The vexing problem of health inequalities in the United States: what is to be done?

The persistence of health inequalities or health disparities between the rich and the poor and between whites and populations of color in the United States is one of the most vexing problems that public health and health care practitioners and policy makers face. According to experts, health inequalities have 3 key characteristics: (1) they influence the health status of certain populations regardless of their utilization of health services; (2) they can be compounded by the lack of availability and accessibility of health services for “disadvantaged populations,” and by the treatment these populations receive even after they enter the health care system; and (3) they are unjust, unfair, and, most importantly, avoidable. Over the past 3 decades, a growing number of studies has documented the pervasive existence of inequalities in health and health care. It is now time to move beyond merely describing these inequities and to begin focusing on the steps we can take to minimize these avoidable conditions. The factors that lead to health inequities can be partitioned into several different domains, each of which must be addressed to fully eliminate inequalities. The 4 areas that feature most prominently in the health disparities literature are: (1) socioeconomic and demographic factors, which, over the life course, result in better or poorer health status among populations; (2) access factors, which relate to whether or not patients can obtain prompt, high-quality preventive services, and/or curative services for their health problems; (3) health system factors, which are related to the ability of health care institutions and/or clinicians to deliver high-quality care to patients; and, (4) interpersonal and psychosocial factors, which may influence the amount and quality of care individual clinicians provide to their patients from certain socioeconomic, racial, or ethnic groups. All 4 of these domains are closely interrelated and are strongly influenced by conditions of poverty. A great deal of research has been conducted on the adverse impact that the first of these domains, socioeconomic and demographic factors—frequently referred to as the “social determinants of health”—have on the health status of lower income populations and people of color. These studies show clearly that populations composed largely of individuals with low income, low education, high unemployment, and poor nutritional status, and whose communities tend to be characterized by low-quality housing stock, blighted neighborhoods, poor public services (police, fire, sanitation), and high levels of air pollution and violence, are much more likely to have higher morbidity and ageadjusted mortality rates than populations that generally fare better in many, if not all, of these sociodemographic characteristics. Not only are these “disadvantaged populations” more likely to suffer from poor health status because of the interplay of these social factors, they are also more strongly affected by the second domain, access to preventive or curative services. That is, they are less likely to have a medical home or to obtain appropriate preventive services, and they