Unequal Treatment: Confronting Racial and Ethnic Disparities in Health CareThe National Academies Office of News and Public Information

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Copyright © 2002 by the National Academy of Sciences

Minorities More Likely to Receive Lower-Quality Health Care,
Regardless of Income and Insurance Coverage

WASHINGTON -- Racial and ethnic minorities tend to receive lower-quality health care than whites do, even when insurance status, income, age, and severity of conditions are comparable, says a new report from the National Academies' Institute of Medicine. The committee that wrote the report also emphasized that differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities.

"Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable," said committee chair Alan Nelson, a retired physician, former president of the American Medical Association, and current special adviser to the chief executive officer of the American College of Physicians-American Society of Internal Medicine, Washington, D.C. "The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them."

The congressionally mandated report says a large body of research underscores the existence of disparities. For example, minorities are less likely to be given appropriate cardiac medications or to undergo bypass surgery, and are less likely to receive kidney dialysis or transplants. In addition, several studies show significant racial differences in who receives appropriate cancer diagnostic tests and treatments. Minorities also are less likely to receive the most sophisticated treatments for HIV infection, which could forestall the onset of AIDS. By contrast, they are more likely to receive certain less-desirable procedures, such as lower limb amputations for diabetes and other conditions.

The committee's first recommendation for reducing racial and ethnic disparities in health care is to increase awareness about them among the general public, health care providers, insurance companies, and policy-makers. Consistency and equity of care also should be promoted through the use of "evidence-based" guidelines to help providers and health plans make decisions about which procedures to order or pay for based on the best available science. Other specific steps to reduce and eliminate disparities are presented in the report.

There are many possible reasons for racial and ethnic disparities in health care, the committee said. Unequal treatment occurs in the context of persistent discrimination in many sectors of American life. Some evidence suggests that bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care.

The report says that although it is reasonable to assume that the vast majority of health care providers find prejudice morally abhorrent, several studies show that even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes. In addition, the time pressures that characterize many clinical encounters, as well as the complex thinking and decision-making they require, may increase the likelihood that stereotyping will occur.

Uncertainty about a patient's condition also may contribute to disparities in treatment, the report says. If physicians are having trouble making a diagnosis because the symptoms are not clear-cut, they are trained to place greater emphasis on prior expectations about the patient's condition based on age, gender, socioeconomic status, race, or ethnicity.

Although studies of racial and ethnic disparities have been controlled for insurance status, they have not fully accounted for variations among health plans. Minorities are more likely to be enrolled in more affordable but "lower-end" health plans -- so called because they are characterized by fewer resources per patient and stricter limits on covered services. The disproportionate number of minorities in these plans is a potential source of disparities in treatment, the committee said.

Even when insured at the same level as whites, however, minorities are less likely to enjoy a consistent relationship with a primary care provider, in part because of the lack of doctors in minority communities. The quality of care provided does not appear to be better when minority patients and their providers are of the same racial or ethnic group. However, one study shows that concordance of race is associated with greater patient participation and satisfaction. Insurance companies' caps on the coverage of treatment costs can pose greater barriers to minority patients since they are less likely to be able to afford high co-payments or deductibles, the report adds.

A few studies have found that minority patients refuse recommended treatments more often than whites. However, the committee said differences in refusal rates are small and do not fully account for racial and ethnic disparities. Likewise, overuse by white patients of some services does not explain the disparities either.

Real or perceived discrimination in hospitals and society in general has led many minorities to mistrust doctors and nurses. Although it is safe to assume that this mistrust may adversely affect the quality of care received, the committee noted that the provider is obviously the "more powerful actor in clinical encounters" and should shoulder more of the responsibility for seeing that disparities in care do not occur.

Health care plans should not be fragmented along socioeconomic lines, the report says. Public programs such as Medicaid should strive to help beneficiaries access the same level of care as privately insured patients. In addition, if Congress passes a "Patients' Bill of Rights" to protect enrollees in private HMO plans, it should accord the same protections to people in publicly funded HMO plans.

More minority health care providers are needed, especially since they are more likely to serve in minority and medically underserved communities, the report says. To overcome language barriers that may affect the quality of care, more interpreters should be available in clinics and hospitals located in neighborhoods with many foreign-language-speaking residents. Community-based health workers, such as nonmedical personnel who help patients navigate the health care system, are an important tool to reach some minority neighborhoods, and the health care system as a whole should encourage their use. In addition, training for current and future health care professionals should help them understand different cultures.

Patient education programs should be expanded to increase patients' knowledge of how to best access care, ask the right questions during clinical encounters, and participate in treatment decisions, the committee said. Preliminary evidence suggests that education through books and pamphlets, in-person instruction, CD-ROMs, or the Internet can increase the level of patient participation.

The federal government should provide greater resources to the U.S. Department of Health and Human Services' Office of Civil Rights, the committee added. The agency is charged with enforcing laws that prohibit discrimination in health care, but in recent years funding has been insufficient to adequately investigate complaints.

The committee also called for more research to identify sources of racial and ethnic disparities as well as promising intervention strategies. Future research should include a strong effort to better understand the prevalence and influence of bias, prejudice, stereotyping, and clinical uncertainty on the part of health care providers. And to ensure that the nation can track its progress in reducing disparities, hospitals should -- without violating patients' privacy -- collect and report data on health care access and utilization by patients' race, ethnicity, socioeconomic status, and primary language.

The study was sponsored by the U.S. Department of Health and Human Services. Additional support was provided by the Commonwealth Fund and the Henry J. Kaiser Family Foundation. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
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Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care

Alan R. Nelson, M.D.^*(chair)
Special Adviser to the Chief Executive Officer
American College of Physicians-American Society of Internal Medicine
Washington, D.C.

Martha N. Hill, Ph.D.^* (co-vice chair)
Professor and Director
Center for Nursing Research
Johns Hopkins University School of Nursing
Baltimore

Risa Lavizzo-Mourey, M.D., M.B.A.^*(co-vice chair)
Senior Vice President
Robert Wood Johnson Foundation
Princeton, N.J.

Joseph R. Betancourt, M.D., M.P.H.
Senior Scientist
Institute for Health Policy, and
Director for Multicultural Education
Multicultural Affairs Office
Massachusetts General Hospital-Harvard Medical School
Boston

M. Gregg Bloche, J.D., M.D.
Professor of Law, and
Co-Director
Georgetown-Johns Hopkins Joint Program in Law and Public Health
Washington, D.C.

W. Michael Byrd, M.D., M.P.H.
Instructor and Senior Research Scientist
Division of Public Health Practice
Harvard School of Public Health, and
Instructor and Staff Physician
Beth Israel Deaconess Hospital
Boston

John F. Dovidio, Ph.D.
Charles A. Dana Professor
Department of Psychology
Interim Provost; and
Dean of the Faculty
Colgate University
Hamilton, N.Y.

Jose J. Escarce, M.D., Ph.D.
Senior Natural Scientist, and
Co-Director
Center for Research on Health Care
Organization, Economics, and Finance
RAND
Los Angeles

Sandra Adamson Fryhofer, M.D., MACP
General Internist, and
Clinical Associate Professor of Medicine
School of Medicine
Emory University
Atlanta

Thomas S. Inui, Sc.M., M.D.^*
President and Chief Executive Officer
Fetzer Institute
Kalamazoo, Mich.

Jennie R. Joe, Ph.D., M.P.H.
Professor of Family and Community Medicine, and
Director of the Native American Research and Training Center
University of Arizona
Tucson

Thomas G. McGuire, Ph.D.^*
Professor of Health Economics
Department of Health Care Policy
Harvard Medical School
Boston

Carolina Reyes, M.D.
Vice President
Planning and Evaluation
The California Endowment
Woodland Hills

Donald M. Steinwachs, Ph.D.^*
Chair and Professor
Department of Health Policy and Management
Johns Hopkins School of Hygiene and Public Health, and
Director
Johns Hopkins University Health Services Research and Development Center
Baltimore

David R. Williams, Ph.D., M.P.H. ^*
Professor of Sociology and Senior Research Scientist
Institute for Social Research
University of Michigan
Ann Arbor