Article
19 minute read 22 June 2022

US health care can’t afford health inequities

Inequities in the US health system cost approximately $320 billion today and could eclipse$1 trillion in annual spending by 2040 if left unaddressed.

Asif Dhar

Asif Dhar

United States

Dr. Jay Bhatt

Dr. Jay Bhatt

United States

Neal Batra

Neal Batra

United States

Brian Rush, ASA, MAAA

Brian Rush, ASA, MAAA

United States

Wendy Gerhardt

Wendy Gerhardt

United States

Andy Davis

Andy Davis

United States

Inequities across the US health system limit underserved people’s access to affordable, high-quality care, create avoidable costs and financial waste that span society, and impact every individual’s potential to achieve health and well-being. To understand how far-reaching this issue is, Deloitte’s actuarial team developed a model to quantify the link between health care spending and health care disparities related to race, socioeconomic status, and sex/gender. The team analyzed several high-cost diseases (e.g., diabetes, asthma, and cardiovascular disease), determined the proportion of spending that could be attributed to health inequities today, and trended the spending to 2040—while accounting for changes in population and per capita spending.

Our actuaries concluded that health inequities account for approximately $320 billion in annual health care spending signaling an unsustainable crisis for the industry. If unaddressed, this figure could grow to US$1 trillion or more by 2040. If the United States reaches this threshold, we could see a direct impact on affordability, quality, and access to care beyond the challenges that already exist. The projected rise in health care spending could cost the average American at least $3,000 annually, up from today’s cost of $1,000 per year. And the increase in spending likely would have a greater impact on historically underserved populations. This avoidable expense (in dollars and lives) is the result of an inequitable health system and could have major consequences for the health and well-being of all individuals. No individual, family, or health system is equipped to sustain that kind of inefficiency and its implications. We can begin to address this by designing today for an equitable future.

Deloitte’s 2021 report, Breaking the Cost Curve, described how new business models, technological breakthroughs, consumers armed with highly personalized data, and regulations that encourage change could lead to a dramatic deceleration of health care spending by the year 2040. However, health inequities are a major barrier to this vision. In fact, the current trajectory of health care spending is compounded by health inequities (figure 1). As our vision for the Future of Health™ continues to unfold, we’re watching health care spending accelerate and inequities in health and outcomes become more prevalent across race, sex/gender, age, location, and disability status.

Every organization should plan to address health inequities by designing and enabling the future of health care around people and equity. Health care incumbents, industry disruptors, community organizations, and government agencies each have a role to play in removing the barriers that lead to health inequities and turning unaffordable costs into opportunities. This should include: intentionality in design, rebuilding trust, partnerships, measurement, and addressing individual and community level inequities.

Addressing health inequities can help business leaders, boards of directors, and companies improve health outcomes and reduce health care spending by addressing the drivers of health (DOH), removing biases and inefficiencies in care, and enabling data and technology to help monitor, diagnose, and deliver care. In turn, this approach can have a positive impact on health outcomes, patient experience, quality of life, and the greater health and well-being of all individuals.

Health inequities stand in the way of affordability, health, and well-being

The health care sector is under pressure to reduce health care spending while increasing quality of care. Persistent health inequities have a substantial impact on health outcomes and spending. However, the industry hasn’t found a way to address them within this context. Quantifiable differences in health-related outcomes have been documented across many dimensions, including race, gender, age, location, disability status, and sexual orientation. Health inequities can be seen across a wide range of conditions including, hypertension, asthma, diabetes, cancer, mental health, and heart disease. Some communities have lower life expectancies and higher instances of certain diseases simply due to their zip codes. For instance, public health researchers recently drew attention to two neighborhoods in Kansas City—Blue Hills and Armour Hills. In Blue Hills, people die an average of 14 years earlier due to social, economic, and environmental disparities compared to people living in Armour Hills.1

In addition to the negative impact on outcomes and spending within the health system, health disparities can have broader consequences for the economy and quality of life. Health disparities account for roughly $42 billion in lost productivity per year, not including additional economic losses due to premature deaths.2 Health disparities also can have devastating consequences on the quality and value of life for the people, families, and communities most impacted.

“The underlying problem of health care spending is health inequity.” – Pierre Theodore, MD, vice president health disparities, Johnson & Johnson Global Public Health

With more attention on the US health system’s inequities, communities, company executives and board members, regulators, investors, employees, and the general public likely will continue pushing the industry to address health equity. Darrell Gray II, MD, chief health equity officer at Elevance Health, noted that there is “a lot more dialogue on health equity in the industry today. [Which stakeholders] will collaborate to make a meaningful impact towards achieving health equity is a key question. Collaboration and community engagement are instrumental to our ‘Health equity by design’ approach at Elevance Health.”

Achieving health equity could have greater implications beyond improving care for historically underserved groups: Inequities impact everyone, privileged and underprivileged alike. In fact, as Pierre Theodore, MD, vice president health disparities, Johnson & Johnson Global Public Health, explained, “When you address inequities for one population, you raise health for all populations.” In addition to the societal benefits of addressing health disparities, prioritizing health equity could help stakeholders achieve their goals by reducing unnecessary health care spending while improving health outcomes and patient experience. Also, the benefits of addressing health inequities extend beyond reducing unnecessary spending. Making health equitable could extend life expectancies, improve the quality of life, and enable the ability to thrive as individuals, communities, and society. “We are focusing on cost savings. But what's also valuable is the quality of life that you gain,” said Anupam Jena, MD, PhD, professor of health care policy at Harvard University.

With trust, scientific discovery and technology could enable equitable care

In Deloitte’s vision for an equitable Future of Health, health care will transition from treatment of illnesses to promotion of health and well-being while addressing the root causes of health inequities. Science and technology advances are bedrocks of this vision—and so is trust.

As scientific breakthroughs continue to occur at a rapid pace, inequities in the creation of and access to these advances likely have led to distrust and inequities in health care. For instance, since COVID-19 emerged, vaccine research and development efforts have accelerated significantly, and investments have soared. The effectiveness of the COVID-19 vaccines now in use—combined with the rapid speed in which they were developed—changed the nature of vaccines. However, vaccine inequity and distrust, remains a challenge. According to the World Health Organization, vaccine inequity is the “biggest obstacle” to ending the pandemic, and an accelerant to newer variants.3 Similarly, cell and gene editing technologies such as CAR-T and CRISPR are showing tremendous potential in treating, preventing, or potentially curing rare and previously untreatable diseases such as cancer, spinal muscular atrophy, and retinal dystrophy. However, insurance disparities for many vulnerable populations mean such breakthroughs may remain cost prohibitive for many.

To achieve the full potential of our vision for the future of health, it is imperative for stakeholders, including regulators, to acknowledge that these science and technology advances may be exacerbating health inequities and to work on addressing them. Our previous research studies have shown that levers such as intentionality of science and technology design, enhanced clinical trial diversity, and greater transparency about safety, efficacy, and costs, can go a long way in rebuilding trust with communities and reducing health disparities.4

Methodology: Measuring the potential cost of health inequity today and in 2040

Unnecessary health care spending due to structural inequities and biases is well documented. Research has shown that health care spending tends to be higher among certain populations due to delayed care, access challenges, missed diagnoses, and limited access to the latest scientific advances as well as proper preventive services.5 A 2011 study, “Estimating the economic burden of racial health inequalities in the United States,” calculated both the direct and indirect costs of racial and ethnic disparities in health care.6 This study has been a foundation for the industry and was useful in quantifying the link between health care spending and health inequities in our modeling.

What are the health care costs of health inequity today and how might those costs grow if they aren’t addressed? Deloitte’s health actuaries projected the trajectory of unnecessary health care spending among populations that typically experience socioeconomic, racial, and sex/gender inequities. While there are many other types of inequities, such as age and ability, this analysis focused on those that are most frequently interconnected and documented. The model also factored in populations that might face multiple biases. 

Deloitte’s model looked at several high-cost diseases such as breast cancer, diabetes, colorectal cancer, asthma, and cardiovascular disease. For these diseases, our actuaries determined the proportion of spending that could be attributed to health inequities. For instance, Black adults are 60% more likely than white adults to be diagnosed with diabetes and two to three times more likely to have complications, according to research.7 Racial inequity often contributes to a late diagnosis and comorbidities. Our analysis determined that 4.8% of spending on diabetes is associated with health care disparities, which results in $15 billion in unnecessary spending. Similarly, health care spending on asthma is about $56 billion a year.8 About 4.3% of those costs are related to income disparities, which can result in late diagnoses and challenges in accessing appropriate care and medications (figure 3).

This bottom-up approach was used to estimate the percentage of spending due to inequities for various disease states. Aggregated and projected for our analysis, the cost of health inequities today is approximately $320 billion and could top $1 trillion by 2040. (Refer to the “Appendix” for the detailed methodology).

External perspective on our analysis

We conducted small group discussions and individual interviews with several external subject matter experts to review our analysis and gain broader perspective. We consulted leaders in health equity, health economics, academia, and health care and life sciences organizations. The experts agreed that other approaches to estimating costs exist, including focusing on diseases with the greatest health inequities such as maternal health or looking at diseases that exacerbate comorbidities such as obesity. They also acknowledged that modeling can be complicated due to the complex nature of disparities and the interconnectivity of some diseases. These cost estimates may not accurately account for longer term inequities due to public health emergencies, climate-related disasters, or geopolitical situations. For instance, in 2005, Hurricane Katrina offset progress previously made in many New Orleans communities and laid bare the long-term costs of health disparities in the area, which is difficult to predict.9 Similarly, the COVID-19 pandemic resulted in lower life expectancy for Black and Latinx people.10 In general, all agreed that it was important work (see “Appendix” for more information).

What this analysis is not:

Even though achieving health equity and closing health care disparities also can lead to longer life spans and improved quality of life, we didn’t quantify that in our analysis. We acknowledge that longer life spans could result in additional health care costs over the lifetime of an individual. However, our focus for this exercise was direct medical expenditure costs that could be saved due to more equitable care.

We recognize many diseases may be comorbid, and that some diseases, like obesity, may form a base for multiple diseases. Based on the data, it was difficult to isolate and analyze how actions to address one disease may impact other individual diseases. We have tried to be conservative in our estimates within diseases to account for this.

We recognize that it may be difficult to quantify the health care disparities for certain disease areas. For instance, disparities in mental health treatment likely are a large driver of unnecessary health care spending. The complexities within mental health treatment make it a difficult condition to quantify the inequity impact specifically. However, we have attempted to demonstrate the unnecessary costs in this area by analyzing a segment of the population (see sidebar, “The cost of inequities in mental health,” for more information).

The purpose of this analysis is not to prioritize which diseases need to be addressed more urgently. Our analysis is an attempt to highlight the financial burden due to health inequities today and how that could potentially impact the future.

The cost of inequities in mental health

Mental health as a disease area is prone to racial, ethnic, and socioeconomic disparities that are compounded by other issues such as cultural stigma, lack of affordable therapies, and lack of awareness.11 In addition, there is a strong link between mental health and physical health, likely aggravating the disparities.12 These disparities can drive unnecessary health care spending. For our exercise, the scope, data, and validity challenges that accompany mental health as a condition (e.g., the definition of mental health, the belief that it is undertreated today, and the need to understand all the other conditions and diseases that are impacted by mental health) made it difficult to accurately quantify the unnecessary spending due to inequities.

To study the impact of mental health biases on health care spending, one can look at a specific subset of the population impacted by mental health: people who experience homelessness. In 2020, drug overdose deaths were the top cause of death among this group in urban areas.13 People who experience homelessness have an average life expectancy of around 50 years, almost 20 years lower than the housed population.14 People who belong to race or gender minority groups are more likely to experience homelessness than white people, demonstrating multiple forms of disparities.15

People experiencing homelessness with mental health issues (including substance abuse) frequently end up using the emergency department (ED) due to a lack of access to other sites, such as urgent care or outpatient physician clinics. In addition, those who visit the ED for mental health conditions have almost a one in three chance of returning to the ED within 30 days.16 The expense of repeated ED visits is well-documented. In fact, the average ED visit by an uninsured patient costs ten times more than a regular office visit.17 Addressing housing needs can help save significant spending from unnecessary visits in inappropriate sites of care.

The path to a truly equitable health care system

If left unaddressed, health inequities and the additional $1 trillion in overall spending can have profound implications for people, organizations, and the world. Health care costs likely will rise to an unsustainable level, resulting in unaffordable bills and declining health and productivity for the population. Health care stakeholders should consider acting now to mitigate these future consequences because we can’t afford to allow health inequities to go unaddressed (see sidebar, “A lot is at stake, but who are the stakeholders?” for more information).

A lot is at stake, but who are the stakeholders?

Industry incumbents including, health systems, health plans, intermediaries, and biopharma and medtech companies, likely will have a central role to play in achieving greater health equity by looking inward (greater diversity, equity and inclusion among employees, boards, and executive leadership) as well as outward (designing products, services, and research more inclusively, and creating community partnerships and ecosystems).

Federal, state, and local government agencies as a political, social, and regulatory authority is both an enabler and a beneficiary of an equitable health care system. Government is currently the primary funder of health and social services, which support well-being and address the DOH. Proactive policies incentivizing and supporting health equity can help ensure the health care system reaches an equitable future.

Community organizations are trusted members of their communities and have extensive experience addressing the needs of their communities, including the DOH. Without collaborations between these organizations, incumbents, and other stakeholders, we likely will continue to face hurdles on the path to a more equitable future of health.

New entrants including, health tech startups, big tech, and retail organizations, are redefining the fundamental notion of “health care” by focusing on well-being and delivering a convenient, digital, data-enabled, affordable, and differentiated experience. They should balance innovation with gaining consumer trust by intentionally addressing and not exacerbating inequities.

What will it take to eliminate health disparities and achieve a better future of health? As companies are developing products and services, investing in their communities, partnering with others, and improving the diversity, equity, and inclusion of their workforce, they should consider designing for equitable health. This can help ensure the health and well-being of all individuals and provide access to affordable, high-quality care in all communities. Here are five underlying mechanisms that should be considered:

1. Be intentional: Stakeholders across the health care ecosystem should approach health care’s future with intentionality and engage in continuous thinking on health equity. Infusing equity-centered thinking into business choices now is something that should be prioritized to build wellness-focused, outcomes-driven prevention and delivery systems that seek to serve everyone, regardless of race, ethnicity, and socio-economic status. As Pierre Theodore, MD, vice president health disparities, Johnson & Johnson Global Public Health, told us, “Interventions to offset disparities cannot be imposed on a population. Interventions should instead be designed collaboratively in direct consultation with representatives of the population experiencing health inequity.”

Questions for stakeholders to consider:

  • Can we create new products and services, or enhance existing ones, to improve the ability to detect diseases early or prevent them altogether?
  • Are the services and products we offer affordable and accessible to everyone? Have we built support systems to improve access to those products and services? Are they being targeted to all populations that would likely benefit?
  • Are people of all races, genders, and ethnicities and other characteristics being used to test our new products or services?

2. Form cross-sector partnerships: The current set of health care stakeholders can’t solve for this on their own because the magnitude and complexity of the problem is too significant. In fact, as David Meltzer, professor, and director of The Center for Health and The Social Sciences, University of Chicago, explained, “Health care as only a piece of a much bigger problem is important in thinking about what this transformation looks like.” To truly enable health equity, organizations should form partnerships across the industry. It likely will require current actors, new actors, and the government to collectively make a change. Health care organizations should collaborate with agencies, organizations, and coalitions that work on initiatives to address the root causes of health inequities. As Samantha Artiga, director, racial equity and health policy program, Kaiser Family Foundation, recommended, “You need to look outside of health care for the mechanisms. Understanding the drivers outside of health care and working with the partners and sectors outside health care, will be key.”

Questions for stakeholders to consider:

  • What are my organization’s core capabilities? What new capabilities can be gained (and which existing capabilities can be enhanced) by developing relationships with other organizations?
  • How can my organization create relationships with other stakeholders (peers, regulators, community organizations, etc.) to achieve health equity goals?
  • Which organizations hold strong stakeholder relationships and can serve as a credible voice in the community?

3. Measure progress: Accessible, platform-agnostic, and inclusive data and technology infrastructure paired with representative data collection, key performance indicators, and ongoing evaluation likely will be necessary to define and track progress in tackling health equity. Adaeze Enekwechi, PhD, operating partner, health care, Welsh, Carson, Anderson & Stowe, noted that, “Currently we have care gaps for underserved populations, and yet health care data is in pockets across the system. This creates significant data and information challenges. This is important to call out (on what we need to address) for equitable outcomes.”

Questions for stakeholders to consider:

  • What data does my organization require to understand the disparities of the population we serve? Do we have access to that data?
  • Is the data we use to make decisions representative of the population?
  • Does the data we’re collecting consider race and social demographics?
  • What does my organization measure progress against? What are my organization’s goals—beyond traditional financial and health outcomes?

4. Address individual and community-level barriers: Up to 80% of health outcomes are affected by social, economic, and environmental factors. These DOH (also known as social determinants of health) include physical environment, food, infrastructure, economy, wealth, employment, education, social connections, and safety.18 There is extensive evidence that these nonmedical factors can have a negative impact on health. Moreover, barriers, such as health and digital literacy and care infrastructure, can hinder access to care. Addressing the DOH, removing barriers to access, and creating healthy environments will likely require investments in data, technology, and public health infrastructure at the federal, state, and local level. To advance health equity, “payers and providers have a significant role to play. But we can’t do this alone. There is a dire need for cross-industry collaboration and community engagement, optimization of the public health infrastructure, and investment in data and technology interoperability and standards,” said Darrell Gray II, MD, chief health equity officer, Elevance Health.

Questions for stakeholders to consider:

  • Do we understand the unique needs of the communities and people we serve?
  • How do consumers learn about our products or services? What is the most effective way to reach members of the community?
  • How can we address nonmedical drivers of health to improve health and wellness within the communities we serve?

5. Build trust: Trust across the system, from individual practitioners to institutions and in data and technology, is crucial. It will be important to rebuild trust with people and communities intentionally by understanding needs, improving experiences, and building a more diverse and inclusive workforce. As Lovisa Gustafsson, vice president for controlling health care costs, The Commonwealth Fund, shared, “How do you build trust when there have been centuries of mistrust, for good reason. Trying to find a way to make everyone move in the same direction through trust (will be an important mechanism).”

Questions for stakeholders to consider:

  • Do we understand the perspective of the communities and people we serve?
  • Are we creating a feedback loop that allows everyone to be heard and instituting processes to act upon that feedback?
  • Does our internal workforce reflect the populations we serve or intend to serve?

There’s no question that we all can play a role in achieving greater health equity. After all, it’s a societal issue that could improve quality of life and help individuals and communities thrive. Addressing health equity not only can help improve health outcomes for the groups most impacted by health care disparities but can help ensure better well-being and care for all people. It can also position organizations to reduce health care spending, improve quality and outcomes, and enable health and wellness. As we move toward the future of health that we envision, stakeholders face a choice between embracing the opportunity to design equitable health for all or letting history dictate the future. We should make the choice now while it’s still ours to make.

Appendix: Research methodology

We undertook a multipronged research approach to quantify and vet the costs of health inequities. The key stages included:

Defining the scope

At Deloitte, we believe health inequities can be the result of multiple biases. Based on a literature review and the input of credible sources to make meaningful assumptions, our research focuses on three significant forms of biases: socioeconomic (including class), racial (including culture and language), and gender. Our analysis didn’t study biases related to age, ability, and sexuality due to paucity of data and credible sources.

Conducting the analysis

To arrive at the costs of health inequities—both today and in 2040—we took a three-step approach:

Vetting the analysis with external experts

We conducted multiple small group discussions and individual interviews to review our analysis with external subject matter experts. We consulted with a group of seven academics, economists, health equity experts, and executives from health care and life sciences organizations. The panelists and interviewees reacted to the analysis estimates and added their perspectives on how we can achieve greater health equity. The experts include:

Samantha Artiga, director, racial equity and health policy program, Kaiser Family Foundation

Adaeze Enekwechi, PhD, MPP, operating partner, healthcare, Welsh, Carson, Anderson & Stowe

Darrell M. Gray, II, MD, MPH, FACG, chief health equity officer, Elevance Health.

Lovisa Gustafsson, vice president, controlling health care costs, The Commonwealth Fund

Anupam B. Jena, MD, PhD, Ruth L. Newhouse professor of health care policy, department of health care policy, Harvard Medical School

David Meltzer, MD, PhD, director, The Center for Health and The Social Sciences, University of Chicago

Pierre R. Theodore, MD, vice president health disparities, Johnson & Johnson Global Public Health

The executives’ participation in this article are solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the companies mentioned, nor does Deloitte advocate or endorse the services or products provided by these companies.

This publication contains general information and predictions only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional adviser. Deloitte shall not be responsible for any loss sustained by any person who relies on this publication. 

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Yale Yoon supported the development of the concept, storyline, and implications.

Deloitte’s health actuarial team—Brian Rush, Yale Yoon, Maria Fendrich, Steph Falk, Stefani Klapperich, Sulekha Mandal, Radhika Gupta, Sam Kraus, and Sarah Gorzek—conducted the literature review, analysis, and modeling.

Peggah Khorrami and Maulesh Shukla assisted in interpreting the data, conducting the external expert sessions, and writing sections of the report.

The authors would like to thank Asif DharElizabeth Baca, Nicole Kelm, Matt Piltch, and Megan Woody for their expertise and help in shaping this research.

The authors would also like to thank Laura DeSimio, Rebecca Knutsen, Zion Bereket, and the many others who contributed to the success of this project.

This study would not have been possible without our research participants who graciously agreed to participate in the interviews. They were generous with their time and insights.

Cover image by: Natalie Pfaff and Kevin Weier

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The Deloitte Health Equity Institute, under the guidance of leaders Jay Bhatt and Kulleni Gebreyes, conducts original research and disseminates findings to help drive data-based equitable outcomes, as well as activate interventions that address systemic inequities.

Andy Davis

Andy Davis

Principal

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