Tuesday, September 13, 2011

Race/ethnicity, not health insurance, as primary barrier to quality care

As a community-based organization committed to the elimination of health disparities, Bronx Health REACH works closely on access to health care issues in underserved communities. One of our signature issues is advocating against the segregated health care system in New York City, which separates patients into two systems based on their health insurance status. This two-tiered system discriminates on the basis of health insurance, steering patients on Medicaid or with no insurance toward the clinic system while those with private insurance are seen in faculty practices. We have found that public insurance or no insurance can be a barrier to accessing quality care due to the poor follow-up, lack of continuity of care, and long wait times that plague the clinic system. However, a recent study published in the journal Cancer, found that lack of health insurance may not be the primary barrier to proper diagnostic care for minority women.

The objective of the study was to determine the impact of race, ethnicity, and health insurance on follow-ups from breast cancer screenings in Washington, D.C., an area that has high mortality rates from breast cancer compared with national rates. The researchers’ hypothesis when they began the study was that patients with health insurance would have a shorter diagnostic time (defined as the number of days from a suspicious finding from a breast cancer screening to a definitive diagnosis for the patient) than patients without health insurance. However, after analyzing the diagnostic times of over 1500 women, the researchers found that health insurance was not the main determinant in longer wait times. On average, the diagnostic wait times for white, black, and Hispanic women were half a month, 1 month, and 2 months respectively. For white women on government insurance the average diagnostic time was 12 days; however for black women with the same insurance it was 39 days and for Hispanic women it was 70 days. Similar trends occurred when comparing women with private insurance from the three different racial/ethnic groups (16 days for whites; 27 days for black; and 51 days for Hispanics). The huge difference in diagnostic time between the different racial/ethnic groups suggests that health insurance status may not be the primary barrier to care.

This research highlights the alarming disparity in quality health care between minority groups and whites. While having health insurance does mediate this issue somewhat, the fact that women on the same insurance but of a different racial/ethnic background would have such varied waiting times shows that the system does discriminate against minority groups. In this particular case, the women were waiting to hear whether a breast abnormality identified by a clinician was benign or malignant. Depending on the stage of the cancer, a difference in diagnostic time between 12 and 70 days could be a serious impediment to proper treatment and halting the spread of the cancer. Other studies have shown similar disparity in treatment between white and minority patients. One well-known study by Dr. Kevin Schulman looked at the effect that race and gender had on physicians’ recommendations for cardiac catheterization and concluded that African-Americans and women were less likely to receive a referral than whites and men, with black women being the least likely group to get a referral.  Another study conducted by the Department of Veterans Affairs found disparities in health care between black and white veterans across all clinical areas. The study also suggested that disparities in health care delivery between the two groups are contributing to disparities in health outcomes.

This research all points to the conclusion that racial and ethnic disparities in health care access and delivery are a critical problem in our health care system. Through community outreach and education efforts, such as the health disparities education conducted by Bronx Health REACH, community members are becoming more aware of their patient rights and learning how to advocate for proper care. However, policy and system change must take place both in the training of physicians and in how care is delivered in order to affect lasting change.  

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