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Promoting health care equity: is health literacy a missing link?

The need to improve quality and achieve equitable care for all Americans remain critical goals, and several national initiatives are underway that are sponsored by the federal government (e.g., Value Driven Health Care, http://archive.hhs.gov/valuedriven/index.html) and through ongoing private efforts such as those of the Robert Wood Johnson Foundation (RWJF). Two examples of RWJF's efforts: the Brookings Institution is leading The High-Value Health Care Project (http://www.healthqualityalliance.org/hvhc-project to make valid, timely, consistent information about the quality and cost of health care widely available in the United States; and the Aligning Forces for Quality initiative (http://www.forces4quality.org/welcome) is designed to lift the overall quality of care in 17 communities across the country. A key component common to each of these efforts seeks to target reducing disparities and promoting equity in health care, with a central focus on the systematic collection of race, ethnicity, and primary language data by health care organizations to identify at risk populations. Although recognizing that limited health literacy is a key risk factor in the receipt of lower quality care and a contributor to health care disparities, these efforts do not currently focus on collecting data about populations at risk for low literacy skills—which we argue may overlook an important link in the efforts to redress inequities in health care. 
 
Despite more than a decade-long focus on addressing disparities in health care, high value and high quality are not trademarks of our health care delivery system for many disadvantaged groups. Inequities in health care remain prevalent for the most vulnerable members of our society, particularly individuals who belong to racial/ethnic minority groups, with limited English proficiency (LEP), and with less educational attainment and limited literacy skills. These characteristics are not mutually exclusive; individuals from underserved populations often share aspects of all these vulnerabilities as a consequence of known inequities found in other systems in our society (e.g., the educational system). Yet lately, there has been increasing interest in promoting health literacy as an immediate strategy to reduce disparities and provide patient-centered care. Here, we highlight the intersection of limited health literacy and disparities in health care as contributors to low-quality care, discuss opportunities for improvement in the health care delivery system, and propose the role health services researchers can play in getting us closer to our goal of a high quality and equitable health care system.