The Veterans Health Administration (VHA) affords an important opportunity for health equity research because access to health care is similar across veteran populations, thus eliminating access to care as a potential confounder or complicating factor in measuring differences in health. Second, VHA has unique and comprehensive data on all of the veterans it serves; such data is a rich source of information that can be used for analysis.  Additionally, the VHA's coordinated structure may allow the health system to implement improvements efficiently and broadly. Finally, achieving equity in health care is fundamental to the VHA, which is committed to providing the highest-quality and most cost-effective health care to all veterans, regardless of race, ethnicity or gender.

No. Equal access to health care does not eliminate inequalities in health or even inequalities in health care among populations. Studies have shown that inequalities in health and health care can occur in systems that provide equal access to health care, such as the National Healthcare System in the United Kingdom, and within the VHA here in the US. Such inequalities in health may occur because many of the most important determinants of health, such as income, education and environment, have little to do with the quality or delivery of health care.  Inequalities in health care within equal-access systems could be due to systemic factors, patient factors or factors having to do with the patient-provider interaction.

Most health and health care disparities research falls into three generations. The first generation of health disparities research consists of research that identifies and documents health and health care disparities. The enduring lesson of first generation research is that if you look for disparities in health or in health care, you can find them everywhere. Second generation research digs a little deeper and explores the root causes of health and health care disparities. Second generation research has revealed that complete answers will be invariably complex, most likely involving combinations of a number of factors including, but not limited to, individual behavior and biology, the social and physical environment, the health care system, and public policy. Understanding the underlying causes of disparities will lead to the third generation of research. Third generation research aims to develop and test interventions to reduce disparities and, in so doing, improve the health of all.

A few studies indicate that patient choices may play some role in some health care disparities. For example, some research has shown that African Americans veterans tend to refuse joint replacement and lung cancer tumor removal surgeries. However, we need to understand what drives these choices. They may reflect a lack of information or they may reflect deeply held values that should be respected and preserved. It is unlikely however, that patient lifestyles or choices for their care are the sole reason for the vast number of health disparities that have been observed. To be blunt: there is no evidence to suggest that differences in life expectancy, and the burden of diseases such as hypertension, tuberculosis, and diabetes result from informed patient choices.

While there is some evidence that racial prejudices and cultural stereotypes influence the health care that minorities receive, that evidence fails to explain the vast scope and degree of health and health care disparities. The actions of a few health care providers could not possibly be the sole or even majority explanation for all of the racial disparities in health and health care. Additionally, health care provider racism cannot explain disparities observed across geographic areas, socioeconomic levels, educational attainment, and gender.

Biological and genetic differences might explain some differences in life expectancy between men and women. However, biology and genetics are unlikely to explain the substantial differences in life expectancy observed between blacks and whites, and it is implausible to think biology explains differences in health care received.

There is evidence to suggest that poor living and working situations, social isolation and segregation, economic vulnerability, and other complex social forces conspire to reduce the health and health care of poor populations. But if these complex social forces are the cause of observed disparities in health and health care, then we must reveal the underlying mechanisms and work to address them.

Both absolute and relative differences are important in assessing health disparities. In the same sense that absolute and relative risk are both important in assessing the effectiveness of any health care treatment, it is important to consider both of these in assessing differences in health outcomes. Which is more important depends to some degree on what the baseline rates are, as small relative differences translate into large absolute differences with high baseline mortality rates and small absolute differences equate to large relative differences at low baseline mortality rates. Comparison of absolute rates implies an additive model for examination of health disparities whereas relative differences imply a multiplicative model (increased relative risk). Relative risks are probably a better measure of health disparities because biologically it seems more likely that, to the extent that being uninsured or being of a certain racial group is a risk factor for worse outcomes, this effect would manifest itself as an increased relative risk across a spectrum of disease conditions as opposed to a constant additive risk.