The Real World of Health Policy

Race, Ethnicity, and Health Care

Racial and ethnic disparities in health care—whether in insurance coverage, access, or quality of care—are one of many factors producing inequalities in health status in the United States.1 Eliminating these disparities is politically sensitive and challenging in part because their causes are intertwined with a contentious history of race relations in America. Nonetheless, assuring greater equity and accountability of the health care system is important to a growing constituency base, including health plan purchasers, payers, and providers of care. To the extent that inequities in the health care system result in lost productivity or use of services at a later stage of illness, there are health and social costs beyond the individual or specific population group.

Background

About 1 in 3 residents of the United States self-identify as either African American, American Indian/Alaska Native, Asian/Pacific American, or Latino. Few would disagree that for most of this nation's history, race was a major factor in determining if you got care, where that care was obtained, and the quality of medical care. However, the influence of race today is more subtle. Public policy efforts, most notably the enactment of Medicaid and Medicare in 1965, along with enforcement of the 1964 Civil Rights Act, have made an enormous difference in reducing the health care divides in the U.S. So much progress has been achieved that many think that the disparities that remain are inconsequential, but they are not.

The Institute of Medicine (IOM) landmark report Unequal Treatment: Confronting Racial and Ethnic Disparities in Care provides compelling evidence that racial/ethnic disparities persist in medical care for a number of health conditions and services.2 These disparities exist even when comparing individuals of similar income and insurance. Evidence of racial/ethnic disparities among patients with comparable insurance and the same illness has been the most troubling since health insurance coverage is widely considered the "great equalizer" in the health system.

The momentum to address health care disparities has grown largely in response to the step taken by the Department of Health and Human Services (DHHS) in 1999, establishing a national goal of eliminating health disparities by the end of this decade. Disparities between racial/ethnic groups and geographic areas were of major concern.3 The decision for the U.S. to have one set of goals for all Americans, rather than separate goals for the health of whites and minority populations, has helped to focus public and private sector attention on racial/ethnic disparities in the nation's health and thus, health care system.

Policy Challenges in Addressing Health Care Disparities

Although attention to racial/ethnic disparities in care has increased among policymakers, there is little consensus on what can or should be done to reduce these disparities. The U.S. Congress provided early leadership on the issue by legislatively mandating the Institute of Medicine (IOM) (www.iom.edu) study on health care disparities and creating in statute, the National Center on Minority Health and Health Disparities at the National Institutes of Health. Congress also required DHHS to produce an annual report, starting in 2003, on the nation's progress in reducing health care disparities.4 These efforts have provided an important foundation for addressing health and health care disparities.

The IOM study committee for Unequal Treatment recommended the use of a comprehensive multi-level strategy to address potential causes of racial/ethnic disparities in care that arise from circumstances or interactions at the level of the patient, provider, and health care system. The recommendations point to four broad areas of policy challenges:

• Raising public and provider awareness of racial/ethnic disparities in care;

• Expanding health insurance coverage;

• Improving the capacity and number of providers in underserved communities; and

• Increasing the knowledge base on causes and interventions to reduce disparities.

NOTES:

1. Disparities in "health care" and in "health" are often discussed as if they are one in the same. A health care disparity refers to differences in, for example, coverage, access, or quality of care that is not due to health needs. A health disparity refers to a higher burden of illness, injury, disability, or mortality experienced by one population group in relation to another. The two concepts are related in that disparities in health care can contribute to health disparities, and the goal of the use of health services is to maintain and improve a population's health. However, other factors (e.g., genetics, personal behavior, and socio-economic factors) also are major determinants of a population's health.

2. Institute of Medicine. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press.

3. U.S. Department of Health and Human Services, Healthy People 2010. pp.11-16.

4. U.S. Department of Health and Human Services. 2003. 2003 National Healthcare Disparities Report. Washington, DC: U.S. Department of Health and Human Services.

SOURCE: Henry J. Kaiser Family Foundation. 2004. "Health Care & the 2004 Elections: Race, Ethnicity and Health Care." October, Report no. 7187. This information was reprinted with permission of The Henry J. Kaiser Family Foundation. The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national healthcare philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.

Although the nation's population is diverse, with differences in health-related needs and disparities in health status and access to the benefits of the services of the healthcare system, a rather homogeneous set of values directly affects the basic approach to health in the United States. To a great extent, many in American society place a high value on individual autonomy, self-determination, and personal privacy and maintain a widespread, although not universal, commitment to justice for all of its members. Other characteristics of the core society that significantly influence the pursuit of health include a deep-seated belief in the potential of technological rescue and, although it may be changing, a long-standing obsession with prolonging life with scant regard for the costs of doing so. These values help shape the private and public sectors' efforts related to health, including the elaboration of public policies germane to health and its pursuit.

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