JAMA: Healthcare reform doesn't address care inequities
The Patient Protection and Affordable Care Act (PPACA) is the federal government’s response to the shortcomings in achieving high-quality healthcare across the U.S. However, according to an Aug. 9 commentary in the Journal of American Medical Association, PPACA’s quality focus is overshadowed by concerns about pervasive and persistent disparities in care, including such factors as sex, race/ethnicity, social class, insurance status and language.
In the commentary, Matthew M. Davis, MD, from the pediatrics division at the University of Michigan in Ann Arbor, and colleagues wrote that such inattention to healthcare inequalities in the PPACA is worthy of noting, not only from a quality perspective, but also because of a lack of emphasis on disparities is inconsistent with recent positions taken by the Agency for Healthcare Research and Quality (AHRQ) and the Institute of Medicine (IOM).
The AHRQ and IOM have said reducing disparities is an unambiguous priority to improving the quality of healthcare. This is consistent with analyses suggesting that reduced disparities based on social factors may actually improve healthcare quality more than marginal improvements in overall medical care.
Given these disconnects between the PPACA provisions and federally endorsed approaches to what amounts to “equality-in-quality,” it’s worth exploring the philosophical and empirical underpinnings of these disparities. While working toward achieving quality improvements, striving for equality-in-quality is not merely an aspiration, Davis and colleagues noted, but should be a foundation for all of healthcare. Failing to address disparities may consign healthcare quality improvements—originating from the PPACA or other initiatives—to less successful results than would otherwise be realized.
To quantify the benefits of equality-in-quality, childhood immunizations provide a solid example of such success. Childhood immunizations are exemplary because they address an area of medicine and public health with a national program that acknowledged the disparities in race/ethnicity, social class, insurance coverage and location (i.e., urban vs. rural settings), as well as made a concerted effort to measure and resolve these disparities, the authors wrote.
For example, a generation ago, deadly outbreaks of measles predominantly in minorities in metropolitan areas highlighted the disparities that existed in vaccinations. These disparities saw disadvantaged children with increased risk for disease, sometimes with vaccination rates of less than 50 percent. However, just a few years later, through quality and disparity improvements, and measurements, the Centers for Disease Control and Prevention found that national childhood vaccinations for the recommended immunization series (e.g., polio, measles, diphtheria and tetanus toxoids and pertussis, and Haemophilus influenzae type b) had reached 77 percent. Yet, this national average did not tell the whole story, because it masked 8 percentage point disparities in immunizations by race/ethnicity and an 11 percentage point disparity for children living in poverty versus their peers.
Policy, public health and clinicians created a multifaceted response to reducing disparities while improving childhood vaccinations. The federal government addressed the economic disparities through the Vaccines for Children Program, which purchased increasingly expensive vaccines for children who were uninsured, who were on Medicaid, were of Alaskan Native or American Indian heritage, or had private insurance that didn’t cover recommended vaccines.
In 2010, while national vaccination quality (as measured by overall vaccination coverage with multiple recommended series) has remained the same or increased slightly over the past 15 years, racial/ethnic disparities have decreased to 4 percentage points (for minorities vs. non-Hispanic white children), and have been reduced to 3 percentage points for poverty-related inequalities.
The effect of improved measles vaccinations has been profound, Davis and colleagues stated. In 1989, during the national measles outbreak, almost 18,000 cases of measles were reported in the U.S. By comparison, during 2006 to 2010 there were fewer than 150 measles cases reported annually. While the population benefits through herd immunity from broader vaccinations, there is a quality improvement result, as well. Reducing disparities through targeted federal efforts paved the way to improved national quality levels.
In the commentary, Matthew M. Davis, MD, from the pediatrics division at the University of Michigan in Ann Arbor, and colleagues wrote that such inattention to healthcare inequalities in the PPACA is worthy of noting, not only from a quality perspective, but also because of a lack of emphasis on disparities is inconsistent with recent positions taken by the Agency for Healthcare Research and Quality (AHRQ) and the Institute of Medicine (IOM).
The AHRQ and IOM have said reducing disparities is an unambiguous priority to improving the quality of healthcare. This is consistent with analyses suggesting that reduced disparities based on social factors may actually improve healthcare quality more than marginal improvements in overall medical care.
Given these disconnects between the PPACA provisions and federally endorsed approaches to what amounts to “equality-in-quality,” it’s worth exploring the philosophical and empirical underpinnings of these disparities. While working toward achieving quality improvements, striving for equality-in-quality is not merely an aspiration, Davis and colleagues noted, but should be a foundation for all of healthcare. Failing to address disparities may consign healthcare quality improvements—originating from the PPACA or other initiatives—to less successful results than would otherwise be realized.
To quantify the benefits of equality-in-quality, childhood immunizations provide a solid example of such success. Childhood immunizations are exemplary because they address an area of medicine and public health with a national program that acknowledged the disparities in race/ethnicity, social class, insurance coverage and location (i.e., urban vs. rural settings), as well as made a concerted effort to measure and resolve these disparities, the authors wrote.
For example, a generation ago, deadly outbreaks of measles predominantly in minorities in metropolitan areas highlighted the disparities that existed in vaccinations. These disparities saw disadvantaged children with increased risk for disease, sometimes with vaccination rates of less than 50 percent. However, just a few years later, through quality and disparity improvements, and measurements, the Centers for Disease Control and Prevention found that national childhood vaccinations for the recommended immunization series (e.g., polio, measles, diphtheria and tetanus toxoids and pertussis, and Haemophilus influenzae type b) had reached 77 percent. Yet, this national average did not tell the whole story, because it masked 8 percentage point disparities in immunizations by race/ethnicity and an 11 percentage point disparity for children living in poverty versus their peers.
Policy, public health and clinicians created a multifaceted response to reducing disparities while improving childhood vaccinations. The federal government addressed the economic disparities through the Vaccines for Children Program, which purchased increasingly expensive vaccines for children who were uninsured, who were on Medicaid, were of Alaskan Native or American Indian heritage, or had private insurance that didn’t cover recommended vaccines.
In 2010, while national vaccination quality (as measured by overall vaccination coverage with multiple recommended series) has remained the same or increased slightly over the past 15 years, racial/ethnic disparities have decreased to 4 percentage points (for minorities vs. non-Hispanic white children), and have been reduced to 3 percentage points for poverty-related inequalities.
The effect of improved measles vaccinations has been profound, Davis and colleagues stated. In 1989, during the national measles outbreak, almost 18,000 cases of measles were reported in the U.S. By comparison, during 2006 to 2010 there were fewer than 150 measles cases reported annually. While the population benefits through herd immunity from broader vaccinations, there is a quality improvement result, as well. Reducing disparities through targeted federal efforts paved the way to improved national quality levels.