Ending health disparities requires full federal government, National Academies panel says

To narrow the nation’s deeply entrenched health disparities, a permanent entity with regulatory powers should be created by the president to oversee health equity efforts across the entire federal government, says a report issued Thursday by the National Academies of Science, Engineering, and Medicine.

In its many recommendations, the committee that wrote the report called for Congress to create a scorecard to assess how new federal legislation might affect health equity; urged all federal agencies to conduct an equity audit of current policies; asked the Centers for Disease Control and Prevention to create and facilitate the widespread use of measurements of social determinants of health, including racism; and urged the Office of Management and Budget to oversee efforts to improve the poor and sporadic collection of data about the nation’s racial and ethnic groups.

The report’s authors stressed that improving health equity cannot be accomplished by the government’s health agencies alone. Education, income, transportation issues, and the quality of neighborhoods, the report noted, all play a role in harming or helping people’s health. While programs like Medicaid and the Children’s Health Insurance Program have proven to be the most effective policies to reduce health disparities, the report found policies that increase the federal minimum wage or close gaps in education spending have also promoted better health.

“It’s not just HHS or the Department of Veterans Affairs, it is a much deeper problem,” said Sheila Burke, a former government official, a policy analyst with the law firm Baker Donelson, and a nurse who led the National Academies committee. “One of the things that was important to us was not to say, ‘This all gets solved by health insurance.’ Credit scores, incarceration policies — these all contribute to health inequities.”

The report was produced at the direction of the Office of Minority Health in the Department of Health and Human Services, which charged the National Academies with going beyond looking at how poverty and racism affect health — issues that have been studied before — to examine how past federal policies might have created health disparities and what new policies might reduce them.

The report details the nation’s many racial and ethnic disparities, including the fact that maternal mortality rates are two to three times higher in Black and Native American populations, and notes that in 2019, Black Americans lived more than four years less than white people and Native Americans lived more than five years less than those who are white.

Native Americans and Alaska Natives fare the worst in almost all measures of health, the report said, stating that Congress should fund the Indian Health Service at parity with other health agencies and that the director of the IHS should be elevated to a Cabinet-level position. “This population has a unique set of issues,” said Burke. “They are underappreciated and misunderstood.”

Because income is so closely tied to health and because past policies, such as redlining neighborhoods, have led to the massive loss of generational wealth for many Black Americans, the report urged the adoption of policies to boost income and housing security. These include providing more housing vouchers for low-income people; offering government-subsidized savings accounts for children; promoting fairer financial services that offer lower-cost credit for people with low incomes; and expanding social benefit programs to many who have been left out, including immigrants, people who have been incarcerated, and adults who do not have children.

The committee said the government needed to do a far better job of collecting data about different racial and ethnic groups. Data collection is worst, the report said, for the nation’s smallest populations, those who are American Indian, Alaska Native, Native Hawaiian, or Pacific Islander. “Sharing of inaccurate or imprecise data about these communities means the (federal) agencies have been unprepared,” Burke said.

The report also underscored the importance of engaging with communities while undertaking health equity work, by seeking input and truly listening to community needs. “Including community voices in the policy process is of paramount importance,” Daniel Polsky, a professor of health economics in the Bloomberg School of Public Health at Johns Hopkins University and the committee’s co-chair, said in a statement.

The authors are under no illusion that these sweeping recommendations for change will be adopted quickly or without hard work. They come, after all, at a time of severely divided government when the adoption of new policies has been difficult and slow. “I’m acutely aware of the challenges of getting any agency to move,” said Burke, who served as chief of staff to the late Senate Majority Leader Bob Dole.

While some recommendations could be implemented quickly, such as increasing funding for data collection or reinstating the Indian Affairs Committee in the House of Representatives, Burke said others would take more time. “This is not a short-term effort,” she said. “The reality is many of these things will only take place over time.”

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.