Equity and disparities in health care and outcomes have been in the spotlight during the COVID-19 pandemic. Much of the data, including the latest release from the Kaiser Family Foundation (KFF), show that some racial and ethnic minority populations have consistently been disproportionately harmed by COVID-19 cases, serious illness, and death.

Unfortunately, such disparities are not new. In 2002, the National Academies’ Institute of Medicine released “Unequal Treatment,” a detailed report about the health care disparities racial and ethnic minorities were experiencing. According to the report, prior analyses generally suggested that it was mostly poverty or lack of insurance that caused a lack of access to care. The report acknowledged these problems while highlighting longstanding structural racism—inequity built into the system itself—as a major cause of disparities in outcomes.

This week, a special report from STAT News shows that little has changed in the 20 years since “Unequal Treatment” came out. Black Americans still face poorer outcomes and higher death rates—up to five years earlier than white Americans. One of the authors of the original report, who was interviewed for the STAT project, struck a particularly somber note, saying that, “There hasn’t been a lot of progress in 20 years,” and calling much of the current system “what some would call medical apartheid.”

How the health care system became mired in structural racism is the topic of a recent Health Affairs report: Storymap: The Problem Of The Color Line. This in-depth exploration of historical perspectives as well as implicit actions and deliberate policy choices around segregation, health care financing, and housing shows just how deeply rooted some of the issues are. The authors conclude that dismantling these racist systems will require, in part, ensuring “that all people have access to comprehensive health insurance to more readily access and use health care services.”

While our health system has taken steps in this direction, it has a long way to go. For example, Medicare has greatly improved health equity and reduced disparities, but it did not eliminate structural racism. Medicaid has also done much to improve access to care, but some states have wielded Medicaid’s power in harmful ways or refused to extend coverage—decisions that disproportionately affect people of color.

Tackling these issues is not easy. But history teaches us that we cannot just expect disparities to resolve themselves. Instead, we must actively address the underlying, and overarching, policy decisions that maintain a health care, and societal, system that penalizes racial and ethnic minorities.

Read “Unequal Treatment.”

Read the 20-year retrospective on “Unequal Treatment” from STAT News.

Read Storymap: The Problem of the Color Line.