Divided

Racism pervades the provision of health care in America with severe consequences, as these authors show.

Disparities in health-insurance coverage must be addressed as an important first step toward eliminating the health care disparities that disproportionately affect the economically disadvantaged and people of color. Examples of such health care disparities include the black infant-mortality rate, which at 13.6 infant deaths per 1,000 live births is double that of non-Hispanic whites (NHWs) at 5.7. Another example is diabetes; 13 percent of Hispanics and 15 percent of black adults have diabetes versus 8 percent of NHWs.

The causes of these health disparities are complex and multifactorial and include issues related to the environment, poverty, housing, education, health behaviors, and even segregation and discrimination. Another important contributor to these health care disparities is the difference in quality of the health care received by racial or ethnic minorities versus that of NHWs. Examples of these health care disparities include blacks’ receiving fewer bypass surgeries and kidney transplants than NHWs. Although blacks are one and a half times more likely to die from heart disease than whites, the rate of bypass surgery among whites was 9 per 1,000 versus 4 per 1,000 among blacks in 2001. Similarly, while over 50 percent of NHWs have received age-appropriate colorectal cancer screening, only 35 percent of Asians and Hispanics have had such tests.

In 1999, Congress commissioned the Institute of Medicine (IOM) to produce an in-depth report on health care disparities. The charge was to examine the existence of disparities that were not due to known factors such as health-insurance coverage and ability to pay. What the IOM found was that even after accounting for insurance, members of racial and ethnic minorities received lower-quality health care than NHWs. Yet, as this landmark report points out, disentangling the impact of known causes of disparities, such as access to affordable health insurance, from broader economic and social inequities is an “artificial and difficult distinction.”

The IOM noted that while disparities in access to affordable quality health care are “likely the most significant barrier to equitable care,” other factors such as bias, discrimination, and negative racial stereotypes are also important barriers to equitable care. Additional contributors to health care disparities included cultural and linguistic barriers, lack of a stable primary-care clinician, and fragmentation of the health care system.

The annual statistics published by the Census Bureau portray a dismal picture of health-insurance coverage among minorities. The data show that one-third of Latinos in the United States lack health-insurance coverage and 20 percent of both blacks and Asians in the United States are uninsured as well. In contrast, only 10 percent of NHWs are uninsured. Further, from 1987 to 2005, the proportion of the uninsured population in the United States that is minority has increased from 42 percent to 53 percent.

Among Latinos and Asians, the most vulnerable are immigrants. Over half of noncitizen Latinos and nearly a third of noncitizen Asians in the United States lack health coverage. It is also estimated that nearly 80 percent of undocumented immigrants lack insurance. However, even U.S.-born Latinos (over 60 percent of all Latinos are U.S. born) are twice as likely as NHWs to lack coverage. Thus, immigration status by itself does not explain a large proportion of the disparities in health coverage between minorities and NHWs in the United States.

MEDICAL APARTHEID IN THE UNITED STATES

In the absence of a system of universal health care, a multi-tier health care system has developed in the United States, one that results in what can be described as health care segregation. In the highest tier are those who have private insurance coverage, usually through their employer or Medicare. These insurance programs are widely accepted by physicians and hospitals.

At the other end are the uninsured. In theory, they can pay for their health care services out of pocket. In reality, as most of the uninsured are either poor or middle class, they often forgo necessary care. Their alternative is to rely on a safety-net patchwork of providers, including community health centers, outpatient departments of public and some not-for-profit hospitals, and emergency rooms. While an important source of care for the uninsured, such patched-together systems are a far cry from the care received by privately insured and Medicare populations. In particular, access to subspecialty care and a stable source of outpatient medications are major barriers to care in these safety-net systems. While 85 percent of NHWs in this country belong to the highest tier of health care, only 63 percent of blacks and 50 percent of Hispanics belong to this top tier of access. Further, while racial and ethnic minorities make up less than a third of the U.S. population, over half of all persons in this lowest tier of health care are minorities.

In the middle tier are those covered through the various insurance programs serving the poor such as Medicaid and the State Children’s Health Insurance Programs (SCHIP). These programs are critical components of the health care safety net and cover 40 million children and adults. Unfortunately, as is true for most other poverty programs, they suffer chronic underfunding and applicants face onerous eligibility and recertification requirements. In some states, over half of all persons who enroll are disenrolled in under a year. Further, when facing budgetary difficulties, limiting enrollment in these programs or rationing health care services through cutbacks of services covered is a favorite ploy of many legislators. Thus, for many enrollees, such programs are a far cry from the comprehensive, ongoing health care access that persons in the first tier enjoy.

The real reason that these underfunded programs are segregated is that in most states providers are paid at levels much lower than Medicare. As an example, in New York a private physician can be paid six times more to see a patient with Medicare versus Medicaid. As a result, fewer than half of all providers nationally choose to accept Medicaid patients. In many localities, this forces most Medicaid patients to receive care through the same network of safety-net clinics that exist for the uninsured. Further, access to subspecialty care in these settings is often as problematic as it is with the uninsured. In one large hospital in New York City, the wait for a Medicaid patient to see a gastroenterologist is eight months. In contrast, a patient with Medicare could be seen within two weeks in the private offices that are part of the same medical center but do not accept Medicaid patients. The government also reinforces this segregated system of care, because it provides additional subsidies or grants for designated safety-net providers and clinics to see Medicaid patients but does not make such funds available to providers in private practice. This segregationist system is quite effective at ensuring that those in the first tier receive a different level of care from those in the second and third tiers. A report by one advocacy coalition, Bronx Reach Coalition, extensively described this system of segregated care and unequal access faced by poor and predominantly minority patients as “Medical Apartheid.”

Among the report’s conclusions were that people who are uninsured or publicly insured (through Medicaid, Medicaid Managed Care, Family Health Plus, and Child Health Plus) are often cared for in separate institutions from those who are privately insured. The coalition also found that even within health care institutions, separate and unequal systems of care exist. The uninsured, people covered by Medicaid, and sometimes even those enrolled in Medicaid Managed Care, Family Health Plus, and Child Health Plus receive poorer care in different locations, at different times, and by less trained physicians than those who are privately insured. Finally, the report shows that when patients are sorted according to their insurance status, this segregated care leads to different health outcomes.

Under a comprehensive national health-insurance plan, a wealthy NHW male would have the same level of coverage as a low-income black female. Detractors claim that this one-size-fits-all approach is not consistent with American values and that individuals should have the freedom to choose the level and quality of health care they wish to receive. However, such detractors have a hard time identifying persons who would want to receive low-quality health care. Clearly, under the mantra of choice, it would be minorities who would disproportionately be stuck in the lowest levels of health care. From a perspective of basic fairness, it is clear that having one system of care in which access to high-quality health care would be a right of all is far superior to one in which quality of coverage is determined by income.

DOES EVERYONE IN AND NO ONE OUT INCLUDE ALL IMMIGRANTS?

Immigrants contribute tens of billions of dollars to our economy, and the sustainability of programs such as Social Security and Medicare to a significant extent depends on taxes paid by such workers. Further, health costs for immigrants are about one-third those of NHWs. Ethical, religious, and humane issues could all be raised to support improving access to care for such immigrants. However, the main reason all immigrants would be included in national health insurance (NHI) is financial. Not only are immigrants relatively inexpensive to cover, but to exclude them would mean maintenance of very expensive administrative systems of billing and indirect and inefficient safety-net reimbursement mechanisms. Simply put, NHI would be much more costly if a system needs to be maintained to exclude 12 million undocumented persons. Thus, comprehensive coverage of all residents of the United States would be far more humane and less costly.

POLITICAL AND ORGANIZATIONAL SUPPORT FOR NHI AMONG MINORITIES

Since NHI is the only proposal for universal coverage that would ensure equitable high-quality health care for all, it has long been supported by the Congressional Black Caucus. Over half the members of the Congressional Hispanic Caucus also support HR 676. NHI also enjoys support among large minority medical groups such as the National Medical Association and the National Hispanic Medical Association. In response, the strategy favored by the insurance and pharmaceutical industries has been to partner with minority political leaders and organizations on other important disparities issues such as workforce diversity, cultural competency, and language barriers—but not on NHI. By lavishing groups with funding for other initiatives, these opponents of single payer hope not only to gain the goodwill of these political leaders and organizations but also to divert advocacy on behalf of NHI. Fortunately, so far this approach has had limited success, with the majority of minority leaders and organizations remaining strong advocates of NHI.

Will NHI end disparities? No. Health disparities are an extremely complex and multifaceted problem that has long plagued our society. As we’ve said earlier, disparities in health are due to a variety of factors—including environment, housing, poverty, education, and racism—that go far beyond just having insurance. Indeed, even in countries that have universal coverage, the wealthy and privileged enjoy better health status and find ways to receive better access to care than those in poverty. However, the magnitude of health care disparities in those countries is significantly less than in the United States. Many of us believe that once we have enacted a system of equitable, comprehensive coverage for all, we can then focus on addressing other important issues. These include ensuring a health care workforce whose diversity is reflective of our society, health care providers who are culturally and linguistically competent to provide care to persons from a wide variety of racial and ethnic backgrounds, and a health care delivery system that is free of the many racial and ethnic biases and stereotypes that plague our society. But since disparities in access to quality health care are a major contributor to disparities in health, health insurance is the key driver of many health care disparities, and efforts to address disparities must start with the most glaring and obvious factor.

Adapted from 10 Excellent Reasons for National Health Care.