This summer, the Blue Cross Blue Shield (BCBS) of Massachusetts Foundation produced a report about the impact of health reform in Massachusetts since its implementation in 2006. One of the findings was boldly announced in the headline of Bureau of National Affairs article, Massachusetts Health Law Has Erased Racial Disparity in Coverage, Report Says. This is relevant for the rest of us because federal health care reform hopes to expand health coverage based in large part on the Massachusetts model of requiring everyone to purchase insurance through a centralized insurance exchange. We also know that lack of insurance coverage is a barrier to health care access and contributes to worse health outcomes for many racial minorities, which is why universal coverage has been an important goal for many civil rights and health advocates.
While celebrating this good news, however, we should not overlook the bad: despite equality in coverage in Massachusetts, racial and ethnic disparities in access persist. This is not a new or shocking finding - countless studies have documented disparities in access and health outcomes in the U.S., even after controlling for insurance coverage. Here are just a few recent examples:
- The BCBS study in Massachusetts found that "[post-reform] disparities in access to and use of care persisted. For example...racial/ethnic minority adults continued to report more emergency department visits for non-emergency conditions and lower quality of care."
- In October 2009, the UCLA Center for Health Policy Research reported that African-American HMO enrollees in California were more likely to delay obtaining needed medications and use the emergency room than other racial/ethnic groups in comparable HMO plans, even for those with a usual source of care. Latinos were less likely to have seen a doctor or have a usual source of care when compared to African Americans with the same insurance status and delivery type. African-American members reported having a worse health status than whites, but better or similar health status compared to Latinos, Asian or Pacific Islanders, or other ethnicities.
- In 2008, the NY Times reported on a study of Medicare claims by researchers at Dartmouth who found evidence of racial disparities in treatment. For example, black Medicare patients with diabetes or vascular disease were nearly five times more likely than whites to have a leg amputated, and less likely than whites to receive annual hemoglobin testing. The study also highlighted the disparities based on geographic region: while disparities between whites and African-Americans existed across regions, it was clear that in some regions, whites and African-Americans were receiving less care and having worse outcomes.
- Pain management is another area where racial and ethnic disparities are pervasive. Undertreatment of pain is a serious problem, and minorities are at greater risk for undertreament. A number of studies show that minorities are more likely to receive no prescription pain medication or receive less analgesia than whites, despite similar pain complaints and insurance status. These pain treatment disparities exist in many clinical settings, including the emergency department, acute postoperative care, HIV/AIDS treatment, cancer treatment, nursing homes, and chronic pain settings. (Studies are on file with author)
These findings simply highlight what health and civil rights advocates have been saying for years - insurance coverage is necessary but not sufficient to eliminate health care disparities for racial and ethnic minorities. While it is difficult to know the specific cause of disparities in every case, the studies point to a number of important factors besides insurance coverage that must be addressed if we are serious about eliminating disparities.
One problem is the lack of available medical providers in many communtiies, an acute problem for people in particular geographic regions, rural areas, and poor urban areas. This lack of providers can be due to difficulty in recruiting providers, inadequate funding and health care resources to support medical providers, the failure of state and local health agencies to monitor and ensure an adequate distribution of hospitals and other medical facilities, or some combination of the above. As the NY Times article correctly noted, the local character of health care delivery means that access and quality are often determined by local medical practice and resources; however, national standards for quality do exist, and state and local governments that benefit signficantly from federal funding must comply with federal requirements ensuring equal access and prohibiting racial discrimination in the allocation of health care resources.
Another factor identified is the conscious or subconscious bias by providers about certain patients' medical needs or trustworthiness. This is particularly important in cases where self-diagnosis and reporting is critical to proper treatment, such as in pain management. Trust and communication are critical elements in the physician-patient relationship; both are necessary to ensure that patients can access the care they need, and will follow through on physicians' advice. In the face of constant evidence of treatment disparities that cannot be explained by income, insurance, or even severity of medical condition, physicians have an ethical and legal obligation to examine their own assumptions and practices to determine if they are contributing to these disparities in some way; that is, they should become more sensitive to and conscious about the way racial and ethnic difference may be impacting treatment.
Finally, in some cases, it is the patient's own behavior that leads to these disparities. For example, despite insurance coverage and having a primary care physician (a usual source of care), some racial and ethnic minorities do not seek out care early, do not follow the medical regimen recommended by their physician, and still end up in the emergency room more than white patients. Lack of resources may be the problem, especially if insurance does not fully cover a patient's visits or other medical regimen, like expensive medication. Lack of trust is certainly another problem, particularly for many older minorities who remember the Tuskee Syphilis Study, a harmful and unethical medical experiment on black men that was carried out from 1932-1972 by physicians with the help of the federal and local governments.
But, increasingly, attention is being paid to the problem of health literacy - the ability of patients to obtain and understand basic health information and services necessary to help them make appropriate health decisions. This includes things that many of us take for granted: the ability to read and comprehend prescription bottles, the ability to understand written and oral health information given by medical professionals, and the ability to navigate the health system and make appointments. Studies show that poor health status is disproportionately high among patients with low functional health literacy; and older people, minorities, immigrants, and those with low incomes are dipsporportionately more likely to have low health literacy.
Disparities can only be eliminated with a multifaceted approach that attacks each of these problems by: (1) strengthening private enforcement of civil rights laws; (2) requiring data collection and a more robust oversight process for monitoring the distribution of health care resources, and (3) directing federal resources to health care providers and minority communities for education that enhances awareness, trust, communication, and health literacy.
For more information on health care disparities, the Kaiser Family Foundation provides regular analysis and updates about disparities along racial, ethnic, gender, and economic lines.
