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The writer Augusten Burroughs wrote, “If you have your health, you have everything. If you don’t have your health nothing else matters.” In the United States there are millions of people living with a poor quality of health. Focusing on racial and ethnic minorities, a 2011 Agency for Health Care Research and Quality report found that African-American, Native Americans, and Hispanics all received worse care and worse access to care than whites according to quality measures. The report also noted that racial and ethnic minorities experienced less patient centered care for 40 percent of the measures and less preventive care for 30 percent of the measures. The one area where African-Americans saw better outcomes than whites was in cardiovascular health.
These results are notable because of the rhetoric the last three presidential administrations have used regarding eliminating racial and ethnic health disparities. In 1998, President Bill Clinton set a bold goal for improving American health care: eliminating such disparities by the year 2010. The goal was supported with $400 million dollars for prevention and outreach programs, increasing health insurance and expanding medical research. Health and Human Services Secretary Donna Shalala would repeat the President’s 2010 target date, even as she specified six areas in which health disparities would be eliminated, including infant mortality, diabetes, AIDS/HIV and immunizations.
Executive branch efforts to eliminate health disparities continued in the Bush administration. In 2003, Secretary of Health and Human Services Tommy Thompson unveiled a plan to establish eight Centers for Population Health and Health Disparities. These centers seek to utilize the tools of multidisciplinary research to gain a better understanding of the causes of health disparities. Thompson said, “This initiative is an exciting step toward understanding and eliminating health disparities for numerous diseases throughout the United States.” While the effort in the Clinton administration focused specifically on disparities among racial and ethnic minorities, the effort under President Bush included low-income whites and the elderly.
Under President Obama, the primary policy objective of the first term was the passage of health care reform to expand insurance coverage to 32 million Americans who were previously uninsured. Garnering less attention in 2011, more than a year after the passage of health care reform, was the administration’s announcement of a National Prevention Strategy for health care. This strategy was intended to build partnerships between the federal government and partners in the public and private sectors in service of four strategic directions, including eliminating health disparities. The Obama administration plan for eliminating health disparities was based on expanding education through lowering the high school dropout rate and improving employment through job creation programs. In her public comments, HHS Secretary Kathleen Sebelius particularly focused on eliminating disparities regarding obesity and diabetes among Hispanics and African-Americans. She also noted the importance of increasing access to care for Native Americans.
The Obama administration’s focus on education and employment to eliminate health disparities, brings to mind the multi-pronged explanation articulated by President Clinton. “Perhaps inadequate education, disproportionate poverty, discrimination in the delivery of services and cultural differences are all contributing factors,” Clinton said. This highlights the complexity and difficulty of eliminating racial and ethnic health disparities. There are two ways we can look at health disparities: disparities in the manner in which people receive health care and disparities in the quality of health that people experience. Either would easily fall into the category of a “wicked problem,” as described by Rittel and Webber.
Disparities in the manner in which people receive health care may seem like the more likely candidate for a government solution, but all of the potential contributing factors that Clinton cited still apply. Lack of education contributes to lack of insurance coverage, as the less educated are more likely to lack employment and have difficulty accessing programs that could offer assistance. High poverty areas, both in rural and underserved areas, tend to be medically underserved, even if the people did have the means to avail themselves of health care. Hispanics in the United States are especially affected by the problems of discrimination and cultural differences, as undocumented immigrants and those perceived as being undocumented immigrants struggle to find treatment.
Looking at disparities in terms of quality of health care experienced, the same myriad of problems apply. Those who lack education tend to have less access to healthy food, exercise less, and engage in unhealthy behaviors such as smoking and drinking. People living in high poverty areas tend to confront more hazardous environmental conditions, both in their homes and the surrounding communities. Those fighting discrimination based on cultural differences are often relegated to physically strenuous and sometimes unsafe working conditions in order to support their families.
This is not an argument that eliminating health disparities should not be a long-term goal of the federal government, only that when we discuss eliminating health disparities we must always be mindful of its complexity. Eliminating health disparities will require a whole government approach. We have seen some movement toward this kind of approach over the last presidential administrations, with the Bush administration funding multidisciplinary research and the Obama administration promoting collaborations between HHS and other cabinet-level departments to take on food safety and quality, environmental health dangers, improving education, cutting fraud in health care programs, and protecting all Americans from emerging health threats.
In setting forth the goal of eliminating health disparities, we must acknowledge that we are also setting out to eliminate education disparities, economic disparities, environmental disparities, and cultural disparities. The effort to eliminate health disparities is the effort to eliminate disparities across the board. An America where health disparities have been eliminated will truly be a country where the goal of social justice will have been realized. To become a reality, it will require a government where the silos between agriculture, education, environment, justice, security and health policy have been replaced with a collaborative network. To paraphrase Augusten Burroughs, “If you have your health, you have everything. If you do not have your health, it may be because so much that matters is missing.”
Author: Nathan Myers is an assistant professor of political science in the MPA program at Indiana State University.