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Advancing Racial Equity in U.S. Health Care

The Commonwealth Fund 2024 State Health Disparities Report
Doctor in mask examines girl in mask's ear on table

Dr. Reshma Chugani checks 7-year-old Zoe Oliver’s ears during a medical visit at Atlanta Children’s Clinical Center on September 29, 2023. Health care system performance varies widely by race and ethnicity, both within states and between states. Photo: Alyssa Pointer for the Washington Post via Getty Images

Dr. Reshma Chugani checks 7-year-old Zoe Oliver’s ears during a medical visit at Atlanta Children’s Clinical Center on September 29, 2023. Health care system performance varies widely by race and ethnicity, both within states and between states. Photo: Alyssa Pointer for the Washington Post via Getty Images

  • Deep-seated racial and ethnic health disparities persist across the United States, even in states with otherwise high-performing health systems

  • American Indians and Black Americans die at significantly higher rates from preventable and treatable causes than members of other racial and ethnic groups

  • Deep-seated racial and ethnic health disparities persist across the United States, even in states with otherwise high-performing health systems

  • American Indians and Black Americans die at significantly higher rates from preventable and treatable causes than members of other racial and ethnic groups


For nearly two decades, the Commonwealth Fund has tracked health and health care in each state, seeking both to understand how the policy choices we make affect people’s health outcomes and to motivate the change needed to improve the health of all communities across the United States. But assessing how well a state performs on average can mask the profound inequities that many people experience.

This report evaluates disparities in health and health care across racial and ethnic groups, both within states and between U.S. states. We collected data for 25 indicators of health system performance, specifically focusing on health outcomes, access to health care, and quality and use of health care services for Black, white, Hispanic, American Indian and Alaska Native (AIAN), and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations. We then produced a health system performance “score” for each of the five racial and ethnic groups in every state where we were able to make direct comparisons between those groups and between groups in other states. (For complete details on our methods, see How We Measure Performance of States’ Health Care Systems for Racial and Ethnic Groups.)

Our hope is that policymakers, health system leaders, and community stakeholders will use this tool to investigate the impact of current and past health policies on different racial and ethnic groups and to take steps to ensure an equitable health care system for the future.

Overview of Health Disparities in the United States

Profound racial and ethnic disparities in health, well-being, and life expectancy have long been the norm in the United States. These disparities are especially stark for Black and AIAN people, who live fewer years, on average, than white and Hispanic people1 and are more likely to die from treatable conditions, more likely to die during or after pregnancy and suffer serious pregnancy-related complications, more likely to lose children in infancy,2 and are at higher risk for many chronic health conditions, from diabetes to hypertension.3

The COVID-19 pandemic only made things worse. Its disproportionate impact on Black, Hispanic, and AIAN people caused a sharper decline in average life expectancy since 2020 for these groups compared to white people.4

Factors contributing to health disparities. Deep racial and ethnic disparities in health are driven by factors inside and outside state health care systems. For example, in many communities where people of color live, poverty rates are higher than average, levels of pollution and crime are elevated, and green spaces are few — all key contributors to health disparities.5 A lack of affordable, quality health care options, meanwhile, can make it difficult to get timely treatment — a barrier that people of color disproportionately face. Black, Hispanic, and AIAN people are also less likely than other groups to have health insurance, more likely to delay care because of costs, and more likely to incur medical debt.6 And they are less likely to have a usual source of care or to regularly receive timely preventive services like vaccinations.7

Studies show as well that many people of color contend with interpersonal racism and discrimination in health care settings and more often receive worse medical care than white patients.8 According to an assessment by the federal Agency for Healthcare Research and Quality (AHRQ), Black patients received worse care than white patients on 52 percent of quality measures in 2023.9 The study also found marked disparities in quality of care and patient safety with respect to heart disease, cancer, stroke,10 maternal health outcomes,11 pain management,12 and surgery.13

The policy choices that federal, state, and local leaders have made over many decades have led to economic suppression, unequal educational access, and widespread housing segregation, all of which have contributed in their own ways to worse health outcomes for people of color.14 While the nation’s steady and slow progress toward universal, comprehensive coverage has narrowed racial and ethnic disparities in coverage and access to care, it has not eliminated them. In particular, the 10 states that have yet to expand eligibility for Medicaid under the Affordable Care Act (ACA), have the largest coverage gaps by race and ethnicity.

A Note on the Racial and Ethnic Categories Used in This Report

None of the five racial and ethnic groups discussed in this report are homogeneous: each encompasses distinct communities with a range of cultures, experiences, socioeconomic levels, and immigration challenges. Such groupings thus conceal substantial differences, as evidenced by the great variation seen in health insurance coverage rates among Asian Americans.15

Aggregation of these categories was necessary to obtain sufficient sample sizes for our analysis of state health system performance, but state and local stakeholders should interpret the findings within the context of their communities. Our report should be considered only as a starting point for more targeted research exploration and policy development.


Racial and ethnic disparities are pervasive across all states.

Health care system performance varies widely by race and ethnicity, both within states and between states (Exhibit 1). Mirroring national patterns, substantial health and health care disparities exist between white and Black, Hispanic, and American Indian and Alaska Native (AIAN) communities in nearly all states.


Massachusetts, Rhode Island, and Connecticut stand out for their relatively high performance for all racial and ethnic groups,16 yet, even so, these states have considerable disparities in access to care, the quality of care people receive, and health outcomes. Health care systems in certain states, including Oklahoma, West Virginia, and Mississippi, perform poorly for all groups for which we were able to calculate overall performance scores.

Our overall health system score for each group within a state represents aggregate performance across three domains: health outcomes; health care access; and quality and use of health care services. Below we discuss findings for each of these aspects of health system performance.

Health Outcomes

Death rates and prevalence of health problems vary significantly by race and ethnicity in every state.

Health outcomes, as measured primarily by death rates and the presence of health problems, differ significantly by race and ethnicity. Historically, Black and AIAN people have had lower life expectancies compared to other groups in the U.S. They also experienced greater loss of life from COVID-19 infections.17

We tracked deaths before age 75 from health conditions considered preventable and treatable — a measure known as “premature avoidable mortality.” This measure is highly correlated with life expectancy.18 On average, Black people are more likely than Asian American, Native Hawaiian, and Pacific Islander (AANHPI), Hispanic, and white people to die early from avoidable causes (Exhibit 2). AIAN residents of South Dakota, Wyoming, Montana, and North Dakota had among the highest rates of any group in any state. Average premature mortality rates were lowest for AANHPI communities.

Nationally, Hispanic people generally have lower premature mortality rates compared to Black and white people, despite having higher uninsured rates and worse access to health care than these groups. It is important to note that the U.S. Hispanic population is highly diverse, and health care access and outcomes for groups within this population vary, particularly by immigration status.19 Lower rates of premature mortality could also stem from the relative youth of U.S. Hispanic populations and their lower rates of risky health behaviors, such as smoking.20 Nevertheless, recent research shows rising mortality and prevalence of chronic conditions over time within Hispanic populations.21


We found distinct regional patterns in premature avoidable mortality. For example:

  • Preventable mortality rates are higher for both Black and white residents in several southern and south-central states — Arkansas, Mississippi, Louisiana, Tennessee, Kentucky, and Missouri — compared to most other parts of the country (Appendix B2).
  • For AIAN people, rates are highest in the northern plains and southwestern states (Appendix B2).
  • In several southwestern and mountain states, including New Mexico, Arizona, Colorado, Oklahoma, Texas, and Wyoming, premature mortality rates for Hispanic residents are higher than the low rates for that group found elsewhere in the U.S., where they align more closely with rates for white residents.

There are also sizeable disparities in mortality rates for conditions that are considered treatable. (Appendix B2). Breast cancer is considered treatable when detected early but is more likely to be diagnosed at later stages among Black women, who have much higher age-adjusted death rates for the disease than other women in most states.22 And in most areas of the U.S., infant and maternal mortality rates are highest for Black and AIAN residents, a pattern that has been documented by other studies.23

Health Care Access

Racial and ethnic health disparities are perpetuated by less insurance coverage and unequal access to high-quality care.

Large disparities in health care access between white people and members of most other racial and ethnic groups are apparent across states. Hispanic people have the highest uninsured rates and cost-related problems in getting care.

Lack of comprehensive insurance coverage is a key contributor to disparities in access. Health insurance is essential for accessing health care. Since the Affordable Care Act (ACA) became law, the number of people with insurance has climbed steadily. The law created a federal standard for comprehensive insurance and made subsidized coverage available through marketplace plans as well as expanded Medicaid eligibility. Policy changes enacted during the COVID-19 pandemic and extended by Congress in 2022 further boosted coverage. In 2024, a record 21.3 million people enrolled in ACA marketplace plans.24

Still, 25 million people remain uninsured, and the unwinding of the pandemic-era policy keeping people continuously enrolled in Medicaid will likely lead to an increase in that number this year as people lose their coverage.25 Moreover, surveys indicate that a large percentage of U.S. residents with any kind of health insurance — including employer plans, which cover the majority of Americans — face high deductibles and other cost sharing that often lead to delays in care. Many people suffer negative health effects from delayed treatment.26 Research has also found that millions of Americans who do get care struggle later to pay off medical debt.

While the ACA’s insurance expansions led to coverage gains across all racial and ethnic groups, coverage disparities remain (Exhibit 3).27 In nearly all states, uninsured rates continue to be higher for Black, Hispanic, and AIAN residents than they are for white and AANHPI residents (Appendix B3). In 2024, Hispanic and Black Americans remain disproportionally represented in the 10 states that have not taken up the ACA’s Medicaid expansion, which elsewhere has significantly reduced disparities in coverage and access.


Some Hispanic and AANHPI populations continue to face immigration-related barriers to getting subsidized coverage through Medicaid or the ACA marketplaces. AIAN people also face unique access concerns related to the underfunding and limited availability of Indian Health Service (IHS) facilities as well as to socioeconomic factors and geographic barriers.28

Being uninsured or underinsured has consequences. When people are uninsured, have gaps in coverage, or are in plans that don’t provide comprehensive coverage, they are unable to get care when they need it or have to pay high out-of-pocket costs for their care.29 With comparatively lower incomes and fewer savings, Black, Hispanic, and AIAN people are more likely to report experiencing delays in their care or financial distress.30

Many people of color in the U.S. are also less likely to have a usual source of care, a crucial point of first contact with the health system that helps ensure people get treatment when they need it (Appendix B3). Lack of a regular care provider is associated with a lack of coverage as well as with Medicaid’s low payment rates, which limit the network of participating providers and hospitals in neighborhoods where people of color live.31

Quality and Use of Health Care Services

Racial and ethnic disparities in care quality are driven by unequal access to and use of primary care.

Racial and ethnic disparities in quality of care and use of services have been extensively documented.32 Across and within most states, white people overall receive better quality of care than Black, Hispanic, AIAN, and, often, AANHPI people.

Primary care clinicians play an especially critical role in providing people with high-value services, including preventive care like cancer screenings and vaccines as well as chronic disease management. In fact, when people of color have access to clinicians of the same racial background as themselves, they tend to have better health care experiences, more efficient health care utilization, and better health outcomes.33 When there are barriers to obtaining primary care, such as costs or a lack of providers, people are more likely to get care in more intense and costly care settings, particularly an emergency department (ED).34 For example, Black Medicare beneficiaries are more likely than white beneficiaries to be hospitalized for acute exacerbations of chronic conditions that are treatable and manageable with appropriate primary care, and they are more likely to seek and receive care in an ED for conditions that are nonurgent or can otherwise be treated in a primary care setting (Exhibit 4).

For all Medicare beneficiaries, greater use of primary care services is associated with less use of EDs for treatable conditions and fewer hospital admissions.35



This report highlights persistent racial and ethnic disparities in health care across the United States. These disparities are fueled by inequities in access to high-quality care that affect health outcomes.

Advancing equity in health and health care should be a top priority of health care leaders and policymakers. A good start would be to identify policies that impede progress toward this goal. Leaders at the federal, state, and local levels could consider evaluating existing and emerging laws and regulations for their implications for the health of people of color. And they could pursue reforms to remedy the longstanding disparities described in this report.

To monitor trends in disparities and promote accountability, policymakers and health system leaders can support the ongoing development and use of standardized, equity-focused measures across all regulatory and performance-reporting agencies and institutions.36 Such metrics can be used to track whether states, health systems, and health plans are reducing racial disparities in clinical outcomes, insurance coverage, access to clinicians, and other areas.

What Policy Changes Can Bridge the Gap?

Policymakers at every level of government, along with leaders in the health care sector, have many tools to make U.S. health care more equitable and to narrow persistent racial and ethnic disparities in health outcomes. Following are some options for them to consider.

Ensuring universal, affordable, and equitable health coverage. Twenty-five million people in the U.S. are still uninsured, and they are disproportionately people of color. About one-quarter of U.S. working-age adults are underinsured, facing high out-of-pocket costs and deductibles relative to their income.37 To address these coverage gaps:

  • Congress could permanently extend the enhanced marketplace premium subsidies set to expire in 2025.
  • The 10 states that have yet to expand their Medicaid programs could do so. As a fallback, Congress could allow Medicaid-eligible people in the coverage gap in these states to enroll in zero-premium marketplace plans.38
  • Congress could reduce deductibles and out-of-pocket costs for marketplace insurance plans. Two options are to extend cost-sharing reduction subsidies further up the income scale and change the benchmark plan that determines the size of premium subsidies from silver to gold.
  • Congress could lower immigration-related barriers to coverage. An estimated 3 million uninsured adults cannot enroll in Medicaid or subsidized marketplace plans because of their immigration status.39 Lawmakers could allow certain groups of undocumented, low-income immigrant adults and children to enroll in Medicaid or other affordable coverage, as several states already have done.40
  • The federal government could promote more equitable treatment of enrollees in commercial insurance plans. Policymakers could require insurers to collect and report information on race and ethnicity during enrollment and make it linkable to claims data;41 meet ACA requirements for including essential community providers in their networks;42 and obtain health equity accreditation.

Strengthening primary care and improving the delivery of services. Predominantly Black and Hispanic communities tend to have fewer primary care providers and lower-quality health care facilities than mostly white communities.43 To reverse these disparities, federal and state policymakers could:

  • Reimburse primary care providers based on the value of care they deliver to patients. Doing so would encourage investment in health promotion, disease prevention, and chronic disease management.44 For example, North Carolina’s Medicaid program uses a prospective payment model that emphasizes primary care–based population health management. Oregon and Washington are linking Medicaid provider payments to performance on equity measures.45
  • Offer financial incentives, such as higher reimbursement rates and/or loan repayment, to providers who serve in medically underserved communities.
  • Expand training for community health workers and incorporate them in multidisciplinary care teams. As residents of the communities they serve, these individuals can help people navigate the health system to get the care they need. They can help arrange for interpretation and translation services, provide culturally appropriate health education and information, and lend other assistance.46 Evidence shows that a community-based workforce can help improve patient-reported quality of care as well as reduce hospitalizations and 30-day readmissions.47
  • Diversify the health workforce by strengthening pipelines into the health professions for people of color and monitoring and chronicling the impact of policies on diversity in health care.48
  • Modernize medical licensing to allow health care professionals to practice across state lines.49

Reducing inequitable administrative burdens affecting patients and providers. Americans seeking to enroll in health insurance or get health care face far higher administrative hurdles than residents of other high-income nations.50 Recent research points to the negative impact these barriers have on access to care for lower-income individuals, including many people of color.51 To reduce such barriers:

  • Congress could create a longer period of continuous Medicaid eligibility. Disruption in Medicaid coverage because of eligibility changes, administrative errors, and other factors can leave people uninsured and unable to get care. These disruptions particularly affect people of color, given their disproportionate enrollment in Medicaid. Lawmakers could apply the lessons of the pandemic and give states the option — without having to apply for a waiver — to maintain continuous enrollment eligibility for adults for 12 months.
  • Congress could create an auto-enrollment mechanism. Research shows that many uninsured people are eligible for Medicaid or subsidized marketplace coverage. By allowing auto-enrollment in comprehensive coverage, Congress could move the nation closer to universal coverage.52
  • Public and private insurers could simplify rules for quality reporting, care management, utilization review, and prior authorization programs. These programs can create unnecessary red tape, and even financial penalties, for underresourced providers of care to communities of color. Administrators could audit oversight and accountability programs for their disproportionate impact on these providers.

Investing in social services. The U.S. spends less on economic and social supports for children and working-age adults than most other high-income countries. Given the socioeconomic disadvantages these groups face, this relative lack of investment is likely contributing significantly to racial and ethnic disparities in health outcomes.53 To remedy this inequity, federal and state policymakers could:

  • Expand economic support for lower-income families, such as by expanding unemployment compensation, the Earned Income Tax Credit and child tax credit programs, and childcare, food security, and targeted wealth-building programs.54
  • Increase investment in affordable housing, public transportation, early childhood development, and affordable higher education.55
How We Measure Performance of States’ Health Care Systems for Racial and Ethnic Groups

Our measurement strategy was designed to produce a state health system performance score for each of five racial and ethnic groups in every state where direct comparisons are possible among those groups and among groups in other states. The five groups are: Black, white, Hispanic, American Indian and Alaska Native (AIAN), and Asian American, Native Hawaiian, and Pacific Islander (AANHPI).

We started by collecting data for 25 performance indicators, stratified by state and by race and ethnicity. Indicators were grouped into three domains: health outcomes, health care access, and quality and use of health care services.

Scoring method. For each of the 25 indicators, we calculate a standardized score for each state or population group with sufficient data. As an example, for adult uninsured rates, we calculate standardized scores using point estimates for 211 state racial and ethnic group pairs (e.g., 51 white, 48 Hispanic, 41 Black, 40 AANHPI, 31 AIAN) with sufficient data.

Within each performance domain, we combined indicator values to create a summary score. We then combined the domain summary scores in each state to create a composite state health system performance score for each racial and ethnic group — Black, white, AIAN, and AANHPI (non-Hispanic), and Hispanic (any race). The ability to generate these scores is dependent on having a sufficient population sample size for each indicator.

Based on the totality of composite scores, each racial or ethnic group within each state received a percentile score providing both national and state-level context on the performance of a state health system for that population. The percentile scoring, from 1 (worst) to 100 (best), reflects the observed distribution of health system performance for all groups measured in this report and enables comparisons within and across states. It is important to note that because scores are set relative to one another rather than to a predefined benchmark, there is still room for improvement in health system performance at or near the 100th percentile.

Use of racial/ethnic data categories. The five racial and ethnic data categories often group together populations with different experiences, cultures, immigration barriers, and other socioeconomic factors. This includes a wide range of culturally distinct Hispanic communities and Asian American communities. Such groupings are imperfect, as they mask significant differences. For example, past research has shown variability in health insurance coverage rates among Asian American subpopulations and between Asian Americans and Native Hawaiians or Pacific Islanders.56

These categories are necessary, however, because they reflect the ways that populations are grouped in the data sources we drew upon for this report, and because our analysis required sufficient sample sizes. States and localities should interpret the findings within the context of their own communities, using them as a starting point to help guide more targeted research and policy solutions.

Refer to the appendices for complete study methods, list of indicators, and health system performance scores for each state and racial and ethnic population.


We owe our sincere appreciation to the researchers who developed indicators and conducted data analyses for this report. These include: Sherry Glied and Dong Ding, New York University Robert F. Wagner Graduate School of Public Service; and Caitlin Burbank, Gulcan Cil, and Shreya Roy from the Center for Evidence-Based Policy at Oregon Health & Science University. In addition, we would like to thank the four-member advisory panel who provided crucial feedback and review throughout development of the methods used in this report: Cara James, Ph.D. (Grantmakers In Health); Zinzi Bailey, Sc.D., M.S.P.H. (University of Miami Miller School of Medicine); Dolores Acevedo-Garcia, Ph.D., M.P.A.-U.R.P. (Brandeis University); and Marc Elliott, Ph.D., M.A. (RAND Corporation).

We would like to thank the following Commonwealth Fund staff members: Joseph Betancourt, Sarah Christie (health equity fellow), Melinda Abrams, and Rachel Nuzum for providing constructive feedback and guidance; and the Fund’s communications and support teams, including Chris Hollander, Bethanne Fox, Jen Wilson, Paul Frame, Sam Chase, Josh Tallman, Barry Scholl, Relebohile Masitha, Celli Horstman, Avni Gupta, Alexandra Bryan, Sara Federman, and Evan Gumas for their guidance, editorial and production support, and public dissemination efforts.

Finally, we wish to acknowledge Maya Brod of Burness for her assistance with media outreach, and the Center for Evidence-Based Policy at Oregon Health & Science University for its support of the research unit, which enabled the analysis and development of the report.

  1. Elizabeth Arias et al., Provisional Life Expectancy Estimates for 2020 (NVSS Vital Statistics Rapid Release no. 15, National Center for Health Statistics, July 2021); and Indian Health Service, “Disparities Fact Sheet,” Oct. 2019.
  2. Mortality amenable to health care, deaths per 100,000 population,” Commonwealth Fund Health Systems Data Center, n.d., and calculations from 2018–19 CDC National Vital Statistics System; Eugene Declercq and Laurie C. Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020); “Infant mortality per 1,000 live births,” Commonwealth Fund Health Systems Data Center, n.d.; and Centers for Disease Control and Prevention, “Infant Mortality,” last updated Sept. 13, 2023.
  3. Jesse C. Baumgartner et al., Inequities in Health and Health Care in Black and Latinx/Hispanic Communities: 23 Charts (Commonwealth Fund, June 2021); and IHS, “Disparities Fact Sheet,” 2019.
  4. Arias et al., Provisional Life Expectancy, 2021; and Jessica Arrazola et al., “COVID-19 Mortality Among American Indian and Alaska Native Persons — 14 States, January–June 2020,” Morbidity and Mortality Weekly Report 69, no. 49 (Dec. 2020): 1853–56.
  5. Gina Kolata, “Social Inequities Explain Racial Gaps in Pandemic, Studies Find,” New York Times, Dec. 9, 2020; Samrachana Adhikari et al., “Assessment of Community-Level Disparities in Coronavirus Disease 2019 (COVID-19) Infections and Deaths in Large U.S. Metropolitan Areas,” JAMA Network Open 3, no. 7 (July 28, 2020): e2016938; and Nancy Krieger, Pamela D. Waterman, and Jarvis T. Chen, “COVID-19 and Overall Mortality Inequities in the Surge in Death Rates by Zip Code Characteristics: Massachusetts, January 1 to May 19, 2020,” American Journal of Public Health 110, no. 12 (Dec. 2020): 1850–52.
  6. Shiwani Mahajan et al., “Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999–2018,” JAMA 326, no. 7 (Aug. 17, 2021): 637–48; Health Insurance Coverage and Access to Care for American Indians and Alaska Natives: Current Trends and Key Challenges (ASPE, July 2021); and Jesse C. Baumgartner, Sara R. Collins, and David C. Radley, Inequities in Health Insurance Coverage and Access for Black and Hispanic Adults: The Impact of Medicaid Expansion and the Pandemic (Commonwealth Fund, Mar. 2023).
  7. Mahajan et al., “Trends in Differences,” 2021; Jesse C. Baumgartner, Sara R. Collins, and David C. Radley, Racial and Ethnic Inequities in Health Care Coverage and Access, 2013–2019 (Commonwealth Fund, June 2021); and Jesse C. Baumgartner et al., How Prepared Are States to Vaccinate the Public Against COVID-19? Learning from Influenza and H1N1 Vaccination Programs (Commonwealth Fund, Dec. 2020).
  8. Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Institute of Medicine, 2003); Kiran Clair et al., “Disparities by Race, Socioeconomic Status, and Insurance Type in the Receipt of NCCN Guideline-Concordant Care for Select Cancer Types in California,” Journal of Clinical Oncology 38, no. 15 suppl. (May 2020): 7031; and William L. Schpero et al., “For Selected Services, Blacks and Hispanics More Likely to Receive Low-Value Care Than Whites,” Health Affairs 36, no. 6 (June 2017): 1065–69.
  9. Agency for Healthcare Research and Quality, 2023 National Healthcare Quality and Disparities Report Appendixes, AHRQ Pub. No. 23(24)-0091-EF (AHRQ, Dec. 2023).
  10. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (National Academies Press, 2003).
  11. Madeline Y. Sutton et al., “Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020,” Obstetrics and Gynecology 137, no. 2 (Feb. 2021): 225–33.
  12. Kelly M. Hoffman et al., “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites,” Proceedings of the National Academy of Sciences 113, no. 16 (Apr. 19, 2016): 4296–301.
  13. Matthew J. Best et al., “Racial Disparities in the Use of Surgical Procedures in the U.S.,” JAMA Surgery 156, no. 3 (Mar. 2021): 274–81.
  14. Zinzi D. Bailey, Justin M. Feldman, and Mary T. Bassett, “How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities,” New England Journal of Medicine 384, no. 8 (Feb. 25, 2021): 768–73; and Jamila Taylor, Racism, Inequality, and Health Care for African Americans (Century Foundation, Dec. 2019).
  15. Munira Z. Gunja et al., Gap Closed: The Affordable Care Act’s Impact on Asian Americans’ Health Coverage (Commonwealth Fund, July 2020).
  16. These states performed comparatively well for all race and ethnicity groups for which there were sufficient data to support the calculation of performance scores; for AIAN residents in Connecticut, Massachusetts, and Rhode Island, we were not able to calculate a performance score, nor were we able to calculate one for AANHPI residents in Rhode Island.
  17. Elizabeth Arias et al., Mortality Profile of the Non-Hispanic American Indian or Alaska Native Population, 2019 (National Vital Statistics Reports, vol. 70, no. 12, Nov. 2021); GBD U.S. Health Disparities Collaborators, “Life Expectancy by County, Race, and Ethnicity in the USA, 2000–19: A Systematic Analysis of Health Disparities,” The Lancet 400, no. 10345 (July 2, 2022): 25–38; and Elizabeth Arias et al., Provisional Life Expectancy Estimates for 2021 (NVSS Vital Statistics Rapid Release no. 23, National Center for Health Statistics, Aug. 2022).
  18. The correlation between mortality amenable to health care and life expectancy holds for all racial and ethnic groups analyzed in this report. Commonwealth Fund analysis using 2018 and 2019 data from the Centers for Disease Control and Prevention’s National Vital Statistics System (NVSS); and 2021 County Health Rankings: Data and Documentation (University of Wisconsin Population Health Institute). See also: Stephen C. Schoenbaum et al., “Mortality Amenable to Health Care in the United States: The Roles of Demographics and Health Systems Performance,” Journal of Public Health Policy 32, no. 4 (Nov. 2011): 407–29; and Margaret E. Kruk et al., “Mortality Due to Low-Quality Health Systems in the Universal Health Coverage Era: A Systematic Analysis of Amenable Deaths in 137 Countries,” The Lancet 392, no. 10160 (Nov. 17, 2018): 2203–12.
  19. Luisa N. Borrell, “Hispanic Health Is Not Homogenous,” podcast, season 7, episode 4, National Patient Advocate Foundation; Kimberly D. Miller et al., “Cancer Statistics for Hispanics/Latinos, 2018,” CA: A Cancer Journal for Clinicians 68, no. 6 (Nov./Dec. 2018): 425–45; and Eduardo Velasco-Mondragon et al., “Hispanic Health in the USA: A Scoping Review of the Literature,” Public Health Reviews 37 (Dec. 2016): 31.
  20. Velasco-Mondragon et al., “Hispanic Health,” 2016; and Lourdes Medrano, “The ‘Hispanic Paradox’: Does a Decades-Old Finding Still Hold Up?,” American Heart Association News, May 10, 2023.
  21. Steven H. Woolf et al., “Changes in Midlife Death Rates Across Racial and Ethnic Groups in the United States: Systematic Analysis of Vital Statistics,” BMJ 362 (Aug. 2018): k3096.
  22. Clement G. Yedjou et al., “Health and Racial Disparity in Breast Cancer,” in Breast Cancer Metastasis and Drug Resistance. Advances in  Experimental Medicine and Biology (Springer, 2019).
  23. Declercq and Zephyrin, Maternal Mortality Primer, 2020; “Infant mortality per 1,000 live births,” Commonwealth Fund Health Systems Data Center, n.d.; Danielle M. Ely and Anne K. Driscoll, Infant Mortality in the United States, 2018: Data from the Period Linked Birth/Infant Death File (National Vital Statistics Reports, vol. 69, no. 7, July 2020); and Gopal K. Singh and Stella M. Yu, “Infant Mortality in the United States, 1915–2017: Large Social Inequalities Have Persisted for Over a Century,” International Journal of Maternal and Child Health and AIDS 8, no. 1 (2019): 19–31.
  24. Historic 21.3 Million People Choose ACA Marketplace Coverage,” press release, Centers for Medicare and Medicaid Services, Jan. 24, 2024.
  25. Brian Tsai, “U.S. Uninsured Rate Hits Record Low in First Quarter of 2023,”NCHS: A Blog of the National Center for Health Statistics, Aug. 3, 2023; Sara Rosenbaum and MaryBeth Musumeci, “The Broader Policy Implications of the Medicaid Unwinding Crisis,” To the Point (blog), Commonwealth Fund, Nov. 28, 2023; and KFF, “Medicaid Enrollment and Unwinding Tracker,” Feb. 2024.
  26. Sara R. Collins, Shreya Roy, and Relebohile Masitha, Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer — Findings from the Commonwealth Fund 2023 Health Care Affordability Survey (Commonwealth Fund, Oct. 2023).
  27. Baumgartner, Collins, and Radley, Inequities in Health Insurance Coverage, 2023.
  28. Mark Walker, “For Tribal Members in Oklahoma, Medicaid Expansion Improves Access to Specialty Care,” New York Times, Sept. 22, 2021; Eric Whitney, “Native Americans Feel Invisible In U.S. Health Care System,” NPR, Dec. 12, 2017; Medicaid and CHIP Payment and Access Commission, Medicaid’s Role in Health Care for American Indians and Alaska Natives (MACPAC, Feb. 2021); and Office of Minority Health, “American Indian/Alaska Native Health,” U.S. Department of Health and Human Services, n.d.
  29. Sara R. Collins, Munira Z. Gunja, and Gabriella N. Aboulafia, U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020).
  30. William Darity Jr. et al., What We Get Wrong About Closing the Racial Wealth Gap (Duke University, Samuel Dubois Cook Center on Social Equity, Apr. 2018); “Individuals with high out-of-pocket medical spending,” Commonwealth Fund Health Systems Data Center, n.d.; and Sara R. Collins, Gabriella N. Aboulafia, and Munira Z. Gunja, As the Pandemic Eases, What Is the State of Health Care Coverage and Affordability in the U.S.? — Findings from the Commonwealth Fund Health Care Coverage and COVID-19 Survey, March–June 2021 (Commonwealth Fund, July 2021).
  31. Cindy Mann and Adam Striar, “How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost,” To the Point (blog), Commonwealth Fund, Aug. 17, 2022; Roosa S. Tikkanen et al., “Hospital Payer and Racial/Ethnic Mix at Private Academic Medical Centers in Boston and New York City,” International Journal of Health Services 47, no. 3 (July 2017): 460–76; Elizabeth J. Brown et al., “Racial Disparities in Geographic Access to Primary Care in Philadelphia,” Health Affairs 35, no. 8 (Aug. 2016): 1374–81; Darrell J. Gaskin et al., “Residential Segregation and the Availability of Primary Care Physicians,” Health Services Research 47, no. 6 (Dec. 2012): 2353–76; and Emily P. Terlizzi et al., “Reported Importance and Access to Health Care Providers Who Understand or Share Cultural Characteristics with Their Patients Among Adults, by Race and Ethnicity,” HHS National Health Statistics Reports 130 (Oct. 8, 2019).
  32. Agency for Healthcare Research and Quality, 2022 National Healthcare Quality and Disparities Report (AHRQ, 2022).
  33. John E. Snyder et al., “Black Representation in the Primary Care Physician Workforce and Its Association with Population Life Expectancy and Mortality Rates in the U.S.,” JAMA Network Open 6, no. 4 (Apr. 14, 2023): e236687.
  34. Jody A. Vogel et al., “Reasons Patients Choose the Emergency Department over Primary Care: A Qualitative Metasynthesis,” Journal of General Internal Medicine 34, no. 11 (Nov. 2019): 2610–19.
  35. Correlation between primary care spending, expressed as a share of total per beneficiary spending, and hospital admissions for primary care–sensitive conditions was stronger among Black beneficiaries (r = –0.49) than among white beneficiaries (r = –0.22). Similarly, higher levels of primary care spending were associated with lower levels of emergency department use for nonemergent conditions, with a stronger correlation among Black beneficiaries (r = –0.40) than white beneficiaries (r = –0.24).
  36. Sherita Hill Golden and Neil R. Powe, “Hospital Equity Rating Metrics — Promise, Pitfalls, and Perils,” JAMA Health Forum 4, no. 10 (Oct. 13, 2023): e233188.
  37. Sara R. Collins, Lauren A. Haynes, and Relebohile Masitha, The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey (Commonwealth Fund, Sept. 2022).
  38. Collins, Roy, and Masitha, Paying for It, 2023.
  39. Sara R. Collins and Gabriella N. Aboulafia, “Will the American Rescue Plan Reduce the Number of Uninsured Americans?,” To the Point (blog), Commonwealth Fund, Mar. 22, 2021.
  40. Katherine Rizzolo et al., “Access to Kidney Care for Undocumented Immigrants Across the United States,” Annals of Internal Medicine 176, no. 6 (June 2023): 877–79; Melody Gutierrez, “California Expands Medi-Cal, Offering Relief to Older Immigrants Without Legal Status,” Los Angeles Times, July 27, 2021; and Justin Giovannelli and Rachel Schwab, “States Expand Access to Affordable Private Coverage for Immigrant Populations,” To the Point (blog), Commonwealth Fund, Feb. 8, 2024.
  41. Kevin McAvey and Alisha Reginal, Unlocking Race and Ethnicity Data to Promote Health Equity in California: Proposals for State Action (Manatt Health, Apr. 2021).
  42. Katie Keith, “How Insurers Can Advance Health Equity Under the Affordable Care Act,” To the Point (blog), Commonwealth Fund, Aug. 10, 2021.
  43. Brown et al., “Racial Disparities,” 2016; Gaskin et al., “Residential Segregation,” 2012; and Elizabeth A. Howell et al., “Black–White Differences in Severe Maternal Morbidity and Site of Care,” American Journal of Obstetrics and Gynecology 214, no. 1 (Jan. 2016): 122. e1–122.e7.
  44. Diane Alexander and Molly Schnell, The Impacts of Physician Payments on Patient Access, Use, and Health, Working Paper 26095 (National Bureau of Economic Research, July 2019, revised Aug. 2020); and Commonwealth Fund Task Force on Payment and Delivery System Reform, Six Policy Imperatives to Improve Quality, Advance Equity, and Increase Affordability (Commonwealth Fund, Nov. 2020).
  45. Mandy Cohen et al., “Buying Health, Not Just Health Care: North Carolina’s Pilot Effort,” To the Point (blog), Commonwealth Fund, Jan. 27, 2020; and Sophia Tripoli et al., “To Advance Health Equity, Federal Policy Makers Should Build on Lessons from State Medicaid Experiments,” Health Affairs Forefront (blog), Apr. 14, 2021.
  46. National Heart, Lung, and Blood Institute, “Role of Community Health Workers,” National Institutes of Health, last updated June 2014.
  47. Shreya Kangovi et al., “Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial,” JAMA Internal Medicine 178, no. 12 (Dec. 2018): 1635–43.
  48. Laurie C. Zephyrin, Josemiguel Rodriguez, and Sara Rosenbaum, “The Case for Diversity in the Health Professions Remains Powerful,” To the Point (blog), Commonwealth Fund, July 20, 2023.
  49. Commonwealth Fund, Six Policy Imperatives, 2020; Donnie L. Bell and Mitchell H. Katz, “Modernize Medical Licensing, and Credentialing, Too — Lessons From the COVID-19 Pandemic,” JAMA Internal Medicine 181, no. 3 (Jan. 13, 2021): 312–15.
  50. Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021).
  51. Michael Anne Kyle and Austin B. Frakt, “Patient Administrative Burden in the U.S. Health Care System,” Health Services Research 56, no. 5 (Oct. 2021): 755–65.
  52. Linda J. Blumberg, John Holahan, and Jason Levitis, How Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and Implementation Issues (Commonwealth Fund, June 2021).
  53. Roosa S. Tikkanen and Eric C. Schneider, “Social Spending to Improve Population Health — Does the United States Spend as Wisely as Other Countries?,” New England Journal of Medicine 382, no. 10 (Mar. 5, 2020): 885–87.
  54. Oxfam America, The Best and Worst States to Work in America – During COVID-19 (Oxfam, Aug. 2020); Erica Williams, Samantha Waxman and Julian Legendre, States Can Adopt or Expand Earned Income Tax Credits to Build a Stronger Future Economy (Center on Budget and Policy Priorities, Mar. 2020); and Shera Avi-Yonah and Danielle Moran, “NYC, Connecticut Start ‘Baby Bond’ Programs to Shrink Inequality,” Bloomberg, July 8, 2021.
  55. Schneider et al., Mirror, Mirror, 2021.
  56. Gunja et al., Gap Closed, 2020.

Publication Details



David C. Radley, Senior Scientist, Tracking Health System Performance, The Commonwealth Fund

[email protected]


David C. Radley et al., Advancing Racial Equity in U.S. Health Care: The Commonwealth Fund 2024 State Health Disparities Report (Commonwealth Fund, Apr. 2024).