Report 1 of the Council on Scientific Affairs (I-02)
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Racial and Ethnic Disparities in Health Care

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Despite steady improvements in the overall health of Americans, racial and ethnic disparities in health status remain.¹ For instance, African Americans experience higher rates of morbidity and mortality from a number of diseases, including heart disease and stroke, cancer, diabetes, asthma, HIV/AIDS, and cerebrovascular disease. Similarly, Hispanic Americans experience disproportionate rates of morbidity and mortality from diabetes, cancer, and heart disease. American Indian and Alaska Natives are disadvantaged on a number of health status indicators, including life expectancy and infant mortality. Finally, some Asian American subpopulations experience rates of certain cancers that are well above national averages. The reasons for these disparities are complex and poorly understood. Socioeconomic inequality, individual behavioral risk factors, and cultural factors are all correlated with health status.^2-3 Disparities in access to health care also clearly play a role. Of most concern is evidence suggesting that even at equivalent levels of access to care, racial and ethnic minorities receive lower quality and quantity of health services compared to white Americans.⁴

Methods

A systematic review of the literature was conducted using the MEDLINE database for the years 1985 to 2002. English-language articles were selected based on their ability to: (1) inform as to the extent of racial and ethnic disparities in health care today; (2) articulate the causes and consequences of health care disparities; and (3) illustrate the appropriate role of physicians and physician organizations in addressing health care disparities. Other sources included the recent Institute of Medicine (IOM), Kaiser Family Foundation, and Commonwealth Fund reports on health care disparities. Further relevant articles and books were selected from the reference listings of the primary journal articles and foundation reports.

Terminology

For the purposes of this report, health care refers to the continuum of services provided in traditional health care settings, including hospitals, clinics, community-based health centers, and nursing homes. Disparities in health care are defined as racial and ethnic differences in the quantity or quality of health care that are not due to clinical needs, patient preferences, or the appropriateness of the intervention. Racial and ethnic groups are defined by the Office of Management and Budget (OMB) classification system for data on race and ethnicity. The revised OMB standards establish five categories for "racial" groups (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White) and two categories for "ethnic" groups (Hispanic or Latino and Not Hispanic or Latino). While these definitions have been subject to considerable debate, it should be noted that the Council on Scientific Affairs has reviewed numerous classification systems and has recommended the revised OMB classification system for collection of data on race and ethnicity.⁵

Evidence for Racial and Ethnic Disparities in Health Care

Racial and ethnic disparities in health care have been extensively documented. Minority race and/or ethnicity has been linked to a lower likelihood of having a regular source of care, fewer physician visits, less-intensive hospital visits, and lower total health care expenditures.^4,6-9 Minority race and ethnicity are also risk factors for less--if not lower quality--care across a range of health care services.^4,7,9-14 For example, minority race or ethnicity has been linked to disparities in receipt of appropriate cancer diagnostic tests and treatment^4,7,15-24; screening, diagnostic and therapeutic interventions for heart disease and stroke^4,7,25-37; diabetes care^38-40; clinical procedures for cerebrovascular disease^7,41-43; HIV care^44-45; renal transplantation^29,46-48; asthma care^7,49-51; and a range of other preventive and specialty health services.^4,7,10,52-55 Most studies have examined disparities in health care only among adult populations. However, racial and ethnic minority children and adolescents are also at considerable disadvantage, with minority status associated with a lower likelihood of having a usual source of care,^9,56-60 receiving treatment for common but significant health problems,^60-63 access to selected preventive services,^{9,56,60-61,64-65} and receiving prescription medications.^62,66-68

Most of the studies reviewed for this report contain one or more weaknesses in study design methodology. Their findings, however, are compelling when examined in the context of the consistencies found in the larger body of literature.^4,69 Recent studies have also sought to control for potential confounding factors that may account for disparities in care. Studies of cardiovascular care provide some of the most convincing evidence of racial and ethnic disparities, as many control for access to care and assess both potential underuse and overuse of services by using established diagnostic criteria to control for disease severity.^4,33,70-72 For example, studies of differences in treatment following coronary angiography suggest that disparities in care are not fully explained by access variables such as insurance status or type of hospital,³⁶ or by clinical factors such as racial differences in the severity of coronary disease, or overuse of services by whites.^28,70,73-75

Racial and ethnic minority patients experience a lower quality and intensity of health care and diagnostic services across range of other diseases and procedures, including maternal and child health care,^76-77 mental health,⁷⁸ rehabilitative services,^79-80 long-term care,⁸¹ and pain management.⁸² For example, the recent Surgeon General’s report on mental health care⁸³ found minority patients to be diagnosed less accurately when suffering from depression and seen in primary care⁸⁴ or when they were seen for a psychiatric evaluation in an emergency room.⁸⁵ However, it should be noted that not all disparities are negative. In some cases minorities are more likely to receive certain procedures or services (eg, adolescent reproductive health services).^86-87 These cases, however, are usually the exception and often may involve generally less desirable services (eg, bilateral orchiectomy and amputation).^4,88

Linking Disparities in Health Care to Health Outcomes

While the connection appears intuitive, disparities in health care have only recently been linked directly to disparities in health outcomes. In part, this is because health outcomes may be a consequence of a number of factors of which health care is only one. These include, but are not limited to, socioeconomic status, genetics, risk behavior, disaffiliation, geographic location, residential segregation, and discrimination.^3,89-93 While population studies suggest that medical care makes only a limited contribution to health status outcomes,^94-95 the relative impact of health care is much greater for racial and ethnic minorities due to existence of multiple vulnerabilities.⁹⁰ This contention is supported by a number of recent studies examining the impact of health care disparities. For example, research suggests that disparities in coronary revascularization procedures are directly associated with higher mortality rates among African Americans.⁷⁵ Similarly, disparities in cancer care are associated with higher death rates among minorities.^19,96 Finally, differences in the quality of care for patients with HIV are associated with poorer survival rates among minorities, even controlling for access to care.^97-98

Why Health Care Disparities Exist

Like our understanding of health status, the reasons for disparities in health care are complex and poorly understood.^4,7,10 As more potential confounding variables are controlled for, the magnitude of racial and ethnic disparities in health care decreases, but does not disappear. Insurance status and access to health care emerge as key predictors of the quality and intensity of health care for racial and ethnic minorities.⁹⁹ A related factor influencing the quality of health care is the location where it is received, with minorities more likely to access care in public and non-teaching hospitals and clinics where the quality of health care may be lower than in teaching hospitals and private settings.^4,100 However, health insurance coverage and income combined typically account for less than half of the disparities observed.¹¹

Beyond access-related issues, a range of patient-, provider-, and system-level factors may all play a role in the production of racial and ethnic disparities in health care (see Table).^{4, 101} Studies of minority patients suggest that they may delay seeking care or adhere poorly to treatment regimens.^17,102-103 These behaviors typically occur because of lack of familiarity with disease/treatment, mistrust of physicians or the health care system, poor prior interactions with the health care system, and/or poor recall or a misunderstanding of provider instructions.^10,103-108

System-level factors result from the way in which health care is organized and financed and include cultural and language barriers,^4,109-110 time pressures,⁴ cost-control efforts,^4,111-112 and the geographic availability of health care services.^4,113-114 For example, geographic availability and the cost-control model of managed care have made it more difficult for minority patients to maintain continuity of care.^{100,110-111,115-117} Similarly, failure by the health care system to address language or cultural barriers negatively affects the use of health services and clinical outcomes for minorities.^4,104,108

Provider-level factors include individual bias, clinical uncertainty, and prior beliefs (eg, stereotypes) about the health or health care preferences of minority patients.^4,118-120 Research also suggests that clinical uncertainty contributes to disparities in health care.¹²⁰ Clinical uncertainty (or simply the volume of information) also increases physicians’ explicit or implicit reliance on prior attitudes or beliefs about the patient, which may vary according to the patient’s race or ethnicity. Stereotyping and/or discrimination, in turn, may negatively affect health care utilization and care outcomes.^4,119-121

Patient-, system-, and provider-based factors may each explain only a fraction of disparities in health care. The relative influence of these individual factors is complex and poorly understood.⁴ Patient factors may actually account for the least amount of variation in health care utilization,^29,122-123 suggesting that greater responsibility for racial and ethnic disparities in health care, independent of access, may fall on the system or provider. Of these, the organization of the health care system may be the most influential. To illustrate, clinical decision-making is clearly influenced by provider uncertainty, and bias and beliefs that affect the overall care experience and may contribute directly or indirectly to health care disparities.^118,124-125 However, these provider factors are aggravated by increasing time pressures and resource restrictions (system-level factors) dictating many clinical encounters. These system pressures decrease opportunities for patient-centered care^101,126 and increase the probability that medical decision-making will reflect greater subjective variability and the preferences of the physician.^4,127 The likelihood of disparate care is further increased by other system factors, such as the fragmentation of health care and the relegation of many racial and ethnic minorities to more restrictive health plans.^4,128

The provision of health care in the United States must be understood in the broader context in which race and ethnicity have long been used to organize and give meaning to social interaction.^129-130 Social categorization is a powerful influence on differential thought and behavior in social interaction, engendering often-harmful stereotypes and attitudes (both implicit and explicit) toward members of social groups that significantly shape the outcomes of interpersonal interactions.¹³¹ This is evident in both the patient and provider factors discussed above; because both are members of society they share a need to process and recall information about others. Over time, however, social categorization and the stereotypes and attitudes it engenders also influence the operation of systems or institutions in society. This institutionalization of group differences is the key process in perpetuating greater and more lasting inequalities. This is especially true in the United States, which is an increasingly diverse nation with a long history of inequality based on race and ethnicity.

Professionalism Revisited: The Role of Physicians in Eliminating Health Care Disparities

Racial and ethnic disparities in health care represent a clear public health problem, threatening ongoing efforts to improve the nation’s health.¹³² For physicians, these disparities also pose moral and ethical dilemmas that, according to the recent Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, ^{4(p 30)} "will be among the most significant challenges of today’s rapidly changing health systems." Physicians are faced with ever-increasing sets of expectations. On the one hand, they are increasingly called upon to serve as managers of limited health care resources, while, on the other hand, they have professional and ethical obligations to serve as patient and public health advocates.^133-134 Complicating matters is the fact that, as a prototypic profession, medicine is organized around service to the most vulnerable populations in society. ¹³⁵ Obligations of the health care professional to these vulnerable classes of people are articulated in the American Medical Association’s (AMA) Principles of Medical Ethics, which call on physicians to support access to medical care for all people and to recognize their responsibility to contribute to the improvement of the community and the betterment of public health.¹³⁶ Practicing nondiscrimination based on race or ethnicity has also been a clear ethical standard within medicine for more than 20 years.¹³⁷

Concern exists, however, that medicine is being deprofessionalized--that professional standards are being sacrificed to the pressures of increasingly dominant market forces.^138-139 There are seminal differences between medicine and business, not the least of which are the spirit of public service and those behaviors that demonstrate that physicians are worthy of the trust bestowed on them by patients and the public. In short, physicians and physician organizations have a clear professional and moral responsibility to advocate and care for vulnerable populations and to prevent suffering.^135,137,140

Physicians and physician organizations can help eliminate health care disparities through medical practice and through leadership roles in health advocacy policy and public health promotion.^140-142 In particular, the tools of population-based medicine (PBM) can be employed to improve health care for racial and ethnic minorities. Population-based medicine is a clinical strategy that attempts to manage the health care of a population as a whole, placing the individual within the context of a larger community of both sick and well individuals. Population-based strategies allow physicians to identify the most prevalent diseases or conditions among patients in a practice or community. They also enable physicians to identify variations in health outcomes and health care among these patients and to examine possible correlations between variations in care and individual patient factors (eg, race or ethnicity), provider factors, and/or system factors.¹⁴³ Thus identified, interventions can be considered to eliminate racial and ethnic health care disparities at both the level of the individual patient and the level of the community.

Interventions at either level must involve health care providers in a variety of settings, including hospitals, outpatient settings, and long-term care facilities.¹⁴⁴ At the community level, physicians and their associations must lead the movement for reform within the health care delivery system, as they have the knowledge, capacity, and opportunity to effect meaningful and lasting (system) change.¹⁴⁵ Efforts begin with, but are not limited to, advocacy for universal access to appropriate and effective care and for the elimination of bias in health care, including efforts to counter the fragmentation of health plans along socioeconomic lines. Physicians also have a professional responsibility to take leadership roles in sensitive efforts to rebuild trust in the health care system among minority populations.¹⁴⁶ At the practice level, the elimination of health care disparities is best addressed as a quality improvement function, as disparities in health care delivery represent a fundamental threat to quality.¹⁴⁷ Currently, there are clear racial and ethnic disparities in care as measured against existing clinical quality improvement guidelines.^148-150 Evidence also suggests that adherence to evidence-based clinical guidelines may actually reduce health care disparities.^151-152 Despite this promise, however, existing quality measures fail to adequately identify socioeconomic and racial/ethnic disparities in quality.¹⁴⁷ Physicians and their associations are also challenged to move beyond simply the development of clinical quality standards and actively develop and promote companion tools and programs designed to improve health care for minorities. These include, but are not limited to, efforts to promote culturally appropriate care, to support the use of interpretation services where community need exists, and to work to increase the health literacy of patients.

Conclusion

Racial and ethnic health care disparities are significant problems, both to the individuals who seek care and to a society that prides itself on equal opportunity.⁴ The individual repercussions for the patient and physician are obvious and have been discussed. Racial and ethnic disparities in health care also constitute a major public health problem, affecting all members of society. For this reason, Healthy People 2010 established as its overarching goal the elimination of health disparities.¹³² Economic repercussions also exist, with disparities in health care related to disease complications, poorer health outcomes, and higher overall health care expenditures.⁴ For these reasons, disparities in health care are unacceptable. Physicians are also called upon for leadership in addressing this important issue.⁴ Efforts must be informed; however, there are clear needs for additional information on the nature, causes, and implications of health care disparities.⁴ Improved data collection is critically important to ongoing efforts to understand and eliminate racial and ethnic disparities in health care. At the very least, better delineation of those variables that must be included in multivariate analyses must be accomplished to ensure better understanding of the relative contribution of access and socioeconomic status, as well as patient, provider, and system factors, on the quality of health care for racial and ethnic minorities.

AMA Policy

The Council on Scientific Affairs believes that more action is clearly needed if physicians are to take the lead in improving the health care and health of minorities.

RECOMMENDATIONS

The following statements, recommended by the Council on Scientific Affairs, were adopted as AMA policy and directives at the 2003 AMA Interim Meeting:

1. The AMA recognizes racial and ethnic health disparities as a major public health problem in the United States and as a barrier to effective medical diagnosis and treatment. (Policy)
2. The AMA reaffirms the dedication of physicians to serving those in need of medial care and their commitment to the principle that no one shall be denied necessary medical care because of inability to pay for care (AMA Policy H-160.987). Furthermore, the AMA reaffirms its position of zero tolerance toward racially or culturally based disparities in health care (AMA Policy H-350.974). (Reaffirm Policy)
3. The AMA will create a program on health disparities using expertise in science, medical education, and ethics to: (a) work with members of the Federation and other relevant medical and nonmedical organizations to make the health care community more aware of health disparities and their effect on health outcomes; (b) identify and help providers implement strategies to reduce disparities in health care; (c) advocate for the appropriate role of the profession in eliminating health care disparities; and (d) work with the US Department of Health and Human Services (DHHS) under the DHHS-AMA Memorandum of Understanding supporting the goals of Healthy People 2010, including the elimination of health disparities. (Directive)
4. The AMA encourages the development of evidence-based performance measures that adequately identify socioeconomic and racial/ethnic disparities in quality. Furthermore, the AMA supports the use of evidence-based guidelines to promote the consistency and equity of care for all persons. (Policy)

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