Don’t Despair over Disparities

The Weekly Standard, March 1, 2004

By Sally Satel and Jonathan Klick

Just before Christmas the Department of Health and Human Services released the National Healthcare Disparities Report. It documents an all-too-familiar problem in public health: the poorer health status of individuals on the lower rungs of the socioeconomic ladder and the fact that they often receive different treatment than those with more resources and higher education.

The term disparity, though, refers not just to differences. Over the last few years it has acquired another connotation in public health circles, referring to differences in care determined by ethnicity. And therein lies the potential for race politics. In mid-January, those politics surfaced. “Racial Disparities Played Down; At Request of Top Officials, Report on Health Care Differs From Draft,” ran an article in the Washington Post. At issue were changes to the executive summary of the HHS report. These included using the more neutral word difference instead of disparity; removing statements that disparities are “national problems” that are “pervasive” and exact a “personal and societal price”; and the substitution of some examples of health differences in which minorities fare better than the general population for those depicting minorities as doing worse.

On January 13, Henry Waxman, ranking minority member of the House Government Reform Committee, sent a scathing letter to HHS Secretary Tommy Thompson protesting these prepublication changes. The substance of the roughly 200-page report, brimming with documented differences in health status and treatment, was not at issue–simply the summary–yet Waxman warned Thompson that the changes “alter the report’s meaning . . . and fit a pattern of the manipulation of science by the Bush Administration.” An accompanying press release, signed by members of the Congressional Black Caucus, Congressional Asian Pacific American Caucus, and Congressional Hispanic Caucus, claimed that “by tampering with the conclusions of its own scientists, HHS is placing politics before social justice.”

Further context for the “tampering” charge was provided by H. Jack Geiger, an emeritus professor of community medicine at the City University of New York. His January 27 op-ed in the Washington Post (“Why is HHS Obscuring a Health Care Gap?”) praised a 2002 report from the Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health,” to which he was a contributor. That report suggested that racial differences in health care are “rooted in historic and contemporary inequities” and asserted that “stereotyping,” “prejudice,” and “bias” by doctors, hospitals, and other care providers contribute to the disparities.

Having seen both versions of the executive summary of the HHS report, we agree that the earlier one was more powerful and detailed. (Indeed, on February 10, Thompson agreed to release the executive summary in its original form, saying that a “mistake” was made.) But the contents of the full report were never disputed, and there is little reason to worry that HHS is downplaying the disparity issue. “Eliminating health care differences resulting from unequal opportunities must continue to be a public policy priority,” says the HHS report within the first few pages. Nevertheless, the report’s critics perceived the revision as a malign effort, in Geiger’s words, “to avoid the truth”–namely, that gaps in treatment are also the product of racial discrimination in the health care system. More than a thousand studies, Geiger insists, document “inequities” in the health care provided for minorities.

Inequities? Not so fast–especially since “inequity,” as Geiger has made clear in his writings on race and health, implies inferior care based solely on the patient’s race. Let’s be clear about what those studies do show, bearing in mind that the vast majority of them–which were assembled by Physicians for Human Rights with Dr. Geiger’s assistance–are not sufficiently detailed to even begin to illuminate the recesses of the treatment gap.

The most rigorous studies control for numerous variables that could explain why minorities are less likely to undergo procedures such as cardiac catheterization–variables such as other illnesses that might make the procedure inadvisable. But because most of the disparity studies rely upon review of hospital charts or large Medicare databases, they cannot take into account such important factors as patient preferences or supplemental insurance. Nor do they reveal how doctors made their treatment decisions.

Then there is the matter of rational inference. Physicians base their clinical decisions on experience and statistical norms. These are sometimes influenced by race (or sex or class, for that matter). But judgments that appear to be made on race may actually be made on other variables that simply correlate with race. Level of education is such a variable. As recent work by Dana Goldman and James Smith of RAND shows, adherence to treatment regimens in patients with HIV and diabetes varied greatly with the patient’s level of schooling.

In practical terms, if a physician thinks that a patient will not comply with triple therapy for HIV, he might either forgo the medication or give the patient a compliance “trial,” wherein the patient must at least keep a second appointment in order to receive medication. To the extent that a physician does the former without strong clinical justification, he has acted unethically. At the same time, failure to draw rational inferences about patients–especially the likelihood of their taking potent medications properly or caring for surgical wounds once discharged from the hospital–can lead to worse health outcomes for minority and white patients alike. A conscientious doctor cannot simply prescribe complicated therapies and hope for the best.

For doctors, data about health care disparities serve a consciousness-raising function, prompting them to ask themselves whether they are giving every patient the opportunity to benefit from treatment. But to elevate the phenomenon of making clinical generalizations to the level of a civil-rights violation is a huge leap–yet one the disparity-equals-racism crowd is eager to make.

Research in health disparities often boils down to the assumption that more is always better. Consider: A 1999 study from Memorial Sloan Kettering Cancer Center found that black patients with operable lung cancer underwent surgery for removal of part of the lung less often than whites. Insurance coverage was not a factor. Five years later one quarter of the black patients, and one-third of whites, were still alive, strongly suggesting that surgery would have saved many black lives. (Even so, this was a study based on Medicare records and a National Cancer Institute database, so there were clinical subtleties–for example, results of pulmonary function tests and patients’ desire for the operation–that remained unknown and could have affected the picture.)

But differences in care do not inevitably translate into differences in outcome. In fact, according to a Kaiser Family Foundation review of cardiac care studies, the overwhelming majority found no mortality differences between races despite lower rates of procedures for blacks. One possible explanation is that catheterization may be overused in white patients, meaning that the procedure is performed even when it will probably not benefit patients.

Often, such overuse of procedures is the result of nonclinical influences. For example, numerous researchers have documented the practice of “defensive medicine,” in which physicians provide care with infinitesimal or nonexistent expected benefits solely to protect themselves from liability in subsequent legal proceedings. This research shows that doctors facing lower liability exposure thanks to state medical malpractice law reforms perform fewer procedures and clinical tests with no adverse effects on patient health. This implies that a doctor’s expectations of future litigation will influence his care decisions. If different racial groups have different propensities to sue, or if eventual judgments are correlated with race, care disparities will arise, but it is not clear that those disparities have any consequences for patient health.

Such socioeconomic complexities are too often ignored in the debates over health care disparities, where insinuations of racism are a sure media draw. This is unfortunate, since constructive policy proposals require a reliable diagnosis. Yet many medical schools, health philanthropies, policymakers, and politicians are proceeding as if “bias” were an established fact.

For example, there is now a “cultural competence training” industry that, among other activities, has been known to conduct patronizing racial sensitivity training for doctors. This is not to be confused with the need to learn the local anthropology of unacculturated populations, a vital necessity for physicians who work with cultural minorities. In addition, medical schools are forthright in lowering academic and performance standards in the service of building a more racially diverse workforce. The main rationale for these racial preferences is to take advantage of the fact that minority doctors are more likely to practice in underserved areas and to fulfill the (unfounded) premise that minority patients overwhelmingly prefer same-race doctors. Yet a more fair and clinically responsible way to get good doctors into poor neighborhoods is to offer financial incentives.

Inferring discrimination from the existence of disparities is a divisive distraction from the factors that have undisputed and sizable influence on disparity: access to care, quality of care, and health literacy. When access to care is excellent and quality of care and patient characteristics are relatively homogeneous–such as in military health care systems–there are negligible racial disparities in care.

The HHS report on health care disparities rightly attacks the disparity issue as a socioeconomic problem tied to access to quality care and to the health literacy of potential patients. There was no “papering over” of health care differences, as its critics allege. If anything, to say that the differences–which are real and surely need attention–are born substantially of racial discrimination in the health care system is the true manipulation of the science.

Sally Satel is a resident scholar at the American Enterprise Institute, and Jonathan Klick is associate director of the AEI Liability Project.