Twenty years ago, the Institute of Medicine (now the National Academies of Medicine) released a report detailing persistent and pervasive racial and ethnic health inequities in the United States. In addition, they suggested that health care providers' bias, prejudice, and discrimination significantly contributed to these inequities. The “Unequal Treatment Report” was a bombshell in the health care community: providers and institutions could no longer explain away racial and ethnic inequities in health as attributable solely to factors considered “outside” the purview of health care institutions. Two decades later, many of the same inequities persist. To look back in 40 years and say there has been improvement, we need to comprehend the reasons behind the current state of incomplete progress. This requires a consideration of the social and political context that surrounded the production of the Report and the implementation of its recommendations, then and now.

WHY THIS MATTERS

Efforts by health care researchers, funders, leaders, and policymakers to address inequities are influenced by the sociopolitical context within and outside health care. Contending with that context will facilitate enduring change.

WHAT WE FOUND

The years leading up to and following the Report were marked by periods of progress in naming and addressing racial disparities in health care, followed by periods of retrenchment. Across the ebb and flow of efforts, we see a transition in how the health field thought about the root causes of those disparities from an overemphasis on the individual to a consideration of the institutional and systemic structures that drive inequities, including structural racism. We will highlight several of the Report’s recommendations influenced by social and political forces and provide a critical analysis of research since the Report’s publication to determine where progress has stalled. Finally, we examine how the public sphere has reacted to the naming of structural racism as a root cause of racial and ethnic inequities.

KEY TAKEAWAYS

There are significant opportunities to eliminate racial and ethnic inequities in care. We highlight several promising approaches, including (1) focusing on communication, (2) prioritizing interventions that directly address racism and its structural drivers impacting care, and (3) acting on inequities through alliance-building to address the drivers of care quality that exist both within and outside of the health care system.