What Would American Healthcare Look Like If It Were More Equitable?
Former Surgeon General David Satcher writes about his efforts to eliminate healthcare disparities in the U.S.
The following is an excerpt from My Quest for Health Equity: Notes on Learning While Leading by David Satcher, MD, PhD.
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My Quest for Health Equity: Notes on Learning While Leading by David Satcher, MD, PhD
Health disparities are preventable differences in the burden of disease, injury, and violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups and communities. These disparities are unjust, unfair, and directly related to the historical and current unequal distribution of social, political, economic, and environmental advantages.
The Centers for Disease Control and Prevention, the National Institutes of Health, and several other agencies have defined “disparities in health.” Common to most definitions is a focus on real differences in health-related outcomes between different groups of people (not only different racial and ethnic groups), including sexual minorities, people with disabilities, people with mental health disorders, people who live in rural areas, and others. These differences are generally considered preventable.
When the Institute of Medicine published its 2002 report on health disparities, Unequal Treatment: Confronting Racial and Ethnic Disparities in HealthCare, the focus was on differences in health care services, quality of care, and access to care. The report documented these differences in groups labeled “Majorities and Minorities.” In the early 1940s, when I had a near-death experience with whooping cough and pneumonia, issues of access to health care and quality of care were both paramount, but they were also related to racial segregation, discrimination, and poverty.
More than fifty years later, as surgeon general and assistant secretary for health, I bore a major responsibility for the health of the American people and for leading in the development of goals and objectives for the Healthy People 2010 Initiative. The Healthy People Initiative was begun in 1979, during the administration of President Jimmy Carter, by Surgeon General Julius Richmond, with the vision of making America’s communities healthier and happier places to live. This program articulates broad goals, objectives, and inputs for the health of the country for the next decade. It is important to note that Healthy People 2000, released in 1990, spoke to disparities in health with a commitment to reducing health disparities but not eliminating them.
Healthy People 2010 was released in January 2000 and introduced the commitment to eliminate disparities in health. The overarching goals were to increase the quality and years of healthy life for all Americans and to eliminate racial and ethnic health disparities. The commitment to eliminate disparities (not simply reduce them) galvanized the public health community by making the goal more measurable and by demonstrating a level of boldness that had not been verbalized before. Goals are aspirations, and these aspirations push everyone concerned to work for high achievement. Goals do not, in and of themselves, have timelines, but they allow for objectives that establish timelines for components of the goals.
As a result of the commitment to eliminate disparities in health, Congress passed the Minority Health and Health Disparities Research and Education Act, which led to the creation of the National Center for Minority Health and Health Disparities (NCMHD) at the NIH, in 2000. The center was renamed the National Institute on Minority Health and Health Disparities (NIMHD) in 2010, with authority for grant making. At the CDC, the articulation of the new goal led to the development of the Racial and Ethnic Approaches to Community Health Program (REACH). The REACH program funded communities directly to develop programs geared toward the elimination of disparities—for example, programs that would address quality of care and control of conditions such as hypertension and diabetes.
That particular day in Washington, DC, when Healthy People 2010 was to be released, was a very unusual day. Six inches of snow covered the ground and continued to fall when I went out for my morning walk on the NIH campus. Even though the federal government was technically closed, Secretary of Health and Human Services Donna Shalala and I agreed, by phone, that we should proceed with the release, given all the preparation that had taken place, especially since more than two thousand people were waiting in hotels, having traveled to Washington to participate in the ceremonies. Among those gathered were the ministers of health from both Egypt and Uruguay, to whom I had made a commitment to attend the release of Healthy People Egypt and Healthy People Uruguay later that year.
There is no substitute for well-defined goals and their associated objectives. Setting goals and objectives forces us to make clear decisions and to associate them with measurable outcomes and even timelines. Perhaps even more important, goals and objectives allow us to come together in our commitment to progress. Such was the nature of our gathering.
It is important to make clear the reality and nature of disparities in health. We can measure the frequency of occurrences of various diseases, measure mortality rates, and compare them among different groups. In the United States, among others, there are significant disparities in infant mortality, cardiovascular deaths, excess deaths, cancer prevalence, and the occurrence and complications of diabetes. While there has been great improvement in health for both African Americans and Caucasians, especially in areas such as infant mortality, cardiovascular disease, HIV/AIDS, and even cancer mortality, the ratios between African Americans and Caucasians have not improved. For example, African American infant mortality rates remain 2.4 times the white rates.
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What if we were equal? After leaving government and moving to Morehouse School of Medicine, I participated in a study, published in the Journal of Health Affairs in 2005, that asked that question. In an attempt to find an answer, differences in mortality rates between Caucasians and African Americans were measured and compared, using data from 1960 through 2000. These mortality rates included conditions such as cardiovascular disease, diabetes, HIV/AIDS, and cancer, but we also looked at issues related to access to care and measures such as the level of insurance coverage. We calculated that if we had reduced mortality ratios such that by the end of the twentieth century we would have eliminated disparities in health, the picture of health for African Americans would be quite different. For example, in the year 2000 there would have been 83,500 fewer African American deaths, including 24,000 fewer deaths from cardiovascular disease; 22,000 fewer from diabetes; 7,000 fewer from HIV/AIDS; and 4,700 fewer from infant mortality or death during the first year of life.
These so called “excess deaths” were the targets of efforts to reduce and ultimately eliminate disparities in health. However, our concerns were not limited to mortality. If we had eliminated disparities in the uninsured, or the risk of African Americans being uninsured, so that African Americans had the same insurance coverage as whites, in the year 2000 there would have been 2.5 million more insured African Americans, including 620,000 more insured children. Such measures of disparities will allow us to measure our progress toward health equity as we move forward.
In January 2009, WHO released the official report of the CSDH, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. This report had a major impact on Healthy People 2020, which was released in 2010. Whereas Healthy People 2010, released in 2000, included two very important goals—increasing the years and quality of healthy lives and the elimination of disparities in health—the Healthy People 2020 goals represent the incorporation of the recommendations of the commission and the goal of health equity. The four overarching goals of Healthy People 2020 are:
These goals have moved us to a new level in the effort to eliminate disparities in health. This focus on the environment, social relationships, income, and education represents new targets for the Healthy People Initiative.
If health equity involves the conditions, especially the social conditions, in which people are born, live, learn, work, and age, then our efforts must be focused on creating the opportunity for people to achieve optimal conditions for good health, whether those conditions be related to education, income, environment, or safety.
So the journey from the goal of eliminating disparities in health, as articulated in Healthy People 2010, to the goal of health equity, articulated first by WHO in 2009 and incorporated into Healthy People 2020, is a journey that the Commission on Social Determinants of Health helped to define in its four years of global travel.
This journey will require vigorous leadership and recognition that policies related to health and the social determinants of health must be amended. We need to develop integrated leadership to promote an attack on disparities in health, by attacking the social determinants of health, including the public health system itself.
The Affordable Care Act, passed during the Obama administration, represented some major policy changes. These changes greatly impacted access to care, reducing the uninsured population by over 20 million people. The ACA also made mental health an essential health service, requiring parity of access for the first time in the United States. The Mental Health Parity and Addiction Equity Act had already greatly impacted access, but the ACA put in place the policies that could be used to make sure these measures were implemented. This meant that provider coverage and services had to include mental health; these were indeed essential health services.
The ACA allowed for children to stay on their parents’ insurance policy until age 26, and perhaps most notably, the ACA made it illegal to exclude anyone from coverage due to any preexisting conditions! This was very important for so many families, in which children may have a mental health problem, diabetes, a disability, or something else that would prevent them from accessing the insurance market. The passage of the law, and the failure of the many efforts to repeal it, show that we have built momentum in the fight for health equity. The journey continues and, in my opinion, cannot be easily stopped.
The following is adapted from the new paperback edition of My Quest for Health Equity: Notes on Learning While Leading by David Satcher, MD, PhD. Copyright 2020. Published with permission by Johns Hopkins University Press.