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date: 17 January 2018

Health Disparities

Abstract and Keywords

Despite technological advances and changes in healthcare delivery, some groups in the United States continue to have better health-related outcomes than others. This article discusses health disparities—differences in health status and healthcare utilization that are influenced by complex social structural, economic, and cultural factors. Illustrations are offered of health disparities found among diverse populations in this country. The “problem” with health disparities is then explored. From an ethical standpoint, health disparities can be seen as unjust. From a cost perspective, health disparities exact not just a financial toll that is borne by society, but individual, group, and community consequences, as well. From a human rights vantage, health disparities can further disadvantage people who are already vulnerable and marginalized—health disparities can cost people their lives. Factors contributing to health disparities, commonly referred to as social determinants, are reviewed. Finally, future directions, including social workers’ role as advocates, are considered.

Keywords: health, health disparities, diverse populations, racism, social determinants, social justice

Health Disparities

The development of social and economic inequalities based on race and ethnicity has been a central theme—and a central dilemma—of the history of the United States.

— (Pedraza & Rumbaut as cited in Byrd & Clayton, 2003, p. 458)

Since the 1980s, a great deal of attention has been given to racial and ethnic differences in health status and access to healthcare. United States government officials interest in this issue was first signaled by the release of a report by the Department of Health and Human Services (HHS) on the nation’s health, Health, United States, 1983 (Gibbons, 2005). Gibbons (2005) noted that despite improvements, “major disparities existed in ‘the burden of death and illness experienced by blacks and other minority Americans as compared with the nation's population as a whole’” (e50 [p. 2]).

Margaret Heckler, the Secretary of HHS, created a secretarial task force to investigate the health problems of America’s racial and ethnic minorities. At its conclusion, the secretarial task force released a report entitled Report of the secretary’s task force on black and minority health [hereafter Heckler Report]. In her introduction to the report, Secretary Heckler acknowledged that, for members of minority groups, “the stubborn disparity remained—an affront both to our ideals and to the ongoing genius of American medicine” (U.S. Department of Health and Human Services [DHHS], 1985, p. ix). The secretarial task force defined disparities as “excess deaths,” and identified “cancer; cardiovascular disease and strokes; chemical dependency, measured as deaths due to cirrhosis; diabetes; homicide and accidents (unintentional injuries); and infant mortality” as the primary health conditions giving rise to excess deaths among members of minority groups (DHHS, 1985, pp. 3–4).

Since the release of the Heckler Report, the phrase health disparities has come into common parlance among public health officials, medical and social science researchers, program administrators, healthcare providers, and social work practitioners. The phrase has been applied widely, encompassing not just physical health conditions or diseases, but also mental health and dental health. Yet, although the term is widely used, there is no single definition of what is meant by a health disparity. Defining the concept of health disparity requires answering a number of questions that are not primarily of a technical nature, but that instead involve values, preferences, ideologies, and politics (Carter-Pokras & Baquet, 2002).

Defining Health Disparities

There will always be differences, if only in a statistical sense of distributional variation. A variety of factors can contribute to differences, especially in the realm of health. To understand what a health disparity is requires first deciding if the term means something other than simply difference, which has been considered value-neutral (Klick & Satel, 2006). If health disparities are understood as something more than mere variations, then two additional questions need to be resolved: Disparities of what? and Disparities for whom?

Are disparities simply differences?

In 2003 the Institute of Medicine (IOM) published a landmark report: Unequal treatment: Confronting racial and ethnic disparities in health care (Smedley, Stith, & Nelson, 2003). The report crystallized long-standing concerns about differential health status outcomes among racial and ethnic groups in America and cast those differences as health disparities—differences rooted in bias, racism, stereotyping, and discrimination, especially on the part of medical care providers and the healthcare system more generally. Although some critics (see, e.g., Klick & Satel, 2006) objected to this characterization, arguing that the language was “charged and divisive” (Klick & Satel, p. 59) and contributed to a false view of the problem, an understanding of health disparity as a difference with a normative meaning has come to be widely accepted.

According to Braveman (2014), Braveman, Kumanyika et al. (2011), and the Kaiser Family Foundation ([KFF], 2008), disparities are not matters of individual choice or statistical distributions of disease, but are systematic and systemic, and result from and in differences that are biased (Association of State and Territorial Health Officials, 2012; Commission on Social Determinants of Health [CSDH], 2008; Office of Disease Prevention and Health Promotion [ODPHP], n.d.a). Health disparities arise from social causes—factors built in to the cultural, social, economic, historical, and political structures of United States society. Miranda, McGuire, Williams, and Wang (2008) argued that “any inequality in health due to social factors or allocation of resources is unjust and, therefore, constitutes a disparity” (p. 1102). To highlight the unfair and avoidable nature of these differences, the phrase health inequity has been gaining currency (Adler & Stewart, 2010; Koh et al., 2010), with the term health equity being used to represent the intended goal (Braveman, 2006, 2014). As such, government policy can, and should, play a role in the eradication of health disparities (IOM, 2012).

Disparities of what?

Accepting that health disparities are something more than simple differences then requires specification of the dimensions along which health disparities occur. That is, are morbidity and mortality the principal indicators of health disparities or are there other dimensions that should be assessed as well? Some definitions of health disparity hone in on differences in individual and group health status and health outcomes, whereas others also include differences in healthcare access and usage (Adler & Stewart, 2010; Braveman, 2006; Carter-Pokras & Baquet, 2002).

The first approach is exemplified by the Minority Health and Health Disparities Research and Education Act of 2000, which formulated disparities in terms of “disease incidence, prevalence, morbidity, mortality or survival rates” (p. 2498). In contrast, the United States Health Resources and Services Administration defined health disparities in terms of “a population-specific difference in the presence of disease, health outcomes, or access to care” (as cited in Carter-Pokras & Baquet, 2002, p. 430). A third approach was adopted by Ubri and Artiga (2016), who resolved the what question by distinguishing “health disparities” and “health care disparities,” defining the former in terms of “illness, injury, disability, or mortality” and the latter as involving “health insurance coverage, access to and use of care, and quality of care” (p. 2).

Disparities for whom?

A definition of health disparity also needs to indicate which groups are being assessed and how they are being compared. Initial articulations of health disparities in the 1980s focused on African American and other racial and ethnic minority groups in comparison to the majority Caucasian population (DHHS, 1985). Much work in the area of health disparities in the United States continues to focus on people of color (Braveman, 2006) and to contrast health indicators for people of color with those for the general population (Minority Health and Health Disparities Research and Education Act of 2000) or for the white population (Braveman, 2006).

However, the scope of attention has expanded over time to include other groups. The United States is becoming a much more diverse society, and there is increasing recognition that a variety of “isms” constrains the rights, life circumstances, and health of various population groups. Thus, for instance, Healthy People 2020, the national agenda which establishes decade-specific national health objectives and measurable data-collection activities, proposed that health disparities can exist in relation to “religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (ODPHP, n.d.a, Disparities section, para. 5), as well as in relation to race and ethnicity. Similarly, Ubri and Artiga (2016) argued that in addition to racial and ethnic disparities in health and healthcare, “they [disparities] occur across many dimensions, including . . . socioeconomic status, age, location, gender, disability status, and sexual orientation” (p. 1).

Moreover, investigations of health disparities have come to assess within-group (Schwartz & Meyer, 2010) as well as between-group comparisons (Artiga, Young, Garfield, & Majerol, 2015). It is important to consider within-group differences when conducting health disparities research because no single population group is homogeneous (Ubri & Artiga, 2016). The health of individuals within a given racial or ethnic group can vary by socioeconomic status, country of origin, or length of residency in the United States. Thus, for example, Vega, Rodriguez, and Gruskin (2009) examined health disparities among specific subgroups within the Hispanic population, whereas Meara, Richards, and Cutler (2008) investigated mortality and life expectancy of Caucasians and African Americans in relation to gender and education.

In what follows, a definition of health disparity consistent with that of Healthy People 2020 is employed. Health disparities are differences that have meaning. They are associated with “social, economic, and/or environmental disadvantage” (ODPHP, n.d.a, Disparities section, para. 5) as well as with historical and cultural forces that give rise to discrimination and exclusion. Further, health disparities include not only indicators of disease incidence, prevalence, morbidity, and mortality, but also measures of engagement in health-promoting behaviors as well as healthcare access, utilization, and quality.

Why Care About Health Disparities?

There are several reasons why social workers should care about health disparities. First, social work professionals have commitments to service, social justice, cultural competence, and social diversity (National Association of Social Workers [NASW], 2008). These ethical imperatives direct attention to situations that are discriminatory, that constrain people’s ability to exercise self-determination, or that limit individuals’ capacity to participate fully in society. Health disparities easily meet these criteria—they can, in fact, rob people from already vulnerable populations of their very lives. Thus, there is a professional imperative that focuses social workers’ attention on the issue of health disparities.

Second, social work has a long history of involvement in health concerns, dating back to the turn of the 20th century (NASW, 2016). Social work in healthcare remains a robust field of professional practice. In 2015, for example, 16% of MSW programs in the United States offered a health track as a field of study, with an additional 5% offering integrated health or behavioral health as a field of study; 18% of programs offered a joint public health degree (Council on Social Work Education, 2015). A survey of NASW members found that 14% were employed in the healthcare sector, making it the second most common arena of social work practice (Whitaker & Arrington, 2008). NASW (2016) has specified 13 standards for social work healthcare practice, a reflection of the importance and complexity of this field of practice and the profession’s “leadership role in the psychosocial aspects of health care” (p. 5).

Third, health disparities exact costs. Individuals, communities, and society as a whole pay a high price for the existence of health disparities. Health disparities can limit the nation’s ability to realize improvements in people’s health and in the quality of healthcare services (Ubri & Artiga, 2016).

Finally, the social determinants of health, which impact health disparities, are based in our social environment. In part, the core foundation of social work practice is knowledge acquisition required to understand the inter-relationship between human behavior and social environment.

Individual, Group, and Community Costs

The costs of health disparities can easily be identified in relation to health status, death rates, life expectancy, and healthcare expenditures (Edberg, 2007; Hanlon & Hinkle, 2011; Health Affairs, 2011). Diverse populations groups in the United States experience health status disparities in relation to a variety of chronic and acute health conditions. For example, rural residents, compared to those in urban areas, are more likely to characterize “their health as fair or poor” (Florence, Pack, Southerland, & Wykoff, 2012, p. 56). They display poorer health in general and a greater likelihood of chronic illnesses than do their urban counterparts (Rural Health Information Hub, n.d.). Adults living in rural parts of the United States are more likely than urban residents to experience obesity, with the proportion experiencing obesity increasing in relation to the degree of rurality. Furthermore, obesity is an issue not just for rural adults; fully a third of children in rural areas are obese (Florence et al., 2012).

Health status also varies in relation to socioeconomic status, with poorer individuals having poorer health (Wolfe, 20112012). Lower socioeconomic status is linked to a variety of behaviors that increase the risk of cancers (e.g., smoking, lack of exercise, obesity); poorer individuals also are less likely than more affluent persons to follow through on cancer screening suggestions (National Cancer Institute, 2015). Moreover, growing up in poor families can be detrimental to children’s health. Childhood poverty is associated with more frequent asthma attacks, shorter stature, and increased risks of cardiovascular disease, hypertension, and pulmonary disease in adulthood; children from poor families also are more often identified as having behavioral problems or depression (Pascoe, Wood, Duffee, & Kuo, 2016).

Many disparities in health status have been identified in relation to race and ethnicity. For example, American Indians and Alaskan Natives have the worst 5-year cancer survival rates, compared to all other racial/ethnic groups for all types of cancers (National Cancer Institute, 2015). People of color, compared to their white counterparts, have had a “higher prevalence of diabetes, stroke, and other largely preventable diseases and conditions” (Health Affairs, 2011, p. 1). Between 2011 and 2014, Hispanic children and adolescents had the highest prevalence of obesity, in contrast to African American, white non-Hispanic, and Asian children and adolescents. During that same period, African American men and women were more likely than those of other racial and ethnic groups to suffer from hypertension. From 1999 to 2013, infant mortality rates were highest among African American women (National Center for Health Statistics [NCHS], 2016). In 2014, African American women, compared to women of other racial or ethnic backgrounds, had the highest percentage of preterm births (NCHS, 2016).

Health disparities also reduce the life expectancy of some Americans. Those born in 2014 in the United States have a life expectancy of 78.8 years, which has not changed since 2012 (Kochanek, Murphy, Xu, & Tejada-Vera, 2016). However, life expectancy varies across groups. Analysis of data from 2001 to 2014 for individuals ages 40 to 76 found that longevity increased as income increased. Compared to that of the wealthiest 1%, the life expectancy of the poorest 1% was 14.6 years shorter for men and 10.1 years less for women (Chetty et al., 2016). Further, Chetty et al. (2016) found that life expectancy differences have increased over time, with greater gains in life expectancy going to those with more income. The Harvard Gazette, in announcing the publication of the Chetty et al. study, summed up the findings by saying: “Being poor in the United States is so hazardous to your health . . . that the average life expectancy of the lowest-income classes in America is now equal to that in Sudan or Pakistan” (Reuell, 2016).

Singh and Siahpush (2014) reported that those residing in rural areas have a shorter life expectancy than their urban counterparts, with the difference widening over time. And although the gap has closed, African American men’s lives are still shorter than those of non-Hispanic white men or women or African American women (Powell, Adams, Cole-Lewis, Agyemang, & Upton, 2016). In fact, in international comparisons, United States life expectancy fell from seventh place in 1980 to 27th in 2009 (Robert Wood Johnson Foundation, 2014).

Financial Costs

In addition to the above, the burdens of poor health, chronic illnesses, and shorter life spans have financial implications. For instance, health problems in childhood, including untreated vision and hearing problems, can limit school participation, increase absenteeism, and decrease academic achievement. These factors, in turn, can make it harder to achieve economic success later in life (Case, Fertig, & Paxson, 2005; Rossin-Slater, 2015). Children in poor health are more likely also to have poor health as adults, and their health status as adults adversely affects their economic status (Adler & Stewart, 2010).

Health disparities among adults can restrict labor force participation and earnings. Employee absenteeism, lost productivity, and premature workforce departure are just some of the consequences of health disparities. According to Ayanian (2015), the annual toll on the United States economy of health disparities based on race is “$10 billion in illness-related lost productivity, and nearly $200 billion in premature deaths” (para. 4).

Increased healthcare expenditures are another consequence of health disparities. Most often examined are the economic effects of health disparities related to race and ethnicity. For example, “if non-Hispanic Blacks had had the same adjusted rate of preventable hospitalizations as non-Hispanic Whites from 2004 to 2007, it would have resulted in . . . $3.4 billion in savings” (Hanlon & Hinkle, 2011, pp. 1–2). Hanlon and Hinkle (2011) estimated that for the period 2003 to 2006, healthcare expenditures due to racial and ethnic health disparities were $229 million, with an additional economic loss of $1 trillion. Waidmann (2009) estimated that in 2009, “disparities among African Americans, Hispanics, and non-Hispanic whites . . . cost the health care system $23.9 billion dollars” (p. 1). Waidmann also projected that racial and ethnic health disparities would cost $337 billion over the period 2009 to 2018, with annual costs rising to “$50 billion by 2050 as the representation of Latinos and African Americans among the elderly increases” (p. 1).

Social Determinants of Health: Factors Contributing to Health Disparities

A variety of factors influence health and health disparities. Determinants of health disparities are shaped by income, power, and global, national, and local resources (CSDH, 2008). According to Healthy People 2020 (ODPHP, n.d.b), a broad array of social, economic, and political factors influence health and health disparities. Health is affected not only by individual-level characteristics, such as biology, genetics, and personal behaviors, but also by “policymaking, social, and health service” characteristics (ODPHP, n.d.a, Determinants of Health section para. 4). Other factors that impact health and health disparities include unequal treatment of people of color, lack of diversity among healthcare providers, lack of insurance and access to care, communication barriers, low health literacy, stereotyping, and poor-quality healthcare (American Medical Association, 2005).

Researchers, policymakers, and practitioners refer to the social determinants of health to highlight the factors that both give rise to health disparities and are amenable to intervention. Social determinants of health involve the “conditions in which we are born, grow, live, work, and age” (CSDH, 2008, p. 1). These conditions include, but are not limited to, the social environment, the physical environment, the built environment, the economic environment, and the health systems environment (ODPHP, n.d.a), domains that interact in complex ways to facilitate positive and negative health status outcomes (Centers for Disease Control and Prevention [CDC], 2014).

Healthy People 2020 identified five critical domains of social determinants:

  • Economic stability

  • Education

  • Social and community context

  • Health and health care

  • Neighborhood and built environment (ODPHP, n.d.b, Social Determinants of Health section, para. 11)

Influence of Economic Factors

Poverty is a well-known driver of health problems and health disparities in the United States (Beckles & Truman, 2013; Health Affairs, 2011) as well as internationally (CSDH, 2008). Adults in the United States who live in poverty are more likely than their economically better-off counterparts to rate their health as fair or poor, to experience worse health, and to have more functional limitations. Despite their health problems, poor adults, compared to those with higher incomes, are more likely to delay or not receive dental care, medical treatment, or prescription medications because of cost (Wolfe, 2015). In 2013, people living in households with incomes at or below the federal poverty threshold reported having less access to and lower-quality healthcare than those in higher-income households (Agency for Healthcare Research and Quality, 2016). Yet “although socioeconomic status accounts for a large portion of health disparities, race/ethnicity is an added burden that is linked to poor health” (IOM, 2012, p. 19). Kawachi, Daniels, and Robinson (2005) argued for considering race and class as separate but interacting factors affecting health disparities.

The relationship between economic status and health during childhood also is well documented (Currie & Reichman, 2015). Children from lower-income families, in contrast to their more prosperous peers, are more likely to be in poorer health and to have more severe health problems. Even when poorer and wealthier children have the same health problems, poorer children do worse (Case & Paxson, 2006). “Differences in social advantage can influence health both over lifetimes and across generations” (Braveman, Egerter, & Williams, 2011, pp. 388–389).

Further, economic instability can precipitate problems with housing and nutrition. As income declines, so do housing quality and food security, defined as “access by all people at all times to enough food for an active, healthy life” (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2015, p. 2). “Inadequate and unhealthy housing disproportionately affects the populations that have the fewest resources (e.g., persons with lower income and limited education)” (Raymond, Wheeler, & Brown, 2011, p. 24). Inadequate and unhealthy housing exposes residents to a variety of potential health risks, ranging from mold to lead paint to unsafe electrical wiring (Raymond et al., 2011). Similarly, nutrition and food security remain problems in the United States (Coleman-Jensen et al., 2015; Grimm, Moore, & Scanlon, 2013), and those who are nutritionally deprived are vulnerable to a number of diseases and health problems (Neff, Palmer, McKenzie, & Lawrence, 2009).

Influence of Educational Factors

Educational attainment and income are intertwined. Individuals with lower educational attainment (and lower incomes) often lack the personal and concrete resources needed to shield themselves from health risks (Beckles & Truman, 2013). “Increased rates of mortality, morbidity, and risk-taking behaviors and decreased access to and quality of health care” are more often a challenge of those with less education and less income (Beckles & Truman, 2013, p. 15). In fact, there has been a growing gap in life expectancy between those who have a high school degree or less and those who have post-high-school education, with all life expectancy gains during the 1980s and 1990s being experienced by people with higher educational attainment (Meara et al., 2008).

Influence of Social and Community Factors

Social and community factors that contribute to health disparities include such things as lack of social cohesion and social capital, limited involvement in the life of the community, and discrimination and exclusion. Resources produced through social relationships (i.e., social capital) can promote health by providing individuals with access to social support, linkages, and resources (Gilbert, Quinn, Goodman, Butler, & Wallace, 2013). Engaging in reciprocity—helping others, for example—has been found to enhance a person’s health. Moreover, feeling positive about, and participating in, the life of the community have been shown to be health enhancing (Gilbert et al., 2013). According to Batista and Cruz-Ledón (2008), civic engagement in the form of volunteering is associated with better physical and mental health for older adults.

Discrimination, bias, and prejudice have been predominant explanations for disparities in health and healthcare, especially disparities related to race and ethnicity (Williams & Mohammed, 2009). Racism has a long history in the United States and continues to cast a shadow on contemporary events, including healthcare and health status (Braveman, Egerter et al., 2011). The infamous Tuskegee syphilis study is a commonly cited example of racial prejudice infecting the healthcare and public health systems (Feagin & Bennefield, 2014). Twenty-five years after the Tuskegee study was terminated, President Bill Clinton issued a public apology, noting:

It was a time when our nation failed to live up to its ideals, when our nation broke the trust with our people that is the very foundation of our democracy. It is not only in remembering that shameful past that we can make amends and repair our nation, but it is in remembering that past that we can build a better present and a better future . . . So today America does remember the hundreds of men used in research without their knowledge and consent . . . To our African American citizens, I am sorry that your federal government orchestrated a study so clearly racist. That can never be allowed to happen again.

(The White House, Office of the Press Secretary, 1997)

Interestingly, Brandon, Isaac, and LaVeist (2005) found that although mistrust of medical care varied significantly between African Americans and whites, knowledge of the Tuskegee study did not predict medical care mistrust.

More recently, Skloot’s 2010 book, The immortal life of Henrietta Lacks, recounted the experiences of Mrs. Lacks and her family—a very human story built on a scaffolding of questionable ethics, racism, poverty, and miscommunications. Diagnosed with cervical cancer in 1951, Mrs. Lacks, a poor African American mother of five, received radiation treatment at Johns Hopkins Hospital, and it was during her treatments that cell samples were taken from her cervix without her knowledge, no less her consent. When Mrs. Lacks died on October 4, 1951, neither she nor her family had any inkling that her cells would go on to gain worldwide fame as HeLa, a line of immortal cells (i.e., capable of being reproduced in the laboratory) that would play a pivotal role in the development of “most important vaccines and cancer medications, in vitro fertilization, gene mapping, cloning” (Skloot, 2013, para. 1). Little thought was given to surviving family members in the decades that followed—to their health, well-being, or privacy. Six decades after her death, an agreement was reached in August 2013 between members of the Lacks family and the National Institutes of Health on how to protect the family’s privacy and how to involve the family in decision-making on the use of the HeLa genetic material (Caplan, 2013).

Discrimination, bias, and prejudice also contribute to mental health problems, substance abuse, and suicide among lesbian, gay, bisexual, and transgender individuals, who all too frequently are subject to violence and victimization (ODPHP, n.d.b). Similarly, Chrisler, Barney, and Palatino (2016) contended that older women’s healthcare experiences are negatively influenced by the joint effects of ageism and sexism. Johnson, Fitzgerald, Salganicoff, Wood, and Goldstein (2014) argued that men and women experience diseases differently and that more research focusing on illnesses among women needs to be undertaken.

Influence of Health System Factors

Attributes of the healthcare system itself can contribute to health disparities. Health insurance is an important facilitator of access to, and use of, healthcare services. For both adults and children, having health insurance coverage is associated with improved access to preventive, primary, and specialist care services as well as better management of chronic conditions. Having health insurance matters to health: “uninsured adults with asthma, cancer, COPD, diabetes, heart disease, or hypertension are at least twice as likely as their insured peers to say they were unable to receive care or had to delay receiving a needed prescription” (IOM, 2009, p. 65). Lack of health insurance can exacerbate the challenges experienced by already vulnerable populations. For example, those residing in rural areas, in contrast to urban dwellers, have been less likely to have health insurance (Florence et al., 2012). People of color also have been less likely to have health insurance, even if a member of the household was working full-time (KFF, 2013).

Disparities related to race and ethnicity as well as to socioeconomic status are found in access to, and quality of, healthcare (Agency for Healthcare Research and Quality, 2016). Gender differences exist, too. For instance, in contrast to male substance abusers, women who abuse alcohol or drugs have a harder time accessing substance abuse and mental health treatment programs (Substance Abuse and Mental Health Services Administration, 2016). According to King et al. (2008), language barriers, communication barriers, sociocultural differences, and stereotyping inform patient–provider interactions and can result in adverse health outcomes for patients and greater health disparities.

People living in rural America face particularly daunting hurdles to obtaining medical care. Although about a quarter of the nation’s population resides in rural areas, less than 10% of the country’s doctors are located there. Further, travel times are often lengthy; public transportation is limited at best, and often nonexistent; and privately owned cars can be expensive to operate (Florence et al., 2012). Healthcare costs can pose an additional barrier. Rural residents “on average spend 20% more out of pocket on health care than their urban counterparts”; not surprisingly, perhaps, adults living in rural areas more often report putting off medical care because of costs (Florence et al., 2012, p. 55).

Even when medical care can be accessed, differences in the timing and types of treatments received can produce health disparities. For example, although similar proportions of African American and white women reported having mammogram screenings, African American women, compared to their white counterparts, received later follow-up services and different healthcare interventions. “Black women are 40% more likely to die of breast cancer than white women” (CDC, 2012, second bullet). In addition, between 1999 and 2014, African American women, compared to women of other racial/ethnic groups, had the highest percentage of low-risk cesarean deliveries (NCHS, 2016).

Influence of Neighborhood and Built Environment Factors

Finally, health disparities can result from characteristics of the neighborhood and built environment. The built environment includes land use and zoning, open spaces and parks, locations of grocery stores and other consumer-oriented businesses, employment settings, health clinic and hospital locations, and transportation (Frank, Kavage, & Devlin, 2012; Russell, 2011). In recognition of its potentially deleterious influence on health, the Federal Collaboration on Health Disparities Research, established in 2006, cited “the built environment as one of the top priorities for eliminating health disparities” and established the Built Environment Workgroup with the charge of “promoting research and collaboration . . . to examine how conditions related to socio-economic factors may affect the health of disadvantaged and vulnerable populations” (Hutch et al., 2011, p. 587).

Poorer, more racially/ethnically segregated neighborhoods frequently impose limits on residents’ choices, locking them into failing schools, inadequate (or no) supermarkets, dilapidated housing, and limited transportation options. Such communities can be detrimental to residents’ health because they often lack “health-enhancing resources,” while having a surfeit of “conditions that present health risks” (IOM, 2012, p. 11; see also Braveman, Egerter et al., 2011). Impoverished neighborhoods can harm children’s health, “above and beyond individual- and family-level factors” (IOM, 2008, p. 27).

Poor neighborhoods can be unhealthy places. Living in a neighborhood characterized by high rates of crime and disorder can be stressful (Russell, 2011). Curry, Latkin, and Davey-Rothwella (2008), in a study of current and former drug users in Baltimore, Maryland, found that respondents’ perceptions of neighborhood disorder and experiences of violence contributed to depression. Exposure to neighborhood crime and violence may be especially detrimental to children’s mental health and may have long-term effects, including post-traumatic stress and major depression in adulthood (Lowe et al., 2016).

Where people live can also expose them to environmental hazards that negatively affect health and increase health disparities. “Environmental racism,” or the “intentional siting of hazardous waste sites, landfills, incinerators, and polluting industries in communities inhabited primarily by minorities and the poor” (Russell, 2011, p. 34), contributes to many health problems, and may be particularly detrimental to the health of infants and young children, although individuals of all ages can suffer adverse health consequences. Environmental conditions—water, air, or ground pollution, for instance—are often worse in African American and lower socioeconomic urban neighborhoods (Health Affairs, 2011). The American Lung Association (2016), for example, has argued that “the burden of air pollution is not evenly shared. Poorer people and some racial and ethnic groups are among those who often face higher exposure to pollutants and who may experience greater responses to such pollution” (p. 36). Further, environmental hazards may interact with psychosocial stressors and place-based social and economic conditions to foster persistent health disparities, especially in the area of maternal and child health (Morello-Frosch & Shenassa, 2006).

Looking to the Future

Americans can rightly marvel at how much change has occurred (and is occurring) in the realms of health-related policy, technology, knowledge, and research. However, as social workers, we also realize how much certain things have not changed and how hard it has been to create improvements in certain health arenas and for certain population groups.

Public Policy

Government actions at the local, state, and federal level can negatively or positively impact health and health disparities. Policies, like politics more generally, determine “who gets what, when, how” (Lasswell, 1958). A residual, means-tested approach to policy has tended to divide individuals into two groups: those who do, and those who do not, merit assistance (DiNitto & Johnson, 2012). This approach can exacerbate health disparities when applied to health policy, as the experiences of Medicare and Medicaid have shown. Yet policies also can expand access to healthcare services and reduce health disparities. The Children’s Health Insurance Program (Leininger & Levy, 2015; Rudowitz, Artiga, & Arguello, 2014; Shone, Dick, Klein, Zwanziger, & Szilagyi, 2005) is an example of how legislative action can positively affect health status outcomes. More recently, the Patient Protection and Affordable Care Act (ACA) of 2010 was designed to improve the nation’s health, reform the American healthcare system, and reduce health disparities (Artiga et al., 2015; Ubri & Artiga, 2016).

Enactment of the ACA has created the most significant changes in the American healthcare landscape since the creation of Medicare and Medicaid in the 1960s. Health insurance has long been seen as an important determinant of healthcare access, primary care usage, treatment of acute and chronic conditions, and health outcomes (Hoffman & Paradise, 2008). Some of the major provisions of the ACA include allowing young adults up to age 26 to obtain coverage under their parents’ policies, creating subsidized insurance marketplaces through which insurers offer different levels of coverage, disallowing insurance denials for pre-existing conditions, and encouraging states to extend Medicaid coverage to those with incomes up to 138% of the federal poverty line (Blumenthal & Collins, 2014).

The provision permitting young people to obtain coverage under their parents’ health insurance plans, implemented in 2010 (Blumenthal & Collins, 2014), has resulted in a substantial decrease in the number of young adults without health insurance (Cantor, Monheit, DeLia, & Lloyd, 2012). Between Fall 2013, when enrollment opened, and Spring 2014, approximately 8 million people obtained insurance through federal or state-run insurance marketplaces, an additional 5 million purchased health insurance directly from insurers, and 6 million took advantage of the Medicaid expansion, available in about half the states, or signed their children up for the Children’s Health Insurance Program (Blumenthal & Collins, 2014). Moreover, Sommers, Gunja, Finegold, and Musco (2015), in an analysis of national telephone interview data, found improvements in all six of their self-reported outcome measures—access to care, having a primary care provider, access to medication, health status, and number of days of restricted activities due to health—after the ACA’s first two open-enrollment periods, with racial and ethnic minorities reporting the greatest gains. Women also have benefitted from the ACA, especially those with lower incomes, and because of their new-found health insurance coverage, the percentage of women reporting not getting necessary medical care due to cost declined by 10% between 2010 and 2016 (Gunja, Collins, Doty, & Beutel, 2017). In the period from 2010 to early 2016, 20 million Americans obtained health insurance because of the ACA’s provisions (Uberoi, Finegold, & Gee, 2016).

Despite the gains made, the future of the ACA is very uncertain. Yet, even with the ACA-related gains, health disparities remain. And the ACA itself is far from perfect; problems with the legislations have led some to call for it being repaired and improved (Aaron, 2017). Given the complexity of health disparities, it is doubtful that health insurance changes alone will eliminate all health inequities (University of Wisconsin, 2010).

Evidence-Based Interventions

The development of evidence-based interventions to reduce health disparities is a global priority (CSDH, 2008). In the United States, efforts like Healthy People 2020 (ODPHP, n.d.a, n.d.b) and the CDC’s Racial and Ethnic Approaches to Community Health (REACH) program (CDC, 2015) are attempting to stimulate the creation of replicable intervention approaches, identify best practices, and promote assessment of, and information sharing about, such interventions. In 2011, HHS announced a five-point action plan for reducing racial and ethnic health disparities. According to HHS officials, a confluence of factors, such as the ACA, made the time right for launching this type of undertaking. The plan included five goals—“transform health care,” “strengthen the nation’s health and human services infrastructure and workforce,” “advance the health, safety, and well-being of the American people,” “advance scientific knowledge and innovation,” and “increase the efficiency, transparency, and accountability of HHS programs”—with specific strategies identified for each goal (Koh, Graham, & Glied, 2011, p. 1824).

A wide variety of interventions have been launched to address disparities in health status and healthcare, with most focused on reducing disparities experienced by racial and ethnic minority populations. The literature is replete with program descriptions and case studies (see, for example, Brennan Ramirez, Baker, & Metzler, 2008; CDC, 2007; IOM, 2008; Schlotthauer, Badler, Cook, Pérez, & Chin, 2008).

There also have been a several reviews of program outcomes to identify evidence-based practices (see, for example, Anderson et al., 2015; Horvat, Horey, Romios, & Kis-Rigo, 2014). Although few of the approaches assessed in the systematic literature reviews could be described as “evidence-based,” many practices were characterized as promising. However, even the findings regarding promising practices should be viewed as tentative or suggestive.

Many of the interventions reviewed were directed at patients. Examples of patient-focused interventions found to hold promise in reducing racial and ethnic health disparities include: improved data collection (University of Wisconsin, 2010); use of a reminder system for preventive care appointments (McPheeters et al., 2012; Quiñones et al., 2011); use of a care (or case) manager, community health worker, or layperson to connect the patient to the healthcare system (Anderson et al., 2015; Chin et al., 2012; Quiñones et al., 2011; University of Wisconsin, 2010); provision of an interpreter (University of Wisconsin, 2010); implementation of “culturally tailored education interventions” (Quiñones et al., 2011, p. 27), especially when interactive approaches are employed (Chin et al., 2012) or when groups are led by professionals (Anderson et al., 2015); promotion of techniques for self-managing health conditions (McPheeters et al., 2012); and use of interventions that are “multifactorial, targeting multiple leverage points along a patient’s pathway of care” or that “actively involved family and community members in patient care” (Chin et al., 2012, p. 993).

Horvat et al. (2014) conducted a systematic review of the literature on cultural competency education for healthcare providers. Only five studies, three of which were done in the United States, met Horvat et al.’s inclusion criteria. Findings suggest that cultural competency education for health professionals had a positive effect on patient attendance and patient perceptions of the care provider. Mixed results or no differences were found for other measures of patient health behavior and health status. According to Quiñones et al. (2011), “there is good evidence that cultural competence interventions can improve provider knowledge, attitude, and skills, but there are few good quality studies of effects on patient outcomes” (p. 4).

The University of Wisconsin (2010) identified two organizational and policy-level approaches that appeared effective in reducing health disparities related to race and ethnicity: increasing the number of primary care physicians and increasing the number of healthcare staff from racial and ethnic minority groups. Anderson et al. (2015), in a review of United States and international studies on the use of community coalitions to reduce racial and ethnic health disparities, found that coalitions focused on changing community-level systems—i.e., “sociocultural (e.g. public norms, regulatory processes and policies) and physical environments (e.g. housing, green spaces, neighborhood safety)”—had no impact on health behaviors and minimal or mixed influence on health outcomes. Community coalitions that attempted to intervene at the health-system or social-care-system level (e.g., coordinating staff; modifying “policies, procedures, and technologies”; and expanding “organizational and delivery system capacity and infrastructure”) fared somewhat better, producing positive health behavior and health status outcomes (Anderson et al., 2015, p. 17).

Wilson-Stronks, Lee, Cordero, Kopp, and Galvez (2008) investigated practices used by hospitals to reduce health disparities experienced by culturally and linguistically diverse populations. Qualitative analysis of data from interviews conducted with administrators and healthcare staff at 60 hospitals located in 32 states identified four overarching thematic strategies used by hospitals to reduce health disparities: making an organizational commitment to cultural competence and expressing that through hospital policies and procedures; obtaining community and patient data and using that information to inform hospital policies and practices; tailoring practices to the needs of particular patient groups (e.g., having interpreters available, providing materials and forms in different languages, educating staff; making “patient navigators” [Wilson-Stronks et al., 2008, p. 35] available to assist patients); and developing internal and external collaborative relationships to foster the hospital’s responsiveness and cultural competence.

A variety of reasons have been offered for the paucity of evidence-based practices identified through systematic reviews. Evaluations of programs to reduce health disparities frequently have not used rigorous research designs, such as experimental or tightly controlled quasi-experimental designs (University of Wisconsin, 2010), resulting in what Horvat et al. (2014, p. 2) have called “low-quality evidence.” Further, a lack of comparability of research designs, measures, participants, intervention foci, and intervention elements has constrained cross-study comparisons (Anderson et al., 2015; Quiñones et al., 2011). Programs often have included just one racial or ethnic group, thus limiting assessment of an intervention’s potential to reduce health disparities between groups (Quiñones et al., 2011). Finally, the inclusion of multiple components in intervention models (Schlotthauer et al., 2008) and imprecise descriptions of intervention models (Anderson et al., 2015) have made it difficult attribute change to particular program elements.

Lee, Fitzpatrick, and Baik (2013) identified three general dilemmas in the quest for evidence-based practices that reduce health disparities. First, data related to specific minority groups or to subpopulations within minority groups often are lacking; it frequently is difficult to find baseline information or intervention application data. Second, given that much of the health services research to date has been conducted on Caucasians (often males from the middle class), there is doubt about the generalizability of evidence-based practices identified in those studies to members of racial and ethnic minority groups, as well as to women (Johnson et al., 2014) and the poor (Denny & Grady, 2007). Third, attempts to implement evidence-based practices with racial and ethnic minority groups have not taken these groups’ unique sociocultural conditions into account, thus overlooking how diverse groups actually live in American society.

Conclusion

So where might things go from here? How can systems of care be developed that are appropriate and responsive to the increasing diversity of United States society? And what role can social workers play?

In the rapidly shifting political and policy environments following the 2016 presidential election, advocacy efforts have taken on a new significance and greater urgency. It is still too early to know precisely what the ACA will look like in the future, or if it will be continued at all. During the first six months of 2017, NASW (2017) joined with numerous organizations in letters to Congress and in public advertisements to protest proposal that would reduce Medicaid funding. Although initial efforts by Republicans in the House and Senate to “repeal and replace Obamacare” failed (DeBonis & Phillips, 2017), that doesn’t mean the future of the ACA is secure (Pear, Kaplan, & Cochrane, 2017). In times of uncertainty and change like these, social work advocacy, guided by the values and ethics of the profession, is especially important. Social workers must advocate fearlessly to protect the gains in health insurance coverage made under the ACA (Broaddus & Park, 2016; KFF, 2017); reducing, to say nothing of eliminating, health disparities will never be attainable if millions of Americans lose healthcare coverage and access.

Despite changing roles, practice settings, and intervention approaches, social work in healthcare continues to be an important field of practice for the profession. Social workers are found across the spectrum of healthcare settings—from prevention programs to hospice care—working with individuals, families, and communities, as well as with policymakers, system administrators, program developers, and healthcare researchers (NASW, 2016). “Social workers’ expertise and experience are essential in finding solutions to health disparities” (NASW, n.d., p. 1).

Social workers have an ethical obligation to address health disparities by educating colleagues, the media, allied professionals, decision makers and policymakers, and other stakeholders on the impact of health disparities and unequal access to health services and by engaging in social and political action to reduce health disparities.

(NASW, 2016, p. 30)

There is a critical need for cross-disciplinary linkages and collaborations, as well as partnerships with communities, especially racial and ethnic minority communities and socioeconomically disadvantaged communities. Interventions need to be tailored, which requires a nuanced understanding of individuals’ lived experiences and how social determinants of health shape people’s lives, health status, and use of healthcare resources. Community-based participatory research, an approach rooted in community public health, has been put forth as an effective way to develop collaborative, community-based interventions to reduce health disparities (Wallerstein & Duran, 2010; see also CDC, 2015). Interventions also are needed that go beyond making changes at individual and interpersonal levels, which to date have had mixed results. Interventions should be developed and tested that focus on larger systems that impact people’s health—neighborhoods and communities, organizations and institutions, social and economic structures, and government policies—or what Braveman, Egerter et al. (2011, p. 383) have called “upstream social determinants” (see also Cook, Purdie-Vaughns, Meyer, & Busch, 2014, for a framework for conceptualizing intervention levels and foci). Research and advocacy must accompany intervention efforts (Koh et al., 2010).

There is no silver bullet, no one-size-fits-all solution for reducing health disparities. There is no magic wand that will make them disappear. But they must be addressed; the well-being of individuals, communities, and ultimately the country depends on it. Addressing health disparities, advocating for health equity, and working toward the health and well-being of all people are matters of social justice; they are social work matters.

Further Reading

Barr, D. A. (2014). Health disparities in the United States: Social class, race, ethnicity, and health (2d ed.). Baltimore: Johns Hopkins University Press.Find this resource:

Bywaters, P., McLeod, E., & Napier, L. (Eds.). (2009). Social work and global health inequalities: Practice and policy developments. Bristol, U.K.: Policy Press.Find this resource:

Friedman, B. D., & Merrick, J. (Eds.). (2015). Public health, social work and health inequalities. Hauppauge, NY: Nova Science Publishers.Find this resource:

Gustavo, C., Crockett, L. J., & Carranza, M. A. (Eds.). (2011). Health disparities in youth and families: Research and applications. New York: Springer.Find this resource:

Kronenfeld, J. J. (Ed.). (2013). Social determinants, health disparities and linkages to health and health care. Bingley, U.K.: Emerald Group.Find this resource:

LaVeist, T. A., & Isaac, L. A. (Eds.). (2013). Race, ethnicity, and health: A public health reader (2d ed.). San Francisco: Jossey-Bass.Find this resource:

Marmot, M., & Wilkinson, R. G. (Eds.). (2006). Social determinants of health (2d ed.). Oxford: Oxford University Press.Find this resource:

Schulz, A. J., & Mullings, L. (Eds.). (2006). Gender, race, class, and health: Intersectional approaches. San Francisco: Jossey-Bass.Find this resource:

World Health Organization. (2013). The economics of social determinants of health and health inequalities: A resource book. Geneva, Switzerland: World Health Organization.Find this resource:

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