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Social determinants of health, implicit bias, and other factors impact the health of people from disadvantaged groups. Technology and policy changes can advance equity efforts.
Despite nearly 40 years of well-intentioned effort, healthcare inequalities remain stubborn—and patients suffer real consequences. That’s why my co-authors and I published a Viewpoint in the Journal of the American College of Cardiology: Advances called “Health Equity: A Call to Action for Innovators, Clinical Leaders, and Policymakers.”
In 1985, the U.S. Department of Health and Human Services released the Report on Black and Minority Health in its first effort to address health and healthcare disparities. Yet it wasn’t until 2003 that HHS’s Agency for Healthcare Research and Quality released a report on those disparities, and today, members of historically marginalized groups still live shorter lives than their neighbors.
The research is clear. Black people in the U.S. are 30% more likely to die from heart disease than white people. Members of disadvantaged groups are:
- More likely to die of treatable conditions.
- More likely to die due to pregnancy and to suffer serious complications.
- At higher risk for many significant chronic conditions, such as high blood pressure and diabetes.
Too often, the fundamental human right to high-quality healthcare is out of reach for many people in the U.S. Research has demonstrated why, and technology is bringing solutions within reach. Now is the time to make serious policy and budgetary commitments to ensure all our neighbors can access the care they deserve.
Factors that influence inequity.
Many things contribute to an individual’s ability to access high-quality care. These can include social determinants of health (SDOH), the conditions in which people live, work, and learn.
Research indicates SDOHs are responsible for 80-90% of health outcomes. They include:
- Social and community: The human interactions where you live, including discrimination, social connection, and loneliness.
- Healthcare access: Barriers to care can include financial well-being, insurance status, transportation, childcare, and the ability to take time off work for appointments. Cultural differences, language barriers, and generational trauma from atrocities such as the Tuskegee Study also impose barriers to care.
- Neighborhood and environment: Many American cities are still segregated, with discriminatory housing practices that limit people to neighborhoods with poorly funded schools, high crime rates, low infrastructure funding, and limited access to nutritious foods. These conditions can make illness more common and severe.
- Workplace differences: Work settings’ inequalities can lead to poorer physical and mental health outcomes.
- Education: Inability to access high-quality education most commonly impacts historically marginalized people, limiting their ability to achieve higher education and secure stable, well-paying jobs.
- Income and wealth inequity: Education, geography, language barriers, discrimination, and transportation access limit many people’s ability to build wealth. Without adequate income, other SDOHs become increasingly difficult to overcome.
Each interaction between a patient and a provider includes the circumstances above and for every patient. As clinicians, these are our opportunities to authentically engage with patients, leverage our empathy to understand their perspectives, and work to recognize and overcome our unconscious biases.
Related reading: Research Examines Patient Experiences Behind Disparities in Cauda Equina Syndrome Outcomes.
Dismantle bias with empathy and perspective-taking.
It’s important to begin any discussion of bias by accepting that every person has their own biases, whether unconscious or implicit. We acquire these thanks to upbringing, experiences, education, and more. Every patient has biases, and every provider has biases.
These biases impact care, even and especially when we’re not aware of them:
- One study found cognitive biases were associated with diagnostic inaccuracy in 36.5-77% of cases.
- Seven studies that examined the role of implicit bias on patient-provider interactions found that more provider bias led to poorer communication.
- A 2022 poll found that 40% of patients felt their provider was biased against them, with Black and Hispanic patients being the most likely to report this.
- A study of 400 U.S. hospitals found Black patients were less likely to receive essential surgeries such as coronary artery bypass or angioplasty and that they were discharged from the hospital sooner than white patients. These disparities hold for other conditions and procedures, not just heart health.
As clinicians, it is not our job to pretend these bias-related problems don’t exist nor deny our biases. Instead, we are working to recognize our biases, understand how they inform our decision-making, and create strategies to lessen their impact on our decisions and our patients.
Empathy is a powerful tool to combat implicit bias. My colleagues and I went into medicine because we wanted to help people. Taking a step back to consider each patient’s perspective can help to reduce bias and remind us why we got into this field in the first place – the healing impulse that drives us.
If we move the needle on health equity, it will take more than bias-aware, empathetic clinicians. It will require policy-level change and action from health systems administrators to enact broad changes with budget funding that can allow them to make a real difference.
Related reading: How AI Can Make Clinical Trials More Efficient, Accessible, and Unbiased.
Technology and policy: Ways to help.
We understand why disparities in health and healthcare exist. These are complicated problems deeply rooted in our society, but that doesn’t mean we can’t change them. It means the opposite—it’s time to act.
Digital advances such as video calling, smartphone apps, and internet-connected smart speakers can help more people access care through telehealth and home monitoring initiatives. Artificial intelligence algorithms can identify bias in electronic health records, help patients better understand their diagnoses, and advocate for themselves.
Yet technology itself can’t solve the problem. Developers and engineers must come from diverse backgrounds to ensure the greatest range of perspectives when building these tools, and equity must be front and center.
Changes in how healthcare payments are structured are essential to eliminating disparities. Minoritized communities often don’t have access to the best health solutions because people can’t get insurance. Expanding Medicare to more states will save lives, and alternative payment models for market-driven insurance should prioritize equity.
At a policy level, my co-authors and I recommend structural shifts to help eliminate disparities, including:
- States that have not participated in incentivizing Medicaid expansion should do so, as additional access has been shown to save lives. One recent study found expansion prevented more than 19,000 premature deaths between 2014 and 2017.
- Prioritize training of historically underrepresented healthcare professionals in medical education. A more diverse healthcare workforce, including physicians, nurses, therapists, pharmacists, technicians, and others, can bring more perspectives to care.
- Intentional investment in underfunded communities can help bring technologies like broadband internet to rural and urban communities that have been left behind. These improvements can widen access to telehealth, education, and other critical resources.
- Additional structural changes to address economic opportunity, criminal justice policies, and housing inequities require a commitment from a wide variety of stakeholders to long-term progress to support positive social advances.
Related reading: How Research Can Drive Improved Healthcare Safety and Equity When Using AI.
An opportunity for leadership.
I speak about health equity often to discuss this topic with many different types of people. Too frequently, I hear from patients, “My doctor doesn’t listen to me.”
I can provide a correct diagnosis and advanced treatments, but if a patient leaves my office feeling like they’re not being heard or I can’t be trusted, they’re not coming back. If patients can’t show up in my office as their whole, authentic selves and know I see them and commit to their holistic health, they won’t have a good experience.
I talk to physicians about health equity, and they get it. They understand that disparities are a problem, and they recognize the impact of social determinants of health. In our day-to-day work, we’re on the ground, recognizing our biases and building relationships with our patients.
For necessary systemic changes, health systems administrators nationwide must make significant financial investments in policies, technology, and programs that affect patients.
MedStar Health is leading the charge on important equity issues, including programs like D.C. Safe Babies Safe Moms and its community-partnered work to stem the maternal mortality crisis. We’re making strides, and we’re at a critical moment. We’ve been talking about “Black and Minority Health” since 1985. Our patients’ lives are at stake—isn’t four decades of talk long enough?
Dr. Aubrey Grant is a co-founder and chief equity officer for Equity Commons.
