Why Health Equity Matters in an Era of Health Care Transformation

Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

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Daniel E. Dawes, JD, Executive Director of Government Relations, Policy, and External Affairs, Morehouse School of Medicine and author of 150 Years of ObamaCare
For more than 150 years, advocates have been waging campaigns for health equity in this country. Relying primarily on moral arguments, these campaigns have tackled inequities in racial and ethnic minority health, women’s health, mental health, children’s health, veterans’ health, rural health, and most recently LGBT health. While these various campaigns have faded in and out of the public’s focus for more than a century and a half, the health equity movement as a whole has become increasingly mainstream in recent years and is finally a national priority. The reason for this is simple: Equity has become more than just a moral issue. Today, it is a legal and an economic issue as well—supported by both Republicans and Democrats at federal and state levels.

In fact, it was 30 years ago under the Reagan administration that the federal government initiated efforts to prioritize, in law and policy, issues affecting the health of underserved populations and the disparities experienced by these groups. Every successive administration since then has continued to prioritize this issue by either enacting bills into law, establishing new programs, or including it in national strategies. In 2001, former U.S. Senate Majority Leader William H. Frist (R-Tenn.) pledged to prioritize health equity in the 108th Congress and “focus on the uninsured and those who suffer from health care disparities that we so inadequately addressed in the past.”

Health equity means giving patients the care they need when they need it. Or as the Institute of Medicine (IOM) report put it, health equity means “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”

“This increased federal focus on value-based care, combined with new data and metrics made available through EHRs, provides incredible opportunities for integrating care, improving quality, and achieving health care equity in every community.”

Daniel Dawes, JD, Morehouse School of Medicine

Savvy academic medical centers, public policymakers, insurers, and clinicians have finally realized that health equity—or the lack thereof—increasingly affects the bottom line. It is no surprise that higher rates of chronic and costly conditions, combined with high rates of uninsured individuals among lower socioeconomic and minority populations, result in a greater reliance on emergency services, higher treatment costs, and, ultimately, a financial strain on providers and government programs. We know that preventive medicine and early interventions save money and lives.

In each administration since Reagan’s, our policymakers also have recognized the compelling governmental interest in elevating the health of all populations in the United States. In 2010, the Affordable Care Act (ACA) further prioritized equity as a legal requirement by including 62 provisions specifically designed to reduce and eliminate health disparities among racial and ethnic minorities and other vulnerable populations. Yet each year, approximately $300 billion and countless lives are lost because of health care disparities. With the elections now behind us and a new administration and Congress before us, there will be new challenges and opportunities to advance public laws and policies that prioritize health equity.

ACA provisions align with health equity

Under the ACA, insurers participating in the federal exchanges are required to reward health care providers for programs that reduce health disparities. The law also bolstered opportunities to engage community health workers in health systems across America, established grant programs aimed at eliminating health disparities, and required tax-exempt hospital providers to conduct meaningful community health needs assessments. In addition, the ACA established six new offices of minority health at federal agencies that are tasked with ensuring new federal regulations incorporate health equity measures, and elevated the National Center on Minority Health and Health Disparities to an institute at the National Institutes of Health. Other requirements expanded protections to both clinicians and consumers, especially to those who have experienced discrimination in health care, including women, minorities, people with disabilities, and the LGBT community.

The adoption of electronic health records (EHRs) under the American Recovery and Reinvestment Act as well as the ACA has strengthened data collection and reporting for race, ethnicity, sex, primary language, and disability status. This makes it easier to identify disparities in care and underperforming treatments among different populations. Additionally, there is also a push to include more minorities in clinical trials and strengthen comparative effectiveness research to ensure medical devices and drugs are inclusive of these populations so providers will be able to make more informed decisions about treatments for diverse patient populations.

Make no mistake: The changes brought forth by the health reform law are working. Since 2013, when the bulk of the ACA took effect, 3 million African Americans, 4 million Latinos, and nearly 9 million white adults got health insurance. During that same period, nearly 4 million young adults became insured. These historic gains in coverage have lowered the U.S. uninsured rate to 8.6 percent, down from 16 percent when the ACA passed in 2010. But the next step is equity in the quality of care, and Congress’ passage of the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 helped to accelerate that process.

MACRA reauthorized many of the ACA provisions that were expiring and repealed Medicare’s sustainable growth rate in favor of a new Quality Payment Program, which includes the Merit-Based Incentive Payment System to increase quality of care across the country. This federal focus on value-based care—rather than a volume-based payment system—increases the incredible opportunities for integrating care, improving quality, and achieving health care equity in every community.

Recognizing health equity as a value

Health systems are paying attention to disparities in the quality of their care and seeking remedies as health care costs rise and consumers demand action. They are doing so not just because it is the right thing to do, but because the financial incentives are increasingly aligning, the legal requirements are there, and their bottom lines benefit.

Those institutions and clinicians that do not recognize the importance of achieving health equity in their communities and reducing costs related to health inequity, will struggle more and more in the years ahead as our nation moves toward a health system that is more accessible, equitable, cost effective, and person centered.  While there is uncertainty about the fate of the ACA beyond the insurance coverage, health disparities cannot be ignored by the new administration and congress since they will continue to be a major contributing factor to health care costs and have major implications for our country in the future.