Urban Institute researchers created this guide to serve as a vital resource for advocates and other changemakers tackling the profound inequities in the US health care system. The guide establishes a common understanding of the complex health care landscape, with diverse stakeholders driven by incentives and regulations.

The primary goal of this guide is to equip advocates and changemakers by introducing key information about 10 sectors of the US health care system. It overviews the system’s inequities and highlights the policy, implementation, and accountability levers that can drive change. Ultimately, this collection of resources supplies advocates and changemakers with the knowledge needed to effectively advocate for policies that address racial and ethnic disparities in the US health care system.

Understanding Health Care Systems

The US health care system is fragmented and comprises many sectors and programs. To drive systemic change, changemakers must understand parts of the health care system that cater to patients based on their insurance status, primary health coverage, or health care needs. While there may be some overlap across health care sectors regarding providers, payers, oversight entities, and policies, each part of the system has unique challenges and opportunities. These differences necessitate tailored approaches for policy, practice, and program improvements, all directed toward achieving high-quality and equitable outcomes for patients.

Each guide includes the following:

1. a concise sector description
2. key characteristics of the population served
3. provider information
4. financing details
5. barriers to access, quality, and equitable outcomes
6. a summary of documented disparities
7. a list of primary oversight entities and accountability mechanisms
8. policies and actions to reduce barriers and disparities
9. a patient story illustrating real-life experiences
10. additional resources and a glossary of terms

The Urban Institute team collected this information through public sources, literature, a community advisory board, and expert feedback. While these insights offer a high-level understanding of different health care systems, federal, state, and local program policies and insurance market variations may affect applicability.

Guides

• Medicaid
• Medicare
• Medicare–Medicaid Enrollees (Dual Enrollees)
• Children’s Health Insurance Program
• Health Care for the Uninsured
• Indian Health Service
• Health Insurance Marketplace
• Veterans Health Administration
• Behavioral Health Care
• Pharmacy Services

Recommendations for Advancing Equitable Health Care across Systems

Although each part of the US health care system has distinct players, rules, and leverage points, an overarching theme persists: barriers and disparities permeate all aspects of our health care system. Families at the lower end of the socioeconomic ladder, racial and ethnic minority groups, and those with complex health care often bear the brunt of these challenges.

While the ideal goal is universal, high-quality, culturally and linguistically effective health care, several broad changes can enhance access to care and health outcomes. The recommendations for federal and state policies include, but are not limited to, the following:

• allocating federal funding that is adequate, sustainable, reliable, and responsive to the needs of all federally supported health programs, with particular attention to addressing disparities in the Indian Health Service
• mandating alignment between federal and state health agencies regarding oversight rules, data collection, reporting requirements, and health equity goals
• requiring stakeholder and community engagement in developing, implementing, and evaluating health care policies, with the participation of diverse beneficiaries, patients, providers, payers, and consumer advocates
• supporting a diverse and culturally and linguistically effective health care workforce, including recruiting students from racial and ethnic minority groups into health professions and ensuring adequate reimbursement for health care providers serving disadvantaged populations
• requiring that federally funded health care programs collect, analyze, and publicly report outcomes by race, ethnicity, language, geography, and other characteristics, with accountability for reducing disparities
• developing quality measures that accurately and equitably reflect health status, using surveys and community engagement tools to monitor and improve patient experience and outcomes
• standardizing easy enrollment and renewal for different insurance products while minimizing or eliminating administrative burdens for applicants and programs
• establishing transparent health insurance appeals and complaint processes along with resources for pro bono or sliding scale fees for legal consultation and representation for people filing complaints or appeals
• increasing enforcement of existing health equity policies, including behavioral health parity and standards for culturally and linguistically appropriate services, and penalizing noncompliant institutions
• eliminating the five-year waiting period for lawfully present immigrants to qualify for Medicaid, Children’s Health Insurance Program Medicare, and other federally funded benefits