# Inequities in Health Outcomes in the Twenty-First Century: Understanding New Causes and the Impact of Delivery System Reforms on Health Care Disparities

> **NIH NIH DP5** · HARVARD MEDICAL SCHOOL · 2020 · $423,750

## Abstract

Project Summary/Abstract
 Over the last 15 years, an alarming chasm in health outcomes has emerged across the United States. The
mortality rate of some populations—in particular working-age white adults—has increased by as much as 0.5%
a year, reversing a 20-year trend of declining mortality, while mortality rates among other demographic groups
in the United States and similar age populations in other developed countries have continued to decline.
 Disparities in health have long afflicted racial minorities and socioeconomically disadvantaged populations.
Although this has motivated efforts by government and communities to reduce them, the new mortality chasm
afflicting largely less-educated white populations suggests a widening gap in health by economic class. With a
growing share of the nation's gross domestic product spent on health programs, this reversal of progress on
mortality for any subgroup is particularly troubling.
 Why is this happening? While evidence suggests that elevated burdens of certain health-related behaviors
or diseases (e.g. substance abuse) may play a key role, the increasing disease burden by itself cannot explain
the divergence in progress between subgroups. Moreover, the causal pathways by which social determinants
of health impact mortality and health differently across populations of different race/ethnicity or economic class
remain poorly understood. For example, broad macro-level economic policies in the U.S. (e.g. trade) can affect
economic opportunities and outlook for working-age adults; yet their impacts on health are largely unknown.
 And as the nation moves forward with ambitious reforms of its delivery system—rewarding improved quality
of care and health outcomes at the population level—such reforms may push physicians and hospitals to focus
on improving the care of disadvantaged patients the most, who often have the most room to improve, but these
reforms might also exacerbate disparities in quality and outcomes via the avoidance of disadvantaged patients.
Thus, understanding whether today's reforms will achieve their goals in an equitable way is a crucial task.
 I propose a research agenda with 2 key goals. First, I seek to identify new causal mechanisms behind the
emerging disparities in health outcomes. Using macro-level economic changes as exogenous shocks to social
determinants of health, I will study their impact on outcomes across race, income, and geography. Within this
analysis, I will examine the associated changes in burden of disease to understand the clinical manifestations
of those broader economic shocks. Second, I seek to examine whether today's reforms to the delivery system,
which are designed to change the ways physicians and hospitals deliver care, can impact disparities in health
by race, income, and geography. I will analyze the impact of programs that reward quality and outcomes at the
physician level, such as the Medicare Access and CHIP Reauthorization Act (MACRA), as well as progra...

## Key facts

- **NIH application ID:** 9993597
- **Project number:** 5DP5OD024564-04
- **Recipient organization:** HARVARD MEDICAL SCHOOL
- **Principal Investigator:** Zirui Song
- **Activity code:** DP5 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $423,750
- **Award type:** 5
- **Project period:** 2017-09-01 → 2022-08-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9993597

## Citation

> US National Institutes of Health, RePORTER application 9993597, Inequities in Health Outcomes in the Twenty-First Century: Understanding New Causes and the Impact of Delivery System Reforms on Health Care Disparities (5DP5OD024564-04). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9993597. Licensed CC0.

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