Health care, like everything else these days, has become heavily politicized, which is not only annoying but usually leads to worse health care. And a lot of politicizing relates to supposed “disparities”, which usually is code word for an assumption that vicious racism and bigotry means that some members of society, usually minorities, are being discriminated against in their access to and receipt of health care. The proponents of this concept are completely unserious ideologues who have no interest in really understanding any issue and developing meaningful policies to address legitimate problems. Good, accurate, repeatable research is the key to understanding problems and developing those sound policies. And research often teaches us things we didn’t know, uncomfortably so for the ideologues. A study in Health Services Research provides some interesting insight on the disparities issue. (HSR Article) As the authors initially note, disparities in rates of receipt of health care and in outcomes can be result of many factors, including socioeconomic factors, health status, cultural attitudes and discrimination. The mere fact of a disparity may not even indicate a serious problem that needs to be addressed. Many people believe that there is overutilization of some services, so if a subgroup doesn’t indulge in such overutilization, if it exists, is that a bad thing? Income level and insurance status, themselves often correlated, are powerful predictors of many aspects of health and health care. Racial and ethnic disparities often are substantially reduced or disappear when those factors are taken into account. But health status itself has a lot to do with need for and receipt of health care, and that is where these authors focus.
The researchers analyzed differences in utilization across racial and ethnic groups by health status, using MEPS survey data from 2010 to 2014. For health status they used a broad self-reported categorization of excellent, very good, good, fair or poor. Coverage was divided into public, private or uninsured. Outcomes included use of office and hospital outpatient visits. (I consider it a mistake to not include urgent care and ER visits; many people, rightly or wrongly, use those as primary care sources.) A wide variety of social, economic and demographic factors were used as variables in the analysis. They performed some sensitivity tests around presence of chronic conditions. Caucasians were more likely than African-Americans or Hispanics to report being in excellent health and more likely to be privately insured. Hispanics were more likely than either of the other two categories to be uninsured for the full year. Without adjustment, Caucasians were 13% more likely to have an ambulatory visit than African-Americans and 21% more likely than Hispanics. (Again, I am sure if you included urgent care and ER use, the gap would narrow.) Within each type of insurance, these gaps persisted. When health status was taken into account, however, the gaps greatly narrowed. In other words, African-Americans and Hispanics in poor health showed utilization rates more similar to those of Caucasians. The authors don’t, but should have, further explored the role of income. One primary reason for continued lower utilization, even at the same insurance and health status, can be income in an era when there is typically high-cost sharing. And in fact, the tables in the article indicate that higher income is substantially correlated with more visits. Medicaid would be an ideal place to explore this, since it essentially has no cost-sharing, but the authors lump it in with Medicare, which does have cost-sharing. And of course, there is nothing in the study related to actual health outcomes, nor is there any measure of personal responsibility aptitude.
The most insidious problem is real discrimination; if people are being denied access to health care or treated differently specifically because of race, ethnicity, religion or other factors, that is plainly and obviously wrong and indefensible. But saying that disparities, especially when there is no real analysis of the nature of the disparity, is proof of discrimination is equally wrong and leads to equally stupid policies. One underlying thread of the ideologues’ intent is to actually have people treated differently based on factors like race or ethnicity; to ignore individuality and personal responsibility. That is a recipe for destruction of any country and we can see the pernicious effects at work in our own. I believe in the power, dignity, rights and responsibilities of the individual. And I believe that it is appropriate for a society to help all its members learn how to be responsible, and learn how to maximize outcomes, including health ones, in their lives. That is where our efforts should be directed. But people who refuse the help and refuse to engage in responsible behaviors after being offered the help, should be on their own and not allowed to impose burden on the responsible members of society, the ones who are paying the bills. That is real fairness and justice.