III. General Quality Concerns and Why A Color-Blind Approach Won't Work
The problem of disparity in health care treatments and outcomes experienced by racial and ethnic minorities exists within a health care regime in the United States where overall quality of care is a basic concern because quality is not what it should be given the amount spent and the level of technological sophistication attainable. In a 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) documented how nearly 100,000 people died each year in the United States from medical errors. The IOM's 2001 report on Crossing the Quality Chasm addressed broader systemic issues of quality. This more recent report defined six goals for quality of care and prescribed ten rules of health care delivery redesign to meet the quality goals. One of the six measures of quality is that health care should be equitable--that care should not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. The IOM has recommended several approaches for changing the environment in which health care is delivered so that health care professionals and organizations function more effectively. Among the broad environmental changes the IOM recommends is aligning payment policies with quality improvement so that clinicians are compensated for taking good care of all patients regardless of health status or demographic factors.
The IOM studies have confirmed other assessments of the quality of the United States health system. In 2000, the World Health Organization issued a report analyzing data on the health systems of 191 member countries. The study revealed that the United States has the most expensive health care system in the world based both on expenditures per capita and total expenditures as a percentage of gross domestic product. This study ranked the United States 15th for overall attainment and 37th for performance. On several health indicators, the United States ranks relatively low. For example, in 1996, the United States ranked 26th among industrialized countries for infant mortality rates, a figure that masks significant disparities among racial groups.
Efforts to address overall quality will not necessarily reduce disparities, and could exacerbate disparities. In a recent article, Kenneth Keppel, Linda Bilheimer, and Leda Gurley observed that societal goals of improving quality of care and increasing years of healthy life, and eliminating disparities among populations groups, may not be consistent. This study concluded that “improvement in the health of the total population without any reduction in relative disparities among racial and ethnic groups” was the result of a nationwide health promotion and disease prevention agenda developed by the U.S. Department of Health and Human Services.
One frequently proposed solution to the problem of health care disparities is to mandate universal access to insurance. The assumption of such proposals is that equalized benefits will help equalize the use and benefit of health services. For example, the Medicare program has eliminated this disparity in insurance for the Medicare population--largely the over age 65 adult population. Despite equal eligibility for Medicare regardless of race, ethnicity, or class, racial and ethnic disparities persist in health care usage and outcomes among Medicare beneficiaries. A study of the use of mental health services and pharmaceuticals found that nonwhites and low-income people obtained fewer benefits than whites and high-income people. The impact of copayments, the role of primary care physicians acting as gatekeepers for access to mental health services and pharmaceuticals, and patient attitudes toward the use of prescription drugs and mental health services as compared to alternative remedies and community and social support networks were variables not examined in the study. Another recently published study found that racial and ethnic subgroups are not homogenous in their views of, and experiences with, health care services. Differences among African-American and Asian-American subgroups led the study's authors to conclude that it was important to examine ethnic subgroups separately rather than as one single racial or ethnicity category. One premise of the IOM report, Unequal Treatment, is that targeted measures are necessary to overcome disparities in treatment and outcomes. The NASI study acknowledges that “Targeted efforts will likely be necessary to overcome the special barriers to improving the quality of care for minority [Medicare] beneficiaries.” The NASI study also notes that incentives for providers may widen the quality and income gap by penalizing providers who treat large numbers of disadvantaged minorities. Similarly, the use of public reporting and disclosure on quality and disparities measures could widen disparities because minorities may have less access to public reports and less ability to switch providers.
Against this range of experiences and this panoply of recommendations, in April 2006, the Commonwealth of Massachusetts enacted a statute mandating individual health insurance coverage and setting the goal of reducing racial and ethnic barriers in health care through use of several reporting mechanisms and financial incentives. The next part of this article will describe the relevant provisions of the statute.
