Inequities in U.S. Healthcare

    

Structural inequities and biases impact U.S. social determinants of health according to the healthcare models used by the National Academies of Sciences, Engineering, and Medicine, the Centers for Disease Control and Prevention (CDC), and a wide array of other elite academic medical centers. Social determinants of health include wealth distribution, housing, employment, education, transportation, health services, social and physical environment, and public safety. Most, if not all aspects of civic and personal life are captured in this list. Defining health as a state of complete physical, social, and psychological well-being (not just the absence of disease) empowers healthcare researchers to analyze all components of human existence and develop policy recommendations. The theoretical lens of viewing social determinants of health through the posited presence of structural inequities and racism in America ultimately leads to regulatory changes and funding mechanisms for political reform. The CDC defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health” to be achieved by “address[ing] historical and contemporary injustices, overcoming economic, social, and other obstacles to health and health care; and eliminat[ing] preventable health disparities.”[1]

As currently defined, the health equity model initiates comprehensive technocratic oversight by our government and academic leaders. The National Academies of Sciences considers developing a large workforce of scientists and healthcare professionals to oversee and evaluate American health to be a key step for improving health equity and overcoming structural racism in our healthcare system.[2] In this model, funding from the taxpayer will be critical for ensuring research, policy, and legal reform from cradle to grave. Most Americans would have serious reservations about such extensive bureaucratic oversight over all aspects of our lives. I am not sanguine that structural biases are modifiable by expertise and government intervention. Respect for personal autonomy requires that a complex array of cultural, economic, and individual values inevitably form the health of a nation. Moral agency towards oneself and others is inherently unpredictable - but defines what it is to be human. The government cannot ensure healthy behavior in a free society.

As an obstetrician, I recognize that the U.S. has genuine disparities in healthcare. Women who are poor, minorities, foreign-born, or rural all suffer from inadequate access to obstetrical care. Black women and their infants are 2-3 times more likely to die during childbirth compared to white women and infants in the U.S.[3] Rural hospitals and obstetrical units are closing at an alarming rate[4] with 25.4% of rural women having to give birth in a nonlocal hospital.[5] Implementation of obstetric telehealth holds promise for improving access to prenatal care for women isolated by distance or socioeconomic circumstances. Multiple studies have compared in-person visits and telemedicine care models with no significant difference in obstetrical outcomes.[6] However, women who are challenged in accessing quality care are more likely to have Medicaid. Many jobs in the U.S. do not supply health insurance as a benefit,[7] and Medicaid is not a supportive insurance environment for technologic innovation. Disparities in a patient’s access to healthcare are well recognized. The disabled, those experiencing poverty, and those who are non-white or linguistically isolated will have a higher probability of falling into the digital divide with limited computer ownership, broadband access, and low digital literacy.[8] An individual patient’s geographic location, type of employment, income, race, primary language, along with other socioeconomic factors all impact her ability to access the help of a healthcare provider. 

Are there social determinants to health? The answer obviously is yes. Are there structural inequities to healthcare in America? Yes again. People of goodwill disagree on how to solve these problems. What seems clear is that funding for reforming healthcare inequities has exploded to an incredible degree. President Biden’s White House Press release announced billions of dollars budgeted for combatting equity problems in America, with all major aspects of social determinants of health addressed in some fashion.[9] One piece of the equity initiative is entitled “Maternal Health and Health Equity” which includes $470 million in proposed spending. Some of the $470 million will go to rural communities and other aspects of maternal care, but the funds also target implicit bias training for healthcare providers and the collection and evaluation of health equity data. What will these programs look like and who will benefit? Money can pile into bureaucratic hands with minimal effect. For example, states have not disbursed for any public benefit the hundreds of millions of Federal dollars awarded for tackling COVID health disparities.[10] The National Academies of Sciences’ recommendation for “training and implementation of a large workforce of scientists and healthcare professionals” to “research and analyze” health inequities will transfer large amounts of money from the taxpayer to scientists and healthcare professionals. The predicted outcome of better health for Americans is far from evident.

Furthermore, the goals and actions of elite academic medical centers require sober reflection. Four hundred thousand dollars have been distributed by various healthcare foundations to several medical schools for creating health equity, diversity, and inclusion training programs for their students.[11] The goal is to increase medical students’ and residents’ knowledge of health equity and social determinants of health. Cultural competency will be a core training component to raise the students’ awareness of their own ipso facto racial bias. Across the academic landscape, monies are set aside for JEDI (Justice, Equity, Diversity, and Inclusion) directorships and programs. But while medical schools are raising awareness of health inequities and racism, they routinely charge their students exorbitant tuition. Over four years, a medical student will likely pay between $160,000 to $330,000 dollars.[12] The very students that academic medical centers are convincing of the need to serve our most threatened and impoverished Americans are saddled with crushing debt that practically mandates working in a highly lucrative specialty in a wealthy geographic region.

There is a better way to keep Americans healthy than by transferring wealth to experts. A fundamental ethic of our country is that free individuals have the right to make personal decisions for themselves and their families without the government dictating the content of their lives or thoughts. Each individual and community should be supported in their efforts to secure economic prosperity, a clean environment, and safe neighborhoods without bearing the cost of legions of scientists and professionals telling them what that should look like.

[1] What is Health Equity? | Health Equity | CDC

[2] National Academies of Sciences, Division, H. and M., Practice, B. on P. H. and P. H., States, C. on C.-B. S. to P. H. E. in the U., Baciu, A., Negussie, Y., Geller, A., & Weinstein, J. N. (2017). Communities in Action: Pathways to Health Equity. National Academies Press. https://doi.org/10.17226/24624

[3] Grobman, W., Bailit, J.L., Rice, M.M., et al. (2015). Racial and ethnic disparities in maternal morbidity and obstetric care. Obstetrics & Gynecology, 125(6), 1460-1467.

[4]  Jolles, D., Stapleton, S. Wright, J., Alliman, J., Bauer, K., Townsend, C., & Hoehn-Velasco, L. (2020). Rural resilience: the role of birth centers in the United States. Birth 47, 430-437. https://doi.org/10.1111/birt.12516

[5] Kozhimannil, K., Casey, M.M., Hung, P., Prasad, S., & Moscovice, I.S. (2016). Location of childbirth for rural women: implications for maternal levels of care. American Journal of Obstetrics & Gynecology, 214, 661e1-10. 

[6] Wu, K., Lopez, C., & Nichols, M. (2022). Virtual visits in prenatal care: an integrative review. Journal of Midwifery & Women’s Health, 67(1), 39–52. https://doi.org/10.1111/jmwh.13284

[7] Noursi, S., Saluja, B., & Richey, L. (2020). Using the ecological systems theory to understand black/white disparities in maternal morbidity and mortality in the United States. Journal of Racial and Ethnic Health Disparities, 8(3), 661–669. https://doi.org/10.1007/s40615-020-00825-4

[8] Mack, D., Zhang, S., Douglas, M., Sow, C., Strothers, H., & Rust, G. (2016). Disparities in primary care EHR adoption rates. Journal of Health Care for the Poor and Underserved, 27(1), 327–338. https://doi.org/10.1353/hpu.2016.0016

[9] White House Briefing Room (March 30, 2022) President Biden’s FY 2023 Budget Advances Equity. https://www.whitehouse.gov/omb/briefing-room/2022/03/30/president-bidens-fy-2023-budget-advances-equity/

[10] Galewitz, P., Weber, L., & Whitehead, S. (May 16, 2022) States have yet to spend hundreds of millions of Federal dollars to tackle COVID health disparities. KHN https://khn.org/news/article/covid-health-disparities-federal-funding-state-spending/

[11] Rodriguez, S. (July 15, 2022). Medical schools instill diversity, health equity into training programs. Patient Care Access News https://patientengagementhit.com/news/medical-schools-instill-diversity-health-equity-into-training-programs

[12] Moody, J (May 25, 2021). 10 most expensive private medical schools. U.S. News and World Report https://www.usnews.com/education/best-graduate-schools/the-short-list-grad-school/articles/most-expensive-private-medical-schools#:~:text=The%20median%20cost%20of%20four,Association%20of%20American%20Medical%20Colleges.