Researchers say social and ethnic health disparities can be cut

"Research on racial and ethnic health disparities has greatly expanded in recent years, and the existence of disparities in health and health care cannot be denied." That’s the view of a researcher who conducted a literature review in the Archives of Pediatrics and Adolescent Medicine and is quoted by Commonwealth Fund senior program officer Anne Beal in her September/October 2004 Health Affairs article on policies to reduce racial and ethnic disparities in child health and health care.

While there are many initiatives to address various aspects of health and health care disparities, Ms. Beal said, they are fragmented and would benefit from an oversight body based at the U.S. Department of Health and Human Services (HHS) that would monitor progress and coordinate efforts for eliminating disparities.

She cited problems with health care coverage, child health care, and health care providers in making her case for additional research and for federal oversight and monitoring.

Ms. Beal said that lack of health insurance is a major hindrance to accessing care, and racial differences in uninsurance are the first step in producing health care disparities by limiting access, regardless of the quality of care. Children without health coverage are less likely to have a regular doctor or to receive preventive care and are more likely to have unmet medical needs, she noted.

Given that in the current fiscal environment states can’t provide coverage to all eligible children, Ms. Beal said providing coverage through Medicaid and SCHIP is the most feasible alternative to universal health care coverage. "If every child who was eligible for either Medicaid or SCHIP was enrolled, coverage would be provided to 6.7 million children, 75% of those who are uninsured," she declared. "This would have a greater impact on health care for children of color because they are more likely than white children to be uninsured and to have had no regular source of care prior to SCHIP enrollment."

She said that although SCHIP expansions would raise that program’s costs, further analyses are needed to determine the best methods for increasing enrollment and the degree to which increased costs attributable to higher enrollment would be offset by savings in uncompensated and emergency care.

Even when children of color have access to care, according to Ms. Beal, they may experience poor quality care, caused by bias and poor care delivered by individual providers, but also by poor quality in the health systems that serve children of color. Programs such as Medicaid typically reimburse providers at below-market rates, and most safety net health systems suffer from chronic underfunding and shortages in resources, making them less able than better funded health systems to provide high-quality care.

Ms. Beal suggested that quality improvement efforts within health systems serving children of color would reduce disparities to health care, which essentially are disparities in quality. Framing the issue in terms of quality has advantages, she said, in keeping focus on an issue that often is seen as separate from health care quality in general. "If the health care system is allowed to provide poor quality care to any segment of the pediatric population, then all children are at risk for receipt of such care," Ms. Beal wrote. "The child health care quality movement needs to identify and address threats to health care quality pertinent to children of color, to meet its goal of improving care for all children. Also, efforts to reduce disparities can use the language, tools, and methods developed to improve health care in general, applying them to care for children of color."

She discussed gaps in public settings, current policies and practices in Medicaid and SCHIP, current practices and policies in the safety net, gaps in private settings, and current practices and policies in private settings before recommending collecting data on patients’ race and ethnicity combined with stratified reporting of quality measures by race and ethnicity. Ms. Beal said that if all currently accepted measures of quality were reported stratified by race and ethnicity, it would greatly expand the ability to monitor disparities in care and also would address the so-called disparity in disparities issue by linking improved ability to identify child health disparities with the growing ability to monitor quality of care for all children.

While many of those concerned about health care disparities focus on the need to improve the technical components of care, there also is a need to improve interpersonal aspects of care, improve cross-cultural interactions and communication, and increase patients’ involvement, Ms. Beal said. "All providers must be trained to improve their cross-cultural interpersonal interactions to engage parents from all racial and ethnic backgrounds equally," she asserted. "At the same time, the racial and ethnic diversity of health care providers needs to be increased."

To help address these aspects, she suggested that one of the requirements for state medical license renewal could be participation in cultural competency training. And to improve the diversity of the health care work force, she suggested that communities with documented health disparities and poor school performance be designated "Health and Education Empowerment Zones" and receive additional federal support from the No Child Left Behind Act for improved education and expansion and enrichment of science and health curricula.

"The elimination of child health care disparities will require multiple interventions from various sectors in the health care system," Ms. Beal concluded. "The next step for adopting any of these recommendations is to analyze the costs and feasibility of their implementation and the benefits they would provide. Such analyses will inform debates about the costs and benefits of promoting policies to reduce disparities."

Further research is very important, Ms. Beal tells State Health Watch, noting she has been impressed by how much policy has been informed by anecdote rather than hard data. "We need a body of research to inform and create thoughtful policies," she points out.

Asked if there is a way to prioritize her recommendations, Ms. Beal says it isn’t possible because multifactorial problems require multifactorial solutions from many disciplines. "Addressing disparities shouldn’t be an afterthought," she says. "All segments of the system need to take ownership of the problem."

One of her key recommendations is that overall coordination and monitoring of efforts to reduce disparities be managed within HHS. "A mandate for HHS to address disparities will promote research, public health, and health promotion efforts," Ms. Beal continues. "Such a mandate can be coupled with an advisory council of minority health experts who would oversee the process, promote coordination of efforts across various federal agencies, and receive reports of local efforts to reduce disparities.

"Monitoring progress can be done by an annual review and report to Congress, with an evaluation of changes in outcomes as reported by the National Center for Health Statistics and changes in care as reported by the National Healthcare Disparities Report. Several federal efforts to reduce disparities are under way, and an advisory council would facilitate coordination to promote synergy and reduce replication of these activities," she adds.

[To read the article, go to http://healthaffairs.org. Contact Ms. Beal at (212) 606-3854 or e-mail acb@cmwf.org.]