Healthcare Disparities in the United States

The health care system in the United States (US) has been termed “a paradox of excess and deprivation.”^{1 p.4} Individuals who have private or public insurance have access to health care services which include high quality primary and preventative care with appropriate specialty services.¹ Other individuals receive too little health care because they are uninsured or inadequately insured. Furthermore, cost of health services may be higher for poverty stricken individuals lacking insurance and less for patients who have better paying jobs which include insurance benefits.²

Despite overall improvements in healthcare in the US, racial/ethnic minorities receive a lower quality of health services, are less likely to receive routine medical procedures, and experience higher rates of morbidity and mortality than non-minorities.³ The most consistent health care disparities exist among African Americans, American Indians, and Hispanics.² Infant mortality rates are often used as an indicator of population health. A baby born to an African American or Alaskan Native mother is almost 1.5 times more likely to die before reaching his/her first birthday in comparison to a baby born to a Caucasian mother.³ Furthermore, access to health care and quality of health care play an important role in minority health care disparities (such as preventive and primary care).²

Reducing Healthcare Disparities

Many attempts have been made to reduce racial/ethnic disparities in health care. Groups such as the National Alliance for Hispanic Health, the National Indian Health Board, the Kaiser Family Foundation, Robert Woods Johnson Foundation, and the Agency for Healthcare Research and Quality (AHRQ) work to aid in the reduction of healthcare disparities through publications, guidelines, policy recommendations, conferences, social programs, and advocacy efforts. Healthcare disparities have been a priority for Healthy People 2010 and Healthy People 2020. However, despite the best efforts, disparities exist.³

Many articles have been written that extensively document racial/ethnic disparities in healthcare and have been summarized in several reports such as Unequal Treatment: Confronting Racial and Ethnic Disparities in Health ⁴ and congressionally mandated reports from the AHRQ. Some of the most convincing evidence of healthcare disparities has been documented in reference to underuse and overuse of services regarding cardiovascular care.⁴ Further documentation reveals increased rates of mortality after cardiovascular revascularization among African-Americans.⁴ Healthcare disparities have also been found in other diseases such as renal disease, diabetes, cancer, pain, and HIV care. Renal disease disparities include progression of chronic kidney disease, access to home dialysis, and receipt of kidney transplantations in rural areas and racial/ minority groups.⁴ African-Americans and Hispanics have higher rates of diabetes and increased rates of diabetes related complications and death than caucasians.⁴ Racial/ethnic minorities are less likely to have interventions or treatment for cancer, pain, and HIV.⁴

The US is the only industrialized nation that does not have a universal health care system. The issue of US health care reform has been the subject of political debate since the early part of the 20 ^th century.³ On March 21, 2010, President Barack Obama’s administration passed the Health Care Reform Bill through the House of Representatives with a vote of 219 to 212. The Patient Protection and Affordable Care Act was signed into law. This legislation potentially may achieve universal health care coverage for all citizens of the US through processes to improve current systems.³ The Patient Protection and Affordable Care Act is meant to increase health care access to US citizens, reduce healthcare costs, and improve healthcare outcomes.³

The aspects of health care reform that legislators agree on are the following: insurance reforms, an end to discrimination based on preexisting conditions, expansion of coverage, prevention and wellness programs, rewarding quality health care rather than quantity, and employer incentives regarding health insurance for employees.⁴ Employer and individual mandates for health insurance, subsidies for health insurance premiums, tax increases for health care reform, and the cost of health care reform represent aspects of health care reform that further fuel debates.³ The one provision that attracts the most attention and has appeal is universal health care coverage. However, one can view universal coverage as a positive intervention due to the fact that 32 million more people will be insured.⁵ One component of high-quality health care is adequate access to care.¹

Universal coverage will increase access to health care services, especially for minorities.⁵ These provisions will increase chronic illness screenings and treatment, and will potentially decrease complications caused by chronic illness which is exacerbated due to a lack of these services.⁴ Minorities often experience disadvantages in terms of socioeconomic resources, language barriers, health literacy, cultural diversity, access to health services, and health insurability when compared to Caucasians.³ Therefore, minorities should experience considerable gains with health care reform.

On July 28, 2012, the US Supreme Court upheld the Patient Protection and Affordable Care Act. The US Supreme Court further ruled that the health insurance mandate and extending Medicaid benefits were constitutional.⁶ However, states may elect not to participate with the extension of Medicaid benefits. The majority of the justices voted in favor of the reform (5-4).⁶

Innovations in Practice: The REACH Program

The Robert Woods Johnson Foundation (RWJF) evaluated interventions to reduce racial/ethnic disparities. The most common interventions included patient or provider education, community health workers, case management, integrated health care, and cultural modification.⁷ Policy interventions were lacking.⁷ One proposed policy intervention is pay-for-performance incentives which has been proposed by health care reform advocates.⁵

The Centers for Disease Control (CDC) has initiated the Racial and Ethnic Approaches to Community Health (REACH) program in 1999.² This initiative is instrumental in initiating sustainable programs to reduce health care disparities among minorities. The REACH program is considered a leader among interventions to reduce racial/ethnic disparities in healthcare because of the utilization of multiple strategies at the community level to facilitate systems and policy change.⁸ The REACH 2010 logic model (see Figure 1) is used as the underpinnings of the program to link theory and assumptions.⁹ The five stages of the model are: 1) planning and capacity building; 2) targeted REACH action; 3) community and systems change and change among change agents; 4) widespread change in risk or protective barriers; and 5) reduced health disparity.¹⁰

Figure 1

Figure 1. Logic Model for Racial and Ethnic Approaches to Community Health (REACH 2010)

The planning phase involves assessment of a situation for understanding, causes, and solutions of health disparities which can be achieved through discussions or questionnaires completed with community leaders and community members. Once the assessment is completed, capacity building is contemplated (i.e., what is the community capable of to promote change regarding the assessed healthcare disparity?). Once community capabilities are known, a targeted REACH action is initiated to promote existing activities that could be successful with further initiation and utilize external resources. Barriers and obstacles can be overcome to sustain community and systems change which reduces healthcare disparity.¹⁰

The foundation of the program is building trust relationships with the community and empowering individuals with knowledge and tools to facilitate better health.⁹ Trusted organizations and community leaders are utilized to increase acceptance of the program within the community. Health initiatives are designed with cultural competency and include historical and cultural aspects of racial/ethnic minorities in the US. Advanced practice nurses are key to utilizing the REACH program within communities due to abilities to assess complex causes of racial/ethnic disparities (individual, community, societal, and environmental) to engage multiple strategies such as counseling, education, systems change, and policy initiation to decrease health risks and promote changed conditions and behaviors.

The CDC funds awards to grantees for REACH community projects.⁹ The REACH program focuses on the assessment of underlying causes of poor community health. The assessment is completed by the grantee. Once the assessment is completed, the goal is to implement sustainable community interventions. Sustainable community interventions are evidence-based to increase positive outcomes and reduce costs. The overall goal of the program is to foster optimism, pride, and a promising vision for a healthier future.³ Examples of community based projects include tuberculosis testing for homeless individuals, a diabetes education program with promotoras who speak Spanish, a clinic that provides free healthcare services by utilizing a church and volunteer healthcare providers/ workers, a community walking club that meets on a daily basis, blood sugar and blood pressure testing at a local Wal-Mart with referrals to clinics with sliding scales or no cost services, cardiovascular risk discussions with women at domestic violence shelters, and providing influenza vaccines and pneumonia vaccines at an Indian reservation.

Patient Advocacy through Advanced Practice Nursing

Advanced practice nurses (APNs) will definitely feel the paradigm shift with the advent of health care reform. However, advanced practice nurses can rise to the challenge and offer innovative solutions to meet health care needs through leadership and clinical expertise. Collaboration with colleagues such as physicians, pharmacists, administrators, and others may ease the transition. Communication can be increased by utilization of the patient-centered medical home (a comprehensive approach that facilitates partnerships between providers, families, and patients) and electronic medical records.⁶

Advanced practice nurses are working with patients in different clinical settings (primary care, acute care, internal medicine, and specialist offices) and have advanced knowledge within these areas. APNs have worked with patients as nurses and in advanced nursing roles which increases understanding regarding healthcare disparities. APNs are prepared and capable to be involved in many different systems that influence change such as legislation, education, policy initiation, administration, and politics. Furthermore, APNs participate in disseminating data through professional and public presentations, publishing articles, and professional organizations. Advanced practice nurses become aware of healthcare disparities and work towards providing patient advocacy to reduce healthcare disparities.

Conclusion

Advanced practice nurses have traditionally worked with underprivileged and underserved patients. Therefore, APNs could be tremendous advocates for increased health care access, reducing racial disparities, and increasing health equity for all US citizens. APNs can increase advocacy through involvement at the local, state, and national level through active membership in nursing organizations, political involvement (educating local and state legislators regarding health care issues and reform), increasing public awareness of concerning disparities in health care, decreasing health care disparities at the office and/ or organizational level, increasing cultural competency, and increasing self education in regards to the Patient Protection and Affordable Care Act. Nursing utilization of programs such as the REACH program in his/her home communities would also decrease racial/ethnic disparities.

Advanced practice nurses are community members who value community health. As community leaders, APNs can utilize the Logic Model to initiate community programs that target racial/ethnic groups to increase health and positive outcomes. Currently, the REACH program priorities are breast and cervical cancer, cardiovascular disease, diabetes mellitus, adult immunizations, Hepatitis B, tuberculosis, asthma, and infant mortality.¹¹ APNs can focus on priorities and develop programs to reduce the incidence of disease, increase health promotion, and improve self management of chronic illness among racial/ethnic minorities.

Advanced practice nurses are leaders within the nursing profession and combine expertise, knowledge, and patient preferences to intervene at all levels of healthcare services. Utilization of existing programs such as the REACH program to innovate sustainable programs during a challenging time in healthcare can move the nursing profession forward providing increased potential for APNs to contribute innovative solutions to reform the US healthcare system, reduce racial disparities, and improve patient outcomes.