Published January 13, 2015
In America, you get worse health care if you're black.
We've talked about changing this situation for more than 20 years. Since the mid-1990s, we've tried to do something about it. The result: Unequal health care persists. For some kinds of medical care, it is getting worse.
Two of three studies in this week's issue of The New England Journal of Medicine detail a remarkable lack of progress. The third study offers a ray of hope — but still shows that the fight to end racial inequality in health care has only just begun.
"It is time to stop documenting disparities and turn our efforts to doing something about them," writes NEJM editorialist Nicole Lurie, MD, MSPH, director of the RAND Center for Population Health and Health Disparities.
Worse Care for Heart Attacks
Nothing, they say, is more serious than a heart attack. Yet blacks get worse heart attack care than whites, and women get worse care than men.
It's a double whammy for black women. Heart attacks kill them 11 percent more often than they do white men.
These sobering findings come from Emory University researcher Viola Vaccarino, MD, PhD, and colleagues. The researchers combed through data on some 600,000 patients who had heart attacks between 1994 and 2002.
"Disparities in health care have been described for at least 15 years now. National programs have been established," Vaccarino tells WebMD. "We thought that, over time, we would see decreasing disparities in treatment for heart attacks. ... But we found that there were differences by race, and also by gender, that remained constant."
The differences include lifesaving treatments, including what doctors call reperfusion therapy. That's when doctors restore blood flow to the heart using techniques such as the use of clot-busting drugs or balloon angioplasty.
Not all heart attack patients need the same treatment. So Vaccarino's team carefully sorted through patient records. They compared only patients who would be ideal candidates for each type of treatment.
Compared with white men:
—Reperfusion therapy was given 3 percent less often to white women, 9 percent less often to black men, and 11 percent less often to black women.
—Heart angiography — using dye injections to get critical information about blood flow to the heart — was used 9 percent less often in white women, 18 percent less often in black men, and 24 percent less often in black women.
—Black women had an 11 percent higher risk of dying from a heart attack.
These differences did not narrow over the study's eight-year time span.
Blacks Get Fewer Major Surgeries
For decades, it's been no secret that when people need major surgery, they are much less likely to get it if they are black.
"In the early to mid-1990s, there were a bunch of initiatives, both on the national and local/state level, to do something about reducing these disparities," Harvard researcher Ashish K. Jha, MD, MPH, tells WebMD. "We wanted to know whether, given all this attention, things are getting better."
Jha and colleagues used Medicare and census records to calculate surgery rates for black and whites from 1992 to 2001. All patients had health insurance, Jha says.
"We looked at nine common major surgeries that have an impact on whether people live or die or have an important impact on quality of life," Jha says. "We looked at things like bypass surgery, heart valve surgery, and also hip replacement, knee replacement, and back surgery. We looked at these things over a 10-year period."
The results: As far as getting major surgery is concerned, efforts to end the race gap have been a total failure.
"Things are not getting better," Jha says. "The gap is, if anything, getting wider. We found no evidence things are even starting to get better."
As of 2001, the racial gap got wider for five of the surgeries, did not change for three, and narrowed only for one. The single narrowing — for surgery to repair abdominal aortic aneurisms — may have been because whites were more likely to get a new, less-invasive technique instead of this dangerous surgery.
But maybe, Jha hoped, improvements in some local areas might be getting lost in the national figures. So the researchers looked at surgical rates for three common operations in 158 local areas: coronary artery bypass, carotid endarterectomy (unblocking the major neck artery), and hip replacement.
There were improvements for some procedures in some areas. But nobody, it seems, has a solution to racial disparity in surgical care.
"We found that there wasn't a single region we could identify where blacks and whites receive the same rates of these procedures," Jha says.
Did looking at the nation as a whole hide areas where progress is being made? Hardly. While the gap did narrow in 22 local regions, it got worse in 42 local regions and was unchanged in the remaining 94 regions.
"We found no local regions in which racial differences in care were eliminated altogether by 2001," Jha and colleagues write. "For the decade of the 1990s, we found no evidence, either nationally or locally, that efforts to eliminate racial disparities in the use of high-cost surgical procedures were successful."
A Bright Spot: Medicare Managed Care
But Medicare data show that there has been some progress. Amal N. Trivedi, MD, MPH, of Brigham and Women's Hospital in Boston, and colleagues analyzed 1.8 million patient observations from 183 managed care plans administered by Medicare.
Over the seven-year period of 1997 to 2003, there was a successful effort to make clinical care better. It worked for all enrollees. And it helped narrow racial disparities. Of the nine measures studied, seven showed a narrowing of the gap between blacks and whites.
"Not only did performance dramatically improve, but the gap narrowed as well," Trivedi tells WebMD. "We see this as a major success story. However, not all measures fit this pattern. So while this is encouraging, we obviously have a long way to go to eliminate racial disparities."
The bad news was that the two measures in which the racial gap did not narrow — glucose control for patients with diabetes and cholesterol control among heart patients — represented actual patient care instead of patient testing.
"It was interesting that the things that did not change were outcome measures: improving patients' glucose measurements, for example, as opposed to just ordering the test," Trivedi says. "So we need to have more systems interventions; we need to make medicines more affordable, we need to increase access to care. We don't know, but those are the measures I think we need to focus on where the gaps remain substantial."
Rx: Overhaul, Not Tune-Up
The Trivedi study offers some hope, Jha says. It shows that improving care for everyone cuts racial disparities.
But a more radical solution is needed.
"The studies really tell you that small fixes aren't going to work," Jha says. "We can't just tinker with the health care system and expect major results. It will take major repairs. We need an overhaul of our health care system to make sure everybody gets same quality of service, with special focus on minority populations."
Elements of this broad-based effort would include:
—A national health care policy that makes ending racial disparities a major goal.
—Efforts by insurers and health plans to gather racial information in order to measure and eliminate race gaps in health care.
—Efforts by doctors to recognize and eliminate racial disparities.
—Efforts by patients to understand their health risks, their medical conditions, and appropriate treatments.
SOURCES: Vaccarino, V. The New England Journal of Medicine, Aug. 18, 2005; vol 353: pp 671-682. Jha, A.K. The New England Journal of Medicine, Aug. 18, 2005; vol 353: pp 683-691. Trivedi, A.N. The New England Journal of Medicine, Aug. 18, 2005; vol 353: pp 692-700. Lurie, N. The New England Journal of Medicine,Aug. 18, 2005; vol 353: pp 727-729. Ashish K. Jha, MD, MPH, assistant professor of health policy, Harvard School of Public Health, Boston. Amal Trivedi, MD, MPH, research fellow, Brigham and Women's Hospital/Harvard Medical School, Boston. Viola Vaccarino, MD, PhD, associate professor of cardiology, Emory University School of Medicine, and associate professor of epidemiology, Rollins School of Public Health, Atlanta.