Health care: No level playing field

A study by the National Academies’ Institute of Medicine shows racial and ethnic minorities tend to receive lower-quality health care than whites do, even when insurance status, income, age and severity of conditions are comparable. The committee that wrote the report also emphasized that differences in treating heart disease, cancer and HIV infection contribute to higher death rates for minorities.

The study was done at the request of Congress, which asked the Institute of Medicine to assess the extent of racial and ethnic differences in the quality of health care received by patients that were not attributable to known factors such as access to care, ability to pay or insurance coverage.

At a press conference announcing the report, Dr. Alan Nelson said, “As the committee dug deeper into its work, it became clear that there are many complex sources of racial and ethnic disparities in health care that exist even when insurance status, income, age and severity of conditions are comparable. And because death rates from cancer, heart disease and diabetes are significantly higher in racial and ethnic minorities than in whites, these disparities are unacceptable.”

Dr. Lucille C. Perez, president of the National Medical Association (NMA), which represents African-American doctors, welcomed the report. “It validates what the NMA has been saying for so long - that racism is a major culprit in the mix of health disparities and has had a devastating impact on African Americans.”

“The differences are pervasive,” Martha N. Hill, of Johns Hopkins University School of Nursing, “It cuts across all conditions of health and across the entire country, and we think this is a very serious moral issue.”

“Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases,” Nelson, a retired physician and former president of the American Medical Association who chaired the committee, said in his statement. “The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming.”

Using language typical of that used in such reports, the committee said unequal treatment “occurs in the context of persistent discrimination in many sectors of American life,” and that there is some evidence “suggesting” that bias, prejudice and stereotyping on the part of health care providers “may contribute” to differences in care.

The committee pointed to studies showing that minorities are less likely to be given appropriate cardiac medications or to undergo bypass surgery and are less likely to receive kidney dialysis or transplants. Nelson said several studies show significant racial differences in who receives appropriate cancer diagnostic tests and treatments.

“By contrast,” he said, “minorities are more likely to receive certain less-desirable procedures, such as lower limb amputations for diabetes and other conditions.” He pointed to a study of major medical centers in New York State that found African Americans were 37 percent less likely to undergo angioplasty and other heart procedures than whites and were 3.6 times as likely to have their lower limbs amputated as a result of diabetes. In 90 percent of the cases where the patient did not get the surgery, the doctor had not recommended it.

Minorities are more likely to be enrolled in more affordable but “lower-end” health plans, a situation the report said, that is a potential source of disparities in treatment. “Insurance companies’ caps on the coverage of treatment costs can pose greater barriers to minority patients since they are less likely to be able to afford high co-payments or deductibles,” the report adds.

The committee made several recommendations aimed at eliminating the disparities, among them a call for more minority health care providers who, the report said, “are more likely to serve in minority and medically underserved communities.” The committee added that public programs such as Medicaid should “strive to help beneficiaries access the same level of care as privately insured patients” and that “if Congress passes a ‘Patients’ Bill of Rights’ to protect enrollees in private HMO plans, it should accord the same protections to people in publicly funded HMO plans.”

David R. Williams, a professor of sociology at the University of Michigan called the report “a wake-up call” for doctors and patients. “We have a health system that is the pride of the world,” Williams said. “But this report demonstrates that the playing field clearly is not level.”

Dr. Quentin Young, a leader in Physicians for a National Health Plan, welcomed the report. “Racial disparity in the provision of health care is a terrible reality,” he told the World. “important as it is, the report makes clear that merely having insurance is not the complete answer.” Young said a national health care system modeled after that in Canada “would go far” in equalizing health access to all forms of health care.