Racial Disparities in U.S. Health Care

Many have long suspected that black Americans face life-threatening inequalities in their health care. Now a raft of clinical studies is providing solid evidence that the suspicion is true.

A new study, published this week in the Journal of the American Medical Association, found blacks are significantly less likely than whites to benefit from health- and survival-enhancing interventions.

The study was based on data collected on four clinical services used to measure quality of care among people on Medicare in 1997 — the frequency of women's breast cancer screenings, eye exams for patients with diabetes, use of beta-blockers after a heart attack, and follow-up after hospitalization for mental illness.

Blacks were less likely that whites to receive all four services.

The new study is the latest of many that have found racial differences in everything from flu shots to kidney transplants. Additional research published this week in the journal Cancer, for instance, finds that black women with ovarian cancer have a 30 percent increased risk of death and are 40 percent less likely to have surgery than white women.

And further unsettling data from the Commonwealth Fund 2001 Health Care Quality Survey found that 15 percent of blacks feel they would receive better care if they were of a different race or ethnicity.

Reason for Inequality Is Less Clear

The root causes of these inequalities are less clear, admit experts, and there are likely to be many, such as poor access to good health care or insurance, a lack of understanding of the scope of inequality by physicians or the unwitting biases held by doctors treating minority patients.

"When you think about what could be contributing to these disparities, there could be a whole number of things from the patient perspective, the [physician's] perspective and the health-care plan's perspective," says Dr. Lisa Cooper, associate professor of medicine and health policy and management at Johns Hopkins University in Baltimore.

One example from the latest JAMA study, for example, was that the racial differences seen in breast cancer screening were found to be related to the services that individual health plans offered and not racial differences within plans.

"Our finding that the racial disparity exists [in breast cancer screening rates] seems to be related to which health plans enroll larger numbers of blacks as opposed to being racial disparities in all types of health plans," says Dr. Eric Schneider, lead author and associate physician in general internal medicine at Brigham and Women's Hospital in Boston.

In another example, research has shown that the patient-physician interaction is important and that many minority ethnic groups feel more comfortable interacting with physicians of their own race.

"What I have seen in my work is that ethnic minority patients generally rate the quality of interpersonal care by physicians as being poorer than white patients do," says Cooper. "They are generally less satisfied, particularly when seeing a physician who is not of their same race."

Yet health plans are not designed to take doctor-patient relationships into consideration when making providers available.

"It's difficult. I have black female patients who will ask 'Is there a black female therapist?'" says Dr. Rodney Hood, clinical teaching professor at University of California at San Diego Medical School and immediate past president of the National Medical Association, a national professional organization for black physicians. "Most times I have to say, 'Not on your plan.'"

Culturally Appropriate Intervention

While experts acknowledge there are many factors contributing to racial inequality in health care, facilitating communication between physicians and patients with culturally appropriate interventions could play an important role in addressing the problem.

"If you're talking about what we do about it, it's really not that complicated," says Hood. "We need to start culturally competent education for providers and health-care administrators. They need culturally appropriate education material directed at the vulnerable populations."

Hood feels community outreach utilizing black churches, for example, could help in reaching out to black patients on the importance of medical screening.

Additionally, experts say that health plans and government agencies need to take race and ethnicity into account when monitoring quality of care and to track inequalities so they can be identified and corrected.

"If nobody knows that there is a problem, or if people just have a sort of a general sense that there is a problem, that's really no way of improving," says Schneider.