Diversity, Inclusion, and Health Disparities in American Healthcare

How Health Disparities Arise

Health disparities are present in almost every area of healthcare: “When there is new technology that appears to benefit society, those with more resources and socioeconomic privilege have more access to those interventions. Black adults and families disproportionately occupy the lower end of the socioeconomic spectrum, so there is often exacerbation of inequality, paradoxically, even if there is overall progress,” shares Dr. Bruckner. 

“In the late 1980s surfactants, which helps accelerate lung maturation in premature infants, tended to be used more often for White babies relative to Black babies, for reasons we’re not really exactly sure of. So you had overall you had a general reduction of infant mortality and neonatal mortality for both Black and White babies, but the rate of the decline was faster for White infants.”

“In my research on SIDS, we had a very low-tech public health intervention that was to put your child to sleep on their back. It’s totally different from surfactants because surfactants are administered in high intensive care NICU with high costs, whereas the back-to-sleep position costs virtually nothing. However, even that appeared to benefit White infants more than Black infants, and there’s a variety of discussions as to how that might have happened,” continues Dr. Bruckner. “One argument is that information was disseminated and acted upon more quickly. Another is that Black families are more likely to have intergenerational households. So let’s say if your grandmother’s taking care of your child while you’re working, they might not have adopted the back-to-sleep message as a parent would because of cultural expectations about how to put a child to sleep.”

Health disparities tend not only to follow racial differences but also fall along socioeconomic boundaries. “Healthcare access differs dramatically by place. To the extent that you have an uneven distribution of healthcare across place that often goes across socioeconomic lines, you will inevitably get racial disparities in access to care,” explains Dr. Bruckner. “For example, high-level NICUs tend to concentrate in high-income or urban areas with a smaller minority population.”

Causes of Health Disparities

Health disparities in the US are caused by various factors, including social, economic, and environmental inequities. These disparities are often seen in access to healthcare, quality of care, and health outcomes. Not only do racial and ethnic minorities experience a lower quality of healthcare than non-minorities due to systemic racism and discrimination, but people with lower incomes or who live in rural areas may have limited access to healthcare services or resources.

Many times unconscious bias can affect the quality of care delivered by providers: “One recent paper looked at the racial composition of a provider team, and found worse birth outcomes and increased maternal morbidity if nobody on the provider team was Black. It’s not really clear what the mechanism is because we rarely have information on a patient-provider interaction,” shares Dr. Bruckner. 

Unfortunately, increasing the number of patients with health insurance doesn’t necessarily solve the disparities: “When we expanded Medicaid dramatically because of Obamacare, we didn’t see a huge reduction in disparities What expanding Medicaid did was more people got healthcare, and it reduced the amount of money they had to spend on healthcare. In terms of actually improving lifespan or reducing disparities…that research shows the results are pretty modest to no effect.”

Another cause for the care disparity can be associated with a patient’s insurance: “Sometimes there can be a lower quality of care because Medicaid physicians get paid less and maybe only have 15 minutes of time to spend with the patient,” says Dr. Bruckner. “To the extent that minorities and low-income families are on Medicaid relative to private insurance, the care they receive can be affected.”

Cultural factors can also play a part in the disparity of care. “Black Americans tend to over-rely on the emergency rooms for psychiatric care because there might be stigma in utilizing preventive or routine mental health care. They might delay seeking care until there is an emergency, but emergency psychiatric care is not deemed the best modality because it doesn’t promote continuity of care. Emergency rooms are great at triaging patients but are not necessarily the ideal place to get screened for depression, or to have mental health evaluations to determine which medication you might benefit from,” shares Dr. Bruckner.  

Changes in the overall economy can also exacerbate already existing health disparities. “I’ve studied economic downturns and health outcomes are worse when the economy tanks because Blacks disproportionately occupy jobs that are more likely to be precarious during recessions,” explains Dr. Bruckner. “And so, some of these disparities tend to get worse when you have economic shocks that affect people on the lower income end of the spectrum.”

How Health Disparities Are Being Addressed

Fortunately, many initiatives are being taken to reduce health disparities. The Healthy People 2030 initiative seeks to reduce health disparities by focusing on social determinants of health such as poverty, education level, employment status, and access to healthcare services. 

Additionally, organizations such as the American Medical Association (AMA) are working to improve access to quality care for all patients regardless of race or ethnicity. This includes initiatives such as increasing diversity in medical schools and providing physician cultural competency training.

California has become a national leader in tackling neonatal care disparities with the California Perinatal Quality Care initiative: “They started by collecting data on the disparity first, to really document what’s going on, and then they worked on standardized procedures that address that particular disparity.  One way they do this is by reducing physician choice by developing a standard operating procedure in how you deliver care. This reduces variance across physicians and facilities,” explains Dr. Bruckner. “California is on the leading edge in terms of reducing overall maternal morbidity and mortality associated with childbirth because of this. They’ve been one of the only states to dramatically reduce disparities in maternal morbidity and mortality.” 

As previously noted, access to care doesn’t always mean that underrepresented populations will receive it, but telemedicine is being explored to reduce disparities. “I think telemedicine could be a wonderful thing for mental health care for so many reasons. It reduces the financial barriers and the transportation barrier to seeing a provider. It could also potentially destigmatize having to get a visit because it can be done discretely from home,” shares Dr. Bruckner. “Utlizing just a phone…might reduce the unconscious bias that physicians exhibit when they’re screening patients and looking at their skin tone.” 

Lastly, Dr. Bruckner believes that addressing the physician shortage in the US will profoundly impact the healthcare disparities in this country. He advocates for radical solutions to bridging this gap. “We could easily double the amount of physicians we have in the US if we just allowed foreign physicians to pass a test, come to the US, and practice. The US has the most onerous medical school training,” he argues. 

“The American Medical Association essentially restricts the supply of physicians on purpose so that their salaries remain high. No other country has salaries as high as physicians do in the US. There’s no global shortage of healthcare providers. What we’re really talking about is a distribution issue. We can affect big change by reducing barriers to licensing care workers. The system that we’ve created replicates these inequities of healthcare access and providers across the country.”