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Perspectives From Congress

Overcoming Disparities In U.S. Health Care

Abstract

 
Disparities in U.S. health care result from a complex mixture of systemic quality and access problems intertwined with historic injury. The many dimensions of health disparities include race, ethnicity, socioeconomic status, and geography. It is critically important for policymakers to define the problem correctly so that our solutions address their intended goal—health security for all regardless of socioeconomic characteristics. Further, U.S. efforts to eliminate disparities must also be part of a broader effort to transform health care and thus must focus, first and foremost, on improving the quality of care delivered to the individual patient.

Fourscore and seven years ago our fathers brought forth upon this continent a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.... It is for us, the living...to be dedicated here to the unfinished work that they have thus far so nobly carried on. —Abraham Lincoln, 1863

Nearly 150 years after Abraham Lincoln delivered the Gettysburg Address, we still have much unfinished work to do. I fervently believe that the medical profession is a principled one and that medicine is rooted more deeply than perhaps any other profession in the ideals of equality. That is why I, and many other medical professionals, find the disparities in U.S. health care unacceptable. They are an affront to the U.S. promise of equal opportunity for all.

Disparities in care actually are subsets or symptoms of our overall health care quality chasms and challenges.¹ In fact, they are essentially warnings from the most vulnerable of our more widespread challenges. For instance, recent evidence suggests that even in the best of circumstances, all Americans receive only about 55 percent of the recommended medical care for most major illnesses.² But when researchers examine outcomes associated with race, ethnicity, socioeconomic status (SES), or geography, these systemwide quality problems are even worse.

Needed: A Broad View Of Health Disparities

Top Needed: A Broad View... Health Disparities Solutions: A... Specific Recommendations NOTES

 
The Minority Health and Health Disparities Research and Education Act of 2000 (P.L. 106–525) lists SES and geography alongside racial and ethnic minority status as factors that we must address to overcome health disparities. The federal government made this decision based on sound evidence, good policy, and a sense of fairness. If we do not identify the problem of health disparities accurately, our policy solutions are likely to miss their intended goal.

Race and ethnicity. The literature uncovers many examples of racial and ethnic disparities in health. The list is long and troubling. For instance, African Americans and American Indians/Alaska Natives have higher overall mortality rates than any other population group. These two groups have almost double the infant mortality rate for whites.³ The death rate from all cancers is 34 percent higher for blacks than for whites.⁴ There are eight times as many blacks as whites with AIDS, and blacks are nearly twice as likely as whites to die from diabetes.⁵ Also, Hispanics and American Indians/Alaska Natives are approximately twice as likely as whites are to have diabetes.⁶

Socioeconomic status. Statistics indicate that racial and ethnic minorities are generally poorer than whites and more likely to have family incomes below 200 percent of the federal poverty level. In 2002 more than half of African Americans, Hispanics, and American Indians/Alaska Natives were poor or near-poor.⁷ Researchers note that low SES is usually associated with poor access to care, riskier behavior, fewer community resources, and higher mortality.⁸ Racial and ethnic minorities are more likely to be uninsured as well. In 2002 more than 20 percent of African Americans and more than 30 percent of Hispanics were uninsured. Hispanics are the most likely of any racial and ethnic minority to be uninsured.⁹ Researchers also note that when they control for SES, the respective health disparities are usually greatly reduced but not eliminated.¹⁰

Geography. Even more fundamentally, the United States also has large geographic disparities.¹¹ For instance, one-third of African American and American Indian/Alaska Native populations living outside of metropolitan areas and one-quarter of Hispanic populations are poor, compared with 13 percent of whites living in nonmetropolitan areas.¹² Moreover, Dartmouth researchers recently observed that most health care is delivered locally, and, therefore, it is "critical" to include geography both when evaluating health disparities and when developing solutions.¹³

A number of studies reinforce the impact of geography: In a study regarding disparities in cardiac revascularization procedures, African Americans and Hispanics in three New York City neighborhoods had lower rates of revascularization. The substantial differences in revascularization rates were explained not by race or SES but instead by location. The major differences seemed to stem from the capabilities of the admitting community hospital rather than the characteristics of the individual patients.¹⁴

Further, researchers at Memorial Sloan-Kettering Cancer Center found that to a large extent the primary care physicians who care for whites are an entirely different set from those who care for blacks. The study questions whether, on average, physicians caring for blacks are trained as well as those caring for whites. It concludes that there is a lower rate of board certification in the group caring for blacks and that blacks as a group have more limited access to specialty care and other clinical resources.¹⁵

I believe that this broad view of health disparities allows us to include many more vulnerable Americans and provides a more complete picture of important care discrepancies. Further, it enables us to fashion better, more appropriate solutions.

Health Disparities Solutions: A Focus On Patient-Centered Care

Top Needed: A Broad View... Health Disparities Solutions: A... Specific Recommendations NOTES

 
In spite of evidence that some of the largest gaps in care and access are defined by SES, geography, lack of insurance, and lack of access to high-quality medical care, many argue that disparities are instead exclusively racial and ethnic.¹⁶ Some accuse providers of having ingrained preferences in medical decision making—preferences tainted by implicit racism. They also argue that health disparities are, fundamentally, civil rights matters.¹⁷

Equality has been a principle essential to the medical profession for thousands of years. We cannot and will not tolerate discrimination. However, lawsuits will not eliminate health disparities. Instead, we must improve the overall quality of care and also aggressively promote public health interventions aimed specifically at closing the gaps in quality of care. In this paradigm, the best way to eliminate health disparities is through improvements in the care we deliver to each patient, emphasizing patient dignity and empowerment.

Promote patient dignity and personal responsibility. Patients must be central to our efforts to improve health care. For instance, a person with a chronic illness such as diabetes must essentially "own" that illness if he or she is to have any hope of effectively managing it. Providers can help with high-quality treatment and the best recommendations, but patients must act on those recommendations. They must stop smoking, eat right, exercise, take their medication, and monitor their blood sugar, based on their own volition and usually outside of the clinical setting. Public policies must encourage patients to embrace personal responsibility.

Policies that promote dignity and personal responsibility will help decrease individuals’ risky behavior. The major causes of death among African Americans, for instance, are heart disease, cancer, stroke, accidents, and diabetes. Most of these are chronic diseases rather than acute illnesses, and all of these causes of death are at least arguably preventable. Further, the top three can be reduced by decreasing tobacco use alone.¹⁸ We must promote policies that help people address individual behavior, such as smoking.

Improve communication. Effective communication between health care providers and their patients also is essential for high-quality care. According to the National Adult Literacy Survey, almost ninety million U.S. adults have difficulty reading written text. Further, according to the research, patients with limited health literacy and chronic illness have less knowledge of disease management than those with higher literacy levels.¹⁹

Focus on cultural context. One’s community and cultural background affect perceptions of health. Therefore, providers must understand the communities they serve. One of my colleagues describes a community health center patient who was Latina. This woman had poorly controlled diabetes, but she adamantly and consistently declined insulin. When my colleague asked her what insulin "meant to her" and why she was so frightened of it, she confided that she had many family members with diabetes. Those she knew who used insulin eventually went on hemodialysis and died shortly after that. This patient equated insulin with hemodialysis and death. Only when the patient’s providers understood insulin from her perspective could they and she improve her care.

Specific Recommendations

Top Needed: A Broad View... Health Disparities Solutions: A... Specific Recommendations NOTES

 
In 2004 I introduced comprehensive bipartisan legislation intended to eliminate health disparities. The Closing the Health Care Gap Act of 2004 (S. 2091) builds on the Minority Health and Health Disparities Research Act of 2000.²⁰ It addresses disparities by focusing on five key areas: (1) improving the quality of health care; (2) expanding access to high-quality care; (3) strengthening national efforts and coordination; (4) helping increase the diversity of health professionals and promoting more aggressive health professional education intended to reduce barriers to care; and (5) improving research to identify sources of racial, ethnic, and geographic disparities and assess promising intervention strategies.

Improving quality. Disparities in U.S. health care are largely subsets of our overall quality problems. These result in less-than-optimum care for all and disproportionately worse care for many.²¹ Therefore, as embodied in the Closing the Health Care Gap Act, any policy solution for health disparities must start with improving the general quality of care.

Information technology. First, health information technology (HIT) is critical. Robust care information and access to it will help providers and patients creatively redesign clinical practice in ways that will improve quality and close these gaps. All providers, including safety-net providers, must have access to HIT. HIT will help physicians and nurses who are working closely with their patients to provide higher-quality care at lower cost.²²

Performance measurement. Second, we must be able to assess the clinical care we provide to improve the quality of that care. We do not measure performance uniformly; in fact, we do not even have rudimentary standardized "yardsticks."²³ Therefore, a fundamental step will be to develop appropriate measurement tools. Specifically, federal health programs should develop and implement a uniform set of performance measures so that patients, consumers, and providers can make informed, evidence-based decisions about health care.

Provider incentives. We also must give providers incentives to promote innovative clinical redesign, which will improve the overall quality of care and close the gaps. Government now pays for episodes of care, not quality and outcomes. Federal officials have started to rethink these payment strategies so that we pay for results rather than doctor visits and procedures. Congress has begun to encourage pay-for-performance efforts through legislation, most notably the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108–173). We also should consider paying for care that demonstrably closes quality gaps.

Patient self-management. Improving the quality of care also means that providers must recognize that patients largely manage their chronic illnesses themselves.²⁴ To improve the quality of care, patients need providers to help them get better at self-management.²⁵

Better data. Finally, we need better demographic data about the race, ethnicity, SES, and primary language of people receiving care.²⁶ The current data establish the care disparities, but the federal health programs and the private health market need much better information about these population groups to refine and target interventions. For instance, almost half of insurance enrollees are in health plans that do not collect these data.²⁷

Access to high-quality care. As part of an attack on health disparities, we need to address rising health care costs and lack of insurance. Rising costs increase the number of uninsured people and reduce access to high-quality care.²⁸ The best way to drive down overall costs while increasing value is to foster competitively driven innovation—as we do in the rest of our economy.²⁹ Lower overall health costs, in turn, can help the entire system by making care and coverage more affordable.

The idea is to link payment, effectively and efficiently, to outcomes that patients value, such as healing better and faster or closing care gaps. We should cultivate a health care system that encourages providers and patients, with properly aligned incentives, to work together to improve care. In such a marketplace, patients and providers would decide how to structure a productive clinical interaction—and productivity determined by doctors and patients is not likely to include pushing ever more chronically ill patients through ten-minute appointments in rushed, inefficient clinical settings.

Some have voiced concerns that health care is somehow different: that the therapeutic relationship between doctor and patient should not be subject to competitive forces.³⁰ Further, many argue that quality chasms and health disparities cannot be fixed by fostering competition.³¹ Certainly, competition does not provide all of the answers. We will need a strong safety net and vigorous attention to vulnerable populations. But all of our immediate health care system problems—rising costs, questionable quality, patient safety, rising numbers of uninsured people, and, yes, health disparities—are interrelated and can be improved by empowering patients and providers. We simply cannot afford to forgo the lower costs and increased quality and value that the right kind of competition will drive.

To foster this kind of competition and empower patients, we need to adopt (1) market reforms to make the cost of health care more sensitive to consumer demand; (2) a more stable and consumer-friendly insurance market; (3) a variety of more affordable, consumer-directed health care products such as health savings accounts (HSAs); and (4) broader risk spreading and more effective risk adjustment throughout the individual and small-employer markets.³²

Of course, these changes will not in and of themselves put insurance coverage in the hands of many Americans. Therefore, a variety of tools targeted at different groupings of the uninsured—from refundable tax credits to expanded public programs—are necessary. The Closing the Health Care Gap Act, for instance, provides refundable tax credits for low-income Americans, a solution that would help improve access to care for many who otherwise cannot afford health coverage.

We also need a sturdy safety net. Therefore, we must continue to strengthen this system, particularly our growing network of community health centers (CHCs). We should double the capacity of CHCs over the next ten years and target sufficient resources to maintain that network. As provided in the Closing the Health Care Gap Act, we should also promote specific interventions at the community level, using patient navigators, preventive services, and disease management strategies to bring high-quality, evidence-based care to large groups of patients. CHCs are perfectly situated to develop these interventions.

National leadership. As envisioned in the Closing the Health Care Gap Act, a reauthorized, reinvigorated, properly funded Office of Minority Health (OMH) at the Department of Health and Human Services (HHS) that targets health disparities, broadly defined, will be important. However, a single office is not enough. We must engage and leverage the entire federal health apparatus, including HHS, the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Agency for Healthcare Research and Quality (AHRQ), as well as the Departments of Veterans Affairs and Defense, to systematically address disparities whenever and wherever they may occur. Using the federal health apparatus in this way would bring health disparities to the top of the agenda of all the federal health agencies, so that all of these agencies, not just the OMH, would be charged to consider health disparities as they develop, implement, and manage programs.

The health professions. We also need health care providers who are trained to work with health disparity populations. Providers need to know the patients they are caring for; they need to understand, if not be a part of, these communities. We need evidence-based, model training in cultural understanding and competence. The Closing the Health Care Gap Act, for instance, promotes the development of model curricula in cultural fluency and competence. Our training programs should invest in high-quality, board-certified providers who will work in these communities, and we should provide the right incentives so that these highly trained providers will want to stay in these roles.

Certainly, increasing the number of minorities in the health professions will be a positive step. However, in this national effort, we need to be more focused on outcomes—which care systems and settings close gaps faster and provide the highest-quality care. From that framework, patient-provider race concordance may be extremely important, but the bottom line is the outcome, not the means of getting there.³³

Translating science into cures. It now takes approximately seventeen years for new evidence to be widely adopted by U.S. physicians. That is too long. We also need to ensure that our research evaluates potentially significant racial and ethnic clinical differences.³⁴ In addition, we should refocus our mountains of research at the NIH, the CDC, and AHRQ from the lab bench to the bedside, the clinic, and patients’ homes, where this knowledge will save lives. Finally, we should fund and promote translational research for quality improvement techniques as well as the HIT to help embed science into clinical decision making at the point of care.

Disparities in U.S. health care offend the founding American principle that we are all created equal. We fought a desperate Civil War that challenged and then reaffirmed that creed of equality.³⁵ Together we endured and forged 140 years of progress in racial equality, progress that has at times been agonizingly slow. Admittedly, there have been difficult hours when we have not been true to our creed. But in the last measure, ours has been a nation that has moved progressively toward, not away from, the fruits of these noble ideals for all. I am confident that our generation can meet the challenge posed by the "unfinished work" of health disparities. I am also confident that one day all Americans, regardless of skin color or social status, will have equal opportunity to prevent and overcome disease and live longer, happier, and healthier lives.

Editor's Notes

 
Bill Frist (dean_rosen{at}frist.senate.gov), a physician, is a Republican senator from Tennessee and majority leader of the United States Senate.

The author thanks the following people for their contributions to this paper: Michael Painter, a former fellow with Senator Frist’s office and now with the Robert Wood Johnson Foundation; and Dean Rosen, Senator Frist’s director of health policy.

NOTES

Top Needed: A Broad View... Health Disparities Solutions: A... Specific Recommendations NOTES

 

1. K. Fiscella et al., "Inequality in Quality: Addressing Sociocenomic, Racial, and Ethnic Disparities in Health Care," Journal of the American Medical Association 283, no. 19 (2000): 2579–2584.[Abstract/Free Full Text]
2. E.A. McGlynn et al., "The Quality of Health Care Delivered to Adults in the United States," New England Journal of Medicine 348, no. 26 (2003): 2635–2645.[Abstract/Free Full Text]
3. M. Lillie-Blanton, O. Rushing, and S. Ruiz, Key Facts: Race, Ethnicity, and Medical Care (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, June 2003), 9.
4. U.S. Department of Health and Human Services, "Progress Review: Cancer," Healthy People 2010, www.healthypeople.gov/data/2010prog/focus03 (22 December 2004).
5. DHHS, "Progress Review: HIV," Healthy People 2010, www.healthypeople.gov/data/2010prog/focus13 and "Progress Review: Diabetes," Healthy People 2010, www.healthypeople.gov/data/2010prog/focus13 (22 December 2004).
6. U.S. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, "Diabetes: Disabling, Deadly, and on the Rise," 2004, www.cdc.gov/nccdphp/aag/aag_ddt.htm (23 December 2004).
7. Lillie-Blanton et al., Key Facts, 5.
8. A.L. Stewart and A.M. Napoles-Springer, "Advancing Health Disparities Research: Can We Afford to Ignore Measurement Issues?" Medical Care 41, no. 11 (2003): 1209; and D.A. Cohen, T.A. Farley, and K. Mason, "Why Is Poverty Unhealthy? Social and Physical Mediators," Social Science and Medicine 57, no. 9 (2003): 1631–1641.
9. Lillie-Blanton et al., Key Facts, 12.
10. Stewart et al., "Advancing Health Disparities."
11. See, for example, K. Baicker et al., "Who You Are and Where You Live: How Race and Geography Affect the Treatment of Medicare Beneficiaries," Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.var.33 (23 December 2004).
12. J. Probst et al., Minorities in Rural America: An Overview of Population Characteristics, June 2002, rhr.sph.sc.edu/report/MinoritiesInRuralAmerica.pdf (23 December 2004).
13. A. Chandra et al., "Geography and Racial Health Disparities," NBER Working Paper no. W9513 (Cambridge: National Bureau of Economic Research, February 2003); and Baicker et al., "Who You Are and Where You Live."
14. J. Fang and M.H. Alderman, "Is Geography Destiny for Patients in New York with Myocardial Infarction?" American Journal of Medicine 115, no. 6 (2003): 452–453.
15. P. Bach et al., "Primary Care Physicians Who Treat Blacks and Whites," New England Journal of Medicine 351, no. 6 (2004): 575–584.[Abstract/Free Full Text]
16. B.D. Smedley, A.Y. Stith, and A.R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: National Academies Press, 2002); H.J. Geiger and G. Borchelt, "Racial and Ethnic Disparities in U.S. Health Care," Lancet 362, no. 9396 (2003): 1674[Medline]; J.J. Cohen, "Disparities in Health Care: An Overview," Academic Emergency Medicine 10, no. 11 (2003): 1155–1160[CrossRef][ISI][Medline]; Chandra et al., "Geography and Racial Health Disparities"; C.J. Hogue, "Toward a Systemic Approach to Understanding—and Ultimately Eliminating—African American Women’s Health Disparities," Women’s Health Issues 12, no. 5 (2002): 222–237[CrossRef]; and Sullivan Commission, Missing Persons: Minorities in the Health Professions, September 2004, www.sullivancommission.org (25 January 2005).
17. Smedley et al., eds., Unequal Treatment; Geiger and Borchelt, "Racial and Ethnic Disparities"; and Cohen, "Disparities in Health Care."
18. M.D. Wong et al., "Contribution of Major Diseases to Disparities in Mortality," New England Journal of Medicine 347, no. 20 (2002): 1590.
19. D. Kindig et al., eds., Health Literacy (Washington: National Academies Press, 2004).
20. In addition to S. 2091, I also introduced S. 2217. This second piece of legislation is identical to the first, except that it provides refundable tax credits to help lower-income people obtain more-affordable health insurance coverage. Expanding access to health insurance with measures such as refundable tax credits is an important strategy in our broader efforts to address health disparities.
21. Fiscella et al., "Inequality in Quality."
22. T.G. Thompson and D.J. Brailer, "The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care—Framework for Strategic Action" (Washington: DHHS, 2004).
23. G. Omenn et al., eds., Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (Washington: National Academies Press, 2003).
24. T. Bodenheimer et al., "Patient Self-Management of Chronic Disease in Primary Care," Journal of the American Medical Association 288, no. 19 (2002): 2469–2475[Abstract/Free Full Text]; and J.H. Hibbard, "Engaging Health Care Consumers to Improve the Quality of Care," MedicalCare 41, no. 1 Supp. (2003): I61–I70.
25. Bodenheimer et al., "Patient Self-Management."
26. Smedley et al., eds., Unequal Treatment.
27. America’s Health Insurance Plans/Robert Wood Johnson Foundation, "Collection and Use of Data on Race and Ethnicity," Highlights of a Quantitative Survey, 2004, www.ahip.net/content/default.aspx?docid=5859 (25 January 2005).
28. M. Chernew, D. Cutler, and P.S. Keenan, "Increasing Health Insurance Costs and the Decline in Insurance Coverage," Economic Research Initiative on the Uninsured Working Paper no. 8, April 2004, www.umich.edu/~eriu/pdf/wp8.pdf (25 January 2005); and J. Hadley, Sicker and Poorer: The Consequences of Being Uninsured (Washington: Kaiser Commission on Medicaid and the Uninsured, 2002, updated 2003).
29. M.E. Porter and E.O. Teisberg, "Redefining Competition in Health Care," Harvard Business Review 82, no. 6 (2004): 64–76.
30. D.A. Hyman et al., "Improving Health Care: A Dose of Competition" (Washington: FTC and DOJ, 2004); and G. Shearer, "Impact of ‘Consumer-Driven’ Health Care on Consumers," Testimony before the Joint Economic Committee, 25 February 2004.
31. Shearer, "Impact of ‘Consumer-Driven’ Health Care"; and R. Galvin, " ‘A Deficiency of Will and Ambition’: A Conversation with Donald Berwick," Health Affairs, 12 January 2005, content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.1 (25 January 2005).
32. For additional information, see U.S. Department of the Treasury, "Health Savings Accounts," www.ustreas.gov/offices/public-affairs/hsa (23 December 2004).
33. T.A. LaVeist, A. Nuru-Jeter, and K.E. Jones, "The Association of Doctor-Patient Race Concordance with Health Services Utilization," Journal of Public Health Policy 24, nos. 3–4 (2003): 312–323.[ISI][Medline]
34. G. Corbie-Smith et al., "Adequacy of Reporting Race/Ethnicity in Clinical Trials in Areas of Health Disparities," Journal of Clinical Epidemiology 56, no. 5 (2003): 416–420.[CrossRef][ISI][Medline]
35. G. Wills, Lincoln at Gettysburg: The Words That Remade America (New York: Simon and Schuster, 1993).

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