The Silence Between Reports: 20-year Follow Up to IOM Report on Racial Inequity Shows little progress

Now, two decades later, the silence between those reports has been filled. Not with progress. Not with accountability. But with inaction.

This year, a new report—Ending Unequal Treatment—offers its long-awaited postscript. Its conclusion lands like an indictment: Most racial and ethnic health care inequities have persisted. Some have worsened. Twenty years of policy and politics. Twenty years of promises. And for millions of Americans, health care is still a stratified experience shaped by the color of your skin.

This is not a story about ignorance. This is a story about refusal. The refusal to change what is known. The refusal to dismantle what harms. The refusal to face the full cost of our own inertia.

A System That Was Designed This Way

Every health care system is a mirror. It reflects what a society values, what it fears, and who it’s willing to protect. The American system has reflected a brutal truth for decades: that not all lives are weighted equally.

Despite being the wealthiest nation in the world, the United States ranks dead last among high-income countries on nearly every measure of population health. And the weight of that failure is not distributed evenly. Black women are nearly three times as likely to die in childbirth as white women. Latino children face more severe complications from chronic illnesses. Native Americans are twice as likely to die from pregnancy-related causes. Segregated communities have higher rates of cardiovascular disease, cancer, and COVID-19. Diabetes hospitalizations are 2.5 times higher for Black adults than for whites.

These are not mere statistics. They are markers of abandoned lives. And they are not anomalies — they are features of a system built to tolerate them.

The new National Academies report acknowledges this with a sobering admission: the United States has not created "clear pathways to translate promising approaches into real and permanent change".

In short: we know how to make things better. We just haven’t.

The Illusion of Movement

To read the 2024 report is to walk through a museum of good intentions. Programs were launched. Research was funded. Bias trainings were implemented. Laws were passed. But beneath it all lies a core failure: the refusal to act with urgency or permanence.

Implicit bias training, once heralded as a breakthrough, was widely adopted — but never evaluated with the rigor it deserved. Awareness campaigns became commonplace — but remained superficial. DEI offices were opened — and are now being defunded and litigated into irrelevance.

Meanwhile, the conditions that drive inequity — poverty, lack of insurance, racism in diagnosis and treatment, underrepresentation in the workforce — were left to fester. The Affordable Care Act reduced coverage gaps, but 10 states still refuse to expand Medicaid. Access to primary care is worse than ever. Structural racism was named — but never truly confronted.

It’s not that nothing was done. It’s that everything done was designed not to threaten the status quo.

Where Accountability Should Have Been

At no point in the 400 pages of Ending Unequal Treatment does the report name the people or institutions that blocked progress. There are no hearings. No testimonies. No penalties. No reckoning.

Who failed to fund promising pilot programs when their grants expired? Who refused to implement the civil rights provisions already enshrined in law? Who profited from health care that gets more lucrative as people get sicker?

Instead, the report floats above the fray, mapping the landscape without ever interrogating the architects. Even when it lays bare how financial incentives reward acute intervention over prevention — how hospitals make more money when patients arrive sicker — the report stops short of calling this what it is: a moral failure of national design.

A Case of Maternal Mortality: How the System Breaks Women of Color

Take the story of maternal mortality — a barometer for any health system’s integrity. In 2018, Black women in the U.S. were 2.5 times more likely to die from pregnancy-related causes than white women. By 2021, that gap had widened. Black women were nearly three times more likely to die during childbirth.

This is not about access alone. It's about how care is delivered. Studies show that Black women’s pain is more likely to be dismissed, their symptoms minimized, their needs ignored. Racism is not a side effect. It is part of the clinical pathway.

The system doesn’t just break. It breaks the same people, over and over again.

The Perpetual Pilot Program

One of the most damning insights from the report is that equity programs are never allowed to grow up.

Time and again, promising community-led models show impact — only to be defunded or dismissed as “unsustainable.” Initiatives that center lived experience, that integrate social care with health care, that employ local workers and recognize the value of cultural context — these are repeatedly marginalized, even as billion-dollar systems churn out racialized data without ever using it to course-correct.

In essence, equity remains an experiment. Suffering is perpetual, but the solutions are always temporary.

A System That Cannot Be Tweaked Into Justice

What this report dances around — but never fully says — is this: you cannot reform your way out of injustice built into the business model. You cannot anti-bias-train your way through an insurance industry that profits from exclusion. You cannot diversity-hire your way through a workforce pipeline that remains closed to many and hostile to others. You cannot spreadsheet your way out of a system that still does not see Black or Brown bodies as deserving of equal care.

There is no app for this. No metric or dashboard that can redeem decades of avoidance.

The Truth Between the Lines

The authors of the report understand this. Their conclusions are careful but clear. Racism remains a primary driver of inequity. Financial incentives make the system worse, not better. No one is in charge of ensuring equity. And no one is held accountable when it is denied.

They offer recommendations — many of them important and long overdue: reforming payment systems, scaling effective models, collecting better data, embedding equity into every institution.

But the report ends with a haunting truth: “Forward motion has yet to yield long-term gains”.

This is the sound of a nation trapped in a cycle of learning and forgetting.

We Cannot Wait for Another Report

What happens next is not about science. We have that. It’s not about policy. We’ve written it. What happens next is about power — and whether those who hold it are finally willing to share it.

We cannot afford to be shocked by this report. We must be angered. Emboldened. Compelled.

Because if the past 20 years have taught us anything, it’s this:

Knowledge is not power.

Power is power. And it is time to use it.