Amidst the energy and momentum for health care reform in the United States, it is important to remember that getting an insurance card into everyone's wallet is not the same as guaranteeing equal access to quality health care. Recent studies have shown that, in America, health is not just about having insurance or paying bills: it's also, unfortunately, about the color of your skin.
The Lancet, a journal of global medicine, published an article this last Saturday (free registration required) on persisting racial and ethnic disparities in health, six years following the groundbreaking Institute of Medicine study, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The Opportunity Agenda Research Director and primary editor of the 2002 IOM study, Brian Smedley, is quoted in the Lancet article:
"As the report's study director, I was pleased to see that Unequal Treatment prompted a sober discussion in health policy, academic, and political circles", Brian Smedley, former senior programme officer at the US Institute of Medicine, wrote in a blog to mark the latest issue of the journal Health Affairs, which includes research on health disparities. "But ultimately the report failed to prompt passage of significant new federal legislation or spur the Department of Health and Human Services to adopt its core recommendations. As a result, little has been done, in my view, to systematically address the problem."
Citing some of the papers in the latest issue of Health Affairs, called Disparities: Expanding the Focus[paid subscription required], he said that some of the most shocking health care gaps that were not documented when Unequal Treatment was published, were found in mental and oral health care. Meanwhile, the biggest gains in life expectancy occurred among the best-educated Americans.
Because of the failure of HHS to adopt recommendations to reduce disparities, and the stalling of major legislation in Congress to address disparities, many of the inequities identified half a dozen years ago are still prevalent. In very real terms, this means that communities that often have the most need for quality health care are the ones that receive the least of such care.
The Lancet provides one New Yorker's story:
James North, a 50-year-old African-American, had borderline cardiac function but had been admitted to hospital only once when he went to see Neil Calman in the Bronx, New York City.
Mr North meticulously recited the medications he was taking and explained how he controlled his congestive heart failure by monitoring his weight and adjusting his diuretics.
"I could not provide Mr North with all that New York's great health-care institutions had to offer. He knew that. He often tried to teach me that and was just as often amazed that I was unable to accept it", wrote Calman in the Bronx Health REACH Coalition newsletter in autumn last year.
Mr North's case provides a vivid illustration of the inequalities in health care received by minorities in the USA. His cardiologist never thought of referring him to a heart-transplant centre and it took three separate interventions from Calman to get him a consultation. The echocardiography lab sent him home after Mr North was 10 minutes late because he had to keep stopping to rest on his walk there on a windy day. The pharmacy refused to refill his insulin syringes without a written prescription, even though he had been going to the same place for 2 years.
As the article points out, these differences in the type and quality of care received cannot be explained away by differences in insurance coverage or socioeconomic factors, such as levels of education or income. Perhaps emphasizing that Mr. North is not alone in his experiences,
A New York State Department of Health study found that although African-Americans have the highest rate of hypertension and cardiovascular disease, the use of diagnostic testing, such as cardiac echocardiography, was very low for them. Sophisticated treatment, such as bypass surgery, was also administered less often in comparison with white people.
Similarly, a report authored by The Opportunity Agenda and over 30 other organizations and scholars, submitted earlier this year to the U.N. Committee on the Elimination of Racial Discrimination, Unequal Health Outcomes in the United States found the following with regards to racial and ethnic disparities in American health and health care:
* The 2006 National Healthcare Disparities Report found that, across a range of measures of health care access, Latinos received equivalent care as whites in only 17% of the measures, and that access to care had worsened from previous years for Latinos on 80% of the study measures.
* From 1999 to 2004, the proportion of white senior adults (over 65) who did not receive a pneumonia vaccine dropped from 48% to 41%, but for Asian American seniors rose from 59% to 65%.
* Insured African American patients are less likely than insured whites to receive many potentially life-saving or life-extending procedures, particularly high tech care, such as cardiac catheterization, bypass graft surgery, or kidney transplant.
* People of color are more likely to receive undesirable treatment than whites, such as limb amputation for diabetes.
* And even in routine care there are disparities. 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.
As stated in The Opportunity Agenda's report on health care in New York City, Dangerous and Unlawful, a health care system that is "too expensive, too far away, too inconvenient for working families, too insensitive to our language needs and cultural differences -- in short, too far out of reach for too many" is a dangerous system that is costly to all Americans, contributing to skyrocketing costs and diminishing our quality of life. More importantly, however, a system that is inequitable, where the language you speak or your appearance may determine whether you receive potentially live-saving care, is one that violates our values of equality and community, and builds unlawful barriers to accessing the shared American dream of opportunity.