II. The Race Gap in Health Care Delivery

      An enormous body of well-designed scientific research demonstrates that minorities, particularly African Americans, experience a statistically higher likelihood of poorer health, earlier disability, and earlier death, compared to white Americans. Significant health disparities between [p684] minorities and whites persist despite identification of this pattern and repeated calls for responses from the medical community. Certainly cost-driven treatment decisions are an unavoidable reality for most patients, but other longstanding inequities in the delivery of health care services pose formidable problems for patients of color and the health care community continues to struggle to understand the underlying causes of health disparities. The correlation between health disparities and disparities in the quality of health care delivery received by whites versus racial and ethnic minorities is well-documented. As the Institute of Medicine explained in a recent analysis of the issue, “[r]acial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.”

      Patients of color have expressed a continuing distrust in the health care [p685] system and in individual medical providers, and with good reason. An astonishing number of studies document health disparities between the races and conclude that factors such as genetic differences, lifestyle choices, and variations in access to medical care fail to account fully for these health disparities. Numerous studies concerning virtually every type of medical care strongly suggest that African American patients do not receive the same care as white patients when they seek medical treatment. For example, the utilization rates of coronary drugs and complex coronary procedures, racial disparities in access to organ transplantation, frequency of knee arthroplasty, and disparities in the [p686] provision and availability of pain medications suggest that African Americans and other minorities receive different care than white patients. Another study documented substantial delays in breast cancer diagnosis and treatment for African American women compared with white women, and yet another found that African American women were significantly less likely than white women to undergo genetic testing for increase risk of breast and ovarian cancer.

      Although patient preferences may play a role in certain disparities in the utilization of medical procedures, there is real racial and cultural bias at work as well, at least some of the time. A couple of recent examples starkly illustrate the problem. In one highly publicized study, researchers [p687] found that physicians referred lower percentages of African American patients than white patients for cardiac catheterization, even when all other factors, i.e., age, sex, and severity of disease, were equal. Some studies clearly suggest that even when experts agree on an optimal intervention for a particular medical condition, African American patients may receive that treatment less frequently when they seek care. To take one striking example, several studies have demonstrated that African Americans are less likely to receive surgical treatment of early-stage lung cancer than whites, and, consequently, have a lower overall survival rate for the disease. These differential utilization patterns persist even when investigators control for confounding variables such as income, level of education, insurance coverage, co-morbid conditions, and stage of [p688] disease.

      At least some of these variations in quality of care appear to spring from unconscious bias in individual health care providers. Measuring this sort of racial bias and its impact on clinical decision-making presents very real challenges, and designing well-controlled, targeted studies remains difficult. In the most recent study attempting to document the effect of unconscious racial bias on clinical decision-making, researchers found a striking correlation between the presence of implicit negative stereotypes of African Americans and a decreased likelihood to provide appropriate medical treatment. In commenting on the research, one co-author suggested that the physicians studied appeared to have unknowingly internalized racial stereotypes that had a subtle influence on their clinical judgment. As the authors conclude,

       [i]mplicit racial biases are prevalent in the United States in general, and as such it should not be surprising that they are prevalent among physicians as well . . . . [Such biases] may affect the behavior even of those individuals who have nothing but the best intentions, including those in the medical professions.

      Of course, not all health disparities between the races result from bias in health  care delivery or disparities in access to care. As one commentator has observed, “two truths . . . may seem contradictory but aren't: 1) There is epidemic racism in this country. 2) You can find racism where it does [p689] not exist.” A complex interplay between socioeconomic status, education, lifestyle decisions and other behaviors, patterns of utilization of health services, and genetics influences the prevalence of disease in different racial and ethnic groups. Even more broadly, larger inequalities in society, such as discrimination in housing, employment, income distribution, education, and exposure to violence contribute to an increased risk of disease among minority populations. Nevertheless, evidence demonstrates the persistent effects of racial bias on the quality of medical care received by minority patients and the impact of this phenomenon in perpetuating health disparities. As a result, commentators have called for action to prevent bias and its effects on health.