March 20, 2002

11:45 AM

America, Heal Thyself."Racial and ethnic minorities tend to receive lower-quality health care than whites do, even when insurance status, income, age, and severity of conditions are comparable, says a new report from the National Academies' Institute of Medicine. 'Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable. The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.'"
posted by fold_and_mutilate (17 comments total)

Here's what we might call the "nub" of that little article:
The federal government should provide greater resources to the U.S. Department of Health and Human Services' Office of Civil Rights... And to ensure that the nation can track its progress in reducing disparities, hospitals should -- without violating patients' privacy -- collect and report data on health care access and utilization by patients' race, ethnicity, socioeconomic status, and primary language.
More funding for nosy government agencies, more racial bean counting, the installation of racial commisars in hospitals. Finally, race and identity politics will be able to do to American health care what it has done to the humanities in higher education.
posted by Faze at 12:07 PM on March 20, 2002

More funding for nosy government agencies, more racial bean counting, the installation of racial commisars in hospitals. Finally, race and identity politics will be able to do to American health care what it has done to the humanities in higher education.

Hell yeah, good buddy. And maybe we can turn back the ol' clock to where it oughta be and git those gol-blamed federal troops out of Little Rock, Arkansas and Oxford, Mississippi, too. Just look what *they* did to ed-u-cashun...the states were a doin' a good job with schools until then, just like they were a doin' a good job with the hospitals, and still are, fer my money's worth. And mebbe we can get those nosy Hoover boys and Justice Department fellas to kinda look the other way when it comes to separate (but equal!) drinkin' fountains. Do we really need "racial commisars" or racial commies or whatever the hell you said there, fer damn drinkin' fountains or even votin' booths, fer chrissakes?

Barnett: Must it be over one little boy - backed by communist front -- backed by the NAACP which is a communist front?...I'm going to treat you with every courtesy but I won't agree to let that boy to get to Ole Miss....That's what it's going to boil down to -- whether Mississippi can run its institutions or the federal goernment is going to run things...

-- Mississippi Governer Ross Barnett to Robert Kennedy, September 25, 1962.
posted by fold_and_mutilate at 12:40 PM on March 20, 2002

What an appalling, but unsurprising, conclusion (the study's, not Faze's trolling action, which is just sad).

I like the Institute of Medicine's solution, which is to collect information about disparities in medical care and keep publicizing the issue until people in the medical industry confronts their attitudes and do something about the problem.

It's simply human nature to treat people better if they look like you. It's simple decency to resist that tendency.
posted by Holden at 12:52 PM on March 20, 2002

I'm not saying that the conclusion is untrue but the evidence provided doesn't support the claim. When you look at each of the listed causes, it seems that in many cases the facts don't relate to the conclusion. My read of this is that the factors most impacting the quality of healthcare received are socioeconomic, not racial. Now, race may be a factor in socioeconomics, but it seems difficult to somehow come up with a soultion that overcomes the medical/racial issues without addressing the socioeconomic issues.

For instance, the report seems to indicate that a large portion of the bias is due to differences in coverage, yet somehow concludes that differences in care are racially biased. In another portion of the report, it indicates that even when whites and ethnic minorities have the same or similar insurance coverages, there is a lack of quality medical treatment available in areas with high concentrations of ethnic minorities but then implies this is somehow racially motivated. The report further states that "even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes" then later says that even when ethnic minority patients are seen by doctors of the same enthic minority, there still exists a deficiency in terms of the level of healthcare.

I think when you examine the collective analysis of at least what was published in this article, the indication seems to be a problem of economics rather than race. And one can safely assume that if you begin by attempting to treat racial bias, which does not seem to be the problem, instead of the economic bias, which is the problem, your chances of causing any major improvement is almost nil.
posted by billman at 1:28 PM on March 20, 2002

Jeepers, fold-and-mutilate, as long as you are characterizing me as a Southern segregationist, why not go all the way and portray me as Hitler? What I was trying to say, perhaps a little too compactly, was that after making all these not particularly well-supported racial accusations against health care (see billman's excellent post, above), the authors have nothing better to offer by way of a solution than more federal oversight -- not more education, not more physician involvement, not more emphasis on prevention, etc. Y'all.
posted by Faze at 1:55 PM on March 20, 2002

Holden: opinions you disagree with are not automatically trolls.
posted by gd779 at 2:06 PM on March 20, 2002

they're harder to see
posted by Settle at 2:15 PM on March 20, 2002

Holden: Perhaps you should re-phrase that. It's Holden nature to treat people better if they look like you.

There are people who feel inclined to show how un-racist they are by making overt gestures. I simply choose not to treat anybody differently.
posted by billman at 2:24 PM on March 20, 2002

I simply choose not to treat anybody differently.

That doesn't cut it as far as being un-racist. What about situations in which you are treated differently?

In another portion of the report, it indicates that even when whites and ethnic minorities have the same or similar insurance coverages, there is a lack of quality medical treatment available in areas with high concentrations of ethnic minorities but then implies this is somehow racially motivated.

Don't get hung up on whether there is discernable racist intent in a case like this. When populations of color are without access to quality medical treatment, what is that but racism?
posted by sudama at 5:42 PM on March 20, 2002

The underlying problem here is so basic and so embarassing that it's constantly overlooked, despite the tireless efforts of Oregon's Governor Kitzhaber.

"In order to be eligible for publicly subsidized care, low income Americans must fit into congressionally designated categories such as "families with dependent children," or the "elderly, blind or disabled." Just being poor is not enough. Poor adults without children, for example, are not eligible, even though they may be deeply impoverished. This concept of categorical eligibility underlies the entire system ...

"If caring for the poor is, indeed, a public sector responsibility, then eligibility for public coverage should be based on financial need -- rather than on an arbitrary set of categories. In Oregon, we defined the "poor" in statute as all those with incomes 100 percent of the federal poverty level.

Dr. Kitzhaber is a physician as well as a politician, and his full analysis is really worth reading.

"Whereas my commitment as a physician is to the individual patient, as a legislator (or as a governor), my commitment is to the larger community. As a physician, I am committed to treating my patient to whatever extent I deem necessary regardless of cost. As a governor, I cannot ignore cost and my commitment is to provide as much health care as possible for as many people as possible with the resources I have available.

"The Oregon Health Plan represents the intersection of these two roles - that of a physician and of a publicly elected official. It is a direct challenge to the status quo - to the explicit federal policy of categorical eligibility and to the implicit federal policy of allocating public resources to benefit the few at the expense of the many."
posted by sheauga at 5:48 PM on March 20, 2002

Ah, another classic fold_and_mutilate post: strawmen, trolls, ad hominem attacks, and a Godwin invocation...all within the space of only five comments.
posted by MrBaliHai at 6:53 PM on March 20, 2002

Don't get hung up on whether there is discernable racist intent in a case like this. When populations of color are without access to quality medical treatment, what is that but racism?

What could it be -- how about financial feasibility? If I am a doctor who has to have a minimum of $1 million in malpractice insurance just to maintain my license, am I going to align myself with a large medical center office with the ability to see insurance-covered patients or am I going to go hang a shingle in the middle of a neighbourhood of colour where there may or may not be enough money coming in to cover the rent (almost always overinflated in depressed neighbourhoods, especially in a decent building) let alone the remainder of the extraordinary overhead related to a medical practice?

It's easy to invoke racism, but the flat out finances can be a major stumbling block. I know several physicians who do a great deal of outreach (much of it for free) into minority communities, but cannot afford to set up practices there, as much as they may want to. If minority communities, particularly the very impoverished ones, were revitalised overall then we could see a return to the neighbourhood physician, better access to medical care and improved overall health. But there are many steps that must be taken to get there, and overcoming racism is only one of them, and in many cases, a small one, at that.
posted by Dreama at 7:15 PM on March 20, 2002

sudama:

That doesn't cut it as far as being un-racist. What about situations in which you are treated differently?


Then I react accordingly but even then I am not treating anybody differently because of their race or ethnicity. I am reacting to being treated in a manner I do not see as appropriate which could just as well occur with someone of my own race/ethnicity.

I look at it like this:

Racism is defined as "Discrimination or prejudice based on race." and "prejudice" is defined as "A preconceived preference or idea."

It's a trap to think that racism is defined by hate. Racism can just as easily be defined by patronizing behavior. In fact, that form of racism is even more dangerous because it leads to "white people" trying to solve the problems of other groups which . . . is the problem in the first place. I hope that part of what Faze was getting at in his post is that when the government gets involved in these types of problems, it usually sets up incentives that do nothing to solve the problem, either creating new problems or making existing problems worse. For instance, welfare was a poor idea because it almost mandated single mothers. It was simply one of many examples of good intentions being followed by poor execution.

The issue of healthcare is another potential welfare. A problem that leads to government mandated reactions that are more likely to lead to worse healthcare in ethnic minority areas than improved healthcare. The problem is economics, not racism. As long as people pretend that the reason this or that group can't receive high quality medical care is because of race and not because they live in parts of town doctors don't want to set up a practice in or because it's unprofitable to offer healthcare if 90% of your patients carry healthcare insurance that pays less than your cost of the procedure, you're not going to solve the problem. You do nothing more than create "feel good" policies that make white people feel better because they feel like they've done something when nothing has improved.

Here's another (kinda, sorta related) example. Black owned banks set up to lend to blacks in inner cities, have at least 50% (most closer to 80%) of their loan portfolios outside of inner cities and in many cases, to mostly whites and latinos. Why? Because they lose money on the inner city loans. The default rates are astronomical. They have to carry the non-inner city loans and whites and latinos because they finance the losses in the inner city portion of the loan portfolio. Yet, time and again we see these "expose" stories that show how Bank of America or Citibank doesn't make loans to inner city people and we cry racism. It's not racism, it's not wanting to lose money! So, the government applies pressure, activist groups get up in arms, and the banks make bad loans, loans they know will defualt, and then they charge everyone else higher interest rates to compensate for their portfolio losses. Now, I'm not saying, let's just not make loans to people in the inner-cities. I'm saying that instead of expending all of your time and effort forcing banks to do business in parts of town where it's unprofitable, instead of forcing doctors to provide healthcare under insurance plans that are unprofitable, MAKE IT PROFITABLE!!! Raise the quality of education in the inner cities. Create programs that spur job growth in the inner cities. In other words, fix the problem, which is economics, instead of trying to treat the symptoms. But that's hard which is why we don't do it. It's much easier to sit back and lament the plight of this group or that group from our nice comfy suburban homes and then cry foul everytime one of these half-assed reports come out. See that might mean making sacrafices and we don't want that. We just want those rich old bankers and doctors to make sacrafices.
posted by billman at 11:40 AM on March 21, 2002

Don't get hung up on whether there is discernable racist intent in a case like this.

So, it's like that, huh? "Don't bother looking too closely, it's racism by default."

Classic.
posted by David Dark at 12:15 PM on March 21, 2002

What I was trying to say, perhaps a little too compactly, was that after making all these not particularly well-supported racial accusations against health care (see billman's excellent post, above), the authors have nothing better to offer by way of a solution than more federal oversight -- not more education, not more physician involvement, not more emphasis on prevention...

Well, that's a real, real odd, statement, given that the following actual black and white words appeared in the press release to which I linked:

The committee's first recommendation for reducing racial and ethnic disparities in health care is to increase awareness about them among the general public, health care providers, insurance companies, and policy-makers. Consistency and equity of care also should be promoted through the use of "evidence-based" guidelines to help providers and health plans make decisions about which procedures to order or pay for based on the best available science. Other specific steps to reduce and eliminate disparities are presented in the report.

Well, golly. Imagine that. That sounds ever so much like education and physician involvement. But you went off on a tirade about the federal government getting involved, the exact same argument used by certain folks on issues of race from before the Civil War.

The problem is economics, not racism.
My read of this is that the factors most impacting the quality of healthcare received are socioeconomic, not racial. Now, race may be a factor in socioeconomics, but it seems difficult to somehow come up with a soultion that overcomes the medical/racial issues without addressing the socioeconomic issues.

I had to cut and paste to make sure, but I really *did* see those two sentences by the exact same poster, the latter two juxtaposed in the same paragraph.

Kevlar footgear, my friend. Try it. You need it.

It's much easier to sit back and lament the plight of this group or that group from our nice comfy suburban homes and then cry foul everytime one of these half-assed reports come out.

One awaits your own exhaustive study and report.
posted by fold_and_mutilate at 12:53 AM on March 22, 2002

It's easy to invoke racism, but the flat out finances can be a major stumbling block.
But there are many steps that must be taken to get there, and overcoming racism is only one of them, and in many cases, a small one, at that.

"A small one?" Well, ok, let's hear your figures and how you arrived at that quantification.

(And just a tiny disagreement with an earlier sentence in this poster's remark, but malpractice insurance is usually not (at least not in my state) required for actual licensure. Many physicians (most, based on my experience) are covered under institutional policies instead of having to independently obtain their own.)

But the real objections to the study's conclusion seems for many of you to come down to an argument based on economics. Let's assume for the sake of argument that is true (but note that this study and others below directly address "the economics quibble"). Please provide the congregation with the factors that cause an economic disparity for groups such as African Americans in this country, and explain how racism is unrelated to those factors.

And now (and you know this is out of character for me), please indulge me while I rant:

Black infants have nearly twice the mortality rates as whites. There is no racial difference in mortality until the immediate postnatal period, suggesting that rate differences are caused mostly by social inequality (author's conclusion) [Hunt GJ, 1995].

Blacks have higher prevalence than whites of most life-threatening *but preventable and/or treatable* illnesses: AIDS, cancer, heart disease, and hypertension. [Polednak, 1989].

Please have a look at Dr. Harold Freeman's (now famous) study published in The New England Journal of Medicine, which indicates that men growing up in Bangladesh have a better chance of surviving to their 65th birthday than do black men in Harlem, the Bronx, or Brooklyn. Freeman specifically cited disease, poverty, and inequitable access to medical care as the primary factors responsible for the high death rate among these black men (and not violence and AIDS). [McCord/Freeman, NEJM 322:173-177, 1990]

Black children are 3 times more likely than whites to die of pneumonia or meningitis, diseases that are often preventable. [Garett, 1994].

50% of black women received a first breast cancer diagnosis after the malignancy had become untreatable, compared with 8 percent of white women. [Garrett, 1994].

Blacks are 2-3 times more likely than whites to die from heart attack, were less likely to have bystander-initiated CPR...or be admitted to the hospital [Becker et al, 1993].

A Health Care Financing Administration study concluded that "with blacks, race and not income appear to be the determining factor on access to care." [Reported in American Medical News, Nov 20, 1995, v38 n43, pg 10.]

Peterson and colleagues assessed "racial differences in rates of coronary angiography, angioplasty, and bypass graft surgery among 33,641 men hospitalized for acute myocardial infarction in all Veterans Affairs Medical Centers in the United States. A special strength of this large-database study was the investigators' review of medical records for a random sample of 1000 patients, confirming that 88% had clinical evidence of acute myocardial infarction. In the overall cohort, they found that black veterans were less likely than white veterans to receive major coronary procedures. This study indicates that race can affect medical care in ways that are not simply related to socioeconomic status, because racial differences occurred in a system where care is free and black and white patients are more similar in socioeconomic status than in the general population." [Peterson ED, Wright SM, Daley J, Thibault GE. Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA. 1994:271:1175-1180.]

Kahn et al showed that "black and poor patients do not receive the high level of treatment given other patients in the same facilities. These studies demonstrate the widespread nature of racial and socioeconomic disparities in the delivery of care....Their study of 9932 patients from a broad sample of hospitals in five states is the most rigorous assessment of quality of care in the Medicare program to date, applying explicit quality criteria to detailed clinical data from medical records. The factors that they assessed are basic components of care at all hospitals, including history taking and physical examination, common diagnostic tests such as serum chemistries and chest roentgenograms, and standard therapies such as diuretics and antibiotics. Within each type of hospital in this study--urban teaching, urban nonteaching, and rural--patients who are black or poor received lower quality of care than other patients, on average, and the magnitude of these differences was similar across the three types of hospitals. These data are particularly disturbing because they demonstrate that inequalities by race and class are not limited to any one group of hospitals that provide lower quality of care." [Kahn KL, Draper D, Keeler EB, et al. The Effects ofDRG-based Prospective Payment on Quality of Care for Hospitalized Medicare Patients: Final Report. Santa Monica, Calif: RAND; 1992. (Abstracted in JAMA 1994:271)]

"Within each level of socieoeconomic status, blacks generally have worse health status than whites." [Williams, Collins et al. Annual Review of Sociology, 1995, v21, pg 349.]

Finally, does the Tuskegee Institute Syphilis Study ring a bell with anyone here? You remember, that nice project "down South" (ended circa 1972) where treatment for syphilis was withheld from a large group of black men (who, incidentally, never gave their informed consent to participate in the study). You know, Tuskegee, where they were just trying to find out the long terms effects of syphilis - what better way than by letting people die from it, despite the availability of effective treatment? You recall, where the patients weren't even advised to protect their sexual partners.
posted by fold_and_mutilate at 1:40 AM on March 22, 2002

f_and_m, you're a fascinating person. You are by turns endearing and infuriating. You're endearing in this thread.

I, too, thought of the Tuskeegee study when I read the recent report. Why do black women get diagnosed with breast cancer much later than white women? Maybe because black women don't trust doctors. Why wouldn't they trust doctors? Tuskeegee. It's going to take a lot of time and a lot of good-faith effort to wash away the sin of Tuskeegee.

Here's a good place not to start: by dismissing a thoroughly researched study by the prestigious Institute of Medicine as so much "politically correct" pap and ignorantly criticizing it for not taking economics into account when, in fact, the study does take economics into account.
posted by Holden at 9:00 AM on March 22, 2002