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What is the historical background of disparities in healthcare delivery and how did these disparities evolve? The history goes back to slavery, wherein what Byrd and Clayton have termed the originated and was nourished. In this chapter, the concept that slavery gave rise to a racist system of healthcare delivery is explored, and the observation that this system is still operative is documented by several pointed examples.

Disparities in health status and healthcare delivery have been documented in the United States throughout most of the past two centuries (–). More recently, the Institute of Medicine (IOM) () and the Agency for Healthcare Research and Quality () have confirmed that such disparities are pervasive but improvements are possible. Eliminating these disparities is one of the two over-arching goals of the Healthy People 2010 national public health agenda (). In this endeavor, the availability of reliable, population-based indicators of disparities can be crucial for assessing the magnitude, trends, and impact of interventions designed to reduce and eventually eliminate disparities. These indicators can also serve to inform policy and program development, help set priorities, and assist in identifying areas in which additional research is needed.

The past century has borne witness to a most unique development in the annals of American medicine. The patients who we treat have become more complex, not only in regards to the variety of illnesses that they present, but especially in regards to the increasing mixture of cultures, ethnic groups, and races. This steady progression of heterogeneity presents a challenge of major proportions to the practicing physician who must now acknowledge that the approach to patients cannot be monolithic, but instead should be tailored to fit their special needs.

Straw men are large players in the debate over racial disparity in American medicine. Most have been deployed by the disparities-denying right, but progressives intent on “outing” racism have sent forth their share. In this chapter, I devote some effort to flushing them out. But my larger aim is to understand the competing moral premises that drive the politics of healthcare disparity. At the bottom, I contend, arguments about the scope of disparity and discrimination in medical care are disputes about the appropriate scope of personal responsibility for life circumstances. Further research into the factors that correlate with racial differences in healthcare can shed light on the circumstances that bring about these differences. But whether these circumstances, once understood, should be deemed acceptable is a moral and political matter. Sharp disagreements over the scope of personal and public responsibility for these circumstances are inevitable. These disagreements make it harder to pursue common ground solutions to racial and other inequities in healthcare.

Over the last 200 yr, the United States has experienced dramatic improvements in overall health and life expectancy largely owing to initiatives in public health, health promotion, and disease prevention. Nevertheless, despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited significantly less from these advances. National data indicates that minority Americans have poorer health outcomes (compared with whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others (). Multiple factors contribute to these “racial and ethnic disparities in health.” First and foremost, research has demonstrated that social determinants such as lower levels of education, overall lower socioeconomic status, inadequate and unsafe housing, racism, and living in close proximity to environmental hazards disproportionately impact minority populations and thus contribute to their poorer health outcomes (–). One poignant example of the impact of social determinants is the fact that three of the five largest landfills in the country are in African American and Latino communities, thus contributing to some of the highest rates of pediatric asthma among these populations (). Second, lack of access to care also takes a significant toll, as uninsured individuals are less likely to have a regular source of care, are more likely to report delay in seeking care, and are more likely to report that they have not received needed care—all resulting in experiencing avoidable hospitalizations, emergency hospital care, and adverse health outcomes (–).

The spectacular ascent of medical science at the dawn of the 21st century trumpets a new era in US healthcare and great possibilities for preserving human health. At the same time, it poses serious challenges for policymakers who must make crucial decisions about the safety, efficacy, and affordability of medical technologies. One of the most difficult and contentious matters confronting decision makers is the question of how to ensure the delivery of life-saving technologies to low-income and minority patient populations, whereas simultaneously controlling ever-rising healthcare costs. In theory, the increasingly popular concept of evidence-based medicine (EBM) suggests a potential tool for both cost containment and the reduction of severe racial and ethnic disparities in healthcare delivery. Drawn from systematic reviews of studies that use rigorous research methods, particularly the randomized controlled trial, the “evidence” guiding EBM protocols informs treatment decisions made by physicians, as well as policy decisions regarding the allocation of health technologies at the population level.

Recent US Census data confirm what many Americans have casually observed: racial and ethnic minorities are the fastest-growing segments of the US population. By mid century, nearly one in two Americans will be an Asian American, Pacific Islander, African American, Hispanic, American Indian, and/or Alaska Native. Since 2000, Hispanics have accounted for 3.5 million or over one-half of the population increase of 6.9 million individuals in the United States. The number of Asian Americans grew at a larger proportion (9%) than any other racial or ethnic group during this same time period. And in at least three states (California, Hawaii, and New Mexico) and the District of Columbia, racial and ethnic “minorities” constitute a majority of the population ().

This chapter discusses the role of quality improvement (QI) as a vehicle for eliminating racial and ethnic disparities in healthcare. Disparities in health and disparities are not synonymous. The latter represents only one of many contributors to disparities in health. Furthermore, healthcare disparities result from a complex constellation of patient, provider, organizational, and community/societal factors. Tackling inequities in healthcare requires addressing the predominant cause of a particular healthcare disparity. This can be done through well-designed QI interventions. Such interventions can potentially reduce healthcare disparities through either targeted or universally applied strategies. The former specifically targets minority patients within a healthcare organization or targets organizations that serve largely minority patients. The latter applies QI activities to all patients in the expectation that the intervention disproportionately benefits minorities. A range of QI tools exist to improve care to minorities. Review of available evidence shows that it is possible to reduce, if not eliminate, disparities in healthcare using these tools. However, doing so requires a concerted commitment on the part of health plans and insurance payers to adequately finance such efforts.

Equal access to quality healthcare is a crucial issue facing the United States (). For too long, too many Americans have been equal access to quality healthcare based on race, ethnicity, and gender (). Many factors contribute to disparities: cultural incompetence of healthcare providers, socioeconomic inequities, disparate impact of facially neutral practices and policies, inadequacy of civil rights laws and enforcement, and multiple forms of discrimination. These disparities exist in health status, access to healthcare services, participation in health research and receipt of healthcare financing (). This disparity in healthcare is doubly significant given the devastating racial disparity in health status that exists. The combination of racial disparity in health status, institutional racism in healthcare and inadequate legal protection points to a .

Over the past 20 yr there has been a significant evolution in the role of the Federal government in addressing the problem of health disparities in the United States. In this chapter, the nature of health disparities among minorities and underserved populations in this country, and early governmental approaches to the problem are described in brief. A historical and descriptive overview of the government’s efforts, since 1985, to eliminate health disparities in the United States will be concentrated on.