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Health Care Disparities
By Jim Anderson , PA-C
AAPA Committee on Diversity
Over the past two decades, increasing research and attention has been focused on the disparities, inequalities and inequities in the health care received by racial, ethnic and socioeconomic groups within (and outside of) the United States. As the research expands, the evidence is becoming increasingly clear that different groups receive dissimilar levels of health care services, both in the quality and the quantity of services provided.
When placed within the context of our national wealth and prosperity, the very existence of such disparities in health care stands as a stark contradiction. Never before has the world seen such advanced technological progress as that now found in the United States . From sophisticated imaging and diagnostic devices to biochemical agents capable of engineering astounding feats within the human body, possibilities and promise of medical advances explode all previous notions about limits to medicine.
Yet the gap between those who fund, create and benefit from these advances and those who receive inferior services continues to grow, as does the evidence incriminating this gap as a free-standing cause of poor health in millions of our patients.
What are health care disparities (HCDs)?
Defining the Issues
Basic to discussing the issues of HCDs is the assertion that patients from specific groups receive a lower quality of health care than others do. "Unequal Treatment," a 2002 report requested by Congress and published by the National Academy of Sciences, describes the persistence of this data, even when access issues are removed from the discussion: "Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patient's insurance status and income, are controlled." (1)
While the sources of these disparities are complex and multifactorial, research elucidates the significant role of the health care provider as a potent contributor to this problem. (1)
Key to the medical provider's development of a contextual understanding of disparities and inequity issues is the placement of racial and ethnic disparities within a historical perspective. Racial and ethnic disparities have not just materialized from thin air, nor are they inevitable. Health care has been apportioned throughout our nation's history based on social class, race and ethnic origin of our patients. (1) For many providers, these issues are thought to be shameful and resolved relics of our past. Research regarding HCDs reveals the opposite, evidencing continued racism and discrimination in the arena of health care delivery. (1)
HCD studies frequently use the term "health care inequality," often referring to measurable values used to examine the unequal delivery of health care services to various individuals and groups. One group of researchers asserted that the term "health care inequity" refers to unfair treatment of individuals or groups beyond what are thought to be unavoidable and necessary genetic differences, describing instead inequalities that are the result of social injustice and lack of societal fair play. (2) This distinction lies at the heart of much of the modern research into this topic and challenges the medical community's categorization of HCDs as inevitable and based on natural characteristics of various groups.
Research and Data
According to "Unequal Treatment," the marked differences in the treatment of patients has lead to widely accepted research results indicating disparate health care within the United States: "Despite steady improvement in the overall health of the U.S. population, racial and ethnic minorities, with few exceptions, experience higher rates of mortality and morbidity then non-minorities." (1) This most basic portrayal describes the core problem driving the ever-increasing scope of research aimed at better grasping this complex problem and in visualizing and implementing potential solutions.
Research and discussion regarding HCDs most commonly focuses on one of three areas:
Health care inequality research examines what happens when individuals from different groups present to the health care system with similar maladies, yet receive unequal treatment.
Health care inequity describes studies and research projects that concentrate on issues of fairness and social injustice, often uncovering the hidden role of institutional racism and discrimination and their burdensome impact on numerous groups and individuals.
Income inequality/allostatic load research focuses more specifically on the power of socioeconomic status as a driver of HCDs. This research often looks at the specific ways that income inequality impact patient health, an impact also known as allostatic load.
Health Care Inequality
The exhaustive compilation of research and data gathered in "Unequal Treatment" provides indisputable evidence that specific ethnic and racial groups receive substandard and inferior care. Reviewing articles published in peer-reviewed journals in the 10 years prior to its publishing, editors chose only literature that controlled for differences in access to health care. (1) Categorized into specific body systems, the data serve as an emphatic punctuation mark regarding HCDs, leaving no doubt that the issue is real and pervasive. The cardiovascular segment of "Unequal Treatment" cites the strength of such evidence:
"The preponderance of studies finds that even after adjustment for many potentially confounding factors including racial differences in access to care, disease severity, site of care, (e.g., geographic variation or type of hospital or clinic), disease prevalence, co-morbidities or clinical characteristics, refusal rates and overuse of services by whites racial and ethnic disparities in cardiovascular care remain." (1)
Table 1 summarizes some of the most compelling cardiovascular studies and data revealing such evidence.
Health Care Inequity
While increasing evidence confirms the existence of the unequal treatment of specific groups based on race and ethnicity, there still is no clear cut, widely accepted mechanism by which these disparities occur. Viewing the issues in the context of "health care inequity" is a movement in this direction, with increased focus on issues of fairness and social justice. Using "equity" as a point of reference has brought a shift to a more causal investigation, looking at the clinician's potential in alleviating (or exacerbating) the suffering and inferior treatment received by specific groups.
Abreu's 1999 study exemplifies this broadened scope, different in its increased focus on the genesis of the unequal treatment now widely acknowledged.(2) The study assessed the effect of stereotyping on the clinical impressions of mental health providers, exposing providers to either neutral words (a process called "priming " by the study authors) such as "water," "then" and "about," or exposing them to words associated with African American stereotypes such as "Negroes," "blues" and "rhythm." After observing the words flashed on a computer screen for 80 milliseconds, providers were than asked to evaluate the same hypothetical patient. According to "Unequal Treatment," "Abreu found that therapists primed with stereotype-laden words rated the patient significantly less favorably on hostility-related attributes than [did] therapists exposed to neutral words." (1) Numerous other studies reveal similar evidence, pointing to the significant role of stereotyping and provider prejudice in the process of clinical decision-making (Table 2).
Van Ryn and Fu described the mechanism whereby medical providers may influence and exacerbate racial and ethnic health care disparities: "Providers may both have and intentionally or unintentionally communicate lower expectations for patients in disadvantaged social positions. In this way, providers can influence help seeker's expectations for the future, the degree to which they expect to obtain the resources and help they need, and their expectations for improvements in their situations or conditions, which in turn may account for some of the disparities observed in outcomes and health status." (4)
In discussions of health care inequity, social justice emerges as a common focal point. While the connection between social justice and health care has been made for decades, there has not been consensus about appropriateness of viewing health care in terms of fairness. Daniels has argued that health care should be elevated and viewed as a commodity deserving equal distribution because of the impact of health on opportunity: "Specifically, the central function of health care is to maintain normal functioning. Disease and disability, by impairing normal functioning, restrict the range of opportunities open to individuals. Health care thus makes a distinct but limited contribution to equality of opportunity." (5)
Powe, in discussing the mode in which chronic kidney disease affects ethnic minorities at a disproportionate rate, equated medical professionalism with the promotion of social justice, suggesting that the unequal treatment of minorities in regards to kidney disease is at least partially a reflection of an unfair and socially unjust system. (6) This focus on justice and fairness is uniquely common to discussions of health care equity.
In a review of the 2003 book Medicine and Social Justice , Sandy describes the shifting focus of ethicists and of the concept of social justice, moving away from individual to systemic examination community health: "Bioethicists, heretofore focused on thorny issues in individual patient care, are now beginning to assess the ethical underpinnings of the allocation and distribution of resources in health policy and health care organizations." (7)
Braveman and Gruskin further elucidated the connection between social justice and health care inequities: "Equity in health is the absence of systematic disparities in health (or the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage-that is wealth, power or prestige." This work is significant for its placing at center stage the issue of fairness in looking at the health of patients, rather than the historic tendency to view individual health as a result of individual behaviors.(8)
Green uses stronger language in connecting social injustice and health care: "In the last 20 years, the issue of disparities in health between racial/ethnic groups has moved from the realm of common sense and anecdote to the realm of science. Hard, cold data now force us to consider what many had long taken for granted. Not only does health differ by race/ethnicity, but our health care system itself is deeply biased. From lack of diversity in the leadership and workforce, to ethnocentric systems of care, to biased clinical decision-making, the American health care system is geared to treat the majority, while the minority suffers." (9)
Income Distribution/Allostatic Load
This area of research and discussion has provided a fresh and unique perspective on the cause of HCDs. Bezruchka described one of the underlying tenets of this area of research: "What matters in improving health? While current debates rage over things such as managed care or the growth of high-tech medicine, one of the greatest impacts on health is being totally ignored. Increases in inequality in the U.S. and elsewhere as a result of the triumph of the market are as much to blame for poor health as anything." (10)
Many in the medical community believe that inequality and socioeconomic gapping between groups are natural and unavoidable consequences of modern-day life, and that such issues are "social" in nature and therefore outside the scope of the medical community. Addressing these beliefs will pose a stiff challenge to those driving this area of research.
Wilkinson's description of specific negative health care consequences resulting from inequality squarely disputes such notions and has provided depth to the assertion that "inequality kills." Chronic activation of the sympathetic nervous system is simply thought to wear out the body via actions of the hypothalamic-pituitary-adrenal (HPA) axis. Higher rates of hypertension, insulin resistance, cardiovascular disease and cancer, and a speedier decline in mental function (largely due to increased cortisol levels, also known as allostatic load), have all been shown to result from this accumulated impact of the stressors on our patients of lower socioeconomic status. (11)
Wolfson and colleagues frame this issue in more basic terms, describing the connection between inequality and health care: "Research has shown that higher levels of inequality in income among nations, states or cities in the United States , or other geographically defined populations, are associated with higher mortality." (12) Conversely, significant evidence also indicates that higher relative income has a "protective" effect on health.
Absolute income levels have been shown to matter less than relative income levels. In Japan , the region with the lowest income also has the lowest mortality rate; one of India 's poorest states has a life expectancy nearly equaling that found in the United States. (10)
According to Wilkinson, "Within countries or states, income is closely related to mortality because it measures differences in socioeconomic states. What the income distribution relation tells us is that health is worse when there is greater inequality across this social gradient." (11)
Yet it is not only poor people who benefit from increasing income equality. (11) Nations with the longest life expectancy are not the richest, but rather those with the most egalitarian structures. (11) Reducing income inequality increases the health of citizens at both ends of the socioeconomic spectrum. Marmot and Wilkinson described this key point of their research, citing evidence that wellness in wealthy countries is more closely related to relative income than to absolute income, and concluding that what effects health most in inequality. (13) Kaplan and colleagues also found from their study of income and mortality that there is a significant correlation between income inequality and a host of health outcomes. (14)
Social capital, the term used to describe social cohesiveness, has emerged as a major new piece in examining the relationship between income and health. Wilkinson described the connection between the two, observing the suggestion by recent research that more socially cohesive societies (societies with more social capital) have better health: "There are a number of examples of egalitarian, healthy and cohesive societies. In each, unusually cohesive social relations may have been protective of health." (15)
Since that time, quantitative evidence continues to point to the connection between social cohesion, income equality, and the health of individuals within communities. 15 Kawachi and colleagues found that higher rates of the most serious health care problems (coronary artery disease, malignant neoplasms, infant mortality and cerebrovascular disease) were all associated with low levels of social trust. 16 Other research has reflected similar outcomes, notably Marmot's finding that the quality of social relations, when teamed with degree of social dominance, inequality and autonomy, are key drivers in the determination of population health. (13)
Racial and Ethnic Disparities Exist
Primary care and specialty clinicians may feel overwhelmed and confused when considering ways to address this evidence. Utilizing similar tools used by clinicians when dealing with complex and difficult health issues with patients, PAs and other medical providers can benefit from "starting at the start." Two salient issues rise out of the HCD data, and examining and ordering such evidence can help to make sense out of this complicated and highly charged topic.
The best evidence indicates clearly that racial and ethnic disparities exist, and that specific racial and ethnic groups receive substandard care. But it is also clear that societal beliefs about causes of this unequal treatment do not accurately reflect actual origins. It is a common belief that these disparities are access-related issues; the evidence undermines this belief without ambiguity. Bias, stereotyping and prejudice on the part of clinicians also play significant roles in this problem, even when the providers are well-intentioned and not practicing purposeful discrimination. (1) As is asserted in "Unequal Treatment," "Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life." (1)
Inequality and Poor Health Are Connected
This evidence challenges medical providers' most basic role beliefs. Traditionally, practitioners have seen their responsibility limited to the assessment of patients as individuals and to assigning specific health problems to individual behaviors. Perhaps most perplexing about this view is the evidence that inequality might be a more significant determinant in the health of patients than individual behaviors. Japanese men smoke at a rate twice that of American men, yet their smoking-related deaths are approximately half of American men. (17) This has occurred during a period when Japan has moved to structural changes resulting in more equality throughout the society. One need only look as far as CEO salaries to see evidence of this change. American CEOs average almost 500 times the income as entry-level workers, while their Japanese CEO counterparts receive salaries only 15 to 20 times greater than their lowest-paid citizens. (17)
Recommendations
"Unequal Treatment" makes 21 recommendations for addressing HCDs, encompassing legal and policy issues, health care systems interventions, patient education and empowerment education of health care professionals, data collection and monitoring and research needs. While many of these recommendations are more appropriately targeting non-clinicians, many also relate directly to the scope of influence exercised by medical practitioners. Particularly germane to the clinician are recommendations 2-1 and 2-2, highlighting the need to increase awareness of racial and ethnic health care disparities among the general public and health care providers.
Recommendation 2-1: Increase awareness of racial and ethnic disparities in health care among the general public and key stakeholders. (1)
Recommendation 2-2: Increase health care provider's awareness of disparities. (1)
While this point may seem obvious, the discussion of HCDs is still new enough to necessitate organized and concerted initiatives on the part of clinicians to promote the dissemination of this information to patients and colleagues, encouraging the examination of practice methods in light of this research. Table 3 summarizes other recommendations of the study with specific clinical relevance. (1)
Other Recommendations
Establish diversity principles and create collaborations with non-clinicians.
Diversity consultant Patricia Digh proposes the establishment of "diversity principles." In her vision, such tools could help to nurture settings where diversity is valued, providing fertile ground for the reduction in HCDs. Traditional values of hierarchy, exclusivity and assimilation dominate workplace and clinical cultures characterized by competition, giving and taking orders and clear establishment of lines of control (including providers over patients and management over employees). (18) Digh asserts that moving from those values to more egalitarian ideals of community building, inclusiveness and collaboration can result in better care for an increasingly diverse population.
Horowitz and colleagues also stressed the importance of creating and nurturing collaboration between clinicians and other disciplines including researchers and policy makers, speculating that development of standards for culturally competent care might be one area of collaboration between the clinician and these other participants. (19) Coker similarly suggested that the addressing of racial and ethnic health care disparities cannot be effectively addressed in a disjointed fashion: "It (addressing racial equality and valuing diversity) requires a whole system change from grass roots to senior leadership, from medical education to employment, from primary care to acute care." (20) This observation points to the necessity of creating partnerships among clinicians, managers and other professionals. (21)
Integrate race consciousness into clinical practice.
Watts defined "race consciousness" in the setting of HCDs as "the appreciation of the complex historical journey of these persons (African American patients); knowledge of disparities in health which facilitate or inhibit optimal levels of care for these individuals and their families, and the self-appraisal of one's attitudes, feelings, beliefs and biases towards African Americans and/or persons of color." (22)
Asserting that such an effort should be seen as a lifelong journey for health care providers, Randall also suggested that cultural competence and race consciousness be reflected in clinical leadership by addressing these issues in mission statements and strategic planning. (22)
The PA's Role
Many PAs are perplexed by HCDs and wonder about the role of the medical provider in addressing these issues, both individually and within professional associations. Intertwining issues of fairness, justice and medical outcomes pose profound ethical dilemmas for the medical practitioner. A desire to improve the health of both individuals and communities motivated most practitioners to undertake the practice of medicine. This common goal of striving to decrease human suffering is reflected in vows taken by students graduating from one PA program, where students state in their oath, "I will strive to apply my skills only with the utmost respect for the well-being of humanity."
While some within the profession assert that concern over issues of fairness and equality is not an appropriate area of focus for clinicians and that PAs' efforts and attention are better utilized when focused on more traditionally defined "clinical" issues, it can also be argued that there is an urgent need to rethink the role of clinicians, to understand differently the responsibility of the medical practitioner. Medical training purports to follow rational and logical progressions. PAs learn to recognize disease and treat it, to investigate causes of disease and target those contributing factors. For example, medical schools teach that smoking causes illness, and subsequently, providers are taught to counsel patients to stop smoking. When the medical community learned that mercury exposure resulted in increased illness, organized medicine helped push for increased restriction of mercury exposure. Evidence that diets high in saturated fat contributed to premature morbidity and mortality led medical providers to counsel patients to reduce their exposures to morbidity-fueling foods.
Yet increasing evidence indicates that all these efforts are not effectively addressing the larger cause of these problems. Numerous studies cited here not only indicate that racial and ethnic minorities suffer poorer care than do their white counterparts, but also spotlight inequality within communities as one of the primary reasons. In light of these consistent research results, the role of patient education alone is significantly undermined and appears to be inadequate in dealing with the true root issues. For medical providers striving to uphold a commitment to decrease human suffering, finding new and expanded ways to address, talk about and ultimately reduce inequality can be initiated by an understanding of the relevance of inequality to clinical practice.
The healing potential of the PA might be as powerful outside of the examination room as within. Development of the concept of the "Citizen PA" could help to realize that potential. After all, the medical provider practices within a community and does not practice in a clinical vacuum. PAs and other medical providers are regarded by our patients and our associates as health experts. This perception grants medical providers credibility and power within their communities. Government, academic and media institutions listen carefully to the medical professions, and by speaking individually and as a profession to these institutions, PAs can positively affect the health of racial and ethnic minority patients.
Speaking about the role of inequality may be both a significant first step toward the development of the "Citizen PA" (perhaps moving toward a more complete understanding of an expanded responsibility to patients suffering the ill effects and consequences of inequality), and an emerging ethical responsibility.
Jim Anderson is a PA at Harborview Medical Center in Seattle . This article originally ran in the Jan.-Feb. 2005 issue of ADVANCE for Physician Assistants, http://physician-assistant.advanceweb.com/common/Editorial/Editorial.aspx?CC=66385.
Health Care Disparities : References
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2. Kawachi I, Subramanian SV, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health. 2002;56:647-652.
3. Abreu JM. Conscious and nonconscious African American stereotypes: impact on first impression and diagnostic ratings by therapists. J Consult Clin Psychol. 1999;67:387-393.
4. van Ryn M, Fu SS. Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health. 2003:93:248-255.
5. Daniels N. Justice, health, and health care. In: Rhodes R, Battin M, Silvers A. Medicine and Social Justice: Essays on the Distribution of Health Care. New York , NY : Oxford University Press; 2002:6-23.
6. Powe NR. To have and have not: health and health care disparities in chronic kidney disease. Kidney Int. 2003:64:763-772.
7. Sandy LG. Medicine And Social Justice: Essays on the Distribution of Health Care [book review]. N Engl J Med. 2003:348:1936-1937.
8. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57:254-258.
9. Green A. The human face of health disparities. Public Health Rep. 2003;118:303-308.
10. Bezruchka S. Are the rich making us sick? Washington Free Press Web site. July-August 2000:46. Available at: http://www.washingtonfreepress.org/46/free_thoughts.html. Accessed September 20, 2004.
11. Wilkinson R. Mind the Gap: Hierarchies, Health, and Human Evolution. New Haven , Conn : Yale University Press: 2001.
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16. Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality. Am J Public Health. 1997;87:1491-1498.
17. Bezruchka S. Is our society making you sick? Newsweek. February 26, 2001:14.
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20. Coker N. Understanding race and racism. In: Coker N, ed. Racism in Medicine: an Agenda for Change. London , England : King's Fund Publishing; 2001.
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Last Revised: 5/3/06
