As policymakers confront significant social and economic inequality throughout our country, the role of racial and ethnic disparities in health care must be acknowledged and addressed. The success of these efforts depends on our ability to track relevant health care data about different population groups. How sick are patients when they show up at the doctor’s office? What types of experiences do they have there? What kind of treatment outcomes can they expect? We need to understand whether improvements in morbidity and mortality are shared by the most vulnerable, or if they mostly benefit a select few. Only then can we begin to move to a society where all of us have an equal opportunity to live a long, healthy, and productive life.

Why Measure Disparities in California?

Nowhere is the need to measure disparities greater than in California, one of the few states where people of color compose the majority of the population.

CHCF has released a Health Disparities by Race and Ethnicity: The California Landscape, which looks at racial and ethnic disparities in California. Based on data from multiple sources, this compilation facilitates comparisons across measures to inform potential equity-guided improvement strategies (EGIS). An EGIS identifies specific populations at risk of suboptimal outcomes and delivers customized clinical interventions for them.

What Drives Disparities?

According to the US Centers for Disease Control and Prevention, health is largely determined by the environment in which a person lives and works. These “social determinants of health” include income, education, and social support, and account for more than half of the factors affecting health status. Medical care makes a smaller but significant contribution — around 20%. And another 20% is the result of health behaviors like substance use and a sedentary lifestyle, which can be affected by medical care and the environment.

Assessments and interventions to reduce disparities in health can include social determinants. However, in practice, many interventions focus on medical care and health behaviors, because modifying the environment in which a person lives and works requires activities beyond the traditional scope of health care and population health services. It is simply easier for providers to manage and improve the care they deliver, and this is where most reductions in disparities have been achieved.

What drives disparities within the acute care medical system? An emerging consensus focuses on structural racism, or the effects of persistent discriminatory beliefs and historical decisions around the allocation of resources that negatively affect certain groups today. The role of implicit bias — a set of automatic and unconscious stereotypes and prejudices that affect everyone, including health care providers — must also be acknowledged. The net effect is forgone or substandard care due to a patient’s race, language, immigration status, or sexual orientation.

How Are Disparities Reduced?

While policymakers sometimes assume that they can reduce disparities by improving overall health care performance, improvements in quality do not necessarily produce reductions in disparities. Often, as overall performance improves, the performance of individual groups improve by similar amounts; disparities are still present even though both groups have experienced gains. For example, as colorectal cancer screening rates have improved nationally, differences among groups related to race, ethnicity, and family income have changed little.

But we know that disparities can be reduced. And for any effective disparity-reduction strategy, the first step is measurement. Multiple reports — including this new CHCF report, the California Pan-Ethnic Health Network Landscape Report, the National Healthcare Quality and Disparities Reports, the Commonwealth Fund Scorecards on State Health System Performance, and the National Veteran Health Equity Report — show that disparities are common, and not rare phenomena attributable to a few poor performers. More importantly, these efforts provide crucial population-level benchmarks for policymakers, providers, and purchasers tracking the effectiveness of interventions targeting access barriers and quality failures.

For example, the US Veterans Health Administration (VHA) has long tracked disparities in care delivered in its facilities. By reducing known barriers to care, such as copayments and transportation difficulties, and putting in place strong continuous quality improvement efforts, VHA has largely eliminated many disparities for its clients. Veterans with high blood pressure or diabetes are more likely than patients outside of the VHA to receive all needed services in VHA facilities, and differences among groups of veterans are small.

Another key component of effective disparities reduction is aiming quality-improvement efforts at the care of particular groups. Traditional quality improvement focuses on raising average performance and assumes that different groups of patients are distributed evenly around this average. But through our measurement efforts, we know this is not the case. By applying quality-improvement efforts for groups receiving poor care, the EGIS approach allows concentrated and cost-effective interventions.

An example involving both of these strategies — measurement and targeted improvement — can be found in Covered California, the state’s health insurance marketplace. Beginning this year, plans are required to collect self-reported patient identity data (PDF) from at least 80% of enrollees. Plans are then required to use these data to show year-over-year reductions in race, ethnic, and gender disparities in the care of diabetes, hypertension, asthma, and behavioral health. Further disparities-reduction efforts are expected for other vulnerable populations including speakers with limited English and LGBTQ+ patients.

Toward a Plan to Reduce Disparities in California

In compiling and summarizing so many different types of data on health disparities in California, the CHCF Almanac provides a critical snapshot of current successes and opportunities for improvement. Disparities data will allow equity-guided improvement strategies and disparities-focused policymaking — essential steps on the path toward a society that is stronger by being equitable and efficient.

What else might policymakers seeking to reduce health care disparities in California consider? Additional data are always useful. While we have some information on various groups and their experience in California’s health care system, there are many things we don’t know. Capturing patient race and ethnicity data in California’s new all-payer claims database is one strategy for expanding our knowledge about how care is being delivered. Ensuring that health plans meet and exceed the Covered California patient data targets is another important undertaking.

Prioritizing measurement and reporting on disparities within the Medi-Cal program is also crucial. Medi-Cal is a critical source of coverage for millions of Californians with low incomes. Diversity among Medi-Cal enrollees is striking: more than 70% are members of racial and ethnic minority groups. Almost 40% identify their primary language as other than English. Fortunately, the state recently began publicly reporting on access and quality in Medi-Cal managed care by race and ethnicity. Additional reporting on the experience and outcomes of managed care and fee-for-service enrollees is worth serious consideration.

While what gets measured usually improves, what gets measured and prioritized often improves faster. Policymakers in California should identify specific measures that are amenable to change. What makes a good target? At the VHA, we’ve prioritized diabetes, hypertension, and mental illness for these reasons:

• The root cause of disparities in those conditions can be addressed within the acute care system.
• There are proven interventions.
• We can identify specific places and providers that can improve.

Finally, several interventions within the acute care delivery system hold promise for reducing disparities across a range of conditions and could be considered for widespread adoption. These include increasing access to culturally and linguistically competent care through the use of interpreter services, community health workers, and implicit bias training; supporting patient-centered medical homes; supporting facilities that allow patients enhanced access to primary care services on evenings and weekends; and promoting care coordination initiatives that utilize community-based navigators and integrate physical health with behavioral health services.

Whatever California may choose to prioritize, efforts to reduce racial and ethnic disparities in health care are essential endeavors that will pay dividends to the state and nation. We can begin to realize the American ideal of equal social and economic opportunity for all only with a system that delivers high-quality care to everyone, regardless of who they are or where they live. Let’s continue building that system together.

Ernest Moy

Ernest Moy, MD, MPH, is the executive director of the Office of Health Equity in the US Veterans Health Administration. The office supports and coordinates efforts to understand and reduce disparities in health and health care affecting veterans. Prior to joining VHA, he was a medical officer in the Office of Analysis and Epidemiology at the National Center for Health Statistics of the US Centers for Disease Control and Prevention. Previously he was director of the division in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality (AHRQ), which designed and produced the National Healthcare Quality and Disparities Report and related web tools. The report is submitted annually to Congress.

Donna L. Washington

Donna L. Washington, MD, MPH, is a physician and health services researcher who has devoted her career to the health care needs of vulnerable and underserved populations. Her research addresses on health care access, quality, and equity, with a focus on racial-ethnic minority veterans and women veterans. In current research, she is examining racial-ethnic, socioeconomic, and gender disparities experienced by veterans. Read More