I. Racial and Ethnic Health Care Disparities
Health care disparities are not new; throughout American history, law and social custom have relegated minority groups to different and inferior treatment. Health care is no exception. An important historical antecedent is the racially segregated medical care that arose during slavery. When emancipation ended the plantation system of segregated medical care, Jim Crow laws barred Blacks from the “white” health care system. Even less than 40 years ago, minorities routinely received inequitable care in segregated settings, if care was received at all. Today, some of these problems resulting from de facto discrimination have been ameliorated, but the contemporary health care context remains shaped by this history.
The maximization of health equity represents a central philosophical value. As a society, we profess a moral commitment to equality of opportunity. Through the principle of fair equality and opportunity, influential thinkers like Norman Daniels defend the role of medicine and public health to maintain or promote health because health “makes a significant contribution to protecting the range of opportunities open to all Because the principle of fair opportunity is to be applied to the entire population, Daniels argues that it justifies not only improving population health, but also reducing health inequalities while doing so.
A second moral foundation is offered by proponents of a “capabilities approach” that aims to specify constitutional principles that should be adopted by governments as a minimum standard to adequately respect human dignity. Because health is central to the freedom to choose other functioning in life, these theorists argue that it is essential that governments promote health for all of its citizens. Where disparities exist, they should be minimized to ensure that all have a minimum level of human functioning, a prerequisite for doing all things they are essential to communities--social, political and economic. Finally, from an antidiscrimination perspective, the racial and ethnic disparities among similarly situated patients should trigger heightened moral scrutiny because these groups are “morally suspect categories” analogous to legal suspect categories in equal protection law.
Less obviously, minimizing inequities in health care access, quality and outcomes may well be good for the nation's fiscal health. Poorly managed chronic conditions or missed diagnoses result in avoidable, higher subsequent health care costs that impose cost burdens on public programs, individuals, and other purchasers of private health insurance. Some would dispute the claim that inadequately treated and managed diabetes can lead to far more expensive complications and treatments, such as kidney failure, requiring dialysis or transplantation. The Urban Institute estimates that in 2009, disparities between African Americans and Hispanics, compared to whites, cost the health care system $23.9 billion. Thus, by imposing substantial burdens on the economy, racial and ethnic health disparities inflict suffering on the entire society, not just the individuals who live sicker and die younger.
A. Access and Quality Disparities
Communities of color experience significant disparities relative to whites in both access to care and in the quality of care received. The National Healthcare Disparities Report (NHDR) is an authoritative source for the documentation of access and quality differences. Summarizing a range of measures, the 2010 report found that for some groups, such as African Americans and Latino/as, access to the health care system was worse than for whites in the preponderance of the study's measures. Latino/as experienced the greatest access problems of all ethnic groups; they received equivalent care as whites in only 17% of the measures, while the remaining access measures were overwhelmingly poorer for Latinos.
Turning to health care quality, communities of color again fared poorly relative to whites: African Americans and Latino/as received poorer quality care than whites on 40% and 60% of measures, respectively, and Asian Americans and American Indians (AI/AN) received poorer care on 20% and 40% of measures, respectively. More disturbingly, disparities in quality of care are not decreasing. Over time, the gap between whites and African Americans, Hispanics, Asian Americans, and AI/ANs has either remained the same or worsened for more than half of the core quality measures being tracked.
Although the NHDR provides a window to the health care experiences of communities of color, it fails to sort out the influences of race, income, and insurance. A substantial and growing body of evidence demonstrates that racial and ethnic minorities receive a lower quality and intensity of health care than white patients, even when they are insured at the same levels, have similar incomes, and present with the same types of health problems. The sources of these disparities are complex, rooted in historic inequalities, perpetuated through stereotyping and biases in the health care system, and aggravated by barriers of language, geography, and cultural familiarity.
For example, racial and ethnic differences in the treatment of heart conditions among similarly situated patients are particularly well documented. African-American heart patients are less likely than white patients to receive diagnostic procedures, vascularization procedures like cardiac catheterization, bypass graft surgery, and thrombolytic therapy. Timeliness to interventions is also critical when faced with heart attacks and minorities in general experience longer “door to-balloon” times for cardiac catheterizations than whites. The disparities in cardiac care may begin almost as soon as patients arrive at hospital emergency rooms; a 2010 study reports that African-American and Latino/a patients assessed for chest pain were less likely than white patients to be categorized as requiring immediate care, despite a lack of significant differences in symptoms.
Even routine care suffers. Black and Latino patients are less likely than whites to receive aspirin upon discharge following a heart attack, to receive appropriate care for pneumonia, and to have pain--such as the kind resulting from broken bones--appropriately treated.
Communities of color are also burdened with a higher prevalence of chronic diseases that require treatment in long-term care facilities. Diabetes, for example, is a serious, costly, and potentially preventable public health problem. Both the prevalence and incidence of diabetes have increased rapidly with racial and ethnic groups experiencing the steepest increases and most substantial effects from the disease. In 2005, both African-American and Hispanic adults were twice as likely as white adults to have been diagnosed with diabetes by a physician and also twice as likely to start treatment for end-stage renal disease related to diabetes.
B. Health Insurance Disparities
Persons of color comprise about one-third of the nation's population; however, they make up over half of the millions uninsured. In 2005, nearly two-thirds of Hispanic adults (15 million) and one-third of African Americans (6 million) were uninsured compared to 20% of white adults. People of color are less likely to have health coverage through an employer, in part because they are more likely to be unemployed; however, when employed, they are more likely to work low-wage jobs, which rarely offer coverage. The uninsured often postpone health care, which is one reason people of color are diagnosed at more advanced stages of diseases, and once diagnosed, receive poorer care. Many more of these Americans do not have a usual source for health care, have substantially higher unmet health needs, and high out-of-pocket costs.
Compared to the insured, a larger percentage of the uninsured report problems paying medical bills. They also report relying on home remedies rather than seeking the care of a doctor, skipping dental care, and not filling a prescription due to cost. African Americans and Latino/as compared to whites are more likely to report experiencing these problems.
