Jan. 11, 2017


New Report Identifies Root Causes of Health Inequity in the U.S., Outlines Solutions for Communities to Advance Health Equity

WASHINGTON – The burdens of poor health and the benefits of good health and well-being are inequitably distributed in the U.S. due to factors that range from poverty and inadequate housing to structural racism and discrimination, says a new report from the National Academies of Sciences, Engineering, and Medicine.  Community-driven interventions targeting these factors hold the greatest promise for promoting health equity -- the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance.

Health inequities are systematic differences in the opportunities that groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes.  Health inequity is costly for the United States with respect to health care expenditures, national security, business viability, and economic productivity, the report says.  For example, a 2009 analysis found that eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion for the years 2003-2006.

Beyond international rankings showing that the U.S. has higher rates of infant mortality and shorter life expectancy than other wealthy nations, racial, ethnic, and socio-economic disparities exist at the state level and among and within counties for these health indicators.  Research shows that where one lives is a greater predictor of one’s health than individual characteristics or behaviors.  The report describes nine determinants of health that are drivers of health inequities: income and wealth, housing, health systems and services, employment, education, transportation, social environment, public safety, and physical environment. 

“When our nation’s founders wrote that ‘all men are created equal’ with the right to ‘life, liberty, and the pursuit of happiness’, it is unlikely they envisioned a country where health status and life expectancy could be ordained by zip code, economic, or educational status,” said committee chair James Weinstein, CEO and president of the Dartmouth-Hitchcock health system and Peggy Y. Thomson Professor at the Geisel School at Dartmouth.  “Health inequities are a problem for us all — the burden of disparities in health adversely affects our nation’s children, business efficiency and competitiveness, economic strength, national security, standing in the world, and our national character and commitment to justice and fairness of opportunity.  It is the committee’s hope that this report will inform, educate, and ultimately inspire others to join in efforts across the nation to achieve America’s promise for all the people of this country.”

Communities -- defined in the report as the residents, religious congregations, community-based organizations, and others who live and work in a specific geographic location -- can play a powerful role in changing the conditions for health. Their actions need a nurturing environment, supported and facilitated by public and private sector policies, resources, and partnerships. A community-based solution is an action, policy, law, or program that is driven by the community, affects local factors that can influence health, and has the potential to advance health equity.  The committee that conducted the study and wrote the report identified nine examples of community-based solutions that address health inequities, all of which share the three elements in the report’s conceptual model: making health equity a shared vision and value, fostering multisector collaboration, and increasing community capacity to shape outcomes.

While it will take considerable time to address the root causes of health inequity, all actors in the community — residents, businesses, state and local government, health care and academic institutions, and other partners — have the power to change the narrative and help promote health equity, the report says.  Early and achievable targets might include reducing mortality, increasing graduation rates, reducing environmental hazards, and increasing access to environmental benefits.

In the education sector, infrastructure could be strengthened, modified, or expanded in the interest of improving health outcomes.  State departments of education should provide guidance to schools on how to conduct assessments of student health needs and of the school health and wellness environment, the report says.  In addition, to support schools in collecting data on student and community health, tax-exempt hospitals and health care systems and state and local public health agencies should make schools aware of existing health needs assessments to help them leverage the current data collection and analyses.

Through multisectoral partnerships, hospitals and health care systems should focus their community benefit funds to pursue long-term strategies including changes in law, policies, and systems to build healthier neighborhoods, expand access to housing, drive economic development, and advance other initiatives aimed at eradicating the root causes of poor health, especially in lower-income communities.

Government and nongovernment payers and providers should expand policies aiming to improve the quality of care, improve population health, and control health care costs to include a specific focus on improving population health for the most underserved. As one strategy to support a focus on health disparities, the Centers for Medicare & Medicaid Services could undertake research on payment reforms that could spur accounting for social risk factors in value-based payment programs it oversees.

The report notes the importance of factors such as race, ethnicity, disability status, veteran status, rurality, and urbanicity in shaping inequities.  The committee made recommendations to enable researchers to fully document and understand health inequities, provide the foundation for developing solutions, and measure their outcomes longitudinally.  For example, an expansion of current health disparity indicators and indices to include other groups beyond African-Americans and whites is needed, such as Hispanics and their major subgroups, Native Americans, Asian Americans, Pacific Islanders, and mixed race, in addition to LGBT, people with disabilities, and military veterans.  Government agencies, private foundations, and academic centers of higher education also should support research that examines the multiple effects of structural racism and implicit and explicit bias across different categories of marginalized status on health and health care delivery, and explores effective strategies to reduce and mitigate those effects.

This report is the first of a series of activities of the National Academy of Medicine's (NAM) Culture of Health program, a multiyear collaborative effort funded by the Robert Wood Johnson Foundation to identify strategies to achieve equitable good health for everyone in America.

“This report addresses the root causes of health inequity and lays out several specific approaches for communities to take in order to achieve health equity, which is vital to the health and well-being of the nation,” said National Academy of Medicine President Victor J. Dzau. "With the support of the Robert Wood Johnson Foundation, the NAM is committed to a long term effort to achieve health equity in the United States. Through our Culture of Health Program, we will be working over the next several years with stakeholders from multiple sectors and regions across the U.S. to impact policy, science, and practice to improve many of the social determinants of health that are the drivers of future health of the nation."

The study was sponsored by the Robert Wood Johnson Foundation.  The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine.  The Academies operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.  For more information, visit http://national-academies.org.  A committee roster follows.

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Dana Korsen, Media Officer
Rebecca Ray, Media Assistant
Office of News and Public Information
202-334-2138; e-mail news@nas.edu

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Copies of Communities in Action: Pathways to Health Equity are available from the National Academies Press on the Internet at www.nap.edu or by calling 202-334-3313 or 1-800-624-6242.  Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).


Health and Medicine Division
Board on Population Health and Public Health Practice
Committee on the Community-Based Solutions to Promote Health Equity in the United States

James N. Weinstein, M.S., D.O.* (chair)
CEO and President
Dartmouth-Hitchcock Medical Center, and
Peggy Y. Thomson Professor
Dartmouth Medical School
Lebanon, N.H.

Hortensia de los Angeles Amaro, Ph.D., M.A.*
Associate Vice Provost for Community Research Initiatives
Dean’s Professor of School of Social Work, and
Professor of Preventive Medicine
Keck School of Medicine
University of Southern California
Los Angeles

Elizabeth Baca, M.D., M.P.A.
Senior Health Adviser
Governor’s Office of Planning and Research
Sacramento, Calif.

Ned Calonge, M.D., M.P.H.*
President and CEO
The Colorado Trust, and
Associate Professor of Family Medicine
School of Medicine
University of Colorado

Bechara Choucair, M.D., M.S.
Senior Vice President and Chief Community Health Officer
Kaiser Permanente
Oakland, Calif.

Alison E. Cuellar, Ph.D., M.B.A.
Associate Professor of Health Administration and Policy
College of Health and Human Services
George Mason University
Fairfax, Va.

Robert H. Dugger, Ph.D.
Chair, Advisory Board, and Co-founder
ReadyNation, and
Managing Partner
Hanover Provident Capital LLC
Alexandria, Va.

Chandra Ford, Ph.D., M.P.H., M.S.
Associate Professor
Department of Community Health
Fielding School of Public Health
University of California
Los Angeles

Robert Garcia, J.D.
Founding Executive Director and Counsel
The City Project
Los Angeles

Helene D. Gayle, M.D., M.P.H.*
McKinsey Social Initiative 
Washington, D.C.

Andrew Grant-Thomas, Ph.D.
Amherst, Mass.

Carol Keehan, D.C., R.N., M.S.*
President and CEO
Catholic Health Association of the United States
Washington, D.C.

Christopher Lyons, Ph.D.
Associate Professor
Graduate Director
Department of Sociology
University of New Mexico

Kent McGuire, M.A., Ph.D.
President and CEO
Southern Education Foundation

Julie Morita, M.D.
Chicago Department of Public Health

Tia Powell, M.D.
Montefiore Einstein Center for Bioethics
Montefiore Health System
Bronx, N.Y.

Lisbeth Schorr*
Senior Fellow
Center for the Study of Social Policy
Washington, D.C.

Nick Tilsen
Executive Director
Thunder Valley Community Development Corp.
Porcupine, S.D.

William Wyman, M.B.A.
Wyman Consulting Associates Inc.
Hanover, N.H.


Amy Geller, M.P.H.
Study Director

*Member, National Academy of Medicine