After a year of vociferous debate, health care reform passed. But the unprecedented attention to Americans' health somehow managed to miss one of the country's most alarming health problems: the huge disparities in health outcomes for different population groups.
How big are these disparities?
They are huge. Recent research by the American Human Development Project found that Asian Americans in New Jersey live, on average, 26 years longer than Native Americans in South Dakota. Whites in Washington, D.C. live, on average, 12 years longer than African Americans in D.C.
In 1999, the federal government launched Healthy People 2010, an ambitious project to narrow gaps like these. Its two main objectives were longer, healthier lives for all, and the elimination of health disparities in our society. Healthy People 2010 involved 250 local, state and federal agencies and 400 non-governmental organizations. It set targets for 467 objectives and 28 focus areas.
Setting specific, measurable, time-bound targets was an admirable strategy. Reaching beyond the medical community to include the wide range of actors that influence health outcomes -- from environmental groups to parks and recreation departments to housing authorities -- was a pioneering approach. The conceptual framework was great, the process strong and the targets laudable. But it failed -- and no one noticed.
At least seventy percent of the targets saw no reduction in disparities. On far too many of the indicators, particularly for racial disparities, things went backwards. Why the failure? Because the initiative had no teeth.
Healthy People 2010 did not have a dedicated implementation budget. Grants were made to incentivize performance, but they were too few and too dispersed to make a real difference. There was no law associated with this work, and there was a dearth of visible leadership to ensure accountability. Finally, the effort lacked an effective public campaign. How many people outside of the public health community have heard of Healthy People 2010? Success required, at a minimum, people knowing that the initiative existed in the first place.
Here we are, well into 2010, and there has been "little progress on a large scale overall," according to a leading health official. So now, there is Healthy People 2020 -- with a new set of objectives, targets and indicators.
If we are really serious about reducing health disparities, we need the same focus on bottom line accountability for health that we have for economic and financial targets. We need to monitor, report and act on fundamental indicators of health like the infant death rate and the diabetes rate with the same intense focus we as a society apply to the GDP, to the inflation rate, to interest rates and to gains and losses in the stock market.
Government at all levels, businesses, educators, health practitioners and advocates all have roles to play in attacking the major root causes of health disparities. Medical care and health insurance are only part of the story. Healthy people have access to parks, recreation facilities, sidewalks and bike-paths, and live where their kids can safely play outside. Healthy people have fresh produce and lean proteins available in their communities. Healthy people tend to live and work in healthy environments, without excessive indoor and outdoor air pollution or exposure to toxins, and they don't smoke. And they have access to a decent education, which increases the likelihood they will practice healthier behaviors and support healthier outcomes for their children.
Health care reform passed. Now it's time to tackle the root causes of health disparities. The success of Healthy People 2020 depends on it.