The National Academy of Medicine defines healthcare quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Many factors contribute to the quality of care in the United States, including access to timely care, affordability of care, and use of evidence-based guidelines to drive treatment.
This section of the report highlights utilization of healthcare services, healthcare workforce statistics, healthcare expenditures, and major contributors to morbidity and mortality. These factors help paint an overall picture of the U.S. healthcare system, particularly areas that need improvement. Quality measures show whether the healthcare system is adequately addressing risk factors, diseases, and conditions that place the greatest burden on the healthcare system and if change has occurred over time.
Overview of the U.S. Healthcare System Infrastructure
The NHQDR tracks care delivered by providers in many types of healthcare settings. The goal is to provide high-quality healthcare that is culturally and linguistically sensitive, patient centered, timely, affordable, well coordinated, and safe. The receipt of appropriate high-quality services and counseling about healthy lifestyles can facilitate the maintenance of well-being and functioning. In addition, social determinants of health, such as education, income, and residence location can affect access to care and quality of care.
Improving care requires facility administrators and providers to work together to expand access, enhance quality, and reduce disparities. It also requires coordination between the healthcare sector and other sectors for social welfare, education, and economic development. For example, Healthy People 2030 includes 5 domains (shown in the diagram below) and 78 social determinants of health objectives for federal programs and interventions.
Exhibit 1
Healthy People 2030 social determinants of health domains.
The numbers of health service encounters and people working in health occupations illustrate the large scale and inherent complexity of the U.S. healthcare system. The tracking of healthcare quality measures in this reportiii attempts to quantify progress made in improving quality and reducing disparities in the delivery of healthcare to the American people.
Figure 1
Number of healthcare service encounters, United States, 2018 and 2019.
In 2018, there were 860 million physician office visits (Figure 1).
In 2019, patients spent 149 million days in hospice.
In 2019, there were 100 million home health visits.
Overview of Disease Burden in the United States
The National Institutes of Health defines disease burden as the impact of a health problem, as measured by prevalence, incidence, mortality, morbidity, extent of disability, financial cost, or other indicators.
This section of the report highlights two areas of disease burden that have major impact on the health system of the United States: years of potential life lost and leading causes of death. The NHQDR tracks measures of quality for most of these conditions. Variation in access to care and care delivery across communities contributes to disparities related to race, ethnicity, sex, and socioeconomic status.
The concept of years of potential life lost (YPLL) involves estimating the average time a person would have lived had he or she not died prematurely. This measure is used to help quantify social and economic loss from premature death, and it has been promoted to emphasize specific causes of death affecting younger age groups. YPLL inherently incorporates age at death, and its calculation mathematically weights the total deaths by applying values to death at each age.1
According to the Centers for Disease Control and Prevention (CDC), unintentional injuries include opioid overdoses (unintentional poisoning), motor vehicle crashes, suffocation, drowning, falls, fire/burns, and sports and recreational injuries. Overdose deaths involving opioids, including prescription opioids, heroin, and synthetic opioids (e.g., fentanyl), have been a major contributor to the increase in unintentional injuries. Opioid overdose has increased to more than six times its 1999 rate.2
Figure 2
Age-adjusted years of potential life lost before age 65, by cause of death, 2010–2019. Key: YPLL = years of potential life lost. Note: The perinatal period occurs from 22 completed weeks (154 days) of gestation and ends 7 completed days after (more...)
From 2010 to 2019, there were no changes in the ranking of the top 10 leading diseases and injuries contributing to YPLL. The top 5 were unintentional injury, cancer, heart disease, suicide, and complications during the perinatal period (Figure 2). The remaining 5 were homicide, congenital anomalies, liver disease, diabetes, and cerebrovascular disease.
Among the top three categories contributing to YPLL:
Unintentional injury increased from 791.8 per 100,000 population in 2010 to 1,024.3 per 100,000 population in 2019.
Cancer decreased from 635.2 per 100,000 population in 2010 to 533.3 per 100,000 population in 2019.
Heart disease decreased from 474.3 per 100,000 population in 2010 to 453.2 per 100,000 population in 2019.
Figure 3
Age-adjusted years of potential life lost before age 65, by cause of death and race, 2019. Key: AI/AN = American Indian or Alaska Native; PI = Pacific Islander.
In 2019, among American Indian and Alaska Native (AI/AN) people, the top five contributing factors for YPLL were unintentional injuries (1,284.6 per 100,000 population), suicide (457.7 per 100,000 population), liver disease (451.6 per 100,000 population), heart disease (399.8 per 100,000 population), and cancer (339.6 per 100,000 population) (Figure 3).
In 2019, among Asian and Pacific Islander people, the top five contributing factors for YPLL were cancer (375.7 per 100,000 population), unintentional injuries (299.4 per 100,000 population), complications in the perinatal period (203.4 per 100,000 population), suicide (198.5 per 100,000), and heart disease (197.7 per 100,000 population).
In 2019 among Black people, the top five contributing factors for YPLL were unintentional injuries (1,085.8 per 100,000 population), heart disease (843.5 per 100,000 population), homicide (801.7 per 100,000 population), cancer (652.7 per 100,000 population), and complications in the perinatal period (560.4 per 100,000 population).
In 2019, among White people, the top five contributing factors for YPLL were unintentional injuries (1,080.0 per 100,000 population), cancer (530.1 per 100,000 population), heart disease (406.6 per 100,000 population), suicide (387.6 per 100,000 population), and complications in the perinatal period (215.7 per 100,000 population).
Figure 4
Leading causes of death for the total population, United States, 2018 and 2019.
In 2019, heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, Alzheimer’s disease, and diabetes were among the leading causes of death for the overall U.S. population (Figure 4).
Overall, kidney disease moved from the 9th leading cause of death in 2018 to the 8th leading cause of death in 2019.
Suicide remained the 10th leading cause of death in 2018 and 2019.
The years of potential life lost, years with disability, and leading causes of death represent some aspects of the burden of disease experienced by the American people. Findings highlighted in this report attempt to quantify progress made in improving quality of care, reducing disparities in healthcare, and ultimately reducing disease burden.
Overview of U.S. Community Hospital Intensive Care Beds
The United States has almost 1 million staffed hospital beds; nearly 800,000 are community hospital beds and 107,000 are intensive care beds. Figure 5 shows the numbers of different types of staffed intensive care hospital beds.
Medical-surgical intensive care provides patient care of a more intensive nature than the usual medical and surgical care delivered in hospitals, on the basis of physicians’ orders and approved nursing care plans. These units are staffed with specially trained nursing personnel and contain specialized equipment for monitoring and supporting patients who, because of shock, trauma, or other life-threatening conditions, require intensified comprehensive observation and care. These units include mixed intensive care units.
Pediatric intensive care provides care to pediatric patients that is more intensive in nature than that usually provided to pediatric patients. The unit is staffed with specially trained personnel and contains monitoring and specialized support equipment for treating pediatric patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and care.
Cardiac intensive care provides patient care of a more specialized nature than the usual medical and surgical care, on the basis of physicians’ orders and approved nursing care plans. The unit is staffed with specially trained nursing personnel and contains specialized equipment for monitoring, support, or treatment for patients who, because of severe cardiac disease such as myocardial infarction, open-heart surgery, or other life-threatening conditions, require intensified, comprehensive observation and care.
Neonatal intensive care units (NICUs) are distinct from the newborn nursery and provide intensive care to sick infants, including those with the very lowest birth weights (less than 1,500 grams). NICUs may provide mechanical ventilation, care before or after neonatal surgery, and special care for the sickest infants born in the hospital or transferred from another institution. Neonatologists typically serve as directors of NICUs.
Burn care provides care to severely burned patients. Severely burned patients are those with the following: (1) second-degree burns of more than 25% total body surface area for adults or 20% total body surface area for children; (2) third-degree burns of more than 10% total body surface area; (3) any severe burns of the hands, face, eyes, ears, or feet; or (4) all inhalation injuries, electrical burns, complicated burn injuries involving fractures and other major traumas, and all other poor risk factors.
Other intensive care unit beds are in specially staffed, specialty-equipped, separate sections of a hospital dedicated to the observation, care, and treatment of patients with life-threatening illnesses, injuries, or complications from which recovery is possible. This type of care includes special expertise and facilities for the support of vital functions and uses the skill of medical, nursing, and other staff experienced in the management of conditions that require this higher level of care.
Figure 5
U.S. community hospital intensive care staffed beds, by type of intensive care, 2019. Note: Community hospitals are defined as all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; (more...)
In 2019, of the more than 900,000 staffed hospital beds in the United States, 86% were in community hospitals (data not shown).
Most of the more than 107,000 intensive care beds in community hospitals were medical-surgical intensive care (51.9%) and neonatal intensive care beds (21.1%) (Figure 5).
Critical access hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursem*nt for Medicare services. As of July 16, 2021, 1,353 CAHs were located throughout the United States.3,iv
Figure 6
Distribution of critical access hospitals in the United States, 2021.
According to CMS, CAHs must be located in a rural area or an area that is treated as rural,v so the number of CAHs varies by state (Figure 6).
In 2019, California had a population of 39.5 million and 36 CAHs compared with Iowa, which had a population of only 3.2 million but 82 CAHs.
U.S. Healthcare Workforce
Healthcare access and quality can be affected by workforce shortages, particularly in rural areas. In addition, lack of racial, ethnic, and gender concordance between providers and patients can lead to miscommunication, stereotyping, and stigma, and, ultimately, suboptimal healthcare.
Healthcare Workforce Availability
Improving quality of care, increasing access to care, and controlling healthcare costs depend on the adequate availability of healthcare providers.4 Physician shortages currently exist in many states across the nation, with relatively fewer primary care and specialty physicians available in nonmetropolitan counties compared with metropolitan counties.5
The Health Resources and Services Administration (HRSA) further projects that the supply of key professions, including primary care providers, general dentists, adult psychiatrists, and addiction counselors, will fall short of demand by 2030.6 These concerns have the potential to influence the delivery of healthcare and negatively affect patient outcomes.
Figure 7
Number of people working in health occupations, United States, 2019. Key: EMT = emergency medical technician. Note: Doctors of medicine also include doctors of osteopathic medicine. Active physicians include those working in direct patient care, administration, (more...)
In 2019, there were 3.7 million registered nurses (Figure 7).
In 2019, there were 2.4 million healthcare aides, which includes nursing, psychiatric, home health, and occupational therapy aides and physical therapy assistants and aides.
In 2019, there were 2.1 million health technologists.
In 2019, 2.0 million other health practitioners provided care, including more than 145,000 physician assistants (PAs).
In 2019, there were 972,000 active medical doctors in the United States, which include doctors of medicine and doctors of osteopathy.
In 2019, there were 183,000 dentists.
In recent decades, promising approaches that address the supply-demand imbalance have emerged as alternatives to simply increasing the number of physicians. One strategy relies on telehealth technologies to improve physicians’ efficiency or to increase access to their services. For example, Project ECHO is a telehealth model in which specialists remotely support multiple rural primary care providers so that they can treat patients for conditions that might otherwise require traveling to distant specialty centers.7
Another strategy relies on peer-led models, in which community-based laypeople receive the training and support needed to deliver care for a (typically) narrow range of conditions. Successful examples of this approach exist, including the deployment of community health workers to manage chronic diseases,8 promotoras to provide maternal health services,9 peer counselors for mental health and substance use disorders,10 and dental health aides to deliver oral health services in remote locations.11
The National Institutes of Health, HRSA, and the Agency for Healthcare Research and Quality (AHRQ) have sponsored formative research to examine key issues that must be addressed to further develop these models, but all show promise for expanding access to care and increasing overall diversity within the healthcare workforce.
Workforce Diversity
The number of full-time, year-round workers in healthcare occupations has almost doubled since 2000, increasing from 5 million to 9 million workers, according to the U.S. Census Bureau’s American Community Survey.
A racially and ethnically diverse health workforce has been shown to promote better access and healthcare for underserved populations and to better meet the health needs of an increasingly diverse population. People of color, however, remain underrepresented in several health professions, despite longstanding efforts to increase the diversity of the healthcare field.12
Additional research has found that physicians from groups underrepresented in the health professions are more likely to serve minority and economically disadvantaged patients. It has also been found that Black and Hispanic physicians practice in areas with larger Black and Hispanic populations than other physicians do.13
Gender diversity is also important. Women currently account for three-quarters of full-time, year-round healthcare workers. Although the number of men who are dentists or veterinarians has decreased over the past two decades, men still make up more than half of dentists, optometrists, and emergency medical technicians/paramedics, as well as physicians and surgeons earning over $100,000.14
Women working as registered nurses, the most common healthcare occupation, earn on average $66,000. Women working as nursing, psychiatric, and home health aides, the second most common healthcare occupation, earn only $27,000.14
The impact of unequal gender distribution in the healthcare workforce is observed in the persistence of gender inequality in heart attack mortality. Most physicians are male, and some may not recognize differences in symptoms in female patients. The fact that gender concordance correlates with whether a patient survives a heart attack has implications for theory and practice. Medical practitioners should be aware of the possible challenges male providers face when treating female heart attack patients.15
Research has shown that some mental health workforce groups, such as psychiatrists, are more diverse than many other medical specialties, and this diversity has improved over time. However, this diversity has not translated as well to academic faculty or leadership positions for underrepresented minorities. It was found that there was more minority representation among psychiatry residents (16.2%) compared with faculty (8.7%) and practicing physicians (10.4%). This difference results in minority students and trainees having fewer minority mentors to guide them in the profession.
Racial and Ethnic Diversity Among Physicians
Diversification of the physician workforce has been a goal for several years and could improve access to primary care for underserved populations and address health disparities. Family physicians’ race/ethnicity has become more diverse over time but still does not reflect the national racial and ethnic composition.16,vi
Figure 8
Racial and ethnic distribution of all active physicians (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due (more...)
In 2019, White people were 60% of the U.S. population and approximately 64% of physicians (Figure 8).
Asian people were about 6% of the U.S. population and approximately 22% of physicians.
Black people were 12% of the U.S. population but only 5% of physicians.
Hispanic people were 18% of the U.S. population but only 7% of physicians.
People of more than race made up about 3% of the U.S. population but less than 2% of physicians.
AI/AN people and Native Hawaiian/Pacific Islander (NHPI) people accounted for 1% or less of the U.S. population and 1% or less of physicians (data not shown).
Preventive care, including screenings, is key to reducing death and disability and improving health. Evidence has shown that patients with providers of the same gender have higher rates of breast, cervical, and colorectal cancer screenings.17
Figure 9
Physicians by race/ethnicity and sex, 2018. Key: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian/Pacific Islander. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working (more...)
In 2018, among Black physicians, females (53.0%) constituted a larger percentage than males (47.0%) (Figure 9).
All other groups had a greater percentage of males than females:
Among White physicians, 65.5% were male.
Among Asian physicians, 55.7% were male.
Among AI/AN physicians, 60.1% were male.
Among Hispanic physicians, 59.5% were male.
Figure 10
White physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)
In 2018, among White physicians, males were the vast majority of those age 65 years and over (79.3%) and of those ages 55–64 years (71.5%) (Figure 10).
A little more than half of White physicians age 34 and younger were females (50.6%).
Among White physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
Figure 11
Black physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)
In 2018, among Black physicians under age 55, females made up a larger percentage of the workforce than males. This percentage decreased with increasing age (Figure 11).
Females were 44.2% of Black physicians ages 55–64 and 34.9% of Black physicians age 65 and over.
Figure 12
Asian physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)
In 2018, among Asian physicians, males were the vast majority of those age 65 years and over (72.7%) and of those ages 55–64 years (66.3%) (Figure 12).
Among Asian physicians age 34 and younger, there were more females (52.0%) than males (48.0%).
Among Asian physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
Figure 13
American Indian or Alaska Native physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, (more...)
In 2018, among AI/AN physicians, males were the vast majority of those age 65 years and over (73.2%) and of those ages 55–64 years (62.6%) (Figure 13).
Among AI/AN physicians age 34 and younger, there were more females (57.9%) than males (42.1%).
Among AI/AN physicians age 45 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
Figure 14
Hispanic physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)
In 2018, most Hispanic physicians age 65 years and over (77.5%) and ages 55–64 years (67.5%) were males (Figure 14).
Among Hispanic physicians age 34 and younger, there were more females (55.3%) compared with males (44.7%).
Among Hispanic physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
Racial and Ethnic Diversity Among Dentists
The racial and ethnic diversity of the oral healthcare workforce is insufficient to meet the needs of a diverse population and to address persistent health disparities.18 However, among first-time, first-year enrollees in dental school, improved diversity has been observed. The number of African American enrollees nearly doubled and the number of Hispanic enrollees has increased threefold between 2000 and 2020.19 Increased diversity among dentists may improve access and quality of care, particularly in the area of culturally and linguistically sensitive care.
Figure 15
Dentists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and Other are non-Hispanic. If estimates for certain racial and ethnic groups meet data suppression criteria, they are recategorized into (more...)
In 2019, the vast majority of dentists (70%) were non-Hispanic White (Figure 15).
In 2019, racial and ethnic minority groups accounted for 30% of dentists:
Asian people, 18%,
Hispanic people, 6%
Black people, 5%, and
Other (multiracial and AI/AN people), 1.0%.
Racial and Ethnic Diversity Among Registered Nurses
Ensuring workforce diversity and leadership development opportunities for racial and ethnic minority nurses must remain a high priority in order to eliminate health disparities and, ultimately, achieve health equity.20
Figure 16
Registered nurses by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and (more...)
In 2019, the vast majority of RNs (69%) were non-Hispanic White (Figure 16).
In 2019, racial and ethnic minority groups accounted for 31% of RNs:
Black people, 11%,
Asian people, 9%,
Hispanic people, 8%,
Multiracial people, 2%, and
Other (AI/AN and NHPI people), 1%.
Racial and Ethnic Diversity Among Pharmacists
Most healthcare diagnostic and treating occupations such as pharmacists, physicians, nurses, and dentists are primarily White while healthcare support roles such as dental assistants, medical assistants, and personal care aides are more diverse. To decrease disparities and enhance patient care, racial and ethnic diversity must be improved on all levels of the healthcare workforce, not just in support roles.21
Progress has been made toward increased racial and ethnic diversity, but more work is needed. As Bush notes in an article on underrepresented minorities in pharmacy school, “If we are determined to reduce existing healthcare disparities among racial, ethnic, and socioeconomic groups, then we must be determined to diversify the healthcare workforce.”22
Figure 17
Pharmacists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the exclusion of groups (more...)
In 2019, the vast majority of pharmacists (65%) were non-Hispanic White (Figure 17).
In 2019, racial and ethnic minority groups accounted for 35% of pharmacists:
Asian people, 20%,
Black people, 7%,
Hispanic people, 5%, and
Multiracial people, 2%.
Racial and Ethnic Diversity Among Therapists
Occupational therapists, physical therapists, radiation therapists, recreational therapists, and respiratory therapists are classified as health diagnosing and treating practitioners. Hispanic people are significantly underrepresented in all of the occupations in the category of Health Diagnosing and Treating Practitioners. Among non-Hispanic people, Black people are underrepresented in most of these occupations.
Asian people are underrepresented among speech-language pathologists, and AI/AN people are underrepresented in nearly all occupations. To the extent they can be reliably reported, data also show that NHPI people are underrepresented in all occupations in the Health Diagnosing and Treating Practitioners group.21
Therapists include occupational therapists, physical therapists, radiation therapists, recreational therapists, respiratory therapists, speech-language pathologists, exercise physiologists, and other therapists.
Figure 18
Therapists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the exclusion (more...)
In 2019, the vast majority of therapists (74%) were non-Hispanic White (Figure 18).
In 2019, racial and ethnic minority groups accounted for 26% of therapists:
Black people, 8%,
Asian people, 8%,
Hispanic people, 8%, and
Multiracial people, 2%.
Racial and Ethnic Diversity Among Advanced Practice Registered Nurses
The adequacy and distribution of the primary care workforce to meet the current and future needs of Americans continue to be cause for concern. Advanced practice registered nurses are increasingly being used to fill this gap but may include clinicians in areas beyond primary care, such as clinical nurse specialists, nurse-midwives, and nurse anesthetists.
Advanced practice registered nurses are registered nurses educated at the master’s or post-master’s level who serve in a specific role with a specific patient population. They include certified nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and certified nurse-midwives.
While physicians continue to account for most of the primary care workforce (74%) in the United States, nurse practitioners represent nearly one-fifth (19%) of the primary care workforce, followed by physician assistants, accounting for 7%.23
Nurse practitioners provide an extensive range of services that includes taking health histories and providing complete physical exams. They diagnose and treat acute and chronic illnesses, provide immunizations, prescribe and manage medications and other therapies, order and interpret lab tests and x rays, and provide health education and supportive counseling.
Nurse practitioners deliver primary care in practices of various sizes, types (e.g., private, public), and settings, such as clinics, schools, and workplaces. Nurse practitioners work independently and collaboratively. They often take the lead in providing care in innovative primary care arrangements, such as retail clinics.24
Figure 19
Advanced practice registered nurses by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)
In 2019, the vast majority of advanced practice registered nurses (78 %) were non-Hispanic White (Figure 19).
In 2019, racial and ethnic minority groups accounted for 22% of advanced practice registered nurses:
Black people, 8%,
Asian people, 6%,
Hispanic people, 6%, and
Multiracial people, 2%.
Racial and Ethnic Diversity Among Emergency Professionals
Workforce diversity can reduce communication barriers and inequalities in healthcare delivery, especially in settings such as emergency departments, where time pressure and incomplete information may worsen the effects of implicit biases. The racial and ethnic makeup of the paramedic and emergency medical technician workforce indicates that concerted efforts are needed to encourage students of diverse backgrounds to pursue emergency service careers.25
Figure 20
Emergency medical technicians and paramedics by race (left), and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages do not add to 100 due to rounding. In addition, (more...)
In 2019, the vast majority of emergency medical technicians (EMTs) and paramedics (72%) were non-Hispanic White (Figure 20).
In 2018, racial and ethnic minority groups accounted for 28% of EMTs and paramedics:
Hispanic people, 13%
Black people, 8%,
Asian people, 3%,
Multiracial people, 2%, and
Other (AI/AN and NHPI people), 1%.
Racial and Ethnic Diversity Among Other Health Practitioners
Other health practitioners include physician assistants, medical assistants, dental assistants, chiropractors, dietitians and nutritionists, optometrists, podiatrists, and audiologists, as well as massage therapists, medical equipment preparers, medical transcriptionists, pharmacy aides, veterinary assistants and laboratory animal caretakers, phlebotomists, and healthcare support workers.
Figure 21
Other health practitioners by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)
In 2019, the distribution of other health practitioners closely aligned with the racial and ethnic distribution of the U.S. population (Figure 21).
In 2019, 58% of other health practitioners were non-Hispanic White.
In 2019, Hispanic people accounted for 20% of other health practitioners.
In 2019, racial and ethnic non-Hispanic minority groups accounted for 22% of other health practitioners:
Black people, 12%,
Asian people, 7%,
Multiracial people, 2%, and
Other (AI/AN and NHPI people), 1%.
Racial and Ethnic Diversity Among Physician Assistants
Physician assistants (PAs) are included in the Other Health Practitioners workforce group but are highlighted because they play a critical role in frontline primary care services in many settings, especially medically underserved and rural areas. With the demand for primary care services projected to grow and PAs’ roles in direct care, understanding this occupation’s racial and ethnic diversity is important.
Studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, and patient and staff satisfaction. These providers can also enhance the educational experience of residents and fellows.26 However, a lack of workforce diversity has detrimental effects on patient outcomes, access to care, and patient trust, as well as on workplace experiences and employee retention.27
Figure 22
Physician assistants by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)
In 2019, the vast majority of physician assistants (73%) were non-Hispanic White (Figure 22).
In 2019, racial and ethnic minority groups accounted for 27% of physician assistants:
Asian people, 9%,
Hispanic people, 8%,
Black people, 6%,
Multiracial people, 3%, and
Other (AI/AN and NHPI people), 1%.
Racial and Ethnic Diversity Among Other Health Occupations
Other health occupations include veterinarians, acupuncturists, all other healthcare diagnosing or treating practitioners, dental hygienists, and licensed practical and licensed vocational nurses.
Figure 23
Other health occupations by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)
In 2019, the vast majority of staff in other health occupations (61%) were non-Hispanic White (Figure 23).
In 2019, racial and ethnic minority groups accounted for 39% of staff in other health occupations:
Black people, 19%,
Hispanic people, 11%
Asian people, 6 %,
Multiracial people, 2%, and
Other (AI/AN and NHPI people), 1%.
Racial and Ethnic Diversity Among Health Technologists
Health technologists include clinical laboratory technologists and technicians, cardiovascular technologists and technicians, diagnostic medical sonographers, radiologic technologists and technicians, magnetic resonance imaging technologists, nuclear medicine technologists and medical dosimetrists, pharmacy technicians, surgical technologists, veterinary technologists and technicians, dietetic technicians and ophthalmic medical technicians, medical records specialists, and opticians (dispensing), miscellaneous health technologists and technicians, and technical occupations.
Figure 24
Health technologists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the (more...)
In 2019, the vast majority of health technologists (63%) were non-Hispanic White (Figure 24).
In 2019, racial and ethnic minority groups accounted for 37% of health technologists:
Black people, 14%,
Hispanic people, 13%,
Asian people, 8%, and
Multiracial people, 2%.
Racial and Ethnic Diversity Among Healthcare Aides
Healthcare aides include nursing, psychiatric, home health, occupational therapy, and physical therapy assistants and aides.
Figure 25
Healthcare aides by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and (more...)
In 2019, 41% of healthcare aides were non-Hispanic White (Figure 25).
In 2019, racial and ethnic minority groups accounted for 59% of healthcare aides:
Black people, 32%,
Hispanic people, 18%,
Asian people, 6%,
Multiracial people, 2%, and
Other (AI/AN and NHPI people), 1%.
Racial and Ethnic Diversity Among Psychologists
The United States has an inadequate workforce to meet the mental health needs of the population,28,29,30 and it is estimated that in 2020, nearly 54% of the U.S. population age 18 and over with any mental illness did not receive needed treatment.31 This unmet need is even greater for racial and ethnic minority populations. Nearly 80% of Asian and Pacific Islander people,vii 63% of African Americans, and 65% of Hispanic people with a mental illness do not receive mental health treatment.29,32,33,34
These gaps in mental health care may be attributed to a number of reasons, including stigma, cultural attitudes and beliefs, lack of insurance, or lack of familiarity with the mental health system.35,36,37 However, a significant contributor to this treatment gap is the composition of the workforce.
The current mental health workforce lacks racial and ethnic diversity.34,38 Research has shown that racial and ethnic patient-provider concordance is correlated with patient engagement and retention in mental health treatment.39 In addition, racial and ethnic minority providers are more likely to serve patients of color than White providers.34,36
Among psychologists, a key practitioner group in the mental health workforce,37,40 minorities are significantly underrepresented. Psychologists in the United States are predominantly non-Hispanic White, while all racial and ethnic minorities represented only about one-sixth of all psychologists from 2011 to 2015.
Reducing the serious gaps in mental health care for racial and ethnic minority populations will require a significant shift in the workforce. Workforce recruitment, training, and education of more racially, ethnically, and culturally diverse practitioners will be essential to reduce these disparities.
Figure 26
Psychologists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Psychologists include practitioners of general psychology, developmental and child (more...)
In 2019, the vast majority of psychologists (79%) were non-Hispanic White (Figure 26).
In 2019, racial and ethnic minority groups accounted for 21% of psychologists:
Hispanic people,10%,
Black people, 6%,
Asian people, 4%, and
Multiracial people, 2.0%.
Although the outpatient substance use treatment field has seen an increase in referrals of Black and Hispanic clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients.41
Figure 27
Substance abuse and behavioral disorder counselors by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Key: AI/AN = American Indian/Alaska Native. Note: White, Black, Asian, AI/AN, and >1 Race are non-Hispanic. (more...)
In 2019, the majority of substance abuse and behavioral disorder counselors (58%) were non-Hispanic White (Figure 27).
In 2019, racial and ethnic minority groups accounted for 42% of substance abuse and behavioral disorder counselors:
Black people, 18%,
Hispanic people, 16 %,
Asian people, 4%,
Multiracial people, 3%, and
AI/AN people, 1%.
Overview of Healthcare Expenditures in the United States
U.S. healthcare spending grew 4.6% in 2019, reaching $3.8 trillion or $11,582 per person. Health spending accounted for17.7%percent of the nation’s gross domestic product.42
Hospital care expenditures grew by 6.2% to $1.2 trillion in 2019, faster than the 4.2% growth in 2018.
Physician and clinical services expenditures grew 4.6% to $772.1 billion in 2019, a faster growth than the 4.0% in 2018.
Prescription drug spending increased by 5.7% to $369.7 billion in 2019, faster than the 3.8% growth in 2018.
In 2019, the federal government (29%) and households (28%) each accounted for the largest shares of healthcare spending, followed by private businesses (19%), state and local governments (16%), and other private revenues (7%). Federal government spending on health accelerated in 2019, increasing 5.8% after 5.4% growth in 2018.
Personal Healthcare Expenditures
“Personal healthcare expenditures” measures the total amount spent to treat individuals with specific medical conditions. It comprises all of the medical goods and services used to treat or prevent a specific disease or condition in a specific person. These include hospital care; professional services; other health, residential, and personal care; home health care; nursing care facilities and continuing care retirement communities; and retail outlet sales of medical products.43
Figure 28
Distribution of personal healthcare expenditures by type of expenditure, 2019. Key: CCRCs = continuing care retirement communities. Note: Percentages do not add to 100 due to rounding. Personal healthcare expenditures are outlays for goods and services (more...)
In 2019, hospital care expenditures were $1.192 trillion, nearly 40% of personal healthcare expenditures (Figure 28).
Expenditures for physician and clinical services were $772.1 billion, almost one-fourth of personal healthcare expenditures.
Prescription drug expenditures were $369.7 billion, 10% of personal healthcare expenditures.
Expenditures for dental services were $143.2 billion, 5% of personal healthcare expenditures.
Nursing care facility expenditures were $172.7 billion and home health care expenditures were $113.5 billion, 5% and 4% of personal healthcare expenditures, respectively.
Figure 29
Personal healthcare expenditures, by source of funds, 2019. Note: Data are available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Personal healthcare (more...)
In 2019, private insurance accounted for 33% of personal healthcare expenditures, followed by Medicare (23%), Medicaid (17%), and out of pocket (13%) (Figure 29).
Sources of funds varied by type of expenditure (data not shown):
Private insurance accounted for 37% of hospital, 40% of physician, 15% of home health, 10% of nursing home, 43% of dental, and 45% of prescription drug expenditures.
Medicare accounted for 27% of hospital, 25% of physician, 39% of home health, 22% of nursing home, 1.0% of dental, and 28% of prescription drug expenditures.
Medicaid accounted for 17% of hospital, 11% of physician, 32% of home health, 29% of nursing home, 10% of dental, and 9% of prescription drug expenditures.
Out-of-pocket payments accounted for 3% of hospital, 8% of physician, 11% of home health, 26% of nursing home, 42% of dental, and 15% of prescription drug expenditures.
Figure 30
Prescription drug expenditures, by source of funds, 2019. Note: Data are available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Percentages do (more...)
In 2019, retail prescription drug expenditures were $369.7 billion. Patients paid 15% of these expenses out of pocket (Figure 30), totaling $53.7 billion. All other health insurance entities, including private health insurance, Medicare, Medicaid, other health insurance programs, and third-party payers, accounted for 85% of the total costs ($316 billion):
Private health insurance companies accounted for 44.5% of retail drug expenses ($164.6 billion in 2019).
Medicare accounted for 28.3% of retail drug expenses ($104.6 billion).
Medicaid accounted for 8.5% of retail drug expenses ($31.4 billion).
Other health insurance programs accounted for 3.0% of retail drug expenses ($11.0 billion).
Other third-party payers had the smallest percentage of costs (1.2%), which represented $4.3 billion in retail drug costs.
Variation in Healthcare Quality
State-level analysis included 182 measures for which state data were available. Of these measures, 140 are core measures and 42 are supplemental measures from the National CAHPS Benchmarking Database (NCBD), which provides state data for core measures with MEPS national data only.
The state healthcare quality analysis included all 182 measures, and the state disparities analysis included 108 measures for which state-by-race or state-by-ethnicity data were available. State-level data are also available for 136 supplemental measures. These data are available from the Data Query tool on the NHQDR website but are not included in data analysis.
State-level data show that healthcare quality and disparities vary widely depending on state and region. Although a state may perform well in overall quality, the same state may face significant disparities in healthcare access or disparities within specific areas of quality.
Figure 31
Overall quality of care, by state, 2015–2020. Note: All state-level measures with data were used to compute an overall quality score for each state based on the number of quality measures above, at, or below the average across all states. States (more...)
Overall quality of care varied across the United States (Figure 31):
Some states in the Northeast (Maine, Massachusetts, New Hampshire, and Rhode Island), some in the Midwest (Iowa, Minnesota, North Dakota, and Wisconsin), two states in the West (Colorado and Utah), and North Carolina and Kentucky had the highest overall quality scores.
Some Southern and Southwestern states (District of Columbia,viii Florida, Georgia, New Mexico, and Texas), two Western states (California and Nevada), some Northwestern states (Montana, Oregon, Washington, and Wyoming), and New York and Alaska had the lowest overall quality scores.
More information about the measures and data sources included in the creation of this map can be found in Appendix C.
More information about healthcare quality in each state can be found on the NHQDR website, https://datatools
.ahrq.gov/nhqdr.
Variation in Disparities in Healthcare
The disparities map (Figure 32) shows average differences in quality of care for Black, Hispanic, Asian, NHPI, AI/AN, and multiracial people compared with the reference group, non-Hispanic White or White people. States with fewer than 50 data points are excluded.
Figure 32
Average differences in quality of care for Black, Hispanic, Asian, Native Hawaiian/Pacific Islander, American Indian or Alaska Native, and multiracial people compared with White people, by state, 2018–2019. Note: All measures in this report that (more...)
Racial and ethnic disparities varied across the United States (Figure 32). Many factors may account for the variation in disparities between states, such as differences in prevalence of chronic conditions, policies that limit behavioral risk factors, and availability of infrastructure that allows easy access to quality healthcare:
Some Western and Midwestern states (Idaho, Iowa, Kansas, Montana, Nevada, New Mexico, Oregon, Utah, and Washington), several Southern states (Kentucky, Mississippi, Virginia, and West Virginia), and Maine had the fewest racial and ethnic disparities overall.
Several Northeastern states (Massachusetts, New York, and Pennsylvania), two Midwestern states (Illinois and Ohio), two Southern States (Louisiana and Tennessee), and Texas had the most racial and ethnic disparities overall.
More information about the measures and data sources included in the creation of this map can be found in Appendix C.
- iii
Major updates made to three data sources since 2018, specifically the Medical Expenditure Panel Survey, Healthcare Cost and Utilization Project, and National Health Interview Survey, have had an outsized impact on what the 2021 NHQDR can include. Trend data were provided in prior versions of the NHQDR but were not directly comparable for almost half of the core measures at the time this report was developed. Therefore, the 2021 NHQDR does not include a summary figure showing all trend measures or all changes in disparities. The report includes summary figures for trends and change in disparities for some populations and the results for individual measures.
- iv
More information on providers that may be eligible to become CAHs and the criteria a Medicare-participating hospital must meet to be designated by CMS as a CAH can be found at https://www
.cms.gov/Medicare /Provider-Enrollment-and-Certification /CertificationandComplianc/CAHs. - v
All the criteria for a Medicare-participating hospital to be designated by CMS as a CAH can be found at https://www
.cms.gov/Medicare /Provider-Enrollment-and-Certification /CertificationandComplianc/CAHs. - vi
The most recent data year available is 2018 from the Association of American Medical Colleges, the current source for workforce data broken down by both race/ethnicity and sex.
- vii
The National Survey on Drug Use and Health at the Substance Abuse and Mental Health Services Administration combines data for Asian and Pacific Islander populations, which include Native Hawaiian populations.
- viii
For purposes of this report, the District of Columbia is treated as a state.
