Over the course of its history, the United States has experienced dramatic improvements in overall health and life expectancy, largely as a result of initiatives in public health, health promotion, disease prevention, and chronic care management. Our ability to prevent, detect, and treat diseases in their early stages has allowed us to target and reduce rates of morbidity and mortality. Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities (blacks, Hispanics/Latinos, Native Americans/Alaskan Natives, Asian/Pacific Islanders) have benefited less from these advances than whites and have suffered poorer health outcomes from many major diseases, including cardiovascular disease, cancer, and diabetes. These disparities highlight the importance of recognizing and addressing the multiple factors that impact health outcomes, including structural racism, social determinants of health (SDOH), access to care, and health care quality. On this last point, research has revealed that minorities may receive less care and lower-quality care than whites, even when confounders such as stage of presentation, comorbidities, and health insurance are controlled. These differences in quality are called racial and ethnic disparities in health care. These health care disparities have taken on greater importance with the significant transformation of the U.S. health care system and value-based purchasing. The shift toward creating financial incentives and disincentives to achieve quality goals makes focusing on those who receive lower-quality care more important than ever before. This chapter will provide an overview of racial and ethnic disparities in health and health care, identify root causes, and provide key recommendations to address these disparities at both the clinical and health system levels.
NATURE AND EXTENT OF DISPARITIES
Life expectancy at birth is an important measure of the health of a nation’s population. Although the overall life expectancy in the United States has been increasing since 1900, differences due to race/ethnicity, education, and socioeconomic status have persisted. For example, at every level of education and income, African Americans have lower life expectancy at age 25 than whites and Hispanics/Latinos. Blacks with a college degree or more education have lower life expectancy than whites and Hispanics who graduated from high school. Blacks have had lower life expectancy compared to whites for as long as data have been collected. From 1975 to 2003, the largest difference in life expectancy between blacks and whites was substantial (6.3 years for males and 4.5 years for females) (Fig. 10-1). The gap in life expectancy between the black and white populations decreased by 2.3 years between 1999 and 2013 from 5.9 to 3.6 years (4.4 years for males and 3.0 years for women) (Fig. 10-2).
Life expectancy at birth among black and white males and females in the United States, 1975–2003. (Adapted from S Harper, J Lynch, S Burris, GD Smith: Trends in the black-white life expectancy gap in the United States, 1983-2003. JAMA 297:1224, 2007.)