Equality-in-Quality in the Era of the Affordable Care Act

Abstract

HEALTH CARE RECEIVED BY PATIENTS IN THE UNITED States is of inadequate quality. As part of the federal response to this major shortcoming, ensuring high-quality health care is a central theme throughout the Patient Protection and Affordable Care Act (ACA) signed into law in 2010. The focus on improving quality in the ACA, however, effectively overshadows other major concerns about the US health care system—among them, pervasive and persistent disparities in health care related to factors such as sex, race/ ethnicity, social class, insurance status, and language that fundamentally constrain how much overall quality can improve. The comparative inattention in the ACA to known inequalities in health care is noteworthy, not only in comparison with the focus on quality, but also because the lack of emphasis on disparities in the ACA language is inconsistent with recent positions of the Agency for Healthcare Research and Quality (AHRQ) and the Institute of Medicine (IOM). The AHRQ and IOM have indicated that reducing disparities is an unambiguous priority in working to improve quality in health care. This approach is consistent with analyses suggesting that reducing disparities based on social factors may improve health care quality more than would marginal improvements in overall medical care. Given this disconnect between provisions within the ACA and federally endorsed approaches to pursuing what amounts to “equality-in-quality,” it is worth examining the philosophical and empirical underpinnings of arguments for considering disparities while working to improve quality. Striving for equality-in-quality is not merely aspirational but should be foundational. Failing to address disparities may consign health care quality improvement efforts— originating from the ACA or otherwise—to less success than otherwise could be realized.