Unhealthy Inequality
Brian D. Smedley and Alan Jenkins
April 10, 2007

Brian Smedley is the Research Director of  The Opportunity Agenda , a  
communications, research and policy organization, and formerly served  
as study director and lead editor of the Institute of Medicine report  
on racial and ethnic disparities in health care. Alan Jenkins is  
Executive Director of The Opportunity Agenda.

Five years ago last month, the Institute of Medicine released a  
congressionally-mandated report, Unequal Treatment, concluding that  
minority patients receive a lower quality of health care than whites— 
even after taking into account differences in health insurance and  
other economic and health factors. Authored by a blue-ribbon panel  
assembled by the nation’s foremost health and science advisory body,  
the report went on to say that such inequalities in health care carry  
a significant human and economic toll and therefore are  
“unacceptable.” Yet despite these urgent appeals, little has been  
done to address disparities—leaving too many Americans vulnerable to  
inequitable and inadequate health care.

Critics of the Institute of Medicine report decried the implication  
that intentional racial discrimination is involved—though the report  
levied no such charge. They argued that any evidence of “differences”  
in health care is the result of economics and consumer choices, not  
the race or ethnicity of patients.

It’s easy to understand this skepticism. After all, America aspires  
to be a land of opportunity, a place where everyone is treated  
equally. The U.S. public overwhelmingly supports equality of  
treatment, and old-fashioned discrimination today is rare.

But the evidence shows that, when it comes to health care, unequal  
opportunity persists in ways that run contrary to our national  
values. Insured African-American patients are less likely than  
insured whites to receive many potentially life-saving or life- 
extending procedures—particularly high-tech care such as cardiac  
catheterization, bypass graft surgery or kidney transplantation.  
Black cancer patients fail to get the same combinations of surgical  
and chemotherapy treatments that white patients with the same disease  
presentation receive. Even routine care suffers. Black and Latino  
patients are less likely than whites to receive aspirin upon  
discharge following a heart attack, to receive appropriate care for  
pneumonia and to have pain—such as the kind resulting from broken  
bones—appropriately treated.

The Institute of Medicine report offered over two dozen  
recommendations for public and private sector action to eliminate  
disparities. But with rare exceptions, few of these stakeholders have  
taken up the call. Congress has not passed significant legislation to  
reduce health care inequality since 2000, despite bipartisan efforts  
led by the Congressional minority caucuses. Health care inequality is  
rarely discussed in state health care reform campaigns. And private  
sector efforts have been inconsistent—some leaders, such as Aetna,  
Kaiser Permanente and others have publicly announced efforts to  
eliminate disparities, while many other health systems have yet to  
acknowledge the problem.

As the nation debates ways of affording all Americans health  
coverage, it is time that we seriously addressed health care  
inequality as well. Otherwise, we may end up with a system of  
universal access to grossly unequal services, to the detriment of all  

We can start by acknowledging that racial and ethnic health care  
inequality persists, despite our conscious efforts to eradicate it.  
Hospitals and health care systems therefore should be required to  
report data on the quality and accessibility of health care services  
by patients’ race, ethnicity, education level and primary language.  
This information should be publicly reported, so that health care  
providers and payers are more motivated to press for improvement, and  
so that consumers are better equipped to make educated decisions  
about where to seek their care—should they have the choice.

Health care systems should consistently use evidence-based guidelines  
to improve the quality of health care for all patients. Professional  
interpretation and translation services should be provided for all  
patients who need language assistance, and their costs appropriately  

Federal, state and local agencies that regulate and fund health care  
services must take seriously their obligation to enforce anti- 
discrimination laws like Title VI of the Civil Rights Act of 1964.  
That means, for example, analyzing available data to determine  
whether similarly-situated patients of different races are receiving  
comparable care and services. It means monitoring hospital  
construction, closings, and relocation of services for their impact  
on equal opportunity . And it means offering training and technical  
assistance to health care providers who need help in maintaining fair  
and effective systems.

Community health workers also provide critically important services  
in helping patients to navigate health systems, and should be  
supported. And educational programs should be encouraged, both for  
patients—to help them learn how to best access health care services  
to meet their needs—and providers—to help them manage racial, ethnic,  
cultural and linguistic diversity in their practice and reduce  
quality gaps.

The nation’s health professional workforce will be greatly  
strengthened by increasing its diversity, as minority providers are  
more likely to work—and seek to work—in minority and medically  
underserved communities, and they’re often able to bridge cultural  
and language barriers that contribute to quality and access gaps.

These are but some of the steps that policymakers, public and private  
health systems, health care providers and patients can take to make  
our health care quality better and more equitable for all. What’s  
missing is a sharp prick of the nation’s conscience. Americans deeply  
believe in the power of American opportunity—everyone should have a  
fair chance to achieve their dreams. This is impossible without a  
basic level of health care security. We can and should do better to  
ensure that all patients get the care they need, regardless of their  

s. e. anderson (author of "The Black Holocaust for Beginners" -  
Writers + Readers) +