Bioethics Forum Essay
Ending Unequal Treatment Requires A Shift from Inequitable Health Care to Social Inequities
The National Academies “Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All” is the 2024 follow-up to its 2003 seminal predecessor “Unequal Treatment: Confronting Racial Bias and Ethnic Disparities in Health Care.” A noticeable difference between them is reflected in their titles; whereas the 2003 version made us aware of the systemic causes of racial disparities in health outcomes, the latest edition has moved beyond naming the problem to naming solutions.
Ending Unequal Treatment, however, acknowledges that racial and ethnic disparities in health outcomes still have not ended nor significantly progressed in the 20 years since the original version was first published. What makes this report unique and timely, especially during an election year, is that it names a lack of proper access to health care as a driver of racial disparities in health outcomes and calls on the American government to ensure proper access to affordable health insurance for all people as a solution. Where it misses the mark, though, is its lack of emphasis on calling for the American government to ensure equity in access to the social determinants of health that create health inequities before racial and ethnic minorities enter a clinical setting. Addressing factors such as access to housing, clean air and water, education transportation, and stable communities must be pivotal to any solution to racial disparities in health outcomes.
In 2003 Unequal Treatment made many people aware of racial disparities in health outcomes. It named social inequities such as inadequate access to income and housing and as drivers of health outcomes, but it was unique in calling out racial discrimination within social systems as a major contributing factor. In fact, it noted that even when we correct for social factors like income, people of color—particularly Black, Latino, and Indigenous people—still received worse care in our health care system and it contributed to their worse health outcomes. To address racial disparities in health outcomes caused by structural racism in health care the 2024 report calls on the federal government to make major changes, including ensuring better access to health insurance for all people. The report also calls on Medicaid to reimburse providers as much as Medicare providers are reimbursed, use federal funds to collect race data on patients which can help us have better information about the cause of health inequities and the impact of structural racism, and better fund branches of the U.S. government that are meant to ensure health equity for racialized minorities such as the Indian Health Service and the Office of Civil Rights. All of these policy solutions are meant to eradicate health care of its deeply rooted racial discrimination.
The report frequently mentions how improved access to the social determinants of health can also improve racial disparities in health. For example, it mentions the value of state policies that help reduce income inequities as improved income can lead to improved health for racial minorities. It further acknowledges how some state and federal policies have negatively and positively influenced racial inequities in the social determinants of health, such as the family financial assistance programs in some states that leave Black children with less cash assistance than in other states and programs such as the earned tax credit that have resulted in improvements in Black children’s health.
Convincing people of the importance of the social determinants of health, or our preclinical lives, to our overall health is a thread that ties the 2003 and 2024 reports. While this was a noble cause in 2003, when the social determinants were a less common fixture in health equity discourse, we now have enough research, including research that the 2003 edition contributed to, that demonstrates the importance of the health of our preclinical lives. In fact, by some estimates health care only impacts 20% of our health, while other social factors affect an estimated 80% of our health. Therefore, with its focus on inequities in health care that contribute to racial disparities in health and on improving aspects of health care, such as team-based care approaches in clinical settings, to serve this focus, the 2024 report is concerned with a small portion of the factors that influence our health, but particularly racial minorities’ health.
Ending Unequal Treatment does not advocate enough for using federal and state funding and government policy to eliminate inequities in the social determinants to health that influence racial disparities in health given the magnitude of their influence on our health. For instance, while the authors mention that despite people with asthma’s adherence to their caregiver’s recommended therapy regimen, they may still have trouble managing their asthma because they live in areas with poor air quality caused by pollutants. The authors use this example to demonstrate how health inequities are created by the interconnectedness of social and structural determinants of health. But the authors do not acknowledge that not everyone suffers equally from environmental pollution. Black, Latino, and Indigenous people bear the brunt of environmental injustices more than White people. They also have higher rates of respiratory diseases, like asthma, which can be caused and exacerbated by air pollutants. Pollutants in our air can also contribute to other diseases such as lung cancer and stroke, which also disproportionately impact people of color, specifically Black people.
The connection between racial inequities in health outcomes and inequities in social and structural inequities requires us to use federal and state funding to address the original source of inequities, such as pollution, if we want to end racial disparities in health. Addressing racial disparities in asthma, for instance, by addressing health care would be worthwhile, but would ultimately be a temporary solution. Receiving equitable asthma therapy only to be sent into a world with air pollution as well as racial inequities in pollution exposure is counterproductive. Enforcing current legislation that protects our physical environment and our air and water sources, initiating new legislation that protects our environment and imposes harsher punishments (beyond financial penalties) on entities that pollute our environment will do more for racial disparities in health than improvements to health care.
Ending racial disparities in health outcomes requires us to address racial inequities in our social and economic lives and those that are within the very foundation of health care. But if we don’t take seriously the project of income, housing, education, environmental, and political equity then our world will keep creating patients for health care providers to patch up and send back out into the unhealthy environments that make us patients in the first place. While Ending Unequal Treatment is another valiant effort and much needed resource, a more forceful expansion of its government-based solutions to government sponsored impact on social determinants of health is needed to inspire more long-lasting impact on racial disparities in health.
Keisha Ray, PhD, is the John McGovern, MD Professor of Oslerian Medicine and an associate professor at the McGovern Center for Humanities & Ethics at UT Health Houston where she also serves as the Director of the Medical Humanities Scholarly Concentration. She is a Hastings Center fellow and an advisor to The Hastings Center’s Sadler Scholars, a select group of doctoral students with research interests in bioethics who are from racial or ethnic groups underrepresented in disciplines relevant to bioethics. @drkeisharay
Thank you for this inspiring commentary. I have followed your work, and it is both an honor and a privilege to have joined the field of bioethics during your time. Although it was over a decade ago, I still vividly remember the first time I read the NAS report, Unequal Treatment. I fully support the sentiment that while Ending Unequal Treatment is indeed a valiant effort, there needs to be a more forceful expansion of government-based solutions to address the deep-rooted impact of social determinants of health.
As we push for policy changes and government-sponsored initiatives, we must also recognize the power of grassroots movements, which have historically led the way in enacting change, particularly in under-resourced communities across the United States. These movements address the specific needs of their communities, often bridging the gaps left by government initiatives that may be too broad or disconnected from the realities faced by marginalized populations. As volatile as government efforts can be, it is difficult to leave the responsibility in their hands. By coupling government solutions with the strength and ingenuity of grassroots efforts, we can inspire more sustainable, community-driven change that addresses not only racial disparities in health but also the underlying social conditions that perpetuate them. For real sustainable progress to occur, both top-down and bottom-up approaches must work in concert, so that communities most affected by health disparities are empowered to shape the solutions that will impact their lives.