The Study of Racialism

Hospital inequalities widen the care gap By Liz Szabo, USA TODAY
Tue Oct 25,11:08 AM ET



When Mary Grant had a mastectomy in July, she lost not only her breast, she says, but also her dignity. Grant, 52, of rural Laurens, S.C., never received a prosthesis and is often ashamed to leave her house.

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She can't afford pills to keep her cancer from returning or medications to treat depression and hypertension. "It feels like the walls are closing in on me," she says.


Doctors have known for years that minorities such as Grant, who is black, tend to receive inferior medical treatment to whites, even when they have the same income, education and symptoms.


Many experts initially assumed that blacks and whites went to the same hospitals but were treated differently, says Peter Bach, author of an influential study about racial disparities.


Studies by Bach and others suggest a different explanation: The USA's health care system remains as divided by race as its neighborhoods, schools and other aspects of American life.


"African-Americans live in very different places than whites, and in general they get treated at lousy hospitals," says Amitabh Chandra, an assistant professor at Harvard University and co-author of a new paper about health disparities.


The study, published today in the journal Circulation, suggests that black patients are concentrated in a small number of poorly performing hospitals. Nearly 70% of black heart attack patients went to only about 20% of medical centers, according to the study, which examined more than 1 million Medicare recipients from 1997 to 2001. At hospitals treating the most blacks, death rates for all heart attack patients were 19% higher than at the facilities that saw only white heart attack victims.


"Had blacks been admitted to the same hospitals as whites, there would have been 1,000 fewer deaths," says lead author Jonathan Skinner, a professor at Dartmouth Medical School.


The forces that contribute to health disparities are too complex to be overcome by any single solution, experts say. Many doctors want to increase spending for medical centers for the poor. Others are cultivating "health literacy" among minorities.


Yet many researchers say the country's racial divisions also could show policymakers how to attack the problem. By improving hospitals that see the most minorities, the country could provide better care to everyone and begin to close the racial gap at the same time.


"We can't change where people live," says Bach, a pulmonologist and epidemiologist at New York's Memorial Sloan-Kettering Cancer Center. "But we can change what happens inside an operating room."


Hospitals face gaps, too


Otis Brawley, who directs cancer care at Grady Hospital in Atlanta, says it's easy to see why facilities that treat minorities and the poor are struggling: They lose money on many of their patients. Hospital emergency rooms turn no one away, even those who can't pay their bills, says Brawley, associate director of Winship Cancer Institute at Emory University in Atlanta. Over time, that hurts a hospital's ability to treat all patients.


Hospitals in poor communities also suffer from inequalities in the way the government pays for medical care, says Hoangmai Pham, a senior health researcher at the Center for Studying Health System Change in Washington.


Medicare, the federal program for those older than 65, requires patients to pay 20% of their bills. Many doctors refuse to treat patients without the money or supplemental insurance to cover those costs, Brawley says.


And Medicaid, which covers the poor and disabled, pays doctors nearly one-third less than Medicare does for the same services, according to a 2004 analysis in the journal Health Affairs. The authors found that low Medicaid payments, which are set by individual states, according to their spending priorities, drive doctors away. About 60% accept new Medicaid patients, according to the report.


Because of this, Pham says, the patients she treats at an inner-city clinic often wait months to see specialists, even when they have urgent problems.


"There is a lot of physical segregation, and then there is segregation that is reinforced by payment policy," Pham says. Unless the country changes the way it pays doctors, "the message we are sending to providers is that, 'We don't really care if you take care of poor patients, and we are not going to pay you more if you do.' "