Changing with the Population: HHS Standards Enhanced to Reach More Groups Affected by Health Care Disparities

By Atul Grover, M.D., and Marc Nivet, Ed.D.

The times, they are a-changin’… again. The U.S. Department of Health and Human Services has updated its National Standards for Culturally and Linguistically Appropriate Services (CLAS) for health care organizations in response to evolving attitudes and data surrounding health care disparities. First rolled out in 2000, the CLAS standards have been revised to reflect a broader definition of cultural diversity that goes beyond race, ethnicity, and language, and now includes sexual orientation, spirituality, and disability status. In a society where our zip code is a major predictor of overall health, CLAS added geography as a diversity factor, too.

The Association for American Medical Colleges (AAMC) embraces this broader view of diversity to ensure medical schools and teaching hospitals eliminate health care disparities for all populations with disparate health outcomes. While the overall health of Americans has been improving, data from the Agency for Healthcare Research and Quality shows that people in minority groups are not sharing equally in this progress.

The launch of the Affordable Care Act next year is bound to create an even greater need for cultural and linguistic competency as the underserved gain greater access to health care services. We know, for example, that even when corrected for factors such as income and insurance coverage, studies show that minority groups not only have less access to health care, but also receive lower quality care and have worse outcomes than white patients on average. For instance, although their incidence for heart disease is generally higher, African-Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are whites.

Recognizing these disparities, many of our member medical schools and teaching hospitals that are on the front line in U.S. cities and have a highly diverse patient base are innovating rapidly to address them.  For example, New York–Presbyterian can provide translation assistance for patients in more than 100 languages. Vanderbilt University Medical Center created a comprehensive center to address health care disparities for lesbian, gay, bisexual, transgender, and intersex people. Thomas Jefferson University in Philadelphia offers students a Language Immersion Program where they learn about medical terminology, social-cultural norms, and prevalent diseases associated with Latino sub-groups.

We’ve learned from many studies and reports that when doctors reflect the diversity of our patients, satisfaction and health outcomes improve. Thus, the AAMC has redoubled its efforts to promote the diversity of the physician workforce.  However, simply changing the face of medicine is not enough. We must ensure all physicians and the systems in which they work are culturally and linguistically competent.

The reinvigorated CLAS standards are an important step that reinforces what many of our institutions have already begun to advance the cultural competence of their students, trainees, and physicians. The University of Washington School of Medicine has a program to provide health care outreach to Native American and Alaska Native patients as well as recruit more students from those minority groups. Columbia University College of Physicians and Surgeons formed a partnership with Bassett Healthcare System to create a new track to train students interested in rural medicine.

Health care disparities are avoidable if not deplorable. What’s more, they carry a steep price, not only for minority communities, but for our nation. The resulting economic burden of insufficient and inequitable care for minority patients tops $1 trillion, according to an estimate cited in a recent AHRQ report. The irony is that substandard health care ends up being more expensive when costlier interventions are needed later.

All indicators are that our country will continue its demographic shift away from the white majority. The launch of the Affordable Care Act next year is bound to create a greater need for cultural and linguistic competency within our health care system. But to make further strides in cultural competency and health care parity, we must invest more in education, training, and outreach. The sequester and other potential cuts to funding for doctor training jeopardize all the important work being done in this area. At a time when we are expanding insurance coverage, we should be investing more—not less—to to promote equity and justice in health care for every patient.

groverAtul Grover, M.D., Ph.D., is Chief Public Policy Officer of the Association of American Medical Colleges. Trained as a general internist, Dr. Grover holds faculty appointments at the George Washington University School of Medicine, where he earned his M.D.; and the Johns Hopkins University Bloomberg School of Public Health, where he obtained his Ph.D. in health and public policy. He can be reached at or on Twitter @atulgrovermd.

MarcNivetColorMarc Nivet, Ed.D., is Chief Diversity Officer of the Association of American Medical Colleges. Dr. Nivet holds an Ed.D. degree in higher education management from the University of Pennsylvania Graduate School of Education and an M.S. degree in higher education and student development from Long Island University, C.W. Post Campus. Dr. Nivet earned his B.A. degree in communications studies from Southern Connecticut State University. He can be reached at