Disparities in Care Deserve More Attention

Some Americans receive worse healthcare than others. Some of us are more likely to be uninsured; some of us have poorer outcomes; some have lower health literacy and other obstacles to access. Most would agree that eliminating these care gaps for our fellow citizens should be a top priority.

But add a few details about these disparities and many people start to get uncomfortable. Race and ethnicity are often strong determinants of healthcare quality. Immigrants tend to struggle in the system. Poverty also plays a role and often overlaps with demographics.

It's not that providers, politicians, and the rest of us don't care about these factors. It's that Americans still don't talk about race and ethnic issues very well, or maturely. Our shameful history of segregation, civil rights struggles, and even slavery isn't that far behind us and still taints our discussions, so we often avoid them altogether or treat them as a spectacle.

In all of the debate about reforming healthcare in the last year, very little has been said about the importance of reducing racial and ethnic care disparities. Yet, these disparities persist, and in some cases they are growing more severe.

For example:

• The 2008 National Healthcare Disparities Report found that for minorities and poor people, at least 60% of the quality measures it tracks were either staying the same or getting worse.
• Minorities, particularly Hispanics, are still less likely to have health insurance Although the gap has been closing between white and black Americans, that is largely because now fewer whites have insurance.
• Minority patients are less likely to have surgeries at high-volume hospitals and by high-volume surgeons, according to a new study.
• Minorities are less likely to receive certain regular preventive measures, such as colorectal cancer screenings. New AIDS diagnoses are three times higher for Hispanics as for non-Hispanic whites; for black Americans the rate is more than nine times higher.
• Physician adoption of recommended practices to improve care for minority patients—such as training in minority health issues, providing interpreter services, and following reports about demographic information and care quality—remain “modest and uneven,” according to the Center for Studying Health System Change.

There are numerous other studies that highlight factors ranging from provider discrimination to wellness to genetic differences as possible causes of racial and ethnic disparities. But eliminating these gaps isn't simply a matter of finding a single problem and fixing it. These are complex structural issues for which there aren't always easy solutions.

It has to start, however, with greater acknowledgement of the problem. The national healthcare reform debate was an ideal opportunity for that, which has for the most part been squandered.

As the nation grows even more diverse in the coming decades, issues like cultural competency, care for immigrants, and personalized medicine will become more important to everyday practice. To their credit, physicians and other providers are better than most, particularly politicians, at recognizing disparities and working to correct them, even while facing many other healthcare challenges (including a lack of resources for addressing disparities).

But this isn't a problem physicians can address on their own. If we as a country are truly interested in building a better healthcare system, then we have to start by acknowledging that the system fails certain segments of society in predictable and shameful ways.