Question

Racial Disparities in Medical Health Care - This is an essay paper for English. It requires 6 pages Please

Answer 1

Racial disparities in medical care should be understood within the context of racial inequities in societal institutions. Systematic discrimination is not the aberrant behavior of a few but is often supported by institutional policies and unconscious bias based on negative stereotypes. Effectively addressing disparities in the quality of care requires improved data systems, increased regulatory vigilance, and new initiatives to appropriately train medical professionals and recruit more providers from disadvantaged minority backgrounds. Identifying and implementing effective strategies to eliminate racial inequities in health status and medical care should be made a national priority.

National data reveal that over the past 50 years, the health of both black and white persons has improved in the United States as evidenced by increases in life expectancy and declines in infant and adult mortality (National Center for Health Statistics, 1998). However, black persons continue to have higher rates of morbidity and mortality than white persons for most indicators of physical health. Hispanics and American Indians also have elevated disease and death rates for multiple conditions. Although the role of medical care as a determinant of health is somewhat limited, medical care (especially preventive care, early intervention and the appropriate management of chronic disease) can play an important role in health (Bunker, Frazier, and Mosteller, 1995). Thus, racial and ethnic differentials in the quantity and quality of care are a likely contributor to racial disparities in health status. Compared with white persons, black persons and other minorities have lower levels of access to medical care in the United States due to their higher rates of unemployment and under-representation in good-paying jobs that include health insurance as part of the benefit package (Blendon et al., 1989; Trevino et al., 1991).

More striking, and disconcerting to many is the large and growing number of studies that find racial differences in the receipt of major therapeutic procedures for a broad range of conditions even after adjustment for insurance status and severity of disease (Harris, Andrews, and Elixhauser, 1997; Wenneker and Epstein,1989). Especially surprising to many are the racial disparities in contexts where differences in economic status and insurance coverage are minimized such as the Veterans Health Administration System (Whittle et al., 1993) and the Medicare program (McBean and Gornick, 1994). Other research indicates that, although physicians' ability to detect the severity of pain does not differ for Hispanic versus non-Hispanic white patients (Todd, Lee, and Hoffman, 1994), Hispanic patients are markedly less likely than non-Hispanic white patients to receive adequate analgesia (Todd et al., 1993; Cleeland et al., 1997). Recent studies document that these differences in the receipt of therapeutic procedures have adverse effects on the health of minority group members (Peterson et al., 1997; Hannan, van Ryn, and Burke, 1999). How do we make sense of these differences and how do we move forward with an effective policy and research agenda to eliminate these disparities?

Many observers are surprised and perplexed by these findings. However, we can only regard these findings as surprising if we take an ahistorical and decontextualized view of the data. In compliance with Article 1, Section 2, and Paragraph 3 of the Constitution of the United States, the very first Census in 1790 enumerated three racial groups: whites, blacks as three-fifths of a person, and only “civilized Indians”—those who paid taxes (Anderson, 1988). New racial categories were added in the late 19th Century and beyond (Chinese in 1870, Japanese in 1890, Mexican in 1930) as the need arose to track new marginalized immigrant groups (Anderson and Feinberg, 1995). Race was and is a social category that captures differential access to power and desirable resources in society (Williams, 1997). Throughout the history of the United States, non-dominant racial groups have, either by law or custom, received inferior treatment in major societal institutions. Medical care is no exception.

Thus, understanding racial disparities in medical care requires an appreciation of the ways in which racism has operated and continues to operate in society. The term “racism” refers to an organized system, rooted in an ideology of inferiority that categorizes, ranks and differentially allocates societal resources to human population groups (Bonilla-Silva, 1996). It may or may not be accompanied by prejudice at the individual level. We will illustrate the complex nature of race, racism, and discrimination in society by considering access to housing and employment.

First, Table 1 indicates that there have been important positive changes in the racial attitudes of white persons towards black persons in recent decades and broad current support for the principle of equality in housing and employment (Schuman et al., 1997). In 1963, 60 percent of white persons agreed with the statement that “White people have a right to keep Negroes out of their neighborhoods if they want to, and Negroes should respect that right.” In 1996, only 13 percent of white persons agreed with that statement, documenting a substantial positive attitudinal shift within the white population. Similarly, in 1944, a majority of white persons (55 percent) indicated that white people should have the first chance at any kind of job but, by 1972, only 3 percent of white persons endorsed that view with 97 percent indicating that black persons should have as good a chance as white persons to get any kind of job.

The larger literature on societal discrimination suggests that, although racism has changed over time from a blatant “Jim Crow racism” to a more subtle “laissezfaire racism” (Bobo, Kluegel and Smith, 1997), it persists in contemporary America. As painful as it may be to acknowledge, we must begin with the recognition that discrimination is routine and commonplace in society and likely to be similarly prevalent in medicine. With few exceptions (Smith, 1998; Geiger. 1996; Council on Ethical and Judicial Affairs, 1990), the literature on racial disparities in medical care is reluctant to admit and address racial bias among providers as a critical causal factor. In contrast, the evidence is abundant and clear that racial discrimination is not the aberrant behavior of a few “bad apples” but a widespread societal problem.

It is unlikely that personal discrimination on the part of providers is the sole cause of disparities in health care. In any area of societal evaluation, the causes of racial differences are complex and multi-dimensional, with discrimination being only one of them. Moreover, institutional discrimination is often at least as important as individual discrimination. In the case of racial disparities in medical care, other potential explanations include the geographic maldistribution of medical resources, racial differences in patient preferences, pathophysiology, economic status, insurance coverage, as well as in trust, knowledge, and familiarity with medical procedures (Horner, Oddone, and Matchar, 1995; Smith, 1998). On the surface, patient preferences would be the alternative explanation that would be most consistent with all of the available evidence. However, recent research indicating that patient preferences do not account for these disparities (Hannan, van Ryn, and Burke, 1999) suggests that discrimination remains as a central plausible explanation.

Probably most important, much discrimination today occurs through behaviors that the perpetrator does not subjectively experience as intentional. Much contemporary discriminatory behavior is unconscious, unthinking, and unintentional (Allen, 1995; Johnson, 1988; Lawrence, 1987; Oppenheimer, 1993). As noted earlier, biases based on racial stereotypes occur automatically and without conscious awareness even by persons who do not endorse racist beliefs (Devine, 1989). Recent psychological research indicates that persons who do not see themselves as prejudiced will make health care allocation decisions that adversely affect black persons when other negative characteristics are also present (Murphy-Berman, Berman, and Campbell, 1998). For example, respondents expressed greater resentment, gave lower health care priority scores and were more reluctant to make a financial contribution to the health care costs of patients presented as black and unemployed than as white and unemployed. In real-life medical encounters, the automatic activation of stereotypes may provide the negative characterization that triggers unconscious bias. Most legislation, intervention programs, and policy regarding discrimination have been ineffective because of their focus on purposeful or intentional discrimination (Allen, 1995). Relatedly, our review also suggests that one cannot rely on the stated racial attitudes of white persons or the mere existence of laws prohibiting discrimination to ensure that it does not occur in health care settings.

Although this article centrally addresses racial differences in the quality of care, a comprehensive approach to address inequities must begin by ensuring parity in access to care. Effectively addressing health care disparities will require comprehensive efforts by multiple sectors of society to address larger inequities in major societal institutions. There is clearly a need for concerted societal-wide efforts to confront and eliminate discrimination in education, employment, housing, criminal justice, and other areas of society which will improve the socioeconomic status (SES) of disadvantaged minority populations and indirectly provide them greater access to medical care. The United States also needs to make the moral and political commitment to guarantee access to medical care as a fundamental right of citizenship.

However, efforts to ensure equitable access to care must go beyond the elimination of financial barriers. A broad range of system barriers such as long waiting time, complex bureaucratic procedures, and the failure to treat patients with dignity and respect can lead to patient alienation and the avoidance of contact with the health care system unless absolutely necessary. Research has long indicated that poor persons and racial minorities are not viewed as desirable patients and health care providers deliver inferior care to persons of low SES (Duff and Hollingshead, 1968; van Ryn and Burke, 2000). Problems of patient-provider communication are exacerbated among persons of low SES, with higher SES patients receiving better technical and interpersonal care, and more positive communication than their lower SES peers (Hall, Roter, and Katz, 1988).

Efforts to ensure equitable access to care are urgently needed to counteract two forces that could potentially exacerbate racial disparities in access to care. First, there are closures of a growing number of health care facilities with hospitals located in low income and minority communities being more likely to close than those located in other areas (Whiteis, 1992; McLafferty, 1982). Second, and more important, the movement from a fee-for-service (FFS) system to a managed care system is likely to adversely impact access to medical care for minorities and other vulnerable populations (Schlesinger, 1987; Randall, 1994; McClellan, 1999; Harvard Law Review, 1995).

Critics argue that managed care is likely to exacerbate current racial inequalities in access to medical care in multiple ways. The new competitive pressures in the financing and delivery of medical care can reduce profits generated by treating privately insured patients, leading to cutbacks in the provision of uncompensated care (Schlesinger, 1987). In addition, managed care plans often limit access to minority physicians and other doctors who primarily care for disadvantaged populations (Harvard Law Review, 1995). Managed care plans look for cost effective physicians who order few procedures, write limited prescriptions, and make limited referrals. In contrast, given the high morbidity, comorbidity and greater severity of disease at time of diagnosis in minority and low income populations, these patients require intense management of chronic illness which can involve more medical services and thus higher costs. Accordingly, managed care plans are likely to view physicians who work in minority communities as undesirable and may also limit the physicians that their enrollees, including poor patients and residents of poor communities, can consult. The net result could be that many physicians who work in minority communities may have a smaller patient load and some may be even unable to maintain a financially viable practice (Harvard Law Review, 1995).

However, it is not clear if these fears have materialized. A 1994 survey of black physicians at a national conference found that 92 percent believed that managed care plans terminated the contracts of black doctors more often than those of white doctors (Lavizzo-Mourey et al., 1996). In fact, 88 percent had been refused a contract by a managed care organization (MCO) and 71 percent had lost patients to a MCO with which they were not affiliated. At the same time, 71 percent had at least one managed care contract and 75 percent indicated that their practice had grown or remained stable in the previous year. Some observers also note that it is not inevitable that access to medical care will worsen for minority populations under managed care arrangements. Increased competition could provide a financial incentive for some health care providers to provide treatment to segments of the community that they may have earlier viewed as undesirable (Schlesinger, 1987).

Any concerted effort to address racial bias in the medical arena requires systematic and routine data of its occurrence. As noted, important changes are taking place in the organization and delivery of health care services in the United States and it is critical to monitor the impact of these changes on the health care access and quality for vulnerable populations. Major efforts are currently under way to identify the data elements that should be included in national uniform standardized data sets. It is essential that racial and ethnic status are uniformly and comprehensively assessed in these minimum core data sets. Comprehensive assessment means that data systems should include identifiers for major ethnic subgroups within the standard racial/ethnic categories (Williams, 1996). For example, among Hispanics, it is necessary to distinguish the three largest groups: Mexicans, mainland Puerto Ricans, and Cubans. Given the central role of SES in health and the strong relationship between race/ethnicity, and SES, it is important that indicators of SES are also included in any uniform data set (Krieger, Williams, and Moss, 1997; Williams, 1996).

The pervasiveness of discrimination suggests that racial data should be available for every medical encounter. The National Committee of Vital and Health Statistics, a public advisory body to the Department of Health and Human Services has called for the assessment of race/ethnicity and SES (National Committee of Vital and Health Statistics, 1993) in an enrollment database which could then be linked to data on medical encounters. Years of formal education was suggested as the most practical and convenient SES indicator in this context. The presence of these identifiers in an enrollment database would eliminate the resource intensive ordeal of attempting to request racial data at every medical encounter. Stringent efforts to ensure patient privacy and confidentiality would have to be implemented and the necessary training would have to be provided to health care workers to ensure the uniform collection of racial/ethnic and SES data. The analyses of racial disparities in the HCFA data files illustrate that administrative databases can be very helpful in providing findings that shed light on the nature and magnitude of the problem. However, these analyses have focused only on black-white differences because “black, white and other” were the only racial identifiers present. In the early 1990s, HCFA and the Social Security Administration (SSA) went to considerable effort to improve racial/ethnic identifiers in the SSA and Medicare data systems. What is needed now is the routine analysis and reporting of data for all racial/ethnic groups.

Routine reporting of data would identify which health care institutions, if any, demonstrate racial parity in terms of the delivery of medical care. It is likely that there is considerable variation in racial disparities across multiple settings. This kind of data can be used to establish benchmarks—levels of excellence achieved by industry leaders that could enhance our understanding of these best practices and facilitate their replication (Weissman et al., 1999).

Research is also needed to identify the optimal specific strategies that health care institutions can implement, at least on a periodic basis if not continuously, to detect and respond to patterns of discrimination in medical treatment. It has been suggested that hospitals could develop an anonymous reporting system to facilitate the detection of incidents of systematic patterns of biased medical decisionmaking (Noah, 1998). However, it will be crucial to create an environment that encourages reporting as part of a strategy of constructive problem-solving (Leape, 1997). In general, the five strategies for detecting inappropriate medical treatment, in order of yield and intensity of effort are direct observation, chart review, computer screening, focus groups and voluntary reporting (Leape, 1997).

The availability of data on racial differences in medical care would also facilitate at least some civil rights enforcement efforts. One of the limitations of current antidiscrimination laws is that they often rely on proving subjective discriminatory intent (Allen, 1995). Given that the vast majority of white Americans favor non-discrimination in principle, it is often difficult to prove discriminatory intent. In the legal arena, disparate impact claims require statistical data to document the differential effect of policies on racial groups. It is not a frequently used strategy by individuals seeking relief under civil rights statutes because it usually requires the compilation and analysis of large quantities of data to prove a discriminatory effect. However, routine collection of racial data would facilitate the assessment of racial group disadvantage in the medical arena.

Smith (1998) notes that the emphases on monitoring both clinical and financial information in the managed care environment also provides new opportunities for enhanced civil rights monitoring of health care delivery. He indicates that the addition of racial identifiers to existing data systems would facilitate the creation of report cards that could be used to monitor disparities in health plans, health care institutions, and communities. These report cards would include broadly accepted indicators of health and health care delivery (such as mortality rates and the use of specific screening tests) that have been recommended by various standards organizations for the comparative evaluation of medical care. Smith (1998) indicates that similar reporting requirements in the banking industry have led to a dramatic increase in the number of loans approved for racial minorities. However, in order for report cards to work, they must be a part of a larger system.

There is also a need for intensive and systematic educational campaigns about the problem of racial inequities in health care. The awareness levels of the public and professional community, especially the medical community, must be raised. Research is needed to identify strategies that are most effective to raise awareness of and increase sensitivity to the issues of race in medical practice. Although education has its limits, it is also instructive to know that educational campaigns can accomplish much. For example, in the case of tobacco there has been a per capita decline in tobacco consumption in the United States over the course of the last century whenever there was a major media campaign on the negative effects of cigarette smoking (Warner, 1985). Efforts are clearly needed to impact the medical school curriculum to ensure that issues of race and sensitivity towards these issues are adequately addressed. As Geiger (1996) indicates, “awareness of the dilemmas associated with race and health care should be a part of every physician's training.”

It is not clear that the current emphases and approaches to cultural sensitivity will address the systemic problem of discrimination. Even model cultural sensitivity programs for medical students and residents (Robins et al., 1998; Zweifler and Gonzalez, 1998) do not address unconscious discrimination. Cultural sensitivity programs may enhance and accentuate negative stereotypes. Some cultural sensitivity training focuses on the distinctive behavioral patterns of subgroups in the population and appears to focus primarily on the “strange” behavior of patients. More research is also needed on provider attitudes and behavior (King, 1996) and especially the identification of the strategies that may be most effective in identifying and reducing unconscious discrimination among medical professionals.

Another critical goal of medical education should be to increase the number of minority professionals. Research clearly indicates that black and Hispanic physicians are much more likely than other physicians to care for the uninsured and those with Medicaid and to practice in urban and rural underserved areas where the percentage of residents of their racial/ethnic group is high (Komaromy et al., 1996). A recent study reported that in order to reach racial and ethnic population parity, the United States needs to double the number of black and Hispanic first-year residents and triple the number of Native American residents (Libby, Zhou, and Kindig, 1997). White first-year residents would need to be reduced by two-fifths and Asians by two-thirds.

Current trends do not suggest that these goals are likely to be reached. There has been relatively little increase in the proportion of physicians from underrepresented minority backgrounds in medicine in the last 30 years. For example, black physicians have increased from 2.5 percent of all U.S. physicians prior to 1968 (Carlisle, Gardner, and Liu, 1998) to 2.9 percent currently (Editorial, 1999). The number of underrepresented minorities (black Americans, Mexican Americans, mainland Puerto Ricans, and American Indians) increased in medical schools starting in the late 1960s. Minority enrollment peaked in 1974 at 10 percent of total enrollment but subsequently declined in the wake of reverse discrimination lawsuits (Carlisle, Gardner, and Liu, 1998; Nickens and Cohen, 1996). To reverse this trend the Association of American Medical Colleges launched a new campaign to have 3000 first-year minority medical students by the year 2000. This project was initially successful with enrollment reaching a high of 2014 under-represented minorities (12 percent of all new entrants) in 1994 (Carlisle, Gardner, and Liu, 1998). In 1996, there was a large drop in applications from underrepresented minorities to medical schools (Editorial, 1999) with more than one-half of all U.S. medical schools experiencing a decline in minority enrollment (Carlisle, Gardner, and Liu, 1998). The decline was largest in public medical schools and in the four States (California, Texas, Louisiana, and Mississippi) where affirmative action programs have been banned.

More research is needed to identify what are the most effective strategies for the recruitment and retention of physicians from disadvantaged backgrounds. However, we should also capitalize on the currently available evidence on effective strategies. Affirmative action programs (Federal initiatives that allowed schools and employers to take into consideration a qualified applicant's race, sex, national origin, or disability) have been successful. It is estimated that affirmative action is responsible for 40 percent of all U.S.-trained physicians from underrepresented minority backgrounds (Editorial, 1999). Although underrepresented minority students tend to have lower test scores than other medical students, they do not differ on clinical performance suggesting that other non-cognitive variables are essential in the recruitment of competent physicians (Tekian, 1997). In addition, despite their current unpopularity, affirmative action programs are defensible on multiple grounds including the societal obligation to meet the health care needs of all segments of the population (Nickens and Cohen, 1996). Moreover, recent research documents that racial prejudice, especially contemporary subtle prejudice, is the single most important source of opposition to affirmative action (Williams et al., 1999). These fingings emphasize the critical need to confront and eradicate societal racism in order to develop effective strategies to overcome America's painful history of exclusion and discrimination.

However, McClellan (1999) notes that simply matching physician race with client race is not enough. He cites an uncomfortable but insightful example from the Tuskegee Syphilis Study. In 1969, the Macon County Medical Society endorsed the continuation of the Tuskegee Syphilis Study. At that time, the Society was virtually all-black. McClellan (1999) argues that social class provides an explanation of those black physicians' behavior. That is, because most of the patients in the Tuskegee study were poor and illiterate, the study was not a threat to middle class physicians, their families, or friends. He argues that educational and professional socialization may lead health care professionals to distance themselves in terms of emotional attachment and self-interest from their groups of origin. Unthinking discrimination is likely to occur whenever medical professionals, irrespective of race, endorse negative societal stereotypes of their patients. Research is needed to identify the extent to which these processes operate and what may be the most effective strategies to counter them.

Rather than focusing only on individual characteristics, efforts to reduce racial/ethnic disparities in the quality of medical care should seek to reform the systems for the delivery of care. Is it possible to design and implement systems for the delivery of medical care that can ensure appropriate behavior irrespective of effect and unconscious stereotypes? A definitive answer to this question awaits the necessary research, but Leape (1997) emphasizes that in medicine, as in other occupations, conditions of work can be managed, tasks and processes can be designed, and workers can be trained in ways that minimize undesirable outcomes.

It is a national embarrassment that there are large and persisting racial differences in health. National data reveal, for example, that black persons had an overall mortality rate that was 1.6 times higher than white persons in 1995—identical to the black/white mortality ratio in 1950 (Williams, 1999). Moreover, for multiple causes of death (heart disease, cancer, diabetes, and cirrhosis of the liver) the racial discrepancy was larger in 1995 than in 1950. These inequities fly in the face of cherished American principles given the public's commitment to principles of equal treatment in society. As a society, we need to make it a national priority to build on the cultural support for egalitarian principles and develop strategies to eradicate racial inequities in medical care.

The United States President and other leaders in the executive branch of Government should use the “bully pulpit” to place this issue on the national agenda. President Clinton has drawn much national and media attention to the problem of health disparities by making it a topic of one of his Saturday morning radio addresses and by the establishment of his Commission on Race. Relatedly, in 1994, President Clinton issued an executive order on environmental justice that could be a model of the kind of effort that is needed (Noah, 1998). This executive order created an interagency working group to address questions of environmental justice and to provide guidelines to Federal agencies for coordinating research, collecting data, and developing effective strategies to address inequities. A similar working group on racial disparities in medical care could monitor and coordinate data from multiple sources and provide a coordinated picture of the nature and prevalence of inequities in multiple health care settings. A commitment to the eradication of racial disparities also requires the creation of the institutional capacity to effectively monitor and enforce all existing laws and regulations.

Our review indicates that racism appears to be a technological hazard in the practice of medicine. Much of it may be unthinking and careless and not deliberately hateful behavior. However, regardless of motive, there are pervasive adverse consequences. As a society, we lack data on effective strategies to reduce racism at both the individual and institutional levels. While there are many books published on the topic and many programs on cultural diversity and tolerance, there is little systematic data available about the conditions under which particular strategies are more or less effective. Given the growing body of evidence that indicates that racism adversely affects health in multiple other ways (Krieger, 1999; Williams, 1999), more systematic efforts to develop and assess the impact of various strategies to reduce racism is warranted. Well-funded research centers for excellence should be established to foster interdisciplinary research on understanding and eliminating racial/ethnic disparities in medical care. Courageous moral and political leadership is also needed to take the necessary steps to apply all of the knowledge that we currently have for reducing racial/ethnic disparities in health, and more generally.