Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions

Abstract

The United States has made little progress during the past decade in addressing health care disparities. Recent health care reforms offer an historic opportunity to create a more equitable health care system. Key elements of health care reform relevant to promoting equity include access, support for primary care, enhanced health information technology, new payment models, a national quality strategy informed by research, and federal requirements for health care disparity monitoring. With effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care, these reforms could measurably improve equity. INTRODUCTIONT he United States has made little progress toward greater equity in health care quality according to the annual National Health Care Disparities Reports.1 Recent health care reforms offer an historic opportunity to make inroads. In this commentary, I review key provisions of these reforms, particularly those in the Patient Protection and Affordable Care Act, often shortened to Affordable Care Act (ACA) of 2010, 2 and discuss their potential promise, pitfalls, and steps (prescriptions) needed to jumpstart progress toward more equitable health care (Table 1). I begin by briefl y reviewing causes of health care disparities and then discuss selected, key health care reform provisions within 6 interlocking domains: access related to insurance coverage and costs, strengthening primary care, improvements in health information technology, changes in physician payment, adoption of a national quality, and improved disparity monitoring and accountability. CAUSES OF HEALTH CARE DISPARITIESHealth care disparities related to race, ethnicity, socioeconomic status (SES), and markers of social disadvantage result from a complex confl uence of patient, clinician, and system levels factors.3 These disparities often refl ect reciprocal infl uences between social stratifi cation and ensuing social disadvantage and worse health 4 ; unconscious clinician bias toward socially disadvantaged persons 5,6 ; separate and often unequal care [7][8][9][10] ; and a health care system, including primary care, 11 that is ill-equipped to address the often complex needs of socially disadvantaged patients, who often become underserved patients. 12Equitable health care means more than elimination of bias, it also means creation of patient-centered systems of care that support healing and caring relationships that are responsive to patients' needs, wishes, and context. 13Improving equity requires aligning health care resources and capability with patient needs, particularly patients who have been historically underserved. HE A LT H C A R E R EF OR M A ND EQUIT Y ACCESSImproving equity begins with improving health care system access. System access is strongly affected by insurance coverage and cost. Minority and low-SES patients are more often uninsured than their counterparts. 1 Lack of health insurance is a major contributor to health care disparities 14 ; health care ...

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