce inequity (Darby et al., 2022). He also stressed that most efforts to reduce inequities are not working. For example, diversity and implicit bias training can increase knowledge about and improve attitudes toward diversity, but positive changes are small and short term. He presented data from a study that evaluated the impact of a single dose of propranolol7 on implicit bias in White health care providers (Terbeck et al., 2012). Compared to a placebo, it eliminated implicit bias and reduced heart rate but had no effect on explicit bias. Williams explained that although this intervention provides evidence that fundamental biological processes underlie implicit bias, it is not a practical long-term solution for effectively addressing it in the health care encounter.

Williams said that diversifying the workforce to make racially and ethnically concordant care more available is one long-term strategy to reduce inequities. He presented data showing that patients seeing a doctor of the same race were more likely to talk about other health problems, undergo diabetes and cholesterol screening, and get the influenza vaccine (Alsan et al., 2019). He noted that appropriately implemented interventions to enhance cultural competence can play a role. For example, a study of people living with HIV/AIDS found no racial inequities when they received treatment from physicians with high cultural competence (Saha et al., 2013).

Williams named racial residential segregation as a fundamental cause of large racial and ethnic inequities. He said that these social policies, rooted in racism, lead to differences in both income and median wealth and produce racial inequities through a system that was carefully crafted and is functioning as planned.

One lesson learned over the past 20 years, Williams emphasized, is not merely to focus on changing individual behavior but rather to restructure the systems that are producing the inequities in the first place. He explained that Rush University Medical Center is an example of an institution that has undertaken a comprehensive approach to reducing health inequities based on socioeconomic status (Ansell et al., 2021). He suggested promoting a grassroots social movement and uniting communities across multiple disadvantaged populations to show policy makers that it is essential to make addressing health inequities a priority issue.

Child and Adolescent Health Perspective

Tina Cheng, professor and chair of pediatrics at the University of Cincinnati College of Medicine, director of the Cincinnati’s Children’s Research

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7 Propranolol is a beta-blocker medicine that helps to reduce the symptoms of anxiety.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Foundation, and chief medical officer at Cincinnati Children’s Hospital Medical Center, noted extensive research describing child health inequities and the effect of racism on adult and child health (Gee and Ford, 2011; Gee et al., 2012; Trent et al., 2019). Cheng said that inequities in child health set the foundation for inequities that may accumulate across the life course, highlighting the need to invest early to address them (Cheng et al., 2016).

Cheng noted that children’s health is a product of the interaction of the social and fiscal environments, biology, and behavior, all within the context of policy and care services. She explained that because life challenges accumulate over the lifespan, screening for disease in adulthood may be too late to significantly reduce risk (Hanson and Gluckman, 2014). She noted that Medicaid pays approximately 70 percent, on average, of what Medicare pays for care services, and as a result, a majority of Medicaid patients experience challenges in seeking access to clinicians. She stressed that reimbursement parity between Medicare and Medicaid is necessary to eliminate health care disparities.

Additionally, Cheng said that racism has long-lasting adverse effects that start in childhood and continue through adolescence and into adulthood (Trent et al., 2019). She stressed that health institutions need to consider how they contribute to interpersonal and structural racism and then take the lead in building community opportunity by serving as anchor institutions. Cheng said that “we need to hold all payers and health care systems accountable for equitable outcomes.”

Maternal Health Care Perspective

Kimberly Seals Allers, founder of Narrative Nation Inc., said that bias in health care is particularly acute around maternal and infant deaths. Allers noted that Black people are more likely to die from pregnancy and childbirth-related causes, and over 80 percent are preventable (CDC, 2023). She explained that Irth,8 a nonprofit project of her organization, takes the approach of learning from lived experiences by creating a digital data platform to capture experience specific to bias and racism in maternal and infant care.

Allers said that transparency and community accountability are the fastest ways to address the distrust between health care systems and communities of color, which consistently leads to inequities across the health care spectrum. She suggested that it is essential to use funding-based mechanisms and alternative payment models to establish consequences for inaction or failure to meet the goals for equitable health outcomes.

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8 For more information about the Irth, see https://irthapp.com (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Allers noted that communities should participate in defining problems and developing and implementing interventions to address those problems. She said that communities can be the source of new tools and solutions if researchers listen to them.

Mental Health and Substance Use Disorders Perspective

Valeria Chambers, founder of Black Voices: Pathways 4 Recovery and a certified peer specialist at the Cambridge Health Alliance, said that toxic stress caused by racism, discrimination, sexism, homophobia, classism, mentalism, and other “isms” directly diminishes the health, quality of life, and life expectancy of minoritized populations.

She noted that families and communities can be leveraged to address mental and behavioral health conditions by providing the supports families need to thrive, following community leaders who have learned what is and is not working, and enabling people with lived experiences of mental health and substance use disorders to learn how to engage people compassionately and effectively. Chambers said that almost every state uses peer support to help people recover from behavioral health conditions. She stressed that people in peer-support roles need to earn a living wage and have access to ongoing training.

Aging Perspective

Carl Hill, chief diversity, equity, and inclusion officer for the Alzheimer’s Association and former director of the Office of Special Populations at the National Institute on Aging (NIA), said that the 2003 Unequal Treatment report informed NIA’s health disparities research framework in 2014 (Hill et al., 2015). It has been used as an overarching guide to test discrimination and the weathering hypothesis, which posits that chronic exposure to social and economic disadvantage leads to accelerated decline in physical health outcomes and could partially explain racial disparities in a wide array of health conditions (Forde et al., 2019).

Hill explained that in 2021, the Alzheimer’s Association surveyed caregivers who reported perceptions and experiences of discrimination in the dementia care system (Alzheimer’s Association, 2021). The participants identified race and ethnicity as the number-one reason, with Black respondents reporting the highest level of discrimination. Hill said it is essential for efforts to enhance diversity, equity, and inclusion to maintain a focus on discrimination and how it can affect health through coping patterns and generational patterns of how people obtain health-protecting resources. Hill urged scholars and researchers to become instruments for the community, serve as sources of information and resources, and partner with trusted institutions and organizations.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Disability Perspective

Vivian Haun, senior attorney in the Intellectual/Developmental Disabilities Practice Group at Disability Rights California, said that California’s per capita expenditures on services for people of color with an intellectual or developmental disability (I/DD) are about half as much as for White individuals (Haun et al., 2023). Haun said that in a study to assess inequities in the system for delivering services to people with I/DD, she and her colleagues found that its efforts focused almost entirely on cultural competency and systems navigation (Haun et al., 2023); these two approaches alone are necessary but not sufficient.

Another issue that Haun raised was cost containment. In California—the only state where access to services and supports for individuals with I/DD is an entitlement—service authorization is a primary cost-containment measure, and it can produce racial inequities depending on who decides on the criteria. She stressed that it is essential to shift the focus from identifying racism in individuals or individual interactions to identifying structural racism.

In addition, Haun discussed the importance of paying and training family members who provide home care for adults with I/DD. Access to plain language is an important domain of access to health care. She explained that many issues are inadequately diagnosed and treated because of the difficulties people with I/DD have in talking about their health issues and emphasized that it is essential to amplify their voices to advance health care equity.

Sexual and Gender Minority (SGM) Perspective

José Bauermeister, founding faculty director of the Eidos LGBTQ+ Health Initiative and Albert M. Greenfield professor of human relations at the University of Pennsylvania and chair of the Department of Family and Community Health at the School of Nursing, discussed four areas of concern regarding inequities affecting the health needs of lesbian, gay, bisexual, transgender, questioning, other (LGBTQ+) individuals.

First, Bauermeister pointed out the absence of population-based data, which limits the ability to holistically understand the health of LGBTQ+ people (NASEM, 2022). Second, SGM groups, as well as racial and ethnic minoritized groups, are underrepresented across a multitude of health outcomes (NASEM, 2020). Third, theoretical growth is limited beyond minority stress hypotheses, even though the etiology of inequities and disparities might differ among LGBTQ+ subpopulations. Fourth, evidence-based interventions or practices to address health care inequities, including racial and ethnic inequities, are insufficiently available to SGM populations.

Bauermeister said that differential access to health insurance and health care services, resulting from differences in state policies and laws, contributes to the persistent racial and ethnic health care inequities (Wilson et al., 2022).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

He presented data to show that LGBTQ+ people encounter greater socioeconomic disadvantage, which is even greater for racially and ethnically minoritized individuals, compared to their White counterparts (Wilson et al., 2022, 2023). “Considering intersectionality will be important for thinking about how to improve the health of the LGBTQ+ community,” he concluded.

CONFRONTING RACISM

Camara Jones, the Leverhulme visiting professor of global health and social medicine at King’s College London and senior fellow at the Morehouse School of Medicine, defined racism as a system of structuring opportunity and assigning value based on the social interpretation of how one looks that unfairly disadvantages or advantages some individuals and communities and weakens society through wasted human resources. Antiracism, said Jones, is a process with three tasks: naming racism, which involves stating that it exists, is a system, saps the strength of the entire society, and can be dismantled by action; questioning how racism operates in a system to identify promising levers for intervention and targets for action to start dismantling the system; and organizing and strategizing to act.

Racism is not an individual character flaw, personal moral failing, or a psychiatric illness, said Jones, but a system of power. She added that racism is not something nebulous but rather a system with identifiable mechanisms operating in structures, policies, practices, norms, and values. Recognizing all of these elements might be overwhelming, but Jones emphasized that they are essential for decision making.

Jones suggested four steps to address structural racism. The first step is to actively look for evidence that it exists—whether something differential is happening by race, gender, religion, and region, in both outcomes and opportunity structures. Second, recognize and experience the common humanity of others to start building a common cause. Third, develop a sensitivity to who is not at the table, what is not on the agenda, and what policies are not in place for social justice. Fourth, reveal inaction in the face of need because that is a hallmark for how structural racism operates today.

RACIAL AND ETHNIC INEQUITIES IN HEALTH CARE: CLINICIAN AND HEALTH CARE ORGANIZATION PERSPECTIVES

Several workshop speakers discussed the roles of clinicians and health care organization leaders in contributing to or mitigating racial and ethnic inequities in health care. This discussion included clinicians’ roles in frontline delivery of health care, as health system leaders, in professional organizations, and in regulatory roles.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Nursing Perspective

Rumay Alexander, senior equity advisor for the American Nurses Association and professor of nursing and assistant dean for relational excellence at the University of North Carolina at Chapel Hill, said that it is essential for professional organizations to model accountable and professional comportment so their members can scale those behaviors and make them part of their institutions. She said that about 40 nursing organizations have created the National Commission to Address Racism in Nursing to examine racism within the profession and the impact on nurses, patients, communities, and health care systems and motivate all nurses to speak about individual and systemic racism.9 The commission holds listening sessions and serves as a safe space for difficult conversations that might not be possible within an institution.

A recent survey of a national sample of nurses revealed that approximately one in three either experienced racism or witnessed it in action (National Commission, 2022). Alexander said that from the listening sessions and survey results, the National Commission identified four areas—practice, policy, education, and research—that needed further conversation and were highlighted in its report (Tobbell and D’Antonio, 2022). Alexander said that to make progress on addressing racial and ethnic health care inequities, accountability and consequences are required, such as revoking accreditation and certifications.

Physicians’ Perspective

Aletha Maybank, chief health equity officer and senior vice president of the American Medical Association (AMA), said that in decades past, most physicians denied the bias and racism that existed in the profession. In 2019, AMA established the Center for Health Equity10 to develop policies aimed at eliminating health disparities and racial inequities in health care.

AMA has issued a guide to health equity language, narratives, and concepts to help physicians and the larger health care workforce understand malignant and dominant narratives that undermine actions to advance equity, including regarding individualism, meritocracy, blaming, and denial.11 She noted that the workforce needs a greater understanding of the structural and political drivers in

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9 For more information about the National Commission to Address Racism in Nursing, see https://www.nursingworld.org/practice-policy/workforce/racism-in-nursing/national-commission-to-address-racism-in-nursing (accessed on November 22, 2023).

10 For more information about the Center for Health Equity, see https://www.ama-assn.org/about/ama-center-health-equity (accessed on November 22, 2023).

11 For more about the guide see https://www.ama-assn.org/system/files/ama-aamc-equity-guide.pdf (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

the context of what produces good and bad health and challenges or helps and benefits a health care system. She also noted the importance of both accountability and consequences and the need to evaluate interventions to find out what works and what does not. AMA recently established the Rise to Health Coalition,12 including health care organizations, physicians and other health care professionals, payers, professional societies, and pharmaceutical, biotech, and research organizations, to leverage resources and use a common framework to address historical inequities in health care.

Maybank suggested some areas that need to be considered to advance racial and ethnic health care equity, including more institutional policy that names racism as a driver to be met with advocacy, action, and accountability; more empirical studies published on racism and other systems of oppression, such as White supremacy and ableism; more focus on the political and structural drivers of optimal health and health inequities, tools, and supports for organizational change strategy and management to advance equity; increased narrative change efforts to engage people who do not see themselves as part of the problem; more coalition building and opportunities for solidarity for optimal learning and impact; and more evaluation overall to understand the effect of changes on multiple levels.

Federally Qualified Health Center Perspective

Michael Griffin, president and chief executive officer of both Ascension DePaul Services of New Orleans and Marillac Community Health Centers, said that the more than 1,300 federally qualified health centers (FQHCs), also known as “community health centers,” are anchored in primary care and prevention and offer oral health and dental services, behavioral health services, and discounted medications through the national 340B Drug Pricing Program.13 FQHCs have begun focusing on the social determinants of health (SDOH) and are working with community partners to tackle housing and food insecurity, educational attainment, and other factors that affect community health.

Griffin explained that every FQHC is required to partner with a local hospital, academic medical center, or any other health care facility in the community. They also partner with specialists. FQHCs have incorporated community health workers (CHWs) and navigators and are focusing on integrating them with primary care clinicians to provide a holistic approach to care.

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12 For more information on the American Medical Association Rise to Health, see https://www.risetohealthequity.org (accessed on November 22, 2023).

13 See https://www.hrsa.gov/opa (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Integrated Health Care System Perspective

Andrew Bindman, executive vice president and chief medical officer at Kaiser Permanente (KP), said that KP develops a common set of clinical guidance that it pushes out via the electronic health record (EHR) for all the organization’s clinicians to use. Bindman said that although physicians are not bound by the guidance, KP evaluates how clinicians are adhering to it relative to the race and ethnicity of their patients. “This approach is one way to understand how to use the best clinical evidence and how it is being employed for different patients, through a race and ethnicity lens,” Bindman added. KP is developing the capacity to do this analysis for other key social factors, including sexual orientation and gender identity.

Quality measurement, said Bindman, can be an important approach for understanding how an organization is addressing health inequities (Bindman, 2022). However, the system of quality measurement does not assess whether an organization is doing a good job addressing equity issues. He said that KP routinely measures clinical outcomes, reporting quality measures through an equity lens and capturing and incorporating social factors into performance assessments by screening millions of its members for social risk factors and about their neighborhoods’ characteristics. KP is incorporating neighborhood- and individual-level social factors into outcome assessments and interventions to support its equity work and equity assessment of outcomes into incentive programs. Bindman went on to say that the prevailing approach to measuring quality through processes provides insights into equal treatment, but equal treatment is not sufficient for delivering equitable outcomes because individuals start in different places with regard to their social risk factors and resources. It is a viable approach to have an incentive system that accounts for performance on equity measures, Bindman said. What is not needed, he added, is for every accrediting body and regulatory entity to measure social factors differently, which would make it difficult to create benchmarks, develop shared learning, and accelerate improvement together.

Accrediting Organization Perspective

Jonathan Perlin, president and chief executive officer at the Joint Commission and Joint Commission Resources, said that government’s accreditation is mandatory for hospitals, but their choice for accreditation from the Joint Commission is voluntary. Perlin explained that the Joint Commission sets a high bar for accreditation by including standards beyond those the government requires to advance priorities such as health equity. He said that in 2023, it issued requirements aimed at reducing health care inequities and

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

established the Health Care Equity Accreditation Resource Center14 to identify approaches for assessing and improving equity.

Perlin said that beyond accreditation, hospitals can voluntarily seek advanced certifications, and on July 1, 2023, the Joint Commission launched a new advanced certification in health care equity.15 To be certified, he said a hospital must demonstrate that health care equity is a strategic priority, defined in its leadership roles, and undertaken in collaboration with patients, families, caregivers, and community organizations. Other requirements for the certification include demonstrating that the hospital collects and reviews data from the community, patients, staff, and leaders to identify opportunities to improve health care equity. In addition, a hospital must support diversity, equity, and inclusion for its staff and leaders; provide staff with the education and training needed to provide equitable care, treatment, and services; address health-related social needs of its patients; accommodate the needs of patients with physical, mental, communication, or cognitive disabilities; and analyze its data at least annually to identify opportunities to improve provision of equitable care, treatment, and services.

Language Access: A Case Study in Health Care Inequities

Alicia Fernandez, professor of medicine and associate dean of population health and health equity at the University of California–San Francisco School of Medicine, said that about 26 million adults in the United States fit the definition of limited English proficiency, and of these, about 13 million report speaking English not at all or not well (American Community Survey, 2021). Fernandez said that language barriers make care more difficult, are associated with poor comprehension of medical diagnoses and treatment and less satisfaction with the physician and health care encounter and contribute to worse clinical outcomes. She added that access to language services is critical to health care equity, and insufficient interpreter access is an example of structural racism.

Fernandez said that although Title VI of the Civil Rights Act16 requires access to interpreters, they are substantially underfunded and underused. One study found that only 70 percent of hospitals offered language services, and a survey of office-based physicians found that only 29 percent reported using

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14 For more information on Health Care Equity Accreditation Resource Center see https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center (accessed November 22, 2023).

15 For more information on the Joint Commission’s advanced certificate in health care equity, see https://www.jointcommission.org/what-we-offer/certification/certifications-by-setting/hospital-certifications/health-care-equity-certification (accessed November 22, 2023).

16 See https://www.justice.gov/crt/fcs/TitleVI (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

professional interpreters and 40 percent reported never doing so (Schulson and Anderson, 2022). Many clinicians believe that getting by without an interpreter is an acceptable shortcut, a position premised on valuing certain patients less (Diamond et al., 2009).

Fernandez described a program called “Speaking Together: National Language Services Network,”17 which has been shown to increase interpreter use. “There are actions external to health care organizations that would increase access and use of interpreters,” Fernandez added, including regulatory policies and audits and developing digital tools that make it easier to request and access interpreters, document their use, and automate auditing of adherence to policies. Other steps would include creating financial incentives, providing infrastructure funding akin to the program for EHR adoption, developing educational requirements and methods to certify bilingual language skills, and growing a linguistically and culturally diverse workforce by addressing policy barriers and facilitators.

COMMUNITY EXPERIENCES OF RACIAL AND ETHNIC INEQUITIES IN HEALTH CARE

Invited participants from community-based organizations discussed how communities are addressing racial and ethnic inequities in health care access, use, and quality of care and examined how promising approaches can be replicated and scaled.

Building Community Power

Denise Rodgers, vice chancellor for interprofessional programs at Rutgers Biomedical and Health Sciences and professor of family medicine and community health at the Robert Wood Johnson Medical School, said that the pace of progress in reducing health care inequities since the 2003 National Academies report (NASEM, 2003) has been slow and uneven and the most successful strategies lie in partnerships between academia and communities. She described the Rutgers Equity Alliance for Community Health18 program to support her argument; it combines the resources and expertise of Rutgers faculty, students, and staff with the wisdom, expertise, and experience of those working in communities to

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17 For more information on Speaking Together: National Language Services Network program, see https://www.migrationpolicy.org/content/speaking-together-national-language-services-network-0 (accessed on November 22, 2023).

18 For more information on Rutgers Equity Alliance for Community Health, see https://reach.rutgers.edu (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

generate better solutions to address adverse SDOH. She said that it also aims to change the belief among many academics “that they know what is best for people because of the years of research they have conducted, often in ways that exploit the community.”

Community-Based Participatory Research

Chau Trinh-Shevrin, professor and vice chair for research in the Department of Population Health at New York University (NYU) Grossman School of Medicine, said that during the COVID-19 pandemic, she and her colleagues worked with community partners to cocreate culturally responsive strategies and messages in more than 15 languages to improve COVID-19 risk reduction, testing, and vaccination. Among the lessons learned from this project was that the pandemic magnified social and health inequities. She explained that working with trusted community partners and community health workers was critical in developing culturally relevant materials and reaching minoritized communities experiencing health inequities. Having materials and resources for those with limited English proficiency and low literacy was important, Trinh-Shevrin added.

Insurance, language access, and access to paid sick leave also played a profound role in seeking timely and preventive services and vaccination. She noted that low-income and minoritized populations are still dealing with the effects of SDOH after the pandemic and have an overwhelming need for mental health support and services.

Trinh-Shevrin explained that CHWs can fill the gaps left by the health care system and help account for the role of SDOH in order to support vital linkages. She stressed that what is needed is sustained commitment and political will to support CHWs and community organizations that can strengthen the linkages between medically underserved communities and health care. She also highlighted the importance of small clinical practices that serve racial and ethnic minoritized, low-income, and limited English proficiency communities, and she suggested they need to be a bigger part of the efforts to support equity in health care.

Indigenous Health Equity Perspective

Virginia Hedrick, executive director of the California Consortium for Urban Indian Health, said American Indian and Alaska Native (AIAN) communities suffered disproportionately from COVID-19, losing 6 years of life expectancy (Goldman and Andrasfay, 2022). This was not unexpected, she said, given the high rates of diabetes, high blood pressure, and other risk factors associated with COVID-19. For the past 50 years, California has had a tribally controlled health care delivery system with community health centers that offer

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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medical, behavioral health, and dental services, along with services to address SDOH. She explained that Urban Indian Health is developing a model that would allow traditional healers to be credentialed providers and provide billable services under Medicaid for substance use disorders. The organization hopes that this model could be an entryway into the whole health delivery system. She acknowledged that the lack of metrics for inequities around access to traditional or spiritual health makes this work difficult. “There is a long way to go to address health inequities in Indian country, but solutions will come from thinking about what the community wants to help achieve good health,” Hedrick concluded.

Immigrant Health Equity Perspective

Juan Prandoni, clinical psychologist and training director at El Futuro, said that the immigrants his organization serves need a culturally responsive approach, in which non-Latinx clinicians learn about the importance of being willing to ask and learn. This program provides theory and evidence-based models to capture the nature of the immigrant experience of adapting to life in the United States and navigating foreign systems of care. The goal is to teach mental health and medical care providers that their connection with their patients is ultimately the most important factor. Prandoni said that aside from delivering evidence-based behavioral health care, El Futuro works to build community resilience by addressing identified risk and protective factors. He explained that the organization uses community-based interventions and programming that leverage these protective factors and allows for celebration and building the community’s strengths. The organization also provides trainings on mental health for CHWs and conducts outreach at places of worship, which builds trust and reduces stigma around mental health issues in the Latinx community.

Asian American Health Equity Perspective

Megan Cheung, associate director and clinical director at the Greater Boston Chinese Golden Age Center, said that two important challenges affecting the Chinese American community are navigating the health care system and overcoming the stigma of mental health conditions. Insufficient Chinese language support and a lack of bilingual interpreters in the hospital and community settings are major contributors to navigation issues. Limited bilingual and bicultural clinicians and health care services and a lack of adequate home care services targeting Chinese-speaking elders contribute to health care inequities. Cheung said staff address navigation problems by providing case management and care coordination, including arranging for and coordinating home care. For mental health care, the center offers evidence-based programs for people with depression and anxiety disorders. It is also training CHWs to address the short-

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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age of bilingual and bicultural clinicians. The center plans to develop wellness programs and provide evidence-based programs and hire clinicians to provide one-on-one therapy for people with mild behavioral health conditions.

Mental Health Equity for Black Communities

Yolo Akili Robinson, founder and executive director of the Black Emotional and Mental Health Collective, shared the mission of the organization and said that its programs provide assistance for community leaders and others working in the community with the skills, tools, and resources to support and reimagine what mental health care looks like and offer more extensive psychological intervention. In 2022, the organization trained almost 4,000 people nationwide, and a longitudinal evaluation found it effective and useful (Black Emotional and Mental Health Collective, 2022). Robinson suggested that the field of health care equity needs to move beyond raising awareness to increasing providers’ capacity to intervene and actively disrupt racial and gender biases in health care decision making. Additionally, he suggested changing the insurance reimbursement structure that creates little incentive for many therapists to accept insurance because of the administrative hurdles and low reimbursement rates and paying CHWs and peer-support specialists a living wage for the most grueling and difficult aspects of mental health care.

WHAT COULD BE DONE DIFFERENTLY

Reed Tuckson, managing director of Tuckson Health Connections, said that the past 20 years have demonstrated the importance of community-based and individually centered health promotion and disease prevention for addressing health inequities; one requirement for success in advancing these efforts is robust, data-driven community health planning processes at the local level and sustainable funding for community infrastructure development and community health prevention. He noted that home-based health care will become an important challenge related to establishing the community infrastructure because the hospital-to-home model puts pressures on people of color, who have much greater self-management responsibilities for navigating an increasing number of more complex care duties and technologies.

Trust, said Tuckson, continues to be a significant challenge and this was evident during the during the COVID-19 pandemic. He said that building trustworthiness requires holding every member of the collective health ecosystem accountable for ensuring that every engagement with someone is trust enhancing.

Also, Tuckson observed that the movement to address SDOH is now supported by the incentives in the medical care delivery infrastructure associated with a transition away from fee for service to value-based reimbursement.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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He noted that value-based reimbursement creates significant economic and philosophical opportunities to shift upstream and address the factors, including SDOH, that create health challenges for the individual.

Tuckson suggested that to advance efforts to address racial and ethnic health care inequities, it is essential to fund science and math teachers in underresourced communities to prepare students to participate as responsible adults in the modern health care system; provide federal support for medical schools and hospital systems in their efforts to achieve a level of diversity reflecting the communities they serve; expand the Black nursing workforce though enhanced recruitment in junior and senior high, fair admission policies in schools of nursing, and tuition support, especially for students interested in public health nursing, school nursing, and mental health services; tie performance measurements and value-based reimbursement to patient satisfaction; and demonstrate through evaluation that all people are receiving quality care.

Clinical Perspective

Marshall Chin, the Richard Parrillo Family Distinguished Service Professor of Healthcare Ethics at the University of Chicago, said that if sustainable national health equity is the goal, then no single magic bullet exists; the literature on individual interventions provides puzzle pieces but does not assemble the picture. He emphasized that sustainable state and national transformation to advance health equity requires simultaneously addressing system transformation to address the medical and social needs of persons and communities, creating a culture that prioritizes equity and antiracism, and achieving payment reform that advances health equity.

Chin explained that system transformation requires identifying inequities and conducting root cause analysis and designing interventions with communities. He explained that effective interventions to address racial and ethnic health care inequities are multifactorial, affect multifactorial drivers of disparities, are culturally tailored, provide team-based care involving nurses and CHWs, and engage families and communities (Chin, 2021; Chin et al., 2014).

Additionally, Chin said that creating a culture of equity and antiracism requires buy-in from the entire health care organization leadership and staff and actions that are intentional and prioritized (Cook et al., 2023; Todić et al., 2022). He explained that employees need time and resources to succeed in their equity-focused responsibilities and training on how to operationalize equity in their daily jobs, regardless of their position. “Structural reform must accompany bias and equity training, for the two are mutually reinforcing,” he added. Moreover, Chin said that antiracist financing and payment policies can enable health care organizations to incentivize and support advancing health care equity (Singletary and Chin, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Community Health Perspective

Alyce Adams, the Stanford Medicine innovation professor and professor of epidemiology and population health at Stanford University, said that access continues to be a critical driver of inequitable health care outcomes. But, she added, “removing access barriers alone will not eliminate inequitable outcomes.” She explained that Medicaid expansion and Medicare Part D policy19 reduced disparities in access in some parts of the country. But in states with drug caps that restrict reimbursements per month, for example, disparities worsened in the use of antidepressants among Black and White enrollees with diabetes (Adams et al., 2015).

Adams said that researchers are using artificial intelligence (AI) and other tools to simulate interventions and anticipate whether a change in coverage policy will benefit or harm certain populations They are exploring the use of AI to identify concurrent policies needed locally to complement federal and state policies. However, there are concerns that deploying AI within health care systems might perpetuate biases. She and colleagues are drawing on bioethics principles to identify AI challenges around data representativeness, design and deployment, and other factors that may harm specific subgroups. She and colleagues are identifying potential mitigation strategies and focusing on how clinicians and others will use AI-powered algorithms. Input from patients, caregivers, and community partners have informed much of this work and will continue to inform efforts to design innovative health care interventions.

Primary Care Systems and Innovation

Dominic Mack, professor of family medicine and director of the National Center for Primary Care at Morehouse School of Medicine (MSM), said that racial and ethnic inequities have deep roots in the broader society. He added that neither primary care nor the health care system alone can provide solutions to overcome the barriers to health care in communities. Mack explained, however, that primary care is critical in ensuring population health and equity by providing whole-person care, advocating for polices to accelerate practice transformation, and partnering with sectors outside of clinical medicine, such as social programs.

Mack said digital health tools have tremendous potential to help eliminate health inequities but only if they are in the hands of the frontline clinicians in underserved communities (MSM, 2023). Telemedicine, for example, can eliminate barriers to access, but it suffers from access issues and interoperability difficulties

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19 See https://www.medicare.gov/drug-coverage-part-d/what-medicare-part-d-drug-plans-cover (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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when clinicians want to connect to other physicians in independent practices. “There is a digital divide among consumers and clinicians in rural and underserved communities and efforts are needed to close that divide,” Mack added.

Technology Development and Health Care Equity

Ivor Horn, director of health equity and product inclusion at Google Health, said that information is a critical determinant of health, and access to the right information at the right time can lead to better health outcomes. She said that Google applied the principles developed by a panel of experts assembled by the National Academies on identifying credible sources of health information (Kington et al., 2021). Horn explained that the principles served as a tool to guide Google’s approach to help people find the highest-quality health information possible and reduce the visibility of low-quality information that can mislead or cause harm.

Horn said that YouTube recently updated its medical misinformation guidelines to preserve the balance of removing egregious, harmful content while ensuring space for debate and discussion; the guidelines focus on three areas: preventing misinformation that contradicts health authority guidance on the prevention and transmission of specific health conditions and on the safety and efficacy of approved vaccines; removing content that contradicts health authority guidance on treatments for specific conditions, including promoting specific harmful substances or practices; and removing content that disputes the existence of specific health conditions.20

Horn said that advancing health care equity requires considering where and how people access health information, its quality, how easy it is to understand, and how it helps people act, particularly for underserved communities. She said that although technology can bring many benefits, it can also exacerbate inequities by scaling and embedding existing structural racism and bias in the health care systems. Horn explained that embedding health care equity in an actionable and sustainable manner requires four elements: intentionality; infrastructure at scale, informed by experts and those with lived experience; accountability; and partnerships.

Health Insurance Industry and Health Care Equity

Neema Stephens, national medical director for Health Equity at Cigna, said that it has developed a proprietary Social Determinants of Health Index to iden-

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20 For more information on the YouTube medical misinformation guidelines, see https://support.google.com/youtube/answer/13813322?hl=en (accessed on November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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tify underresourced communities requiring additional resources or community partnerships to reduce barriers to health equity.21 In 2020, Cigna began to conduct health equity audits involving an enhanced review of its medical coverage policies to identify any unintentional biases that might limit access to care.22 The audit triggered changes to medical coverage policies that improved access. She explained that Cigna also developed health equity measures for its value-based health care providers, which incentivizes them to screen for social needs, refer patients to local community resources, and identify and address health inequities in their patient population.

Collaboration with community partners is a key feature of Cigna’s efforts to engage its members, Stephens said. She described several partnerships, including one that engages barbershops and beauty salons as trusted, culturally relevant portals for health education designed to eliminate inequities.23 Another partnership has worked with OB/GYN physicians and nurse case managers to deliver culturally appropriate, high-quality prenatal care and address social needs.24 She noted the systemic inequities, both historical and contemporary, at the community level and said that this is a space for payers to advocate for state and federal legislation and policies to improve health care equity.

Joneigh Khaldun, vice president and chief health equity officer at CVS Health, said that organizations should ask themselves three questions when thinking about health equity: how to embed it into organizational culture, processes, and structures; how to leverage data; and how to be intentional, with a focus on specific clinical outcomes, in achieving progress.

Khaldun explained that health equity cannot be siloed with the chief health equity officer but needs to be part of the company’s executive goals, decision making, processes, and policies, with leaders mandated to address and make meaningful progress on it. She cautioned that focus is important because of the magnitude of the challenges; organizations should pick a limited number of issues they want to address. She added that having a focus enables strategic investing in strategies that will improve outcomes and the ability to measure success.

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21 For more information on Cigna’s proprietary Social Determinants of Health Index, see https://www.cigna.com/static/www-cigna-com/docs/2021-cigna-diversity-equity-and-inclusion-scorecard-report.pdf (accessed November 22, 2023).

22 For more information on Cigna’s CPU, see https://newsroom.thecignagroup.com/innovative-approaches-to-health-equity (accessed November 22, 2023).

23 For more information on Cigna partnerships, see https://newsroom.thecignagroup.com/building-equity-and-equality-4-ways-cigna-supports-the-black-community (accessed November 22, 2023).

24 For more information on Cigna’s OB/GYN physicians and nurse case manager partnership, see https://newsroom.thecignagroup.com/innovative-approaches-to-health-equity (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Khaldun said that CVS Health developed a health equity assessment tool that helps its business units think about how they make decisions, advance equity in a tangible way, and create and implement plans to improve their health equity efforts. Khaldun noted that efforts to improve health outcomes would require more granular data to identify inequities across race, ethnicity, preferred language, sexual orientation, gender identity, and disability status.

SOCIOPOLITICAL AND LEGAL OPPORTUNITIES AND CHALLENGES

Several speakers presented an overview of the ongoing experiences of key populations who have experienced exclusion and discrimination in health care and examined the promises and realities of U.S. civil rights policy as it relates to health care and its enforcement.

Indigenous Health Care Perspective

Donald Warne, professor and codirector of the Center for Indigenous Health at the Johns Hopkins Bloomberg School of Public Health, presented an overview of some U.S. civil rights policy issues as they pertain to the health of Indigenous populations. He discussed treaty rights, the unique political status of American Indians, Indian Health Service (IHS) funding, workforce issues, and traditional medicine. Warne said that tribal nations have hundreds of treaties that were signed with the federal government; some of their language includes the promise that the federal government will provide all proper care and protection to AIAN populations. IHS was created out of that treaty responsibility. Warne added that “unfortunately, we have never seen the treaties fully upheld from the federal government side of that equation.”

He said that AIAN populations have access to Medicare and Medicaid, if eligible, and IHS, but IHS is significantly underfunded relative to Medicare, Medicaid, and the Veterans Health Administration (VHA) (GAO, 2018). In addition, he noted that Medicare and Medicaid do not reimburse for traditional Indigenous medicine and healing practices, but some private insurance plans do.

Warne added that Indigenous populations are underrepresented in the medical workforce. As a result, most training programs are not designed by and for them. In 2023, for example, there were no Indigenous deans of medical schools, and only 39 Indigenous professors of medicine out of more than 39,000 (AAMC, 2022). Warne said this underrepresentation is a civil right issue and called for including Indigenous people in designing health care workforce training programs.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Asian American, Native Hawaiian, and Pacific Islander Health Care Perspectives

Juliet Choi, president and chief executive officer of the Asian Pacific Islander American Health Forum, discussed some civil rights policy issues as they pertain to the Asian American, Native Hawaiian, and Pacific Islander communities. Choi explained that equitable health care is the civil rights issue of the 21st century, one that requires granular disaggregated data to address. She said that certain states have no disaggregated data on the status of Asian American, Native Hawaiian, or Pacific Islander communities, and often “we are still categorized as ‘other.’”

Choi explained that many systemic barriers to accessing care and health information are the basis for Title VI claims and complaints. She said that although the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has the power to enforce civil rights statutes and address the complaints it receives, its budget has been flat for over 20 years.

Additionally, Choi explained that language access is a proxy for national origin discrimination. She said that since 1992, NIH allocated 0.1 percent of its budget to Asian American, Native Hawaiian, and Pacific Islander research even though over 50 percent of Americans with hepatitis B are Asian Americans or Pacific Islanders, asking, “But do our health care providers, our hospital institutions, do our federal grants recognize this?” She urged health care providers, hospitals, and community-based organizations, among others, to raise awareness of the systemic barriers to accessing information, care, and resources.

Immigrant Health Care Perspective

Tanya Broder, senior attorney directing state and local policy work at the National Immigration Law Center, talked about immigrant access to health care and health insurance. Broder said that access to comprehensive health care for immigrants is critical to advancing health care equity, but they are subject to systematic barriers, including documentation and verification requirements, linguistic and cultural competence, and statutory exclusions. She noted that restrictive eligibility rules mean only a subset of lawfully present adults are eligible for Medicaid, and even they often must wait 5 years or longer before becoming eligible for the full scope of services.

Broder said that because immigrants and citizens often live together in families, these barriers and exclusions undermine access to care for the entire household. Families are most likely to enroll in insurance plans when all members can be insured, and barriers for parents often impede access for their children. Joint agency guidance, codified in the Affordable Care Act (ACA) and Medicaid regulations, states that unnecessary inquiries about immigration status or Social

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Security numbers deters mixed-status households from seeking services for which they are eligible, deprives them of equal access, and raises potential Title VI civil rights concerns.25 The health care provider community has led efforts to change restrictive policies by documenting the harm of excluding people from care, consequences when people are afraid to seek care, and benefits of investing in health for all. She added that even when policies improve, there is a continuous need to address confusion, dispel misinformation, and investigate abuses of the rules.

Broder said that since 1996, Congress has restored or expanded access to coverage for some immigrants, and federal agencies have issued guidance to address some barriers, but these actions are insufficient; federal legislative proposals and executive immigration policies could improve access to health insurance, and federal agencies could partner with community-based groups and health care providers to address practices that impede access to care. She urged federal agencies to improve transparency, publish complaints and settlements, and document how restrictions aimed at immigrants disproportionately harm communities of color.

How Health Law Affects Population Health

Dayna Bowen Matthew, dean and Harold H. Green professor of law at the George Washington University School of Law, said that the law can affect population health by addressing injustice—removing the unjust, unfair, and avoidable disparities in health care and SDOH. She explained that the 14th Amendment to the U.S. Constitution includes the equal protection clause, which protects against discrimination in health care. Matthew also emphasized that Title VI prohibits discrimination by anyone spending federal funds, including the health care industry. She presented cases26 in which the federal courts successfully pro-

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25 For more information, see https://www.nilc.org/issues/economic-support/state-online-snap-applications (accessed November 22, 2023).

26 For more information on some of the cases, see:

Cypress v. Newport News General Hospital (1967): https://law.justia.com/cases/federal/district-courts/FSupp/251/667/2249346 (accessed November 22, 2023).

Marabel v. Alabama Mental Health Board (1969): https://law.justia.com/cases/federal/district-courts/FSupp/297/291/2147439 (accessed November 22, 2023).

Coleman v. Aycock (1969): https://law.justia.com/cases/federal/district-courts/FSupp/304/132/1867757 (accessed November 22, 2023).

Battle v. Jefferson Davis Memorial Hospital (1976): https://law.justia.com/cases/federal/district-courts/FSupp/451/1015/1897070/#:~:text=Battle%2C%20a%20black%20physician%20residing,hospital%20and%20its%20governing%20board (accessed November 22, 2023).

Jackson v. Conway (1979): https://law.justia.com/cases/federal/district-courts/FSupp/476/896/1378686 (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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hibited discrimination based on various class actions by patients during the civil rights era.

Matthew explained that although Title VI and Section 1557 of ACA can be powerful tools to fight discrimination, the Supreme Court has been eliminating private causes of actions for disparate treatment. She said that its ruling in SFFA v. Harvard and SFFA v. University of North Carolina,27 which found the affirmative action programs of the two colleges violated the Equal Protection Clause of the 14th Amendment, is a nexus between health and population outcomes. She explained Justice Ketanji Brown Jackson’s dissent argued that facially race-blind policies produce race-based harms, as evidenced by disparate tax treatment, disparate location of environmental toxins, segregated highway locations, and gaps in wealth and education that combine to create health disparities. Matthew stressed that it would take law and medicine uniting to bring the civil rights actions needed to achieve health equity.

Overview of Section 1557 of ACA

Mara Youdelman, managing attorney of the National Health Law Program’s Washington, DC, office, presented an overview of the enactment of Section 1557, its scope, the intent underlying it, and its implementation since enactment in 2010.28 Youdelman said that Section 1557 is a broad nondiscrimination policy that reinforces the long-standing protections prohibiting discrimination by race, ethnicity, national origin, age, disability, and sex. The goal of Section 1557 was to bring all civil rights protections for health into one section. Youdelman explained that Section 1557 applies to any health program or activity administered by an executive agency, which includes HHS, the Department of Defense, the Departmentt of Veterans Affairs (VA), and federal employee health benefit programs. She said that HHS has focused on implementing and enforcing Section 1557, but other agencies have not yet done so. Section 1557 also applies to any entity

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Fobbs V. Holy Cross Health System Corporation (1994): https://casetext.com/case/fobbs-v-holy-cross-health-system-corp (accessed November 22, 2023).

Linton v. Commissioner of Health and Environment (1995): https://casetext.com/case/linton-by-arnold-v-comr-of-health-and-env (accessed November 22, 2023).

Resolution Agreement between HSS and the University of Pittsburgh Medical Center: https://www.hhs.gov/sites/default/files/ocr/civilrights/activities/agreements/upmcra.pdf (accessed November 22, 2023).

27 See https://www.supremecourt.gov/opinions/22pdf/20-1199_hgdj.pdf (accessed November 22, 2023).

28 See https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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created under Title I of ACA, which explicitly includes health insurance marketplaces and participating qualified health plans.

Youdelman explained that the Biden–Harris administration has proposed revisions to Section 1557 that would protect against discrimination based on gender identity, sex stereotypes, pregnancy termination, sexual orientation, and sex characteristics.29 The proposed revisions would require any entity subject to Section 1557 to provide notices that it will not discriminate and provide information about language access and how to access communication assistance for people with disabilities. This also includes provisions specific to Medicaid and marketplace regulations to explicitly extend nondiscrimination provisions based on sexual orientation and gender identity.

Youdelman noted that some of the challenges with the enforcement has been insufficient resources and staff and the varying enforcement priorities of different administrations. She said that to advance racial and ethnic health care equity, it is essential to have regulations that spell out how specific types of service providers should ensure that they do not discriminate, greater enforcement by OCR, more funding for enforcement, and comprehensive demographic data collection to identify inequities. Youdelman presented examples from ongoing work by the National Health Law Program and others to advocate under Section 1557 and how they have fared.30

DATA, MEASURES, AND RESEARCH TO ADVANCE HEALTH CARE EQUITY

Workshop speakers examined data and measurement needs to advance health equity research, discussed the use and effectiveness of health equity assessment tools, explored the gaps in existing research, and discussed opportunities for future research.

Leveraging Upstream Data

Randall Akee, associate professor of public policy and American Indian studies at the University of California–Los Angeles, shared an overview of innovations in data collection. First, he and his colleagues used cellphone traffic data to understand the impact of COVID-19 and related closures (Akee et al., 2023) and see the differential impacts of the shutdowns on access to resources and

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29 See https://www.federalregister.gov/documents/2022/08/04/2022-16217/nondiscrimination-in-health-programs-and-activities (accessed November 22, 2023).

30 For more information about ongoing work by the National Health Law Program, see https://healthlaw.org/our-work/policy (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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institutions. The findings suggest that reservation residents experienced a smaller reduction in visits to health care facilities compared to off-reservation residents.

Another source of data during the early months of the pandemic was social media postings about COVID-19 cases by tribal governments and tribal members (Weeks et al., 2022). Akee noted that for small populations, such as AIAN people, COVID-19 rates were hard to acquire because individuals were often categorized in the “other race” category in national or state datasets, so the data were unreliable.

Akee explained that this type of research can provide insights about what happens and how people respond to major events and what that might mean for longer-term impacts on the quality of health care and health maintenance. He encouraged researchers to partner with Indigenous leadership to determine how to collect data and use them for research. He noted the CARE Principles for Indigenous Data Governance,31 developed by the Global Indigenous Data Alliance,32 to guide how Indigenous data are collected, archived, accessed, disseminated, and publicized.

Leveraging Administrative Data

Cara James, president and chief executive officer of Grantmakers in Health, said that the 2003 Unequal Treatment report contained recommendations on standardizing data collection. Since that time, national publications using administrative data from the Centers for Medicare & Medicaid Services (CMS), CDC, and others have been generated, including the annual National Health Care Disparities Report and National Health Care Quality Report. Imputation models to account for missing data have advanced efforts to expand and create data standards for race, ethnicity, sex, primary language, and disability. James explained that those standards expanded the category granularity for Hispanic, Asian, Native Hawaiian, and Pacific Islander populations.

However, the 2003 data challenges remain, James said, with no standardized data collection on race and ethnicity and limited data on SDOH, although Medicare administrative data on race and ethnicity are fairly complete. For Medicaid, several states have challenges with data completeness, and the federally facilitated health insurance marketplaces and IHS have significant data shortcomings. She added that some datasets from the VA are complete. Despite multiple calls for more granular data, federal data standards have not been updated since 1997, but efforts are under way to update them by 2024.

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31 For more information about the CARE Principles, see https://www.gida-global.org/care (accessed November 22, 2023).

32 For more information about Global Indigenous Data Alliance, see https://www.gida-global.org/whoweare (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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James said that one challenge with administrative data is timeliness, which makes it difficult to incorporate data in real time into quality improvement programs. CMS produces stratified reporting of data outcomes, but consistently collected data are still lacking on SDOH. She said it would be essential for the federal government to take a role in developing guidance and standards for data collection and clarify regulations on data sharing to encourage employers and health care providers to share data with insurance plans and vice versa.

Leveraging Clinical and Biomedical Data with Artificial Intelligence

Peter Embi, professor and chair of the Department of Biomedical Informatics and professor of medicine and senior vice president for research and innovation at Vanderbilt University Medical Center, discussed the continuing advance and use of AI in health care and what is needed to ensure that AI tools are used equitably. Embi explained that because these tools are built and trained using health care–derived data, it important to ensure that those data reflect population diversity and recognize that they come from systems with their own biases and inequities. AI models are dynamic and apt to inherit the biases of the underlying data or the people developing them, making it imperative to have continuous monitoring and optimization.

Embi said that algorithms can have positive and negative effects on health equity, and the only way to know which is true for a given algorithm is to monitor its performance carefully and continuously and then adjust it as it drifts or has unintended consequences. Both known and unknown biases in data can cause an algorithm that works in one setting using data from a specific population to fail with another setting or population. He added that monitoring is necessary to promote trust among patients, clinicians, and health systems. Embi said that a possible monitoring model is the pharmacovigilance procedure that follows drug approval. Embi’s team is developing methods for what he called “algorithmovigilance,” the scientific methods and activities relating to evaluating, monitoring, understanding, and preventing adverse effects of algorithms in health care (Embi, 2021). Monitoring algorithms, he said, can enable a virtuous cycle of quality improvement, he concluded.

Race and Algorithms

Sendhil Mullainathan, professor of computational and behavioral science at the University of Chicago Booth School of Business, shared findings from two studies on race and algorithms to show how they can improve or exacerbate racial and ethnic health care inequities. First, Mullainathan discussed a study that examined the performance of a live algorithm used by many health systems to predict which patients with complex health needs require care coordination

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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(Obermeyer et al., 2019). Although the health systems thought it was predicting who would get sick, it was predicting costs because it was designed to focus on that as the outcome of interest. It was found to be favorably biased toward healthier White patients over sick Black patients because the system was predicting the need for care based on access to health care benefits. Black patients were significantly less likely to be identified for program enrollment than they would have been otherwise due to this bias. Mullainathan said that a fundamental issue with such algorithmic designs is the developer not fully understanding what they are building or the semantic context of the data they are using.

The second study that Mullainathan discussed applied a deep-learning AI approach to knee X-ray images to identify features within the knee joint that could explain the disparities in knee pain in Black populations (Pierson et al., 2021). It identified African American patients with knee pain who had not been diagnosed as having osteoarthritis using the Kellgren-Lawrence grading33 score. The researchers suggested that their results prove bias in diagnosing minority patients and also provide a path for correcting the problem.

Measuring Structural Racism in Health Equity Research

Brigette Davis, research scientist at the University of Minnesota School of Public Health, said that structural racism refers to the concept that systems, social forces, institutions, ideologies, and processes influence the societal environment that creates health inequities and allows them to persist. These higher-level forces interact and influence each other to reinforce inequity and are distinct from interpersonal discrimination. Davis said that all operationalizations of structural racism have been place based and focused on geography rather than individual experiences. However, researchers may not have access to the places or geographic units of analysis that align with the factors they are trying to capture when measuring structural racism.

Racial residential segregation has served as the primary metric for measuring structural racism, but Davis questioned whether it is proper to use an outcome of structural racism that way, enough to say inequities exist versus identifying the individuals and institutions that create inequitable environments and use them to allocate resources, and appropriate to use a singular measure of structural racism or a composite measure that includes multiple domains. She said that more research is needed to identify new ways of measuring structural racism.

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33 Kellgren-Lawrence grading (KLG) is a scoring system used to classify the level/severity of osteoarthritis.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Opportunities for New Research: Implementation Science Perspective

Lisa Cooper, Bloomberg distinguished professor and James F. Fries professor of medicine at the Johns Hopkins Schools of Medicine, Nursing, and Public Health, said that the field of health disparities science has garnered a great deal of knowledge on the related epidemiology and efficacious interventions. However, health care systems have yet to realize these advances because of an implementation gap. Implementation requires transdisciplinary research involving the science of dissemination and translation, which has not traditionally been in the realm of biomedical research.

Cooper noted the many different implementation frameworks used by implementation scientists and now health equity researchers (Cooper et al., 2021). She provided several examples to explain how the frameworks guide the process of taking research findings and translating them into routine practice or policy. She said that the frameworks can also yield insights into the key drivers of a successful implementation and can be used to evaluate success (Cooper et al., 2021). She emphasized that an implementation framework considers the role of community, intervention design, organizational, and patient factors in an intervention’s adoption, fidelity, cost, sustainability, and health benefits. Cooper shared the findings from a study that used an ecological model to review the effectiveness of multilevel interventions addressing health equity (Purnell et al., 2016). The study identified 15 knowledge and translation gaps that limit the use of evidence to reduce health care disparities. Lack of stakeholder engagement, for example, was a translation gap that occurred at all levels of the model. Cooper concluded that it is essential that future health equity interventions address these gaps. She briefly highlighted opportunities to advance health equity through policy implementation research in the areas of data collection, monitoring, and reporting; policies to improve access to care, value-based care, quality, and representation and inclusion in health care and clinical trials; and capacity-building policies and programs for organizations and the workforce (NASEM, 2023).

Opportunities for New Research: Community Engagement Perspective

Melody Goodman, professor of biostatistics, vice dean for research, and director of the Center for Anti-Racism, Social Justice, and Public Health at NYU School of Global Public Health, referenced the CDC definition of community-engaged research34 and said that it is a powerful vehicle for environmental and behavioral changes that can improve the health of a community

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34 Community-engaged research is defined as “a process that incorporates input from people who the research outcomes will impact and involves such people or groups as equal partners throughout the research process” (Yale School of Medicine, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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and its members. Goodman said that community engagement often involves partnerships and coalitions that help mobilize resources and influence systems, change relationships among partners, and serve as a catalyst for changing policies, programs, and practices (Goodman and Sanders Thompson, 2017). She added that community-engaged research helps to ensure that research is community centered and informed by the unique perspectives nonacademic partners have about their needs. It also increases the relevance of a study for nonacademic partners, supports the sustainability of an intervention once funding ends, builds capacity and trust among partners, leverages existing resources of the community and patients, and fosters reciprocal relationships between researchers and nonacademic stakeholders (Arora et al., 2015; Hall et al., 2006; Kagan et al., 2012; Khodyakov et al., 2013; Mainous et al., 2006; Sanders Thompson et al., 2021).

Goodman presented the findings from a systematic review that found that most of the applied measures of stakeholder engagement had not undergone comprehensive validation (Bowen et al., 2017). She presented data from another study showing that research to develop standardized, reliable, and accurate measures to assess stakeholder engagement is essential to understand its impact on scientific discovery and the scientific process (Goodman et al., 2019). Goodman also spotlighted the Research Engagement Survey Tool, which her team developed to examine the level of partner engagement in research studies (Goodman et al., 2022). She concluded that “stakeholder engagement is a science, and we really need to understand how it contributes to our scientific process and scientific discovery.”

Opportunities for New Research: Translational Research Perspective

Brian Mustanski, professor of medical social sciences, psychology, and infectious diseases and founding director of the Institute for Sexual and Gender Minority Health and Well-Being at Northwestern University, discussed challenges and opportunities in advancing research on gender minority populations to create interventions that prioritize their needs. Mustanski noted that intersectionality has been a major theme in research on SGM because some inequities are exacerbated or lessened in minoritized groups (Mustanski and Macapagal, 2023).

He explained that despite the growing body of research, many inequities in SGM health are increasing; research focused primarily on documenting the disparities has not reduced them. Mustanski argued that more research is needed on later stages of the translational spectrum to understand risk and protective mechanisms, develop and test interventions, and implement effective interventions. He stressed the need for multilevel interventions, presenting data on a meta-analysis of 193 studies that found that the cognitive, emotional, behavioral, and self-monitoring demands of concealing sexual orientation due to experienced or anticipated stigma was significantly associated with internalizing mental health problems (Pachankis et al., 2020). Mustanski suggested that it is critical

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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for implementation strategies to consider structural discrimination, and he called for more research on health outcomes beyond behavioral health and including SGM people in the research workforce using an intersectional lens. “One of the big challenges is workforce issues,” Mustanski concluded.

FEDERAL AGENCY INITIATIVES TO REDUCE RACIAL AND ETHNIC HEALTH CARE INEQUITIES

Leaders from federal agencies whose mandates are relevant to the committee’s task shared their experiences on federal efforts and initiatives aimed at reducing racial and ethnic inequities in health care access, use, and quality.

National Institute on Minority Health and Health Disparities (NIMHD)

Eliseo J. Pérez-Stable, NIMHD director, said that ACA requires all HHS operating divisions to have an Office of Minority Health (OMH). NIMHD has defined a health disparity as a health-preventable outcome that is worse in a given population compared to a reference group. He said that as part of its role in monitoring and coordinating research on minority health and health inequities at NIH, NIHMD designates populations with health disparities, noting that in 2016 NIMHD declared SGMs as a population with health disparities. A unifying factor in these designations is that social disadvantage results in part from being subjected to discrimination or racism and being underserved in health care.

Pérez-Stable said that the fundamental pillars of the science of health disparities at NIMHD are that race and ethnicity as identified by the individual person is a social construct, and socioeconomic status can be defined by different metrics. He said that NIMHD intends to continue to focus on the intersectionality of race, ethnicity, and socioeconomic status with populations designated as having health disparities and all other conditions and demographic factors. It will also reevaluate the use of a reference population in research. NIMHD sees race, ethnicity, and socioeconomic status as fundamental factors that influence human health and should always be measured with standardized metrics and considered as possible contributors to outcomes in any research.

Pérez-Stable presented data to show estimated life expectancy at birth by year and race and ethnicity group in the United States from 2000 to 2019 (Dwyer-Lindgren et al., 2022; see Figure 1). Life expectancy overall improved by 2.3 years, but among different race and ethnicity groups, improvements ranged from 0 years for the AIAN population to 3.9 years for the Black population and also varied widely at the county level. Socioeconomic status is also closely related to health outcomes, and the economic burden of health inequities is high (LaVeist et al.,

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×
Image
FIGURE 1 Estimated life expectancy at birth by year and racial/ethnic group, 2000–2019.
SOURCES: Eliseo Pérez-Stable presentation, September 6, 2023; Dwyer-Lindgren et al., 2022.

2023). A large proportion of this burden is due to premature death, and excess medical costs also account for a significant proportion in addition to lost labor market productivity.

Pérez-Stable described the NIMHD research framework, which specifies that health outcomes are determined by multiple factors (NIMHD, 2017). He suggested opportunities to advance racial and ethnic health care equity, including promoting diversity in the scientific and clinical workforce, cultivating community engagement and building trust for sustainable relationships, and developing standardized measures of social and demographic factors for use in research. He also called for more data scientists to get involved in health disparities research. He concluded by saying that it is essential to implement interventions with compelling evidence of effectiveness in populations that suffer the most from health inequities.

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)

Aditi Mallick, acting director of the CMS OMH, said that in 2022 CMS published a framework to further advance health equity, expand coverage, and improve health outcomes for the more than 170 million individuals supported by its programs.35 It consists of five priorities, which encompass both system- and community-level approaches to achieve equity across its programs. The first is expanding standardized data collection, reporting, and analysis. The second is assessing causes of disparities within programs and addressing inequities in policies and operations to close gaps. The third is building capacity of health care organizations and the workforce to reduce health care disparities. The fourth is advancing language access, health literacy, and culturally tailored services. The fifth is increasing all forms of accessibility to health care services and coverage. She noted that each of the priorities is complementary, and their integrated adoption and implementation is central to eliminating barriers to health equity for all.

Mallick said that CMS actions to address health care inequities include engaging a broad range of individuals and communities with lived experience in rural communities; producing communication toolkits and resources in 10 languages to help individuals and families enroll in and maintain coverage; proposing new coding and payment for services such as family therapists, mental health counselors, and addiction counselors who address unmet health-related social needs that can interfere with the diagnosis and treatment of medical problems; and prioritizing health equity in all its operations. She spotlighted the recently launched Advancing All-Payer Health Equity Approaches and Development36 as one model with a core focus on advancing health care equity. CMS is also increasing its focus on tracking and increasing the number of beneficiaries in value-based payment models and innovative models to add providers working in underserved communities. Mallick noted work to include race and ethnicity data on claims. That alone, however, will not solve the broader data problem, she added.

Health Resources and Services Administration (HRSA)

Onyekachukwu Anaedozie, deputy associate administrator for the HRSA Bureau of Primary Health Care, said that HRSA’s Health Center Program funds local health care centers that provide comprehensive, high-quality primary health

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35 See https://www.cms.gov/priorities/health-equity/minority-health/equity-programs/framework (accessed November 22, 2023).

36 See https://www.cms.gov/priorities/innovation/innovation-models/ahead (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

care services tailored to their communities, regardless of ability to pay. It also supports community-based providers that offer services consistent with its requirements but are not its grantees; these local health care centers play a pivotal role in improving health equity by expanding access to care in the most medically underserved communities. Over a 58-year history, the program has grown from two health centers to nearly 1,400 serving more than 30,500 patients at approximately 15,000 sites in every U.S. state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin.37

Anaedozie said HRSA is addressing inequities in maternal mortality rates by funding 35 health centers to implement innovative approaches to improve health outcomes and reduce disparities for patients with the highest risk,38 including offering bilingual doula services, leveraging health technology to reach rural patients, and providing culturally aware mental and behavior health care for pregnant people and their families. In addition, as part of its Diabetes Quality Improvement Initiative,39 HRSA selects about 50 health centers a year to receive technical assistance to improve care. Other activities that Anaedozie described include the National Million Hearts Initiative40 to improve cardiovascular health for all, the Health Center COVID-19 Vaccine Program,41 and HHS Bridge Access Program for COVID-19 Vaccines and Treatments42 to maintain broad vaccine access for millions of uninsured people. Anaedozie concluded that it is essential to tailor funding, training, and technical assistance opportunities in communities where inequities exist based on available data.

Department of Health and Human Services Office of Minority Health (HHS OMH)

Rear Admiral Felicia Collins, deputy assistant secretary for minority health and director of the HHS OMH, said that its mission is to improve the health of racial and ethnic minority populations by developing policies and programs that

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37 See https://bphc.hrsa.gov/about-health-centers/health-center-program-impact-growth (accessed November 22, 2023).

38 See https://www.hrsa.gov/about/news/press-releases/hrsa-address-maternal-health-crisis (accessed November 22, 2023).

39 See https://bphc.hrsa.gov/technical-assistance/clinical-quality-improvement/diabetes-health-centers (accessed November 22, 2023).

40 See https://millionhearts.hhs.gov/index.html (accessed November 22, 2023).

41 See https://www.hrsa.gov/coronavirus/health-center-program (accessed November 22, 2023).

42 See https://www.hhs.gov/about/news/2023/04/18/fact-sheet-hhs-announces-hhs-bridge-access-program-covid-19-vaccines-treatments-maintain-access-covid-19-care-uninsured.html (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

eliminate health disparities.43 She explained that the unifying goal is the success, sustainability, and spread of health equity-promoting policies, programs, and practices. Once successful policies, programs, or practices are identified, OMH works to catalyze their sustainability, spread, and scale by working with other HHS offices and partners to support longer-term implementation.

Collins explained that the unifying goal serves as an umbrella for three OMH strategic priorities. First, it prioritizes supporting states, territories, and tribal organizations in identifying and implementing health disparity-reducing policies, programs, and practices. Second, it supports advancements of the community-based workforce, including CHWs, peer-support specialists, and community health aides, to serve as a sustainable source of trusted messengers and social supports that promote improved health outcomes. Sustainable financing is needed to support the community-based workforce. Third, it prioritizes implementing culturally and linguistically appropriate services (CLAS), a foundational element for eliminating health disparities and promoting health equity. Collins emphasized that OMH continuously works with other HHS offices and partners. She concluded that the recently published National Academies’ consensus report, Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity (NASEM, 2023), funded by OMH, has reinforced the importance of sustained coordination among federal agencies, incorporating community voices in the work of government, ensuring representative and accurate data collection and reporting, and improving federal accountability, tools, and support to advance optimal health for all.

Indian Health Service (IHS)

Roselyn Tso, IHS director, said that its mission is to raise the physical, mental, social, and spiritual health of AIAN people to the highest level. She explained the three strategic goals on which the IHS mission is anchored. The first is to provide comprehensive, culturally appropriate personal and public health services that are available and accessible. The objectives of this goal include recruiting, developing, and retaining a dedicated, competent, and caring workforce; building, strengthening, and sustaining collaborative relationships; and expanding access to health care services. The second goal is to promote excellence and quality through innovation within the Indian health care system. The objectives include creating quality improvement capability at all levels of IHS and implementing culturally appropriate and effective clinical and public health tools to improve the health care needs of AIAN populations. The third

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43 See https://www.minorityhealth.hhs.gov/about-office-minority-health#:~:text=The%20mission%20of%20the%20Office,will%20help%20eliminate%20health%20disparities (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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goal is to addresses issues of management, accountability, communication, and modernized information systems to ensure quality and safe care. The objectives include improving the agency’s internal and external communication and modernizing information technology and information systems to support data-driven decisions.

Tso said that AIAN populations face a lot of challenges daily. She explained that biases, racism, discrimination, and stereotyping, and the challenge of recruiting, developing, and retaining a culturally respectful health care workforce perpetuate health care inequities, and the inequitable distribution of social resources creates challenges for deploying technology to address inequities. She added that geographic access, language barriers, and the unique cultural practices, which many health insurance companies disregard, also create challenges to providing health care. Despite all of these challenges, Tso said that IHS is working to ensure that its tribal and nontribal partners intend to provide safe and quality care. Tso stressed the importance of partnerships and said that IHS has partnered with VHA to provide health care for AIAN veterans.

Veterans Health Administration (VHA)

Ernest Moy, executive director of the VHA Office of Health Equity, said that VA has developed a three-pronged approach to broadly addressing health equity. First is creating a diverse and inclusive work environment, which builds the trust needed for true delivery of quality, equitable care. Second is identifying and addressing the unmet social needs that often underlie many health inequities. He noted that his office has supported the development of a veteran-centric screener for nine SDOH,44 incorporated into the EHR, to enable providers to take social needs into account when delivering clinical care. “This screen is currently being extended throughout our VA system,” he added. Third is eliminating disparities in clinical care. He said that VA data revealed that its overall quality of health care was higher than other health care organizations and inequities in clinical care were fewer but not zero (VA, 2023). He continued that the data also showed that redesigning processes for all veterans does not work. Rather, processes need to be tweaked or augmented for specific groups.

He explained that the VA is guided by an equity-guided improvement strategy for identifying specific groups receiving care in specific VA facilities who are not achieving equitable outcomes. In addition, Moy said that the VA has built equity explicitly into the high-reliability organization framework45 and calls

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44 See https://www.va.gov/HEALTHEQUITY/docs/ACORN_Screening_Tool.pdf (accessed November 22, 2023).

45 See https://www.hsrd.research.va.gov/publications/esp/high-reliability-org.pdf (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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that the “high-equity reliability organization framework,” which emphasizes the importance of considering the veteran perspective when analyzing and developing interventions and training deviation from high reliability. “If we don’t address a veteran’s social needs and disparities in care today, we will pay for it tomorrow when that veteran is sicker,” Moy concluded.

Office of the National Coordinator for Health Information Technology (ONC)

Micky Tripathi, ONC national coordinator, said that it is responsible for coordinating health information technology strategy across the federal government and promoting interoperability and the safe, effective, and equitable use of health information technology in the market. It also certifies EHR systems and adopts standards for clinical data across the health care delivery system.

Tripathi noted that the United States Core Data for Interoperability (USCDI) has increasingly become the minimum dataset of the health care delivery system. This wide adoption of standards provides an opportunity to consider health equity, and ONC has started work to build standardized data elements that will be required in all of these systems. He explained that through the annual processes to update the USCDI over the past several years, ONC has added data elements that are working their way through the regulatory process to be required in certified EHR systems. For example, EHR systems are required to support the CDC dataset for representing race, ethnicity, tribal status/affiliation, language, sexual orientation and gender identity, and SDOH, demographic groups, disability status, and cognitive status as data elements.

Tripathi said that in early 2023, ONC proposed in a draft rule a set of regulations about the transparency of AI-based systems in EHRs.46 He pointed out that the rules are not meant to regulate AI technologies but rather to provide enough information to determine whether a tool is appropriate for a specific circumstance. The rules would also mandate that AI tools include an ongoing measure that would indicate if they have drifted too far from the original test data and may no longer be appropriate. “We have a big focus on AI and transparency, particularly with an eye to the health equity dimensions, so that all users have the ability to assess whether AI-based technologies are appropriate to their setting,” Tripathi concluded.

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46 See https://www.healthit.gov/buzz-blog/health-it-policy/oncs-new-proposed-rule-the-next-step-to-advancing-the-care-continuum-through-technology-and-interoperability#:~:text=The%20proposals%20span%20the%20health,that%20supports%20public%20health%20and (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Department of Health and Human Services Office for Civil Rights (HHS OCR)

Melanie Fontes Rainer, OCR director, said that it enforces federal civil rights laws and conscience and religious freedom laws and is also the lead federal agency with respect to the HIPAA and HITECH Acts. She emphasized that OCR implements major policies around equity. It is also responsible for enforcing Section 1557 of ACA, which prohibits discrimination on the basis of race, color, national origin, age, disability, or sex.

In 2022, OCR relaunched the HHS Language Access Steering Committee to ensure that all HHS agencies evaluate and update their language access plans to ensure that individuals with limited English proficiency have access to programs. OCR released its first annual report on this in 2023. It summarized the progress HHS has made on improving meaningful access to language assistance services.47 Fontes Rainer said that with the unwinding of the Medicaid continuous enrollment provision that was implemented for the COVID-19 pandemic, OCR has launched independent compliance reviews on language access for individuals trying to rejoin Medicaid to help keep people from falling through the cracks and losing coverage. To amplify its efforts, OCR is working with CMS, HRSA, and IHS to leverage their networks, resources, and technical assistance to reach their covered entities. Moreover, Fontes Rainer said that OCR is responsible for enforcing Title VI. For example, it has opened compliance reviews and investigations into a number of health care providers across the country with respect to racial bias.

Office of Management and Budget (OMB)

Robert Sivinski, senior statistician in the Office of the Chief Statistician of the United States and chair of the Interagency Technical Working Group on Race and Ethnicity Standards, discussed likely updates to Statistical Policy Directive 15 (SPD-15), a set of government-wide standards OMB maintains that determine how the federal government collects race and ethnicity data.48 SPD-15 in now undergoing revisions to reflect the nation’s demographic composition as part of the federal government’s responsibility to enforce and monitor civil rights laws. SPD-15 was first established in 1977 and last revised in 1997.

Sivinski explained the Interagency Technical Working Group’s responsibilities and pointed out that the proposed revisions to SPD-15 would combine the current race and ethnicity questions into a single framework to eliminate confusion among Hispanic respondents that affects data quality. The Census

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47 See https://www.hhs.gov/sites/default/files/language-access-report-2023.pdf (accessed November 22, 2023).

48 See https://spd15revision.gov (accessed November 22, 2023).

Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
×

Bureau’s testing found that Hispanic and Latino respondents were more comfortable with the combined question. The revisions would add Middle Eastern or North African as a new minimum category separate from the White category, something advocates have been asking for since the 1980s. The proposal would also require agencies to collect more detailed information beyond the minimum dataset and would eliminate terms that might become outdated, such as removing the words ‘minority’ and ‘majority’ from the text of the standard.

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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Suggested Citation:"Proceedings of a Workshop." National Academies of Sciences, Engineering, and Medicine. 2024. Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/27448.
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Next: Appendix A: Statement of Task »
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A National Academies committee hosted a public workshop series in 2023. Speakers invited by the committee discussed the current state of racial and ethnic health care disparities in the U.S., highlighted major drivers of health care disparities, provided insight into successful and unsuccessful interventions, identified gaps in the evidence base and proposed strategies to close those gaps, and considered ways to scale and spread effective interventions to reduce racial and ethnic inequities in health care. This workshop series is part of an ongoing consensus study examining the current state of racial and ethnic health care disparities in the U.S., building on the 2003 Institute of Medicine consensus report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The consensus study will publish its full conclusions and recommendations in summer 2024.

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