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2023

National Healthcare Quality and Disparities Report Executive Summary

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Suggested citation: 2023 National Healthcare Quality and Disparities Report. Executive Summary. Rockville, MD: Agency for Healthcare Research and Quality; December 2023. AHRQ Pub. No. 23(24)-0091-EF.

2023 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORT Executive Summary

U.S. DEPARTMENT OF HEALTH ANDHUMAN SERVICES Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov

AHRQ Publication No. 23(24)-0091-EF December 2023 https://www.ahrq.gov/research/findings/nhqrdr/index.html

Acknowledgments The National Healthcare Quality and Disparities Report (NHQDR) is the product of collaboration among agencies from the U.S. Department of Health and Human Services (HHS), other federal departments, and the private sector. Many individuals guided and contributed to this effort. Without their magnanimous support, the report would not have been possible. Specifically, we thank:

Primary AHRQ Staff: Robert Valdez, Craig Umscheid, Erin Grace, Karen Chaves, Darryl Gray, Barbara Barton, Romsai Tony Boonyasai, Cecilia Hahn, and Doreen Bonnett.

HHS Interagency Workgroup (IWG) for the NHQDR:, Girma Alemu (HRSA), Anne-Marie Gomes (SAMHSA), Jill Ashman (CDC), Elizabeth Barfield (NIH), Barbara Barton (AHRQ), Doreen Bonnett (AHRQ), Romsai Tony Boonyasai (AHRQ), Christopher Cairns (CDC), Victoria Chau (SAMHSA), Karen Chaves (AHRQ), Xiuhua Chen (CVP), Robin Cohen (CDC), Nathan Donnelly (SAMHSA), Deborah Duran (NIH), Melissa Evans (CMS), William Freeman (AHRQ), Sabrina Frost (HRSA), Darryl Gray (AHRQ), Kirk Greenway (IHS), Monika Haugstetter (AHRQ), Rebecca Hawes (NIH), Kirk Henry (CDC), Sarah Heppner (HRSA), Trevor Hsu (SAMHSA), Heydy Juarez (SAMHSA), Christine Lee (FDA), Doris Lefkowitz (AHRQ), Lan Liang (AHRQ), Jesse Lichstein (HRSA), Shari Ling (CMS), Iris Mabry-Hernandez (AHRQ), Marlene Matosky (HRSA), Tracy Matthews (HRSA), Donna McCree (CDC), Christine Merenda (FDA), Kamila Mistry (AHRQ), Dawn Morales (NIH), Ernest Moy (VHA), Pradip Muhuri (AHRQ), Sarada Pyda (ASPE), Mary Roary (SAMHSA), Rajasri Roy (NIH), Dianne Rucinski (CMS), Asel Ryskulova (CDC), Michelle Schreiber (CMS), Yahtyng Sheu (HRSA), Adelle Simmons (ASPE), LaQuanta Smalley (HRSA), Loida Tamayo (CMS), Caroline Taplin (ASPE), Anjel Vahratian (CDC), Michelle Washko (HRSA), Tracy Wolff (AHRQ), Abigail Woodroffe (AIR), Ying Zhang (IHS), and Rachael Zuckerman (ASPE).

NHQDR Team: Barbara Barton (CQuIPS), Doreen Bonnett (OC), Romsai Tony Boonyasai (CQuIPS), Xiuhua Chen, (CVP), William Freeman (OEREP), Erin Grace (CQuIPS), Darryl Gray (CQuIPS), Cecilia Hahn (CQuIPS), Lan Liang (CFACT), Kamila Mistry (OEREP), Margie Shofer (CQuIPS), Andrea Timaskenka (CQuIPS), Tselote Tilahun (CQuIPS), and Abigail Woodroffe (AIR).

HHS Data Experts: Cuong Bui (HRSA), Lara Bull-Otterson (CDC), Christopher Cairns (CDC), Robin Cohen (CDC-NCHS), Joann Fitzell (CMS), Elizabeth Goldstein (CMS), Irene Hall (CDC-HIV), Katrina Hoadley (CMS), Jessica King (CDC), Amanda Lankford (CDC), Lan Liang (AHRQ), Lori Luria (CMS), Marlene Matosky (HRSA), Anthony Oliver (CMS), Tracy Matthews (HRSA), Robert Morgan (CMS), Richard Moser (NIH-NCI), Pradip Muhuri (AHRQ), Robert Pratt (CDC), Asel Ryskulova (CDC-NCHS), LaQuanta Smalley (HRSA), Alek Sripipatana (HRSA), Rita Wilson (EPA), and Xiaohong (Julia) Zhu (HRSA).

Other Data Experts: Valarie Ashby (University of Michigan), Mark Cohen (ACS NSQIP), Sheila Eckenrode (QSRS-Yale), Clifford Ko (ACS NSQIP), Jill McCarty (IBM), Joe Messana (University of Michigan), Tammie Nahra (University of Michigan), Leticia Nogueira (American Cancer Society), Robin Padilla (University of Michigan), Rebecca Anhang Price (RAND), Jennifer Sardone (University of Michigan), Yun Wang (QSRS-Yale), and Robin Yabroff (American Cancer Society).

Other AHRQ Contributors: Ashley Allman, Cindy Brach, Howard Holland, Edwin Lomotan, Corey Mackison, Karen Migdail, Milli O’Brien, Pamela Owens, Mary Rolston, Ruby Sachdeva, Bruce Seeman, and Michele Valentine.

Data Support Contractors: AIR, CVP Corp.

2023 National Healthcare Quality and Disparities Report 1

Executive Summary The United States is a global leader in scientific discovery and developing innovative technologies to diagnose and treat disease. Health professionals, provider organizations, health insurance plans, and other diverse entities bring those advancements to people. But the various healthcare systems often emerged at different points in our nation’s history, under varied contexts and for different purposes. Thus, they were not always designed to function as a single, coherent system. But it is essential that they work together to ensure that the benefits of science and innovation reach all Americans.

Since 2003, the Agency for Healthcare Research and Quality’s (AHRQ) National Healthcare Quality and Disparities Report (NHQDR) has summarized the status of healthcare delivery in the United States, providing a statistical portrait of how effectively healthcare delivery systems provide safe, high-quality, and equitable care to Americans. At its core, the NHQDR asks: How successful are the nation’s healthcare systems in ensuring that all people benefit from the scientific advancements and treatments available today?

Many partners, including Department of Health and Human Services (HHS) agencies and health officials from all U.S. states, contribute data for the report, which the Secretary of HHS delivers to Congress annually as mandated by law. The 2023 NHQDR examines the data in three sections:

• Portrait of American Healthcare provides an overview of healthcare delivery systems. It characterizes the U.S. population, their leading health concerns, the main components of healthcare delivery, and the nation’s capacity to deliver services to the population.

• Special Emphasis Topics are focused data briefs that examine quality and disparities in healthcare. This year’s special emphasis topics explore the nation’s experiences with COVID-19 healthcare delivery from five perspectives: the U.S. population, hospitals, ambulatory care settings, nursing and residential care facilities, and telehealthcare.

• Quality and Disparity Tables provide statistical assessments of healthcare delivery performance in eight topic-elated areas through the application of more than 550 quality measures.

Portrait of American Healthcare: Key Findings Demographics

• The U.S. population is aging. The number of people age 65 and over increased from 40.2 million to 55.9 million between 2010 and 2021, or from 13.0% to 16.8% of the population. Currently, there is one adult age 65 or over for every three working age adults; the Census Bureau projects that there will be two older adults for every three working age adults by 2060.

■ This trend has important implications for healthcare delivery because older adults are more likely to have chronic conditions; mental disorders, including cognitive limitations; and physical disabilities. A higher ratio of older adults to working age adults raises concern that the number of people who need healthcare services will exceed the number available to provide care.

■ Healthcare delivery systems can respond to this demographic concern by pursuing approaches that promote “heathy aging.” Such approaches include preventing chronic

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diseases, addressing chronic conditions early so they do not lead to disability, and enabling people with disabilities to participate more fully in society.

• The population has become more diverse racially and ethnically. Non-Hispanic (NH) White people accounted for a smaller share of the population in 2020 (57.8%) than in 2010 (63.7%). At the same time, Hispanic (16.3% to 18.7%), NH-multiracial (1.9% to 4.1%), and NH-Asian (4.7% to 5.9%) people increased as a share of the population. ■ The change in racial and ethnic diversity has occurred largely in younger age groups. For

example, 92.2% of Hispanic, 94.0% of NH-multiracial, and 86.8%% of NH-Asian people are under age 65.

■ In contrast, only 79.0% of NH-White people are age 65 years or younger.

This trend suggests an increased need for more culturally and linguistically appropriate services for pediatric care, obstetric care, and mental health care, among others.

• More people are living in metropolitan areas. The population in both metropolitan and nonmetropolitan counties grew between 1990 and 2020, but it grew faster in metropolitan areas. Large central metropolitan areas (“cities”) grew by 32.0%, large fringe metropolitan (“suburban”) counties grew by 52.7%, micropolitan (“small town”) counties grew by 14.5%, and noncore (“rural“) areas grew by 5.7%. Therefore, healthcare services have declined in many nonmetropolitan areas, even as services in metropolitan communities have grown. However, substantial numbers of people (46 million, or 13.9% of the population) still live in nonmetropolitan counties, resulting in a healthcare access crisis for some people in those communities.

Leading Health Concerns • In 2021, overall life expectancy decreased for the second year in a row, further expanding a

life expectancy gap between U.S. residents (76.1 years) and people who live in peer countries, including Japan (84.5 years), Switzerland (84.0 years), Australia (83.4 years), Sweden (83.2 years), France (82.5 years), Belgium (81.9 years), the Netherlands (81.5 years), Austria (81.3 years), Germany (80.9 years), and the United Kingdom (80.8 years).

• The leading contributors to the drop in life expectancy in 2021 were COVID-19 (which contributed 50% of the decrease in life expectancy), unintentional injuries (15.9%, a plurality of which were drug overdose), heart disease (4.1%), liver disease (3.0%), and suicide (2.1%). The decrease in life expectancy would have been even greater except that deaths due to homicide, influenza and pneumonia, congenital malformations, and perinatal events decreased in 2021 compared with historical trends.

• Substantial disparities in life expectancy exist among people of different racial and ethnic backgrounds. NH-Asian people had the highest life expectancy in 2021 (83.5 years), followed by Hispanic (77.7 years), NH-White (76.4 years), NH-Black (70.8 years), and NH- American Indian or Alaska Native (AI/AN) (65.2 years) people. For comparison, the average life expectancy for peer countries in 2021 was 82.4 years.

• All racial and ethnic groups experienced substantial loss of life expectancy during the COVID- 19 public health emergency (PHE) . Between 2019 and 2021, NH-AI/AN communities suffered the greatest loss in life expectancy (-6.6 years, a 9.2% decline), followed by Hispanic (-4.2 years, 5.1% decline), NH-Black (-4 years, 5.3% decline), NH-White (-2.4 years, 3.0%

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decline), and NH-Asian (-2.1 years, 2.5% decline) people. For comparison, the average loss of life expectancy in peer countries during COVID-19 was -0.2 years, a 0.2% decline.

Social Determinants of Health • Social determinants of health, (social, economic, environmental, and community conditions)

often have a stronger influence on the population’s health and well-being than services delivered by practitioners and healthcare delivery organizations. They also influence the extent to which people use healthcare services and how well they respond to treatment and recover from illness.

• One of the most important social determinants of health is having health insurance. The percentage of people under age 65 years with health insurance coverage continued to increase in 2021. Between 2020 and 2021, the percentage of Americans with private health insurance coverage increased 1.1%, and the percentage of those with public insurance increased 0.2%. However, insurance coverage varied by state and by race and ethnicity. States ranged between providing health insurance coverage to as many as 96.7% of their populations to as little as 77.6% of their populations. Hispanic and NH-AI/AN populations are less likely to have any health insurance coverage compared with other racial and ethnic groups.

Healthcare Delivery Systems • Healthcare delivery systems are sectors of the healthcare industry that perform distinct but

overlapping functions. They include healthcare workers and resources, as well as organizations, such as outpatient medical offices, clinical laboratories, pharmacies, home and community-based services, hospitals, and nursing and residential care facilities. Americans receive healthcare services from a diverse range of healthcare delivery systems. (As a concept, “healthcare delivery systems” are distinct from “health systems,” which are networks of healthcare entities that share a central organizational structure, such as a network of medical offices and community hospitals anchored by a tertiary care academic hospital.)

• The number of healthcare workers decreased sharply during the COVID-19 PHE. As of January 2023, overall healthcare workforce participation has returned to levels reported in January 2020. The recovery, however, has varied by healthcare setting and by occupation.

■ Although the population is aging and demand for long-term services and supports has grown, the nursing and residential care facilities workforce shrank during the COVID-19 PHE. In January 2023, there were 8.4% fewer nursing and residential care workers than in January 2020. In contrast, the number of “employed and at work” hospital and ambulatory care workers has returned to or surpassed prepandemic levels.

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■ Although a potential shortage of nurses and doctors has received much attention, the total number of physicians and nurses employed and at work was stable between January 2020 and December 2022. However, the number of workers employed in occupations requiring an associate’s degree or less education (medical assistants, phlebotomists, etc.) decreased from 2.26 million workers in January 2020 to a low of 1.55 million workers in April 2020, before partially recovering to 2.15 million workers as of December 2022. The data suggest that a widely reported shortage of healthcare workers may be driven by loss of workers in occupations that required less educational attainment for entry, many of whom have employment options beyond healthcare.

• Many rural Americans lack access to primary care services, and the primary care providers who are available are often isolated from their professional peers. The Health Resources and Services Administration (HRSA) has designated more than 63% of U.S. counties as “whole county” primary care health professional shortage areas (HPSAs), indicating areas where lack of primary care practitioners threatens access to needed services. Of these 71.7% are rural and micropolitan (i.e., small town) counties.

• Many rural Americans also lack access to hospital care, as 174 rural hospitals closed (i.e., either closed completely or stopped offering inpatient services while continuing to provide other healthcare services) between 2005 and 2020. The pace of rural hospital closures slowed during the COVID-19 PHE, with 2 closures in 2021 and 6 closures in 2022, compared with an annual average of 13.8 closures per year in the preceding 5 years. The slowdown occurred after passage of several federal COVID-19-related bills, which included temporary financial support for at-risk hospitals.

• Nearly one-fifth of the population has provided unpaid long-term and postacute care for a loved one instead of using a formally recognized healthcare establishment. This estimate reflects the growing share of the population that relies on long-term and postacute care services. The long-term and postacute care sector that seeks to address this need is fragmented and consists of many different types of healthcare delivery organizations and varying levels of government support and health insurance coverage.

National Health Expenditures • Where a nation spends its limited resources often reflects its needs and priorities. The

National Healthcare Expenditures provide a financial accounting of healthcare spending. • National healthcare consumption represents the sum of all spending for medical care services

plus governmental health administration and public health activities. As a share of national healthcare consumption, out-of-pocket spending has decreased, correlating with an increase in spending by publicly sponsored health insurance (Medicare and Medicaid). In 2021, publicly sponsored health insurance accounted for 40.4% of all healthcare consumption. Private health insurance accounted for 29.9%, and out-of-pocket spending accounted for 10.7%.

• Spending on public health activities, which includes worksite and school-based healthcare services, maternal and child health programs, the Indian Health Service, HRSA’s Health Center program, and many other federal programs, declined from 18.0% to 12.4% of national health consumption between 1960 and 2019. During the COVID-19 PHE, spending on public health and other federal health programs increased to 19.0% of national health consumption in 2020 before decreasing to the most recent estimate of 14.7% in 2021.

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• Personal healthcare expenditures represent all spending for medical goods and services, excluding government administration and public health activities. They show the nation is transitioning from hospital-based care toward delivering medical services in nonacute care settings.

■ Hospitals’ share of personal health expenditures peaked at 47.8% in 1982. Since then, it has decreased steadily to 37.7% in 2021.

■ During the same period, spending for services typically delivered in nonacute care settings and people’s homes replaced hospital’s share of personal healthcare expenditures. These include increased spending between 1982 and 2021 for prescription drugs (5.4% to 10.6%); home care (1.2% to 3.5%); nonphysician professional care, such as physical therapists and home health aides (1.8% to 3.7%); and durable and nondurable medical equipment, such as wheelchairs, nebulizers, and home oxygen (8.7% to 10.9%).

Geographic Variations in Care • Overall quality of care varied among states. Four states in the Northeast region (Maine, New

Hampshire, Pennsylvania, and Rhode Island), five in the Midwest region (Iowa, Minnesota, Nebraska, South Dakota, and Wisconsin), one state in the South region (Delaware), and two states in the West region (Idaho and Utah) had the highest overall quality scores.

• There also were differences in quality of care by race and ethnicity among states. Five states in the West region (Hawaii, Idaho, Montana, Oregon, and Washington), four states in the South region (Arkansas, Kentucky, Virginia, and West Virginia), and two states in the Midwest region (Kansas and Nebraska) had the fewest racial and ethnic healthcare disparities overall.

Special Emphasis Topics: Key Findings The 2023 NHQDR includes an Overview that describes SARS-CoV-2 and the biologic and clinical considerations that enabled this virus to cause the disease COVID-19. Five other sections examine how the COVID-19 pandemic affected U.S. healthcare delivery from the perspectives of five groups within the healthcare delivery system. Highlights from each are below.

Impact of COVID-19 on the U.S. Population This topic examines the population’s experience during the COVID-19 PHE, which varied across regions and communities due, in part, to the way that SARS-CoV-2 first affected densely populated coastal cities before spreading to suburban, rural, and remote communities. Nationally, COVID-19 death rates increased between the pandemic’s first and second years, despite the nation having more knowledge about the disease and greater availability of testing, treatments, and vaccines.

Two types of factors drove the rise in COVID-19 death rates:

• First were factors that enhanced risks of getting infected. These included the emergence of variants with higher transmissibility, relaxation of public health initiatives that had limited exposure to the virus, and varying use of COVID-19 vaccines.

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• Second were factors that enhanced risk of dying if infected. These included higher lethality of some SARS-CoV-2 variants, case surges that reduced hospital capacity and reduced access to appropriate treatment, and variable use of COVID-19 vaccines.

Healthcare delivery systems, such as hospitals, nursing homes, pharmacies, home and community-based service providers, and medical offices, had crucial roles mitigating both types of risks. They performed essential functions such as conducting surveillance testing, educating the public, and distributing vaccines. Healthcare delivery systems helped because the public health system lacked the resources to deliver these services at the scale needed for a global health crisis such as COVID-19 without health systems’ involvement.

Despite limited vaccine availability in the early months of 2021, the combined efforts of the public health and healthcare delivery systems successfully achieved vaccination levels that were initially expected to confer population immunity. However, populations lacking health insurance, living in low-income communities, and living in rural locations were less likely to receive counseling to get the vaccine and less likely to receive it. As these groups often lack access to personal healthcare providers, the data suggest that healthcare delivery systems may have lacked capacity to equitably distribute vaccines beyond their traditional markets.

The data also show that initial targets for vaccination coverage did not achieve population immunity, as anticipated. This was due, in part, to the emergence of more transmissible variants of the virus, which occurred concurrently with declining adherence to public health guidance aimed at slowing disease transmission. Thus, multiple surges in cases associated with the Alpha (November 2020 to February 2021), Delta (August 2021 to October 2021), and Omicron (November 2021 to March 2022) variants were able to evade the population immunity conferred by vaccination efforts. These surges led to recurring spikes in cases, hospitalizations, and deaths throughout 2021.

Key data findings follow:

• In 2021, more than 70% of adults had received at least one COVID-19 vaccine, and more than half of adults (56.6%) completed a two-dose “primary series” vaccination.

• Vaccine use also varied within the population. Older adults, NH-Asian people, and people living in metropolitan areas were more likely to complete the primary COVID-19 vaccine series than other groups.

• Although a federal mandate covered the cost of COVID-19 vaccines and prohibited prior authorization or cost sharing to get the vaccine, uninsured, publicly insured, and low- income people were less likely to complete the COVID-19 primary series. The data signal that factors other than vaccine costs hindered vaccination efforts.

• Most Americans trust their healthcare professional for information about the COVID-19 vaccine. But the percentage of Americans who received a recommendation to get the COVID-19 vaccine from their healthcare professional was lower than 40% in 2021, and rates were similar among all racial and ethnic groups.

• Uninsured people and people with annual incomes lower than $75,000 were less likely to be recommended for COVID-19 vaccination by a healthcare professional. This was probably because these populations had less access to healthcare professionals, not because healthcare professionals treated them differently.

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• Healthcare professionals were especially vulnerable to SARS-CoV-2 infection and its consequences. Thus, they were prioritized to receive the COVID-19 vaccine early. Healthcare workers were more likely to complete the two-dose COVID-19 vaccination series than other adults in 2021. But healthcare workers in nonmetropolitan areas and in publicly insured, uninsured, low-income, and high social vulnerability groups were less likely to get the vaccine than their colleagues in other groups, mirroring disparities seen in the overall adult population. These findings provide further evidence that financial and structural access barriers hindered health systems’ ability to equitably distribute vaccines.

• Most COVID-19 deaths occurred among adults age 65 and over. But large numbers of deaths also occurred among adults ages 50-64 and 18-49, especially during surges associated with the Alpha, Delta, and Omicron variants. During the second year of the pandemic, adults age 65 and over were less likely to get infected but substantially more likely to die if infected.

• Among racial and ethnic groups, NH-AI/AN, NH-Native Hawaiian/Pacific Islander (NHPI), Hispanic, and NH-Black populations were more likely to die from COVID-19 than other groups. NH-NHPI people were less likely to get infected but more likely to die if infected. Hispanic and NH-Black people were more likely to get infected but exhibited similar risks of dying if infected as NH-White people. NH-AI/AN individuals were both more likely to get infected and more likely to die if infected.

• The varying patterns among different racial and ethnic groups suggest that different underlying factors caused each group’s higher COVID-19 death rates. They signal the possibility that achieving equitable health outcomes may require tailored disease mitigation strategies to address different groups’ specific concerns.

• Disparities in COVID-19 deaths also occurred between metropolitan and nonmetropolitan communities. People in nonmetropolitan communities appeared to be somewhat more likely to get infected and appeared to be at higher risk of dying if infected. Limited access to hospital and critical care services may have contributed to the higher COVID-19 death rates experienced in those communities. Lower uptake of the COVID-19 vaccine in small towns and rural areas may also have contributed to these outcomes.

Impact of COVID-19 on Hospitals This topic examines the healthcare delivery sector that provides acute care services to people with serious, sometimes critical, injuries and illnesses. Hospitals were a vital resource during the COVID-19 PHE. Thus, the nation had strong interest in ensuring that they had sufficient capacity to meet demand for acute and critical care services, particularly during the initial surge of cases in early 2020 and subsequent surges associated with the Alpha, Delta, and Omicron variants.

Key findings follow:

• Hospital and emergency department (ED) capacity was closely coupled with COVID-19 cases. Data show increased ED visits and hospital admissions during the spike in cases associated with the Alpha, Delta, and Omicron variants that occurred throughout 2021. Data also show decreased ED visits and hospital admissions for non-COVID-19 conditions during surge periods, suggesting that non-COVID-19 conditions were crowded out by COVID-19 cases.

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• Admissions for COVID-19 often required critical care services. Among middle-age and older adults hospitalized for COVID-19 between March 2020 and March 2022, the median weekly percentage who required ventilator support was more than 10%. At times, use of ventilators rose as high as 26.6% for adults ages 30-59 and 28.2% for adults age 60 and over. For context, approximately 5.3% of people hospitalized for severe community- acquired pneumonia required mechanical ventilation.

• Adults admitted for COVID-19 age 60 and over were more likely to die in the hospital than adults ages 30-59, but death rates in both groups were high. For example, in the first week of July 2022, during the surge associated with the Omicron variant, 17.5% of adults age 60 and over admitted for COVID-19 died, and 11.9% of a

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