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Inequalities in such things as gender, age, ethnicity, etc. (Figure 2.3) have been recognized as great influences on health outcomes. Socioeconomic status is the number one predictor of poor health. The 2018 NHDR found from 2000 to 2017 (AHRQ, 2019):

 More than half of access measures showed improvement.

 One‐third of access measures did not show improvement.

 Fourteen percent showed worsening.

 Blacks, American Indians and Alaska Natives (AI/ANs), and Native Hawaiians/Pacific Islanders (NHPIs) received worse care than Whites for about 40% of quality measures.

 Hispanics received worse care than Whites for about 35% of quality measures.

 Asians received worse care than Whites for 27% of quality measures, but better care than Whites for 28% of quality measures

FIGURE 2.3 The spectrum of inequality.

Source: https://www.nationalarchives.gov.uk/doc/open‐government‐licence/version/3/ Contains Parliamentary information licensed under the Open Parliament Licence v3.0

The report also noted, even when the overall quality of care improves, health care disparities often still persist across socioeconomic groups, racial and ethnic populations, and geographical areas (AHRQ, 2019). In addition, not enough health care delivery and attention is directed toward the top underlying causes of death in the United States (Table 2.2).

Table 2.2 Top 10 Actual Causes of Death in the United States in 2000

1. Tobacco	4. Alcohol	7. Motor vehicle crashes	9. Sexual behaviors
2. Poor diet	5. Microbial agents	8. Firearms	10. Illicit drug use
3. Physical inactivity	6. Toxic agents

Source: CDC. “FastStats ‐ Deaths and Mortality.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 21 June 2019, www.cdc.gov/nchs/fastats/deaths.htm.

Quality of health care improved overall from 2000 through 2016–2017, but the pace of improvement varied by priority, which are (AHRQ, 2019):

Person‐Centered Care: Almost 70% of measures were improving.

Patient Safety: More than 60% of measures were improving.

Healthy Living: Almost 60% of measures were improving.

Effective Treatment: Almost half of measures were improving.

Care Coordination: One‐third of measures were improving.

Care Affordability: No care affordability measures changed.

Overalls, as one ages, more health care services are utilized; women use health care services more frequently than men; and whites have greater health care access, and therefore higher utilization rates, than do patients of color as reported by the National Healthcare Disparities Report (NHDR), 2018; (AHRQ, 2019). Both financial and nonfinancial barriers to care delivery result in lack of attention to health care disparities and factors contributing to the underlying causes of death, which affects health outcomes. In‐depth information on national health care disparities is reported in the annual National Health Disparities Report (AHRQ, 2019).

For example, disparities in infant morbidity and mortality, cardiovascular and pulmonary disease, diabetes, communicable disease, cancer, and disease prevention (i.e., immunization and health screening) are more likely to be experienced by people disadvantaged by poverty, age, skin color, or ability to speak English. Such differences are further aggravated by miscommunication and misunderstanding, stereotyping, discrimination, and prejudice between patients and providers. Lifestyle behaviors that contribute to illness are higher among vulnerable groups. Because of their financial difficulties and other difficulties in accessing the health care system, vulnerable people often postpone health care. They are more likely to use the acute care system when their illness symptoms are advanced. Use of emergency departments and other acute care facilities for treatment is the most expensive way to obtain health care. In countries with a national health care system, health disparities also exist, but virtually everyone in those countries, regardless of socioeconomic background, is assured of equal access to quality health care. Health care is associated with 10–20% of the modifiable contributors to healthy patient outcomes (Magnan, 2017). The other 80–90% are dependent on health behaviors (e.g., tobacco use, diet/exercise, and alcohol use), social/economic factors (e.g., education, income, and employment), and the individual's physical environment (e.g., air quality, housing, and transit) (Magnan, 2017). These “social determinants” are so important when it comes to health that they have been called the “causes of causes.”

Social determinants of health (SDOH) include access to health care, culture, language, education/literacy, access to transportation, crime rates, and safe housing. Research studies indicate that SDOH do matter and can have a significant impact on a population's health (CDC, 2018).