Brian D. Smedley and Alan Jenkins
April 10, 2007
Brian Smedley is the Research Director of The Opportunity Agenda , a communications, research and policy organization, and formerly served as study director and lead editor of the Institute of Medicine report on racial and ethnic disparities in health care. Alan Jenkins is Executive Director of The Opportunity Agenda.
Five years ago last month, the Institute of Medicine released a congressionally-mandated report, Unequal Treatment, concluding that minority patients receive a lower quality of health care than whites—even after taking into account differences in health insurance and other economic and health factors. Authored by a blue-ribbon panel assembled by the nation’s foremost health and science advisory body, the report went on to say that such inequalities in health care carry a significant human and economic toll and therefore are “unacceptable.” Yet despite these urgent appeals, little has been done to address disparities—leaving too many Americans vulnerable to inequitable and inadequate health care.
Critics of the Institute of Medicine report decried the implication that intentional racial discrimination is involved—though the report levied no such charge. They argued that any evidence of “differences” in health care is the result of economics and consumer choices, not the race or ethnicity of patients.
It’s easy to understand this skepticism. After all, America aspires to be a land of opportunity, a place where everyone is treated equally. The U.S. public overwhelmingly supports equality of treatment, and old-fashioned discrimination today is rare.
But the evidence shows that, when it comes to health care, unequal opportunity persists in ways that run contrary to our national values. Insured African-American patients are less likely than insured whites to receive many potentially life-saving or life-extending procedures—particularly high-tech care such as cardiac catheterization, bypass graft surgery or kidney transplantation. Black cancer patients fail to get the same combinations of surgical and chemotherapy treatments that white patients with the same disease presentation receive. Even routine care suffers. Black and Latino patients are less likely than whites to receive aspirin upon discharge following a heart attack, to receive appropriate care for pneumonia and to have pain—such as the kind resulting from broken bones—appropriately treated.
The Institute of Medicine report offered over two dozen recommendations for public and private sector action to eliminate disparities. But with rare exceptions, few of these stakeholders have taken up the call. Congress has not passed significant legislation to reduce health care inequality since 2000, despite bipartisan efforts led by the Congressional minority caucuses. Health care inequality is rarely discussed in state health care reform campaigns. And private sector efforts have been inconsistent—some leaders, such as Aetna, Kaiser Permanente and others have publicly announced efforts to eliminate disparities, while many other health systems have yet to acknowledge the problem.
As the nation debates ways of affording all Americans health coverage, it is time that we seriously addressed health care inequality as well. Otherwise, we may end up with a system of universal access to grossly unequal services, to the detriment of all Americans.
We can start by acknowledging that racial and ethnic health care inequality persists, despite our conscious efforts to eradicate it. Hospitals and health care systems therefore should be required to report data on the quality and accessibility of health care services by patients’ race, ethnicity, education level and primary language. This information should be publicly reported, so that health care providers and payers are more motivated to press for improvement, and so that consumers are better equipped to make educated decisions about where to seek their care—should they have the choice.
Health care systems should consistently use evidence-based guidelines to improve the quality of health care for all patients. Professional interpretation and translation services should be provided for all patients who need language assistance, and their costs appropriately reimbursed.
Federal, state and local agencies that regulate and fund health care services must take seriously their obligation to enforce anti-discrimination laws like Title VI of the Civil Rights Act of 1964. That means, for example, analyzing available data to determine whether similarly-situated patients of different races are receiving comparable care and services. It means monitoring hospital construction, closings, and relocation of services for their impact on equal opportunity . And it means offering training and technical assistance to health care providers who need help in maintaining fair and effective systems.
Community health workers also provide critically important services in helping patients to navigate health systems, and should be supported. And educational programs should be encouraged, both for patients—to help them learn how to best access health care services to meet their needs—and providers—to help them manage racial, ethnic, cultural and linguistic diversity in their practice and reduce quality gaps.
The nation’s health professional workforce will be greatly strengthened by increasing its diversity, as minority providers are more likely to work—and seek to work—in minority and medically underserved communities, and they’re often able to bridge cultural and language barriers that contribute to quality and access gaps.
These are but some of the steps that policymakers, public and private health systems, health care providers and patients can take to make our health care quality better and more equitable for all. What’s missing is a sharp prick of the nation’s conscience. Americans deeply believe in the power of American opportunity—everyone should have a fair chance to achieve their dreams. This is impossible without a basic level of health care security. We can and should do better to ensure that all patients get the care they need, regardless of their background.