Health, Medicine and Society Program

Equity in health, not just in health insurance

Equity in health, not just in health insurance. From heart disease and diabetes to cancer and childhood diseases, Americans face crippling disparities in both the occurrence of disease and their successful recovery from it. Better stewardship should include pathways to reducing these financially unsustainable health differences based on ethnicity, gender, income, region and language. Transparency is critical. When outcomes are measured and discussed, disparities in care will be unmasked and intolerable.

There are significant racial, gender, and geographic disparities in disease prevalence and outcome in America. These disparities cannot be explained by insurance status or income alone. The Institute of Medicine report on disparities noted that the majority of studies found that racial and ethnic health disparities persisted even after adjusting for socioeconomic differences and health care access.1 For example, some racial and ethnic groups are at much greater risk for many chronic diseases.

·         Hispanics are 1.5 times more likely to have diabetes than whites.2

·         African-Americans are at higher risk for diabetes, hypertension3, and asthma4 than whites and Hispanics.

·         Heart disease, the leading cause of death for all racial and ethnic groups, and stroke (the principal components of cardiovascular disease or CVD) are the first and third leading causes of death in the United States.5 CVD accounted for 30% more deaths among African Americans than white adults in 1998.6

In some cases, disparities appear to arise from interactions with the healthcare system, such as in treatment or screening.

·         In a study of Medicare managed care enrollees funded by The Commonwealth Fund, after adjusting for age, sex, Medicaid insurance, income, education, rural residence, and heath plan, researchers still found that racial disparities were still significant for diabetic eye exams, beta blocker use, and mental illness follow-up measure.7

·         Studies based on gender have found that although heart disease is the number-one killer of women, women are less likely than men to receive diagnostic or invasive cardiac procedures and experience worse outcomes following a CABG or PCI procedure. In addition, women have been found to undergo cardiac revascularization procedures when they are older and more seriously ill than men receiving these procedures.8

Despite modest overall improvements in breast cancer survival rates for women with advanced disease over the last two decades, the rates for black women have not improved and the difference in life expectancy between white and black women continues to widen.9

In 1998, 49% of Asian women received Pap tests, compared to the national average of 64%.10

African-Americans are much less likely to receive critical cardiac care, including diagnostic procedures, revascularization procedures, and thrombolytic therapy.11

In addition to gender and race/ethnicity, language plays a significant role in inequitable care. Language can play a significant role in communication with providers, understanding access to health care systems, and following through treatments. Research examining only Medicare beneficiaries found that those with limited English proficiency had worse access to a usual source of care and were less likely to receive preventive cancer screenings.12 Considering that Medicare beneficiaries generally have similar plans and economic backgrounds, this difference is particularly striking.

Disparities also exist for Americans in living in rural settings. In general, urban teaching hospitals have better technology, more resources, and more providers than rural hospitals. As such, it can be expected that individuals living in areas with access only to rural hospitals could experience worse care than those living in areas with access to urban hospitals. Research suggests this is the case – one study found that for 8 of 12 hospital quality indicators, there were statistically significant differences between urban and rural hospitals, with 7 of the 8 indicators favoring urban hospitals.13

Improvements in healthcare must produce improvements in health disparities. A healthy America needs to provide health to all Americans.

[1] Smedley BN, Stith AY, Nelson AR, ed. “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” Institute of Medicine. National Academies Press, Washington, DC; 20003.

[2] “National Diabetes Fact Sheet.” Available:

[3] “Racial/Ethnic Disparities in Prevalence, Treatment, and Control of Hypertension – United States, 1999-2002.” Available:

[4] “Asthma Prevalence and Control Characteristics by Race/Ethnicity.” Available:

[5] “Cardiovascular Disease.” Available:

[6] “Chronic Disease Overview.” Available:

[7] Schneider, E. et al. “Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care,” JAMA. 287(10): 1288-1994, March 13, 2002.

[8] Holmes JS, Kozak LJ, Owings MF. “Use and in-hospital mortality associated with two cardiac procedures, by sex and age: national trends, 1990-2004.” Health Affairs 26(1): 169-177, January/February 2007.

[9] “Study finds dramatic difference in survival rates among white and black women with advanced breast cancer.” Available:

[10] “US Minority Health: A Chartbook.” Available:

[11] “Racial/Ethnic Differences in Cardiac Care: The Weight of Evidence.” Available:

[12] Ponce NA, et al. “Language Barriers to Health Care Access Among Medicare Beneficiaries.” Inquiry. 43(1) 66-77, Spring 2006.

[13] Lutfiyya MN, et al. “A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States.” International Journal for Quality in Health Care. 19(3): 141-149, April 18, 2007.