Bush's band-aid approach

A prestigious, congressionally mandated report has found that minority Americans receive glaringly inferior medical care. The Bush response: Take a Loved One to the Doctor Day!

By Fran Smith

Published May 2, 2002 7:18PM (EDT)

African-American infants are more than twice as likely as whites to die before turning 1. The average life expectancy for black men is 66, eight years shorter than for white men. Blacks of all ages suffer higher rates of illness and death from just about every major disease, including diabetes, heart disease, AIDS and a variety of cancers.

And the numbers for treatment are just as bad. Inferior care occurs at every step in the system: prenatal checkups, routine care, therapy for life-threatening illnesses, mental health treatment, pain control before death. African-Americans are less likely to undergo heart bypass, angioplasty, kidney dialysis, transplants and other expensive procedures. They get less aggressive treatment for cancer, and they're slower to get the latest drugs for HIV. And in the rare instances when blacks get more aggressive care, it is not necessarily a good thing: They are, for example, more likely to have leg amputations for diabetes instead of sophisticated, conservative limb-saving treatment.

There are no surprises in these data, documented most recently in a congressionally mandated report, by the prestigious National Academies' Institute of Medicine, titled "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care." The most exhaustive analysis ever published on the subject, the institute's 586-page review of just about every study that has appeared in a medical journal reaches some stark conclusions: Disparities in care and treatment for all racial and ethnic minorities are pervasive, harmful to patients, and overwhelmingly not their fault.

The Bush administration finally addressed the issues in the institute's call to action -- part of a chorus that has droned on for years -- with a gesture that has some health experts reeling. The plan, announced by Tommy Thompson, secretary of Health and Human Services, is "Take a Loved One to the Doctor Day," scheduled for Sept. 24 , 2002. Thompson, with cosponsor ABC Radio Networks, is encouraging communities to offer health fairs, screenings and other "wellness" events where participants can be weighed, poked, tested, examined, questioned and counseled. One day to make up for a whole lifetime without ongoing, comprehensive care.

"It's comedy," says Dr. Thomas LaVeist, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. "Or it would be comedy if this weren't such a serious problem. It's very depressing, actually.''

"Take a Loved One to the Doctor Day" is a crusade that essentially pins the problem of healthcare disparities on the patients, as if they were somehow responsible for a healthcare system that often gives them second-rate care or shuts them out altogether. By preaching the virtues of checkups and offering redemption to minorities identified as medical slackers, Thompson ignores the roots of healthcare inequities -- poverty, institutional racism, lack of funding, and the shortage of services in minority communities -- and shifts the blame to the victims. He also sidesteps the very sticky matters of bias in the largely white medical profession, and the failure of HHS to enforce civil rights in healthcare.

"It is disconcerting that the leadership of the Department of Health and Human Services would come up with a solution that is so far off the mark," LaVeist adds. "It really displays a staggering misunderstanding and lack of understanding of the problem."

It is particularly hard to explain such a lack of understanding in the wake of the Institute of Medicine report, published in March, just weeks before the announcement of "Take a Loved One to the Doctor Day." In addition to spelling out, in impressive detail, the nature, extent and impact of disparities of medical treatment, the study also pinpoints the causes, placing heavy responsibility on doctors, hospitals, insurance companies, lawmakers and government regulators.

In their analysis of the health gap, institute researchers first identify barriers to care, the most significant being (no surprise here) money. Blacks are twice as likely as whites (and Hispanics are three times as likely) to have no health insurance, a situation that more or less guarantees that a patient will get no treatment until he or she turns up seriously ill in the emergency room.

But access is not the only cause, or even the major cause, of inequities. The institute report found that even when minorities do get care, it tends to be inferior. In a statement typical of the report's dry and unblinking language, the researchers write: "Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patients' insurance status and income, are controlled."

In other words, simply getting minorities into the examination room is not the answer. Because once they are there, the odds are good that the treatment they get will be compromised by the bias of the doctor. There isn't a nook or cranny of the medical system, according to the report, in which minority patients are not treated differently, by which, according to the data, the researchers mean -- emphatically -- worse.

What has been fairly obvious for years is that disparate treatment stems in part from Medicaid, the public health insurance program. There was a time, long past, when a Medicaid card worked more or less like a Blue Cross card: It got patients into many private doctors' offices. Not anymore. Funding cuts and ever tighter restrictions (on doctors and patients) have largely turned Medicaid into a separate, unequal system for the poor. Minorities, of course, are not alone in this boat, but they are disproportionately stuck there.

But Medicaid is not the whole story. According to the Institute of Medicine, even when minority patients have decent insurance, a solid income, a college degree -- in other words, even when things are the same as for typical white patients except race or ethnicity -- treatment is different. Why? The report puts much of the blame on prejudice and stereotyping by doctors, a startling and courageous assertion when you consider that scores of researchers have documented disparities for more than a decade, and almost nobody has dared to talk about this in a forthright way until now.

The chapter title, cautious to the point of parody, is "Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter." It is no polemic on racism but, like the rest of the report, a sober, dense review of the relevant research. Most of it involves experiments and surveys aimed at teasing out physician attitudes and judgments and measuring their influence on what should be straightforward medical decisions.

In one well-known study, doctors watched videotaped vignettes of patients (really actors) with symptoms of coronary artery disease. Each video featured a different patient -- a white man, a black woman and so forth -- but the complaints were the same. According to the study, doctors were much less likely to propose cardiac catherization for blacks and women than for whites and men.

Does such bias persist even among minority doctors? In another study, medical students -- whites and minorities -- watched vignettes of patients complaining of chest pain. Overall, the students were more likely to provide a "definite" diagnosis of angina for white male patients than for black female patients. But when asked to rate the patients' overall health, the doctors split according to their own race, ethnicity and gender. White students, and male students, tended to assess the black female patients as having worse general health and a lower quality of life than the white male patients -- even though both patient groups presented the same basic information. Minority and women students tended to rate all patients the same on this score.

Studies like these have sparked hot debate in the scientific literature. On the surface, these are arcane arguments over methods: Should the investigators use odds ratios or risk ratios to calculate a patient's chances of getting a specialist referral? But it's no great stretch to assume that something deeper fuels the fire of these controversies. Doctors don't take kindly to allegations of bias. Who does? Nevertheless, the institute pulls no punches.

"Although it is reasonable to assume that the vast majority of health care providers find prejudice morally abhorrent, several studies show that even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes," says the press release on the report.

The pressures of medical practice probably exacerbate these impulses. A doctor spends just minutes with each patient, often patients he barely knows, and must make ever more complex decisions. "If physicians are having trouble making a diagnosis because the symptoms are not clear-cut, they are trained to place greater emphasis on prior expectations about the patient's condition based on age, gender, socioeconomic status, race or ethnicity," the press release said.

Of course, the patient brings baggage, too. Minorities are more likely than whites to say they mistrust doctors and nurses. (Hardly suprising in light of this research.) Suspicion does not make for an optimal doctor-patient dynamic, and it can be frustrating and insulting to a doctor who is working hard to help a seriously ill patient and likely to lose money on the effort. But as the institute notes, the doctor "is the more powerful actor" in this relationship and should bear more of the load for making sure that all patients are treated the same.

The report's first recommendation for reducing disparities is to increase awareness among the general public, doctors, insurance companies, policymakers. It's the flip side of the HHS strategy of targeting African-Americans exclusively. And it makes far more sense. Two recent polls show that a significant majority of Americans believe that blacks get the same quality of healthcare as whites. Minorities apparently know that's not true. A survey released in March by the Commonwealth Fund in New York found that blacks (and Hispanics and Asian-Americans) are more likely than whites to report difficulty communicating with doctors, to feel they are treated with disrespect when they get healthcare, and to believe they would receive better treatment if they were a different race or ethnicity.

The Institute of Medicine also recommends the elimination of two-tier healthcare: People on Medicaid should get the same services, and the same protections, as privately insured patients. (The institute noted that Congress fussed mightily last year over legislation to safeguard the rights of people in private HMOs, but not Medicaid managed care. The report said any patient's rights bill must extend to people in public programs.)

The report also urges Medicaid to bring stability to doctor-patient relationships. These have been trampled by budget cuts and other changes in the program. The institute devotes considerable ink to the importance of consistent, ongoing medical care. Against that backdrop, a one-shot go-to-the-doctor day seems not only misguided but also counterproductive.

In its meatiest recommendation, the report calls for aggressive civil rights enforcement in healthcare. The HHS Office for Civil Rights "has long abandoned proactive, investigative strategies," the report said. Although complaints have increased in recent years, the enforcement budget in fiscal year 2000 was 60 percent of the 1981 funding, adjusted for inflation.

Under Bill Clinton the Department of Health and Human Services pledged to narrow the medical divide by 2010. Inside the giant federal health bureaucracy, some momentum continued after the White House changed hands. Every institute of the National Institutes of Health, for instance, has a mandate to develop a plan for addressing disparities in its programs. In July, the HHS Office of Minority Health will hold a "national leadership summit to eliminate racial and ethnic disparities."

But some minority health advocates worry that the Bush administration, distracted by high-profile issues like the threat of biological terrorism, will not give disparities priority in the agenda. And there's no doubt it will take pressure, and a moral imperative, to move an entrenched medical establishment and to provoke broad concern about an outrageous situation that the public has tolerated too long.

If nothing else, "Take a Loved One to the Doctor Day" by itself provides ample evidence that the alarms raised by the report might be muffled.

"People can take charge of their health, and participating in Take a Loved One to the Doctor Day can be a positive first step," Thompson said at an April 18 press conference. "Prevention and early detection of potential health problems are essential, and there are steps within our reach that we can all take to better protect ourselves and our families."

It is always tempting, and valid to a point, to pin responsibility on patients. Personal behavior is important in healthcare. If you smoke cigarettes, never see a dentist, eat crap, do drugs, live like a sloth, blow off your prescriptions, you put yourself at risk.

But in the context of the health gap, Thompson's message is weirdly patronizing, all the more so because his "Day" is a twist on the ever popular Take Our Daughters to Work Day. Is the subtext here that blacks, like 8-year-olds, must be led by the parental hand and shown what's good for them?

Even if that message was unintended -- and to be fair, let's assume it was -- it's a Band-Aid for what should be recognized as a public health emergency. More than a decade ago, researchers at Columbia University reported that black men in Harlem had a shorter life expectancy than men in Bangladesh. The day after Thompson announced Take a Loved One to the Doctor Day, the U.S. Centers for Disease Control and Prevention reported that in some cities the black-white differences in infant mortality are even more glaring than national statistics suggest.

In Pittsburgh and Tampa, black babies are three times as likely as white babies to die before the age of 1; in San Diego, nearly four times as likely; in San Francisco, nearly five times. Hauling your sister to a health fair in September will not save black infants anymore than trotting your daughter (and now your son) through your cubicle in April will obliterate pay gaps for women.

Nevertheless, some major black organizations and influential minority health advocates have signed up as "partners" in Sept. 24. The list includes Rainbow/Push Coalition, 100 Black Men of America, Congress of National Black Churches, National Black Womens Health Project, and the National Medical Association, the nations largest organization of African American physicians.

"It's always a positive step to get people to seek medical care," says Ruth Perot, executive director of the Summit Health Institute for Research and Education, a Washington, D.C., nonprofit that promotes health equity.

Perot, a passionate voice on minority health, takes a broad, deep view of the problems and remedies. Why did she endorse Sept. 24? She said she hoped it would encourage people not only to go to doctors but also to "very assertively seek the kind of care to which they're entitled."

But if assertiveness is the goal, why not urge people to make appointments for themselves? Didn't the pitch, Take a Loved One, send an opposite message, about patient helplessness, passivity or sheer irresponsibility?

"Im trying to be charitable." Perot says. "Im trying to acknowledge some blooming blossoms where I see them."

It should come as no shock that the blossoms are mostly window dressing. Big, costly improvements in Medicaid were never on the Bush agenda. Neither is more money or more muscle to crack down on civil rights violations, in healthcare or anywhere else.

And the notion that it is each black person's job to close the health gap fits neatly with the famous Bush ethic of personal responsibility. Across the board, from drug abuse to poverty to failing schools, the burden of solving societal problems is shifting from the government to the shoulders of the people who suffer most -- or their "loved ones."

Conveniently, Thompson's crusade also appears to mesh nicely with current public sentiment. Folksy campaigns are the name of the game in medical causes. AIDS has red ribbons and movie stars. Breast cancer has pink ribbons and teddy bears. ALS has navy pinstripe ribbons inspired by Lou Gehrigs Yankee uniform. Diabetes has gray ribbons to depict the despair of the disease and the hope, the "silver lining," that a cure will be found. The American Cancer Society has daffodils.

Now African Americans have Sept. 24, a finger-wagging day of obligation meant to placate poor and poorly served patients with health fairs. America still isn't a country where healthcare is colorblind, but it is the land of equal-opportunity kitsch.

Fran Smith

Fran Smith is a freelance writer and editor who frequently covers health issues.

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