National Scan of CLAS and Disparities Reduction Activities
Little progress has been made to close the gaps in the quality of health care delivered to racial, ethnic and linguistic minorities. Recent legislation invests in cultural and linguistic competence and the elimination of disparities, with increased funding for technical assistance, research and dissemination. Now is the time to identify opportunities to reduce disparities. Here, we examined and catalogued national efforts, and we describe activities and their funding, focus, target audience, scope and impact. We also identify opportunities for greater progress and potential influence, including provisions in recent health reform bills.
Racial and ethnic disparities exist across all regions of the country, among the insured and the uninsured, and across multiple diseases and health care services. Despite efforts to close the gaps in the quality of health care delivered to racial, ethnic and linguistic minorities, little progress has been made.1-5 Over the past six years, disparities between minority populations and Whites decreased on less than half of the quality measures studied in the annual National Healthcare Disparities Report (NHDR).6 The report noted that disparities persist in health care quality and access, across multiple priority populations, although their pattern and magnitude differs in subpopulations.
Demographic changes in the United States will increase the urgency of addressing health disparities. The Census Bureau projects that the non-Hispanic White population will decline steadily to comprise less than 50 percent of the total population by 2050, while the populations of Hispanics, Asians and Pacific Islanders will increase.7 Disparities also contribute to the nation’s rising health care costs. Waidman estimated that $23.9 billion would have been saved in 2009 if minority health equaled that of Whites.7 LaVeist et al estimated that over three years, the direct medical costs associated with health disparities amounted to $229.4 billion. When indirect costs were added, the three-year total increased to $1.24 trillion.8
Over the past decade, national reports have highlighted equity as a value for the health care system and called attention to the needs of our increasingly multicultural population. The Institute of Medicine’s (IOM) two influential reports on quality and disparities (Crossing the Quality Chasm: A New Health System for the Twenty-first Century9 and Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare3) identified equity as one of the six domains of health care quality, and detailed the evidence of pervasive disparities in health care, even after controlling for differences in insurance and socioeconomic status.
The U.S. Department of Health and Human Services (DHHS) in 2000 addressed language needs and cultural competency through several policy actions. The DHHS Office of Minority Health (OMH) issued standards for culturally and linguistically appropriate services (CLAS);10 DHHS issued policy guidance on language access requirements under Title VI of the Civil Rights Act11,12 and made the elimination of health disparities an overarching goal of the Healthy People 2010 initiative.13 The National Institutes of Health established the National Center on Minority Health and Health Disparities.14 Since 2003, the Agency for Healthcare Research and Quality’s (AHRQ) annual reports have tracked quality and disparities.2,4,15 Still, for years there has been little federal effort to implement IOM recommendations.
Recent actions by the federal government and by an increasing number of states, suggest that at least awareness of the problem is growing. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008,16 the Children’s Health Insurance Program Reauthorization Act (CHIPRA)17 and the Health Information Technology and Clinical Health Act (HITECH) of 200918 contain multiple provisions addressing cultural and linguistic competence and health care disparities. The recently enacted Patient Protection and Affordable Care Act (HR. 3590) also addresses these issues, including collection and analyses of race, ethnicity and language data; national strategies for quality improvement (which include disparities reduction); and health workforce development for under-represented minorities. The enactment of the American Recovery and Reinvestment Act (ARRA), CHIPRA and the Office of the National Coordinator of Health Information Technology (HIT) provisions regarding “meaningful use” of HIT may signal the start of a more active federal role.
As these laws are implemented, accompanied by increased funding for technical assistance, research and dissemination, we must identify the greatest opportunities to reduce disparities. The objective of this report is to catalog current, national-level activities to reduce health care disparities and identify gaps and opportunities to accelerate progress in closing the quality chasm. Throughout this paper, the term “health care disparities” is intended to convey both the differences in health care services based on racial, ethnic or linguistic differences and the failure to deliver culturally and linguistically appropriate services.
We conducted an Internet search of existing activities to reduce health care disparities, and interviewed experts in language access, cultural competence and disparities for their perspectives about challenges and opportunities.
We sought national-level activities using combinations of the following search terms: health care, cultural competency, language access, disparities, equity, culturally and linguistically appropriate services, multicultural, minority, underserved, vulnerable populations.
To keep our search manageable and focused on efforts with the potential for national effect, we excluded activities with a disease-specific, population-specific or organization-specific focus; activities regarding social determinants of health disparities; and activities focused on research that did not have an immediate action or implementation aim. We classified activities based on strategy, target audience, topic and funding source. We asked implementing organizations to review our information for accuracy. Iterative reviews by disparities experts identified missing activities and helped classify them.