Care better for blacks, worse for Hispanics

The racial and ethnic gap in health care quality and access is narrowing or remaining steady for blacks, Asians and American Indians, but it is widening considerably for America's largest and fastest-growing minority group, Hispanics, according to a report that the Agency for Healthcare Research and Quality issued in January.

Blacks, Asians and American Indians saw their access to care inch closer to that of whites, according to the "2005 National Healthcare Disparities Report." The black-white health care quality gap improved on 23 of 40 measures the study examines. About half of the quality measures for Asians and American Indians improved, while the other half worsened, the study showed.

In contrast, the interval between the quality of care Hispanics receive versus the care whites receive grew for 20 of 34 items the study measured to determine the caliber of medical treatment. Disparities worsened on five of six items used to measure health care access.

In particular, the Hispanic-white quality gap in treatment of tuberculosis, diabetes and mental illness worsened, as did disparities in timely treatment of injuries and illnesses and regular dental visits.

"It wasn't surprising that Hispanics were worse off," said Elena Rios, MD, MSPH, president of the National Hispanic Medical Assn. "What was shocking was how much worse it was for Hispanics. ... There is a tremendous need, more than we have ever anticipated, for the health system to respond to the unique needs of the Hispanic community."

Congress first asked AHRQ to create a disparities study in 1999. The 2005 report, the third annual report, is a comprehensive review of federal health data. It compiles statistics on 179 measures of health care quality and 51 measures of access to care, but focuses on a smaller number of core measures that experts consider the most clinically important, relevant and reliable measures available.

"This report is one of a kind," said Michael Painter, MD, team leader for the Robert Wood Johnson Foundation's disparities project. "It's an important, thoughtful, sound statement about the nation's health disparities."

With at least three years of trend data under its belt, the report's lead author said the 2005 edition represents the first meaningful attempt to track changes over time.

"Comparing year 1 to year 2, it can be hard to differentiate true change from noise," said Ernie Moy, MD, MPH, an AHRQ senior service fellow. "You could get a blip up or a blip down. This report gives us more confidence that this is actually a trend."

For Hispanics, the picture is not pretty. They received poorer quality of care than whites in 53% of the areas AHRQ measures, compared with 43% for blacks, 38% for American Indians and 21% for Asians.

"The Hispanic issue bothered us and is surprising to us," Dr. Moy said, though upon reflection he said it shouldn't be shocking. "We know a lot about barriers to care. We know that poverty is a barrier to high-quality care, as is language, lack of health insurance, culture and immigration status."

He said all minority groups face some of the barriers, but not all of the roadblocks. "Blacks, for example, generally don't face language barriers. Asian-Americans do better on socioeconomic barriers. Hispanics are unique in that they often have them all," Dr. Moy said.

An AHRQ brief issued in 2005 revealed that 21% of Hispanics younger than 65 reported being continuously uninsured for two years, compared with 10% of blacks, 7.2% of Asians and 7.2% of whites.

Using the data going forward

The AMA said that despite growing disparities for Hispanics, the report contained good news.

"The fact that some racial and ethnic disparities are narrowing gives hope that strategies are being implemented to effectively address the issue," said John C. Nelson, MD, MPH, the AMA's immediate past president.

Dr. Nelson added that with better data on Hispanic disparities, "the picture becomes clearer as to the needs of the Hispanic population and how to address those needs more effectively."

Dr. Rios called the January disparities report a wake-up call that should hasten support to expand "national data sets that can help us understand what's behind these trends," she said.

"We need more research targeted toward Hispanics, instead of just research in general," she added.

Others are looking to find ways to address disparities problems head on.

"We think we're turning from an era of making the case for disparities and finding the contours of it to finding practical, evidence-based solutions," Dr. Painter said, referring to his group's work on disparities in cardiovascular disease, diabetes and depression. "We don't see this is as an opportunity for blame. We see these as systems problems."

The same day AHRQ released its report at a national disparities summit in Washington, D.C., the Dept. of Health and Human Services announced $56.9 million in grants for related research to more than 100 institutions around the country.

Poor get worst care

The only group examined in the report to fare worse than Hispanics was the poor. Defined as having an income at or below the federal poverty line, the poor received worse care on 85% of the measures compared with those earning four times the poverty level or more. The poor's access to care also has worsened over time on five of the six measures examined in the report.

"Across the board, socioeconomics has to be part of the disparities conversation," said Mai Pham, MD, MPH, a senior health researcher at the Center for Studying Health System Change.

"It's important to point out that when you adjust for socioeconomic status, racial and ethnic disparities still exist," Dr. Pham said. "But it's also important to emphasize that if you don't adjust for that, it's going to be the overwhelming majority of thestory."