Pharmacoequity: a new goal for ending disparities in U.S. health care

The Covid-19 pandemic has brought to the public’s attention alarming racial disparities in health. According to new data from the Centers for Disease Control and Prevention, life expectancy in the U.S. fell in 2020 by 1.5 years, the largest drop since World War II. The drop was far greater for Black and Hispanic Americans, who lost three years in life expectancy over the past year.

As a Black physician-scientist who studies health disparities, I have spent nearly a decade examining the reasons for this gap in life expectancy. The past year has demonstrated how racism is, and always has been, a public health crisis and determinant of physical and psychological health for many Americans. The so-called social determinants of health, including access to healthy food, safe housing, and clean air, have also been highlighted as drivers of health during a pandemic that exposed the well-known racial inequalities in these structural systems.

Another factor that has consistently driven health disparities is the undertreatment of chronic diseases in the Black community.

In 2018, my colleagues and I published a study showing that Black people with atrial fibrillation, a quivering or irregular heartbeat, had a 37% lower chance of receiving the newest guideline-based blood thinners to prevent stroke, the most common complication of atrial fibrillation. Up to 60 million people globally live with this heart condition, which also causes high rates of death and disability and reduces quality of life.

On Wednesday, several colleagues and I published in the journal JAMA Network Open an update to our original study. Examining more 110,000 patients with atrial fibrillation who received care within the Veterans Health Administration (VA) system, we again observed that Black patients were far less likely — by up to 26% — to receive newer, more effective, and now standard-of-care blood thinners for stroke prevention. This finding, which held consistent after adjusting for clinical and socioeconomic factors, is particularly worrisome given the VA’s increased access to prescription medications through a low-cost, uniform national drug formulary.

Our findings beg the question: Why do these disparities exist? And what can be done to address them?

The answer may be as simple as A-B-C.

Access to care

Addressing inequities in access to care in the U.S. is the starting point. Decades removed from the establishment of the Medicare and Medicaid programs and more than 10 years from the signing of the Affordable Care Act, 30 million people are still uninsured in the U.S., and millions more have little to no coverage for prescription drugs.

Our study suggests that insurance coverage is not enough, as it alone cannot address the breadth of patients’ pharmaceutical preferences or concerns. It’s time to think more broadly about what “access” means. This includes addressing the dearth of pharmacies in communities of color, now referred to as pharmacy deserts. It also includes advocating for improved health and language literacy in the U.S., including engaging patient pharmacy navigators who can aid with dosing instructions, managing multiple prescriptions, and more.

Bias in care

We must also eliminate health care bias. Like many of my colleagues, I chose a career in medicine to help patients and make a difference. Nonetheless, years of the so-called hidden curriculum in medical training can cultivate implicit or unconscious biases toward those who society deems as less worthy. Black Americans have been treated as such for centuries, with false assumptions made about their ability to adhere to, tolerate, or even warrant medical therapy, from pain medications to novel blood thinners.

Although implicit bias training now fills medical curricula across the country, systemic solutions are also needed. Data audits of provider prescribing practices through health equity dashboards as well as electronic medical record-based innovations that make the right choice the easy choice for physicians to prescribe therapies are just two system-level strategies to reduce the harms of health care bias.

Cost of care

Prescription drug costs, which are up to three times higher in the U.S. than anywhere else in the world, must also be addressed. Before the pandemic, curtailing these costs were a priority for the federal government. The Biden administration has added support for governmental price negotiation of drugs for Medicare and private insurers as part of its “Build Back Better” agenda.

Aiming for pharmacoequity

While the A-B-C solutions are welcome, our study suggests that even in a low-cost health care system, racial disparities exist in receiving medical therapy. That means the country needs a broad approach that encompasses access, bias, and cost to move health care closer to achieving pharmacoequity — a term I coined to portray a health system where all patients, regardless of race, class, or availability of resources, have access to the highest quality, evidence-based medical therapy indicated for their condition.

The pandemic has given public health, health system leaders, insurers, and policymakers the boldness to innovate around the provision of care. In much the same way, now is the time to reimagine what a just and equitable health system looks like: one in which access to life-saving therapy is universal and not determined by the color of one’s skin. Lives depend on it.

Utibe R. Essien is a general internist, assistant professor of medicine at the University of Pittsburgh School of Medicine, and director of the Career Education and Enhancement for Health Care Research Diversity Program for Medical Students. The views expressed here are his alone and do not necessarily reflect those of his employer.