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1 Introduction1 A t the turn of the 21st century, several important reports and events on health disparities took place. These efforts were designed to raise awareness of health disparities and to describe initial efforts to reduce health disparities. In 2000, the Surgeon General’s office released several reports that showed dramatic disparities in tobacco use and access to mental health services by race and ethnicity (HHS, 1999, 2000). People of color were found to experience worse health outcomes than whites, and evidence of both higher levels of tobacco use and lower levels of access to necessary mental health services compared with those for the majority white popula- tion was detected. At the same time, the first real legislation focusing on the reduction of health disparities was passed by Congress and signed into law by President Bill Clinton. Among other actions, the law created the National Center for Minority Health and Health Disparities within the National Institutes of Health (NIH) and authorized the Agency for Healthcare Research and Quality to measure progress on the reduction of disparities on an ongoing basis. A year later, in 2001, the Institute of Medicine (IOM) released a land- 1 The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the Institute of Medicine, and they should not be construed as reflecting any group consensus. 1
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2 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? mark report, Crossing the Quality Chasm: A New Health System for the 21st Century. The report highlighted the importance of a focus on health care quality rather than a focus only on access and cost issues. And in 2003, the IOM released Unequal Treatment: Confronting Racial and Ethnic Dis- parities in Healthcare, the first comprehensive documentation that racial and ethnic minorities have less access to health care and that the care these groups do have access to is often of poor quality. Building upon these seminal reports, the IOM held a workshop on April 8, 2010, that discussed progress to address health disparities and focused on the success of various federal initiatives to reduce disparities. The workshop’s statement of task was as follows: The Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities uses public workshops to inform its meetings and discussions on relevant topics. An ad hoc committee will plan and conduct the workshop that will feature invited presentations and discussions. The planning committee will define the specific topics to be addressed, develop the agenda, select and invite speakers, and moderate the discussions. The workshop will explore progress in reducing health disparities and promot- ing health equity in the past decade. One essential task is to look at various kinds of intervention strategies to improve health outcomes in vulnerable populations, particularly in the present context of enduring economic inequality for people of color nation- wide. Additionally, there are state and local efforts under way to reduce health disparities (IOM, 2011) that involve collaboration among agencies at the federal, state, and local levels such as the Centers for Disease Control and Prevention’s (CDC’s) REACH (Racial and Ethnic Approaches to Com- munity Health) program as well as collaborations with local universities. Several of these collaborative efforts were presented during the workshop. SCOPE OF THE WORKSHOP On April 8, 2010, the IOM’s Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities sponsored a public work- shop to focus on what, if any, progress has been made to address health disparities. The workshop had three major objectives: first, to assess the progress that has been made; second, to consider the scope and effectiveness of efforts to address the social determinants of health disparities; and third, to determine what still needs to be elucidated about efforts to address social determinants and reduce health disparities. The workshop, Ten Years Later: How Far Have We Come in Reducing Health Disparities?, was organized to further advance the dialogue about health disparities by facilitation of a discussion of the topic among stake-
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3 INTRODUCTION holders, including members of the community, academia, the health care community, and business; policy makers; and philanthropic organizations. The goal of the meeting was to consider the progress—or lack thereof— that has been made over the past decade to reduce health disparities. The workshop also highlighted federal, state, and local efforts to reduce health disparities. WORKSHOP AGENDA Following introductory comments by Roundtable chair William Vega, a panel of three experts addressed the question of what progress to reduce health disparities has been made. Brian Smedley of the Joint Center for Political and Economic Studies, David Williams of Harvard University, and Steven Woolf of Virginia Commonwealth University shared their thoughts from a historical perspective. This panel presentation was followed by remarks from the assistant secretary for health of the U.S. Department of Health and Human Services, Howard Koh. A panel titled Federal Perspectives on Reducing Health Dis- parities featured presentations by John Ruffin of the National Center on Minority Health and Health Disparities (NCMHD)2 of NIH and Carolyn Clancy from the Agency for Healthcare Research and Quality. Presentations focusing specifically on the topic of disparities in child- hood obesity were then given by Roundtable member Mildred Thompson, who discussed the obesity program of the Robert Wood Johnson Founda- tion Center to Prevent Childhood Obesity, Susan Sher of the President’s Task Force on Childhood Obesity, and Mary Lou Fulton of The California Endowment’s Building Healthy Communities program in California. A distinguished panel of presenters addressed the question, What do we still need to learn about reducing health disparities? Dennis Andrulis, Roundtable member Anne C. Beal, and Paula Braveman shared their thoughts. The final panel of the day featured presentations by three congressional staff members. Each provided an update on the status of health care reform legislation and its potential to affect health disparities. At the end of each panel, a question-and-answer period was included. 2 At the time this workshop was held, NCMHD was still a center. Since the passage of the Patient Protection and Affordable Care Act (ACA), the center was elevated to an NIH institute, now known as the National Institute on Minority Health and Health Disparity (NIMHD).
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4 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? KEY THEMES Throughout the workshop, individual speakers and workshop partici- pants highlighted several recurring themes: • Persistence of health disparities. Health disparities are not going away. Many participants agreed that health disparities have per- sisted over time and across the life course. Furthermore, people of color experience an earlier onset and a greater severity of negative health outcomes. • The state of the economy. Several participants noted that the cur- rent economic downturn has had—and will continue to have— serious effects on health, particularly for low-income families and people of color. Living in poverty is a major risk factor for poor health outcomes. Furthermore, race/ethnicity and income are inex- tricably intertwined in the United States. • Race and racism. Despite a general feeling that the United States is in a “postracial” period (e.g., Whitehead, 2009), several partici- pants noted that institutional racism and racial discrimination are very much alive and well. Institutional racism and its effects have well-documented negative effects on health outcomes. • The importance of place. Many speakers discussed the important role of community environmental factors in influencing health out- comes. Residential segregation continues to be a major problem for people of color living in low-income communities. • Awareness of health disparities. The need to raise awareness of the existence of health disparities in the United States continues to be important; several speakers commented on the low levels of aware- ness of health disparities by the general public. • Health in all policies. Many participants commented that although the integration of large governmental sectors and policies is com- plex, it is necessary to improve health outcomes for all people. Sev- eral major federal efforts to infuse health into the policies of federal agencies other than those directly related to health are under way. • The role of the community in creating a health disparities agenda. Throughout the day, it was noted that health disparities cannot be addressed without input from the local community level. Addition- ally, communities themselves are creating their own health initia- tives, often funded by the philanthropic sector. • The promise of the Patient Protection and Affordable Care Act (ACA). There are a number of provisions in the law that pro- mote health equity by increasing access to health care and making health insurance more affordable. Throughout the day, participants
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5 INTRODUCTION described the potential for reducing disparities through the imple- mentation of the ACA. • Other topics for further research. A number of participants men- tioned the challenges involved with measurement of cultural com- petence, the need to bring interventions to scale, and the critical role that prevention plays. REFERENCES HHS (Department of Health and Human Services). 1999. Mental Health: A Report of the Surgeon General. Rockville, MD: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. HHS. 2000. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Preven- tion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. IOM. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press. IOM. 2011. State and Local Policy Initiatives to Reduce Health Disparities. Washington, DC: The National Academies Press. Whitehead, C. 2009. The year of living postracially. New York Times, November 4, A31.
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