More than a year after Hurricane Katrina laid waste to New Orleans, images of victims—the majority of them poor and Black—trapped on rooftops and holding aloft signs that begged for help remain embedded on the national consciousness. Health care providers and aid workers who flocked to the area are now discovering that many of the victims had such limited access to health care that they were being treated for chronic ailments for the first time. That, they say, is indicative of the larger issue of racial disparities that occur in health care.
The Snowball Effect
According to Target Market News, African-Americans spent a mere $17.9 billion on health care in 2004, the most current figures available, compared to the $1.9 trillion Americans spent overall that year on health care. The Kaiser Family Foundation, which provides information on key health policy issues, reports that a whopping 21 percent of Blacks were uninsured in 2005, compared to 13 percent of whites, and another 25 percent of Blacks were on Medicaid, compared to 9 percent of whites. With countless physicians in private practice refusing to accept Medicaid because of the program’s low reimbursement rates, minority patients’ access to quality health care remains limited, creating a snowball effect where patients delay treatment for ailments until they become so severe that they require costly visits to the emergency room.
Indeed, according to the National Hospital Ambulatory Medical Care Survey, between 1997 and 2000, emergency room visits for Blacks was more than twice the number of visits for whites, further burdening a health care system that separates those with medical insurance from those without or with inadequate coverage.
Hospitals also are caught up in the snowball effect. “If you have a hospital whose population is made up of underinsured patients, you are going to have different equipment and materials compared to a hospital made up of insured or more affluent patients,” explains Charles Francis, M.D., a cardiologist who once chaired the Department of Medicine at Harlem Hospital in New York City. Wealthier hospitals also have the ability to obtain the latest equipment on their own and when they want it, he says, while he has to wait several months before he receives equipment he requests for city-owned and operated Harlem Hospital.
Francis describes a particularly frustrating lack-of-access scenario: “If you go to a doctor in Harlem, he may not have a specialist he refers his patients to routinely because he may not have hospital privileges where that specialist is located. It’s not just the patients’ finances [that are the issue], but also the resources available to the hospital,” he says.
Race and Gender
Studies have shown that even when Blacks and whites share the same socio-economic status and insurance coverage, disparities still exist. In 1999, a research team led by Kevin A. Schulman, M.D., from Georgetown University Medical Center in Washing-ton, D.C., conducted a study titled, “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization,” the findings of which were published in The New England Journal of Medicine.
The study used eight actors disguised as patients, with equal numbers of Black and white men and women, each of whom, according to the script, had the same insurance coverage and income status and described symptoms of coronary artery disease. Schulman found that physicians referred white men in higher numbers for cardiac catheterization, followed by Black men, white women and Black women last.
“I don’t know why anybody is surprised by these findings,” asserts Rodney Hood, M.D., a general internist and CEO of CareView Medical Group in San Diego, California. Hood is past president of the National Medical Association, the nation’s largest organization of Black physicians. “Doctors have certain stereotypes and biases like anybody else. Once African-American [patients] enter the health care system, they don’t receive the same level of care [as white patients]. It’s part of the overall issue of racism in America that we see in health care,” he says.
To address these health care disparities, Congress passed the Minority Health and Health Disparities Research and Education Act of 2000 (Public Law 106-525), which led to the creation of the National Center on Minority Health and Health Disparities as one of 27 institutes and centers under the auspices of the National Institutes of Health. The NCMHD is tasked with promoting minority health and leading NIH’s effort to reduce and ultimately eliminate health disparities. It has the ability to fund initiatives conducted by health care professionals and community organizations on the local level to address these disparities.
Medical advocates agree that though there is heightened interest in health care disparities, there are no overnight solutions. What is required, instead, is a multi-faceted approach involving patient education, research of medical technology and an overhaul of the current managed-care system in which, critics contend, health maintenance organizations take a more mercenary view of medicine. “Right now the HMOs are trying to run medicine like a corporation, where they make profits for the CEOs and shareholders,” says Daniel Laroche, M.D., president of Advanced Eyecare of New York and its director of glaucoma services. He also is president of Empire State Medical Association (www.nyesma.org), the New York State affiliate of the National Medical Association. “Annually, HMOs make nearly $1 billion in profits, while hospitals lose $1 billion in profits, resulting in many of them closing their doors. The HMOs have become the middle men of medicine,” he says. Solving health care disparities is not rocket science, Hood argues. “You need to shift some of the resources from A to B. But the system won’t allow that to happen because too many folks are making money from the current system,” he says.
Moves to create a hybrid Medicaid/managed-care system and the proposed Pay for Performance system in which physicians receive payment incentives for the quality of the health care they provide, sound like plausible solutions, but such “generic systems don’t account for existing health disparities,” Hood says. “Physicians taking care of minority populations should be compensated more because those patients are dealing with more health issues. Even if the program used a portion of the compensation to fund community outreach programs, allowing doctors to have patient facilitators on their staff to help their patients navigate the health care system, it would be a step in the right direction,” he says. Hood maintains that the most ideal system would be a universal single-payer system.
Drs. Francis, Laroche and Hood agree that key to any successful future initiative is the creation of a pipeline of African-American medical professionals. To that end, Empire State Medical Association’s Saturday Science Academy program targets and mentors students from kindergarten through 12th grade who show an interest in math and science, while its Mock Interview Mentoring Program helps college and medical students polish their interview skills with seasoned physicians serving as mentors.
A key goal of the association is to increase the graduation rate of African-Americans with a Regents high school diploma from the current rate of 25 percent to 75 percent. “There is a whole arena of careers in health care for African-Americans to fill, but if 75 percent of our community is not graduating with a Regents diploma, there’s not going to be a job you can get if you don’t have a college degree,” Dr. Laroche says.
Health Policy Recommendations for New York
Empire State Medical Association, the New York affiliate of the National Medical Association, the premier Black physicians organization, recommends the following public policy measures to help eliminate health disparities in New York communities showing grave disparities in health, education and unemployment.
l Consider eliminating HMOs and decrease administrative cost of medicine;
l Create legislation to allow independently practicing physicians to collectively negotiate contract terms with insurance companies;
l Create and enhance preventive public service announcements and public health education
l Expand the healthcare safety net and create policy to increase access to health insurance for New Yorkers that do not have it. Parity in insurance coverage for mental illness;
l Repeal the N.Y. Medicaid cuts for healthcare for those patients with dual eligibility for Medicare and Medicaid and end Medicare fee cuts;
l Institute tort reform with caps on malpractice awards;
l Reduce the cost of medications;
l Regulate and investigate health insurance
l Create violence reduction, conflict resolution, and preventive law education protocols for junior high school students and the public;
l Improve educational protocols in the zip codes with the highest health disparities;
l Immediately develop job training programs for men in NYC;
l Mandate cultural competency training.