• Report Finds Widespread Health Inequities in United States

    Potential Solutions Include Strengthening Primary Care, Other Policy Changes

    December 23, 2021, 9:03 a.m. News Staff — For anyone who may have wondered why the Academy has formed partnerships that emphasize the importance of primary care and made health equity a foundation of numerous policies and position papers, a recent analysis of state-level health system performance measures helps explain.

    health equity word cloud

    The analysis, “Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of State Performance,”  released by the Commonwealth Fund last month, confirmed what many health experts have long suspected: that substantial racial and ethnic health care inequities exist throughout the United States, even in states that are recognized as providing high-quality health care to their residents.

    Among other things, the paper stated that racial and ethnic inequities are “pervasive” across all state health systems, with considerable disparities in health and health care between white, and American Indian/Alaska Native, Black and Latinx/Hispanic individuals evident in nearly every state. It also found that many of the disparities that have been in existence were exacerbated by the effects of the ongoing COVID-19 pandemic.

    “This report highlights deep disparities in our country and failures in our health care system that we can no longer accept,” remarked David Blumenthal, M.D., president of the Commonwealth Fund, in a news release.

    Story Highlights

    “Decades of policy choices made by leaders at federal, state and local levels — including generations of economic suppression and residential segregation — have produced worse health outcomes for people of color,” Blumenthal continued. “If we want to get the pandemic under control and mitigate these inequities, we need to dismantle the racist policies and practices that have led us here.”


    To create performance scorecards, the report’s authors collected data on 24 health system performance indicators. These indicators were stratified by state and race/ethnicity, and sorted into three broad groups: health outcomes, health care access, and quality and use of health care services. In most instances, indicator data was obtained for the years 2019 and 2020.

    Within each broad group, the authors combined indicator values to create a summary score. They then combined the summary scores to create a composite health system performance score for each state for each of five racial/ethnic groups: American Indian/Alaska Native, Asian American/Native Hawaiian/Pacific Islander, Black, Latinx/Hispanic and white.

    Based on the composite scores, each racial/ethnic group in each state received a percentile score, with 100 being best and 1 being worst. Where sufficient data was available, the authors also ranked the racial and ethnic groups, which allowed for comparisons within and between states.

    Key Findings

    According to the analysis:

    • Health equity did not exist in any state or in the District of Columbia, even in states with robust health systems.
    • In most states, health system performance scored above average for white residents but below average for American Indian/Alaska Native residents and Black residents.
    • In the three states where health system performance for white residents scored below the national average, performance for white residents was still considerably higher for white residents than non-white residents.
    • Only six states (Connecticut, Hawaii, Massachusetts, New York, Oregon and Rhode Island) had health systems that scored above the national average for all racial and ethnic groups studied. Even in those states, however, large health disparities were evident; in all but Massachusetts, health system performance scores were higher for white residents than for other racial and ethnic groups.
    • In most states in which data were available, American Indian/Alaska Native residents and Black residents were more likely than white residents to die early in life from conditions that could be prevented or treated with timely access to high-quality care.
    • In nearly every state in which data were available, American Indian/Alaska Native residents and Black residents were much more likely to die from complications related to diabetes than people of other races and ethnicities.
    • State uninsured rates were generally higher and more variable for American Indian/Alaska Native, Black and Latinx/Hispanic adults.
    • American Indian/Alaska Native, Black and Latinx/Hispanic adults were less likely to receive an annual flu shot than adults of other races and ethnicities.

    Potential Solutions Offered

    To create a more equitable health system, the report’s authors suggested that legislators implement a series of state- and federal-level policy changes, which they grouped into four broad areas:

    1. Ensuring universal, affordable and equitable health insurance coverage.
    2. Strengthening primary care and improving the delivery of services.
    3. Reducing administrative burdens that affect patients and health care professionals.
    4. Investing in social services.

    “Too often in the U.S., race and ethnicity are correlated with access to health care, quality of care, health outcomes and overall well-being,” the authors stated in the report’s conclusion. “This is a legacy of structural, institutional and individual racism that predated the country’s founding and that has persisted to the present day, in large part through federal and state policy. By pursuing new policies that center racial and ethnic equity, expand access to high-quality, affordable care and bolster the primary care workforce, we as a nation can ensure that the health care system fulfills its mission to serve all Americans.”

    Family Physician Provides Context

    Kisha Davis, M.D., M.P.H., a member of the Academy’s Commission on Federal and State Policy and a regional medical director and vice president of equity at Aledade, Inc., told AAFP News that the findings in the analysis were shocking, but not surprising. She also said the persistence of health disparities, even in states that appear to be succeeding on health metrics, points to the importance of examining health outcomes as stratified by race and ethnicity.

    “In my practice I have found health inequities to be multifactorial, largely due to social determinants of health,” Davis said, adding, “But it is important to understand the impact of systemic racism, introduced into the health care system generations ago, still impacts my patients today. Restrictions on where people could live and limitations on who has access to health insurance perpetuates a system of health inequity. I can help advocate through the AAFP to change the system, but I can also impact one patient at a time and ensure that no one, especially my most impacted patients, falls through the cracks.”

    Davis invited family physicians to lead the charge in reducing health disparities among their patients, beginning at the local level.

    “We can begin by making sure that our offices are welcoming to a diverse patient population,” Davis stated. “Look around your local community. How is it similar or different to your patient population? Recognizing and mitigating our own implicit biases helps to make us as physicians part of the solution. There are many resources developed by the AAFP's Center for Diversity and Health Equity to help uncover potential biases, learn more about your community and develop a team-based approach to health equity.”

    Davis also suggested that more action is needed in certain areas to obtain health equity.

    “We are well aware that health disparities are pervasive, and it is important to continue to report on that impact. But we must go beyond just reporting; we must inspire action by setting clear goals aimed at reducing disparity and empower a strong family physician workforce to achieve those goals.”