The Washington, D.C. Metrorail, an architecturally impressive display of vaulted station ceilings contrasted against 100 miles of wrought steel, boasts a daily ridership of over 200,000 people.[1] Everyday, it shuttles a mix of tourists, students, and government employees on lines that span the eight wards of D.C. While the Metrorail itself is an interesting study in logistics, it also happens to provide a microcosmic basis upon which to examine health disparities in the U.S. For instance, traveling fourteen stops with one line switch from Friendship Heights to Anacostia, an unsuspecting Metrorail patron may not realize he just experienced an 833% increase in the HIV prevalence rate, a 364% increase in the infant mortality rate, and a 101% increase in diabetes-related deaths. [2][3] How is it possible that such great differences exist along a mere eleven mile trek?

The issue of health disparities across race and ethnicity was first brought to the attention of the American public in 1998 through the Clinton administration’s Initiative to Eliminate Racial and Ethnic Disparities in Health, which for the first time set equal health goals for all Americans versus setting lower goals for minorities.[4] The Initiative centered around the ambitious goal of eliminating differential health status in five indicative areas by 2010, and yet today, disparities clearly continue to persist- in some public health areas, they have since intensified.[5] Health disparities therefore pose a significant challenge that needs to be confronted now and throughout the upcoming years.

A multi-targeted approach should address data limitations, community program implementation, and improvements in communication. Because successes occur on the local level, data collection must be based on population subsets, as national trends cannot be extrapolated to specific communities.[6] Data also need to include supporting information to better examine why disparities persist via questions that survey the physician-patient relationship, quality of care, and information access.[7][8][9] Integration of all collected data to probe underlying causes then relies on effective measures and models that must be developed.[10]

Preliminary evidence suggests the efficacy of targeted interventions. A 2003 report found a possible correlation between significant investments in community-based cancer programs and high screening rates for African American women, resulting in “no evidence of later stage cervical cancer presentation” when African Americans tend to present with advanced cancers.[11] Community leaders should proactively arrange outreach screenings and awareness campaigns to stimulate conversation between minority patients and providers. In fact, the 2011 federal budget has allocated $290 million for community health centers which are ideal staging grounds for such programs.[12]

Educating physicians is important for self-recognition of internal biases. In 2003, the American Medical Association released a report that outlined its overall strategy regarding the health gap. The main focuses included developing physician tools that encourage cultural competence and adoption of workplace changes.[13] However, the ways in which medical schools can contribute were compiled into one single point ranked low in priority out of ten total recommendations.[14] From an economic perspective, emphasis should instead be placed on graduating classes of physicians who have been educated in the science of health disparities and are equipped with the tools and leadership needed to reverse trends. Students should be introduced to such protocols early in their education to ascertain proper practice and management. Doctors-in-training can then transition to become professionals who are able to interact with patients in a way that suits both parties.

It has also been stated that to adequately address health disparities, the number of providers in underserved communities must increase.[15] This naturally leads to the second major health policy challenge that the U.S. faces and will continue to face in the near future: the shortage of primary care providers (PCPs).

The current debate over healthcare reform has especially called attention to this need, as expanding health coverage could potentially overwhelm the system.[16] However, the American College of Physicians had, since 2006, foreseen the increase in demand for primary care services by an aging population juxtaposed with a limited and shrinking PCP pool.[17] PCPs form an essential first line-of-defense by providing a “medical home,” a source of continuous primary care that allows for early detection of problems and is especially important for the “medically disenfranchised.”[18] Shortages result in either incomplete access to care, which involves shorter visits, longer waiting times, longer distances, and higher prices or complete loss of access.[19]

The economics of physician supply and demand are complicated, and simply expanding enrollment will only moderate versus eliminate the problem.[20] There exist, however, a number of proposals that show promise in alleviating the shortage. First, expanding incentive-based programs such as Medicare-funded residency slots and the National Health Service Corps that help make medical school debt manageable is an option that should run alongside active participation from medical schools. For example, the City College of NY offers a BS/MD program in which students follow a fast-track curriculum with low tuition in return for two years of service in a “designated primary care physician shortage area.”[21] Second, non-physician clinicians should be integrated into the sector to increase physician productivity and alleviate demand.[22] These clinicians can play a larger role in community health centers and clinics, while expanding the Medicare capacity of doctors by communicating with patients via telephone and email.[23] Third, payment for PCP services should increase as recommended by the Medicare Payment Advisory Commission. [24]

There is no one, simple solution to either of the challenges presented here, which is why all stakeholders must remain committed through the next five years and beyond to adequately reduce the health gap, increase access to primary care services, and improve health outcomes for all. Addressing these issues will require much coordination amongst medical professionals, public health scientists, community leaders, and academic institutions to better understand both the etiology of why barriers to eliminating disparities exist and the mechanisms by which we can cultivate a sustainable primary care workforce. Several organizations have already taken steps to refine efforts, and perhaps in the upcoming years we can look forward to a functioning system that no longer includes severe health gradients.