By improving the understanding of health and health care disparities and differing cultural beliefs and values throughout the United States, stronger and more open communication between health care providers and their patients will form, further assisting the policymakers in tearing down the walls of disparities and providing more effective, efficient, and excellent health care to all individuals. The United States health care system must focus on enhancing the knowledge of cultural diversity and the targeted populations, as well as gain an understanding of the specific social determinants of health that surround them, so that the system can be free of such health disparities among its diverse population. Despite the ongoing clinical research, there has been continued growth of disparities in the United States health care system, thus a combination of ideas will need to be pooled in order to minimize these health disparities. Therefore, the authors will discuss health disparities in the United States, specific health disparities that are among us today, how they affect the U.S. health care system as well as the health care providers, and what initiatives are being put into place to address such disparities.
Addressing Health Disparities
One of the most unique qualities that the United States possesses is its immense diversity within the population. In many ways, a diverse population is beneficial to the nation as a whole; however, there are a number of challenges that arise when a population is as diverse as the one that exists within the United States today. A major challenge that adversely affects a large portion of the United States’ population is the existence of disparities in health care. The elimination of disparities requires the acknowledgement of inequities, and discussion about inequities will lead to a massive reduction in disparities. Gaining an improved understanding of health care disparities will lead to a more open and valuable communication between health care providers and their patients, further assisting policymakers in tearing down the walls of disparities and providing higher quality health care that is accessible to all.
Because health care disparities are such a significant reflection of some of the major flaws within the United States health care system, an accurate definition and a thorough analysis of the topic are vital components in breaking down these flaws and improving the overall quality of health care. Promoting factually based discussion and proper education on the subject is the first step in making these changes. To properly analyze the effects of health care disparities, it is essential to have a broad understanding of what defines health care disparities. There is no single definition that encompasses all of what is included in health disparities. The past decade or so has been a time of repeated trial and error when it comes to defining health care disparities in their entirety. Health care is a dynamic industry, and it is vital that the elimination of disparities is one of the next changes to be made. In order for this necessary change to come about, it is essential that the population is presented with adequate information so that they are able to firmly grasp the concept of what defines health disparities. In 2012, the Institute of Medicine published an Unequal Treatment Report defined health care disparities as “all differences except those due to clinical need and preferences” (Cook, McGuire ; Zaslavsky, 2012). This definition is effective in highlighting the fact that disparities equate to differences, but that fact is only part of the full concept that defines health care disparities. This definition is flawed in that it is rather ambiguous; as such, it leaves much of the topic still undefined. The Healthy People 2010 initiative defined health disparities as including “differences that occur by gender, race or ethnicity, education or income, disability, living in rural localities, or sexual orientation (Braveman, et al., 2011). This definition takes a step in the right direction by demonstrating a more expansive perspective regarding what health disparities include. In listing the factors that are the root causes of the disparities that occur, this definition provides a more transparent perspective on how disparities originate. The main flaw in this definition is that it lacks a necessary emphasis on how these disparities affect individuals in a negative manner.
The derogatory connotations that these health care disparities stem from is an essential part of what defines the disparities themselves. A more accurate definition would address the negativity that is associated with the differences caused by these factors. In 2015, the United States Department of Health and Human Services defined a health disparity as “a type of difference in health that is closely linked with social or economic disadvantage” (Thomas & Smith, 2017). This is potentially the best definition that has been proposed thus far. This take on defining health disparities is key in addressing both the broadness of concepts and the negative association in a concise manner. Addressing both subjects allows for an accurate definition that gives a clear explanation of exactly what health disparities are. The term “disadvantage” serves to highlight the negative association that comes with the differences in health, and the concise phrasing of “social or economic” provides a simple and efficient explanation of the individuals affected by disparities without the subject being lost in a long list of specifics. Overall, this definition touches on all of the important points of the aspects of the topic and paints a simple and clear picture of what health disparities are.
In addition to finding an accurate definition to display what health disparities are, it is equally as important to express what they are not. It is essential to distinguish disparities from inequities to better understand what disparities are and are not in the field of health care. Inequities in health are “specifically impacted by social, economic, and environmental conditions or influences” (Johnson, 2015). Health disparities are the consequences that appear because of inequities. While these two terms can be confused easily and mistakenly used interchangeably, they have distinct differences that must be acknowledged in order to gain a thorough understanding of disparities. Inequities refer to the actions and influences; disparities are the results that display evidence of inequities.
In the United States today, there has been steady improvements in the quality of care and overall health for most of the population. However, not all Americans are benefiting due to the effects of health and health care disparities. Johnson stated that “while individual choices and genetic factors are barriers to achieving the full health potential, the concept of health disparities focuses on the social and political factors surrounding certain groups” (2015, p. 574). These specific groups amongst the population can be classified as being underserved, disadvantaged, or underprivileged, and Shi and Singh believed that the roots of such “vulnerability are largely attributable to unequal social, economic, health and geographic conditions” (2017, p. 269). In order for the health care community and policy makers to reduce the status of health and health care disparities, it is important for them to recognize the many causes and risk factors and that “vulnerability is determined by a convergence of predisposing, enabling, and need characteristics” (Shi & Singh, 2017, p. 270).
In 2015, the United States population was estimated at a total of 321 million people (NCHS, 2017). This statistic can be further broken down to show the differences in certain populations that better explain the status of health and health care disparities. There are certain predisposing characteristics that increase the vulnerability of these specific groups in the United States population. Some of these characteristics include race and ethnicity, gender and age, and geographic location. The United States’ rapidly growing population is becoming increasingly more diverse, consisting of 61.6% white, 12.4% black or African American, 17.6% Hispanic or Latino, 5.4% Asian, and 3.0% of all other races (NCHS, 2017). With the minority populations increasing, health and health care disparities are becoming more recognizable. Different minorities and people of color experience greater obstacles to health, which is historically linked to discrimination or exclusion, and therefore, there are significant differences in health for many of the races and ethnicities (Dubay, 2012, p. 608). Shi and Singh explain that compared to whites “there is evidence that suggests that racial/ethnic minorities generally have poorer access to health care, receive poorer quality care, and experience worse health outcomes” (2017, p. 272).
In relation, obesity is also a negative health outcome that affects racial and ethnic minorities disproportionately. According to Taveras, et al., “Many early life risk factors for childhood obesity are more prevalent among blacks and Hispanics than among whites and may explain the higher prevalence of obesity among racial/ethnic minority children (2013, p. 371).Taveras et al also came to the conclusion that “although childhood overweight and obesity rates may have plateaued in some US population subgroups, such as non-Hispanic whites and those of higher socioeconomic status, overall rates remain high, and racial/ethnic and socioeconomic disparities seem to be widening” (2015, p. 732). Chronic conditions that are related outcomes of obesity include heart disease and cancer, which are also two of the leading causes of death across race and ethnicity as well as gender.
Gender is another predisposing characteristic associated with disparities in health care. Out of the United States population in 2015, it was estimated that there were 158 million males and 163 million females (NCHS, 2017). Specific disparities affect men and women differently, and Baker et al. determined that” health outcomes among men continue to be substantially worse than among women, yet this gender-based disparity in health has received little national, regional or global acknowledgement or attention from health policy-makers or health-care providers” (2014, p. 618). Due to chronic diseases such as heart disease, cancer, and diabetes being more prevalent in men, the life expectancy for men is much lower, being at 76 years, compared to women, which is at 81 years (NCHS, 2016). Men also tend to have a higher uninsured rate compared to that of women because men have not historically qualified for Medicaid (NASEM, 2016). Although it has been determined that most diseases affect men more than women, there are certain mental illnesses such as anxiety disorders and major depression that affect twice as many women as men (Shi ; Singh, 2017, p. 276).
Higher risk of obtaining either a disease or a disability comes along with aging. Health and health care disparities between the young and the elderly is greater than to be desired. Jecker stated that “in light of their higher rates of disease and disability, it is not surprising that older people consume on average a far greater share of a nation’s healthcare spending than younger people” (2017, p. 145). Although more money may be spent on the elderly, there is a lack in quality of such health care. Although the need for not only improving the well-being and care for minorities and minors is vast, there is also a call for for improving the health care that is provided for the elderly.
The final predisposed characteristic that will need to be addressed in determining the status of health disparities is demographic location. In 2015, The National Center for Health Statistics conducted a study which estimated that 14.6% of the population, about 46 million individuals, lived in rural areas and roughly 85.6%, about 275 million individuals, lived in urban areas. Although a higher number of individuals live in urban areas currently, rural areas have a higher incidence of disparities because they have not made the same efforts as urban areas in improving population health. Compared to urban areas, rural communities have higher rates of preventable conditions, such as obesity, diabetes, cancer, and injury, as well as higher rates of related high-risk health behaviors, such as smoking, physical inactivity, poor diet, and limited use of seat belts (Crosby, 2012). However, urban communities should not be disregarded when addressing health and health care disparities in the United States. In urban areas, there tend to be influences on health outcomes due to poor housing, unhealthy food choices, more pollution, and unclean water. Even though “individuals have little control over these predisposing attributes,” these aspects contribute to enabling and need characteristics that determine vulnerability (Shi ; Singh, p. 272).
Enabling characteristics and need characteristics also play critical roles in determining the status of health and health care disparities amongst the U.S. population. Enabling characteristics include income status, education level, employment status, and use of health care services (Shi ; Singh, 2017, p. 279). These factors play hand in hand with each other. For example, low-income may cause a lack of insurance which will result in barriers to accessing care, poorer quality care, and worse health outcomes. In a study that examined health outcomes, it was studied that despite being of the same race and ethnicity, individuals with a higher income were “found to be in better health, to engage in healthier behaviors, to have greater use of general health and dental services, and to receive more timely screening for cancer and other health conditions,” compared to individuals with a low income (Dubay, 2012, p. 621). An individual’s education level and employment status increasingly influence health outcomes as well as present barriers in receiving access to as well as the ability to fund their health care. Shi and Singh stated that “the uninsured are likely to be poorer and less educated than insured populations and tend to work in part-time jobs and/or be employed by small firms” as well as seem to be younger individuals, between 25 and 40 years old, because Medicare covers majority of those above 65 (p. 279). Even though policymakers have allowed for more people to become insured, they still need to recognize these factors that allow health care disparities to persistently exist in the U.S. health care system.
As explained by Shi and Singh, “need attributes of individuals include their self-perceived or professionally evaluated health status and quality-of-life indicators” (2017, p. 283). A need characteristic that tends be overlooked is the disability status of United States citizens, which is an estimated 18.7% of the population (Brault, 2012). Majority of the disabilities that individuals have in the United States are either acquired at conception or developed later in life. Living with a disability shapes an individual’s experiences as well as views of the social, economic, and environmental determinants of health, which can “present barriers to accessing health care services and navigating the health care system” (WHO, 2016). Health and health care disparities exist across multiple chronic, acute, and preventable disease processes including diabetes, cancer, cardiovascular disease, HIV/Aids, and obesity (Thomas, 2014, p. 7493). The United States is estimated to have spent over $300 billion per year on health due to the increase in the prevalence of chronic diseases, which have in turn raised concerns about not only an increase about “quality of life and life expectancies” but also in regards to these expanding expenses (Shiavo, 2015). The United States health care system has continued to primarily center the focus on treating acute illnesses. A combination of these predisposing, enabling, and need factors will continue to place limitations on furthering improvement in overall quality of care and population health, which will in turn cause the United States unnecessary costs while widening the equity gap and encouraging the status of disparities.
In order to truly abolish health and health care disparities, there is a necessity for health care policy makers to have a deep understanding of the causes of such social inequalities and health disparities that are currently present in the U.S. (Thurman and Harrison, 2017). Despite ongoing clinical research, there is continued growth of disparities in the health care system, thus a combination of ideas will need to be brought together in order to minimize these health disparities. Although evidence is mixed, it has been studied that managed care organizations are more responsible for defined populations; therefore, they are superior for concentrating on disparities, which requires a population approach to health care (Franks ; Fiscella, 2008). To truly make successful utilization of all the available resources, it is essential to consider social circumstances and inequalities among individuals. The aim is “to reverse the systemic and personal factors which contribute to the failure of the U.S. health care system to meet the needs of diverse patient groups,” resulting in the drastic reduction or, ideally, the elimination of health care disparities (Butler ; Freedy, p. 207). By understanding certain relationships, the United States can develop the proper policies to reduce the previously explained disparities in health care. There is the idea that by improving the knowledge of cultural differences and then communicating and addressing these socioeconomic disparities between the providers and patients, the United States health care system has a greater ability to provide higher quality of care to each and every individual. Betancourt determined that a new health care system was justly needed and within reach, and furthermore, describing the ideal system as one that was “culturally competent, equitable, ethical, and high quality” (2014, p. 147).
Sir William Osler once said, “The good physician treats the disease, the great physician treats the patient with the disease.” The United States health care system must be more focused on enhancing our knowledge of cultural diversity and the targeted populations, as well as gain the understanding of the specific social determinants of health that surround them, so that it can be free of such health disparities among its diverse population. The cultural difference between individuals and health care providers increases adverse health outcomes due to misunderstandings from cultural differences and beliefs, thus causing “less patient participation and providers viewing those encounters more negatively” (Franks ; Fiscella, p. 674).
Studies suggest that effective communication may play a critical role in reducing inequity among the different ethnicities. Warner and Washington explain that policies that allow for better understanding of health care and stronger patient-provider communication will provide minorities with a higher quality of care that is also more easily attainable as well as less expensive (2011). Health care providers must educate themselves on the beliefs of the patients that they serve and how those cultures could possibly affect their health care and health outcomes. Because of the cultural diversity that encapsulates the United States, the medical education community to revamp their teaching methods to instruct on how patients with differing cultural backgrounds and how those individuals may require modification in regards to approaching and managing their health concerns (Vaughn et al., 2009). Exposing medical students to the societal implications of health disparities has proven to be successful in altering knowledge. Vanderbilt, et al. suggested that in order to minimize the gap, medical students must be educated and obtain clinical understanding involving “interactive awareness experiences to become mindful of implicit bias; clinical rotations and electives focused on serving diverse communities and quality improvement projects that focuses on healthcare disparities throughout their years in medical school” (2016, p. 2). Hardoby and Mann agreed that “education in cultural competency can play a key role in achieving the goals of improving the quality of care for minority patients and the development of strategies to reduce racial and ethnic disparities in the medical encounter;” and, also stated that policies should be put in to place to order current physicians are to be educated on cultural competence and health disparities, particularly in relation to their community, in order to preserve their licensure (2013, p. 828).
Along with enhanced communication among health care providers and their patients, the need for higher quality and quantity of health care, primarily preventative care, must come into play. Primary care physicians have been considered the gatekeepers, or the coordinator of an individual’s health care. Because of the decrease in availability of primary care physicians, minorities have been at an even greater disadvantage with trying to receive basic health care. The need for an increase in primary care physicians is higher as it was estimated that 32 million individuals, who were previously uninsured, will have health insurance coverage and therefore, they will be in need of preventative care (Betancourt et al., 2014). It has been proven that there has been a “consistent effectiveness at improving long term health outcomes for disadvantaged children and families, related benefits into adulthood, and are cost effective” with preventative care stemming from childhood health care (Thornton et al, 2016). Because of the need for improvement in the delivery of preventative care, the Affordable Care Act stepped in and supported several different programs (Hamel et al., 2015). The ACA aimed to cover preventative care and “there is considerable interest in understanding how this enhanced coverage of preventive services will impact the use of preventive care and health outcomes” (Sommers & Wallace, 2016).
It is evident that health care in the United States has evolved over hundreds of year from a primitive, unsterile, inexpensive trade to the complex multitrillion dollar industry that it is today. The question that remains is how does the U.S. give the highest quality of health care to the largest population of people and in the fairest manner? One of the reasons a centralized health insurance system has previously failed is because “middle class Americans have been adverse to higher taxes to pay for the increased cost of a national health program” (Shi & Singh, 2017, p. 68). A significant issue that has continued to hold still is the lack of health insurance coverage for all individuals. Hardoby and Hamm simply explain that an individual’s race or ethnicity definitely plays a part in receiving health care, particularly higher quality health care and that “due to these reasons, efforts to maintain and expand health insurance coverage should be a major component of any strategy to reduce racial and ethnic disparities in care” (2013, p. 831). As previously explained, the lack in public and community health care facilities is directly linked to the decrease of health care access, quality care, and health outcomes among minorities.
Even though there are already health reforms and legislation that try to identify and reduce disparities, it has been proposed that “future efforts should focus on identifying gaps where existing measures and program efforts are insufficient, enhancing implementation of existing measures, and addressing barriers to their development or implementation” (Ng et al., 2017). Because major factors such as cultural beliefs and values, social factors, science and technology, economic forces, and political factors have shaped United States’ health care, it is essential then that the U.S. health care system concentrate and invest in the social and environmental factors that contribute to inequality, specifically income inequality, and its impact on the health of the underprivileged. To cancel out the negative effects of such social determinants, Shi and Singh discuss individual level interventions that can be accomplished (2017, p. 48). It was determined that “altering individual behaviors that influence health is often the focus of these individual targeted interventions, and numerous theories have been promulgated to identify the complex pathways and barriers to eliciting changes or improvements in behavior” (Shi & Singh, p.48). Such findings have been useful in formatting strategies for combating social-related disparities. Because the self perceptions of a social tier have placed not only a negative social outcome and have lead to a poorer result in one’s health, it is important to know the social determinates among the more susceptible groups in order to improve the United States’ health system and be able to resolve the disparities.
As previously discussed, specific health disparities are not commonly addressed. As stated by Baker et al. in relation to gender-specific disparities, United States’ poly makers and researchers usually are more focused on studying such related issues in terms of either specifically about women or primarily geared towards women, never both or towards men (2014). In moving forward against such disparities, it is suggested that “any serious effort to improve public health must include attention to the health needs of both sexes and responsiveness to the differences between them” (Baker et al., p. 619). According to Taveras, et al., “efforts to reduce obesity disparities should focus on preventing early life risk factors” (2013, p. 731). Disparities related to childhood obesity could possibly be explained by factors beginning in an individual’s infancy and early childhood and that reducing such related factors, disparities having an effect on childhood health and obesity could therefore be decreased (Taveras, et al., 2013). In discussion of specific health disparities, Myers et al. “suggest the need for public health policies and interventions that account for different regional characteristics underlying obesity prevalence variation across the United States” (2015, p. 486).
Efforts to reduce health care disparities and mold such a system have primarily been brought on by both the Department of Health and Human Services (HHS) Disparities Action Plan, which desired to provide equal access to each and every American, as well as the Affordable Care Act (ACA), which aimed to improve access to health insurance (Gostin et al., p. 19). Although it is a very controversial health care reform and there are many kinks in relation to the ACA, it can be thought of as a footstep in the development of the future plans rather than end goal to solving the United States health care system (Colander, 2017). The basic issue with the United States health care system is that health care costs an astronomical amount and many individuals do not have the appropriate access to this care. Although escalating health care costs and the need to reduce such is what drove the U.S. to a health care reform, a major flaw with “the ACA is that it tries to deal with the U.S. health care problem as an insurance problem, when in fact the fundamental problem with the U.S. health care system is a cost and accessibility problem” (Colander, p. 173). Currently, the U.S. health system is a jumbled mess of the following systems that do not mix effectively: “If government pays, experts appointed by government decide what health care will be available to individuals, and how much government will pay for it. If individuals pay, then individuals decide. If insurance companies pay, then insurance companies decide” (Colander, p. 174). The hope for this new health care reform was also to strengthen the current quality of health care being distributed among the population, specifically those in low income communities. As stated before, there have been many flaws in the Affordable Care Act, but it has also expanding health care coverage to those who did not have access to such care previously. The goal for redesigning the health system is to not only reduce the previously discussed disparities but to primarily improve the quality of health care and aptly distribute such care based upon need.
As the United States continues to become more diverse, it needs to be understood that each culture brings its own beliefs and values which may differ from our traditional or set ways. It is essential then that the U.S. health care system concentrate and invest in the social and environmental factors that contribute to inequality, specifically income inequality, and its impact on the health of the underprivileged in order to drastically improve the United States health system and have the ability to resolve any gaps in care. Times are changing and currently, the United States is substantially more diverse than ever. The effects of cultural beliefs and social changes have definitely been responsible for molding the U.S. health care system. The differences in the beliefs about health care that are at play have had a direct effect on the health care delivery system, and providing care to the different socioeconomic groups is a necessary plan for reducing health inequalities. Therefore, it is indispensable to create a health system that has the ability to provide high quality care to every patient, regardless of any of the reasons discussed.