Confronting Racial and Ethnic Disparities in Health Care

Figure: Rodney G. Hood, MDThe National Medical Association (NMA) is the oldest and largest national organization representing African American physicians and health professionals in the United States. Established in 1895, the NMA is the collective voice of more than 25,000 African American physicians and the patients they serve. Since its inception, the NMA has been committed to improving the quality of health and health outcomes of minority and disadvantaged people. While throughout its history the NMA has focused primarily on health issues related to African Americans and other medically underserved populations, its goals, initiatives, and philosophy encompass all sectors of the population. More than 100 years since its founding, the NMA has become firmly established in a leadership role in medicine and serves as a catalyst for the elimination of disparities in health and the leading force for parity in medicine. The race- and class-based structuring of the health delivery system has combined with other factors, including racism, to establish a “slave health deficit” that has never been eliminated. Historically, racism in medicine and health care has operated at institutional, intellectual, policy, and personal levels and is deeply ingrained in the fabric of the U.S. medical—social culture. Racism has thus played a major role in the creation and perpetuation of the continuum of poor health status and outcomes for African Americans and other minority populations. Throughout U.S. history, two periods of health reform specifically addressed the correction of race-based health disparities. Both had dramatic and positive effects on African Americans' health. The first period, which was linked to Freedmen's Bureau legislation, lasted from 1865 to 1872. The “First Reconstruction in Black Health” led to the establishment of black medical schools, hospitals, and clinics throughout the South. These improvements somewhat slowed shockingly high black death rates, improved many health status and outcome parameters, and may have, ultimately, spared U.S. blacks from predicted extinction by the year 2000. The “Second Reconstruction in Black Health” lasted from 1965 to 1975, and was actually an offshoot of the black civil rights movement. It was tantamount to the modern health system's opening gambit to solve its racial health dilemma and included hospital desegregation rulings in the courts; passage of the 1965 Civil Rights Act, which eventually outlawed racial discrimination in government-funded health programs; passage of Medicare/Medicaid legislation, which allowed huge blocks of blacks access to health care for the first time; the establishment of the community and neighborhood health care movements; and legally forced the racial desegregation of hospitals and the admission of black physicians to most hospital staffs for the first time. African American health improved dramatically in virtually every measurable health status, utilization, and outcome parameter for ten years. Stagnation occurred after 1975, and relative and/or absolute deterioration (compared with whites) began after 1980. However, both of these periods of progress, each lasting less than a decade, failed to eliminate race-based health disparities. If these persistent health disparities are ever to be eliminated, there must be dramatic health system policy, financing, and structural changes, and directed efforts to produce a culturally competent health system and workforce. For these improvements to take place, it is vital and necessary that the use of race continue as a variable in tracking health status and outcomes to serve as a basis to direct all ameliorative efforts. In 1999, the Centers for Disease Control and Prevention (CDC) analysts documented that accurate race and ethnic data in the public health surveillance systems are critical to developing and implementing appropriate public health interventions. Their review of contemporary health data from 1980 through 1999 (1996 and 1997 data being the latest available) suggests that the “slave health deficit” has never been corrected. On October 6, 2000, at the invitation of the U.S. Surgeon General, Dr. David Satcher, and of Dr. Mohammad N. Akhter, the Executive Director of the American Public Health Association, the NMA's president and 35 other national leaders met in a “Call to the Nation” to eliminate racial and ethnic health disparities. The conveners of this historic meeting emphasized that the goal of Healthy People 2010 could not be achieved with governmental efforts alone but would require the collective efforts of the American people and the organizations forming this national coalition. The NMA and the other represented organizations were called upon to form this new coalition to develop and implement specific strategies that would address the needs of their constituents that would coincide with the national strategy to eliminate racial and ethnic disparities in the United States. The NMA has established a Commission for Health Parity for African Americans composed of distinguished health scientists and activists who are committed to this agenda. This commission has created a foundation for the Health Policy and Research Institute, which will develop, study, and recommend corrective actions to eradicate these health disparities. Key recommendations include: ▪ Creation of a Health Policy and Research Institute that would focus on documenting racial bias as a major contributor to the delivery of unequal health care for people of African descent. The institute would serve as a think tank, focusing on (1) racism and its impact on health care disparities; (2) developing policies focused on eliminating racism in the health care delivery system; (3) developing a community-focused action center to mobilize the community; and (4) becoming a repository for research and studies on the issue of racial and health disparities. ▪ Racial bias and racism in medicine in the United States must be accepted as contributing causes and risk factors for the current disparate health status and poor outcomes of African Americans and other affected populations of color. ▪ The goals of Healthy People 2010 must address the impact of racial bias and racism in medicine in order to achieve health parity for African American and other populations of color. ▪ Legislation must be created that supports tax incentives for small businesses to provide insurance for lowwage workers. ▪ Medicaid and Medicare programs must be reformed to restructure eligibility requirements, especially for the elderly and disabled, so that their benefit allocations are more closely related to their medical necessity rather than their socioeconomic status alone. ▪ Medicaid and Medicare programs must be reformed so that provider compensation is tied to severity of illness and co-morbidity. ▪ Congressional hearings on racial bias and the impact of racism in health care in America must be held. ▪ A national presidential and/or Congressional advisory committee on racial bias and ethnic health disparities must be established. It should report annually on the status of health care parity to the president and/or Congress through consolidated reports to the Department of Health and Human Services from the Council of Graduate Medical Education, the National Institutes of Health, and the Office of Minority Health. ▪ The American Association of Health Plans, the Joint Commission on Accreditation of Health Care Organizations, the National Committee on Quality Assurance, and other accrediting agencies—including those on a state level—must adopt uniform standards to collect health care outcome data based on race and ethnicity. These standards should include data on health care participants and providers and should take into account severity of illness, patient confidentiality, methods of collection, and nondiscriminatory use of the data. ▪ The NIH Center for Minority Health Disparities must receive increased funding to coincide with its expanded mission and the growing population it serves. Successful implementation of these recommendations will be difficult. But the goal is no less than the creation of a third period of health reform to correct race-based health disparities—one that will last.