INTRO TEXT That there are big racial disparities in health care no one disputes. Blacks are less likely than whites to undergo bypass surgery. The time between an abnormal mammogram and follow-up testing for breast cancer is more than twice as long for black, Hispanic, and Asian-American women as for white women. Black and Hispanic preschoolers hospitalized with asthma are prescribed medication to prevent future episodes at rates far lower than white children. A 2002 report from the Institute of Medicine, an independent research organization that advises Congress, found that such gaps exist even between those with similar levels of education and insurance coverage.
The cause of those disparities–and what to do about them–is a different matter. The IOM report said that, while there are many factors at play, “some evidence suggests that bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care.” But not everyone is convinced.
“I think the jury is still out on that,” said psychiatrist Sally Satel at a panel discussion on the subject at Harvard’s Kennedy School of Government in February. Satel, a fellow at the American Enterprise Institute in Washington, DC, has emerged as a lightning rod of dissent, penning an essay in The Weekly Standard provocatively titled, “Don’t Despair Over Disparities.” At Harvard, Satel suggested that lack of access to care and inadequate “health literacy”–a topic that was the subject of another IOM report earlier this year –probably explain more of the racial health care gap than does discrimination.
Even when officials try to address the problem head on, controversy ensues. The US Department of Health and Human Services issued a report last year on racial health disparities, but in January, Health and Human Services Secretary Tommy Thompson was forced to apologize for changes in the report that sought to soften its tone and emphasize positive news; he pledged to publish the original version. Senate Majority Leader Bill Frist, a Tennessee Republican and a Harvard-trained heart surgeon, filed legislation in February to increase support for the federal Office of Minority Health and authorize a series of demonstration projects to test various “cultural competency” training programs. But even Frist’s bill drew fire for expanding the scope of health disparities initiatives to include underserved white populations with poor health status, such as those in Appalachia.
Dr. Joseph Betancourt, program director for multicultural education at Massachusetts General Hospital and a member of the Institute of Medicine committee that produced the 2002 report, acknowledges that alteration of the HHS report was “quite troubling to many folks,” and that the Frist bill was seen by some minority leaders as an attempt to take some of the spotlight off racial disparities in health. But Betancourt, a Puerto Rico-born physician who calls himself “an incrementalist,” says he’s glad for every bit of attention the issue gets. Betancourt also applauds recent action by the Massachusetts Legislature to create a special commission on racial and ethnic disparities in health care, as well as a task force that Boston Mayor Thomas Menino announced in April.
But all of these efforts fall short of bringing to the health care system accountability for addressing racial disparities. In areas as varied as banking, housing, and the criminal justice system, there are now varying degrees of legally mandated reporting for the purpose of rooting out racial bias in everything from lending to traffic stops.
Similar measures of accountability are needed in health care, Betancourt says. But so far, most health care institutions don’t even collect data on race. Some private-sector firms are ahead of government and nonprofit hospital providers, Betancourt says, citing the decision of Aetna, the nation’s largest health insurer, to begin collecting race and ethnicity data.
“There’s lots of talk about safety and cost and quality,” he says of the movement to make the health care system more transparent on those issues. Addressing racial and ethnic disparities, he says, “should fall into that rubric.”