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Timothy Stoltzfus Jost

Excerpted from: Timothy Stoltzfus Jost, Racial and Ethnic Disparities in Medicare: What the Department of Health and Human Services and the Centers for Medicare and Medicaid Services Can, and Should, do, 9 DePaul Journal of Health Care Law 667  (2005) (196 Footnotes)(Full Article)


Commentators commonly identify four primary categories of causal factors that contribute to racial and ethnic disparities in the use of health care services: financial barriers; other logistical, organizational, or systemic barriers; provider attitudes and behavior; and patient attitudes and behavior.

Financial barriers are an important factor for explaining racial and ethnic disparities in the United States health care system generally. Racial and ethnic minorities in the United States are disproportionately poor and uninsured. African-Americans are almost twice as likely to be uninsured as white Americans, while Hispanics are almost three times as likely.  timothy stoltzfus jostMinorities covered by Medicare, of course, nominally receive the same benefits received by majority non-Hispanic whites. Medicare coverage, however, leaves significant gaps for all *676 beneficiaries. During 2005, for example, a Medicare beneficiary must pay a $912 deductible before Medicare begins to cover hospital care, and after sixty days of hospitalization must pay a $228 per day copayment.  Part B recipients have to meet a $110 deductible before coverage accrues, and thereafter must pay a 20% copayment for most services. Most Medicare recipients have private supplemental insurance to fill these gaps, which they either purchase individually or receive as a retirement benefit. Racial and ethnic minorities, however, tend to lack supplemental coverage disproportionately. Approximately 45% of African-American and Hispanic beneficiaries have no form of insurance supplemental to Medicare, while only 27% of white beneficiaries lack supplemental coverage.  Many minority beneficiaries worked at low-paying jobs that did not offer retirement benefits, and cannot now afford the high cost of individual supplement policies.

Minority Medicare beneficiaries are disproportionately (compared to majority beneficiaries) covered by Medicaid, which does fill the gaps in Medicare coverage. Over one third of African-American and one quarter of Hispanic beneficiaries receive Medicaid, compared to only a little over 10% of white beneficiaries.  Only the poorest Medicare beneficiaries, however, are eligible for full Medicaid coverage.  Other beneficiaries with incomes up to 100% of the federal poverty level receive mandatory assistance from Medicaid under the Medicare Savings Programs with Medicare premiums, coinsurance, or deductibles; while those who have incomes up to 120% of the poverty level have their Part B premiums covered. Some beneficiaries also receive extended Medicaid coverage under state medically needy programs or other optional state Medicaid programs. Many minority beneficiaries, however, are not quite poor enough to qualify for coverage under Medicaid, and thus must spend their meager income on Medicare deductibles and coinsurance payments or do without health *677 care. Beneficiaries who receive a small Social Security or pension check, for example, may have too much money to qualify for Medicaid, but may not have enough money to cover necessaries such as food and housing, and still have enough to cover Medicare deductibles and coinsurance.

Institutional barriers to minority access to health care are the second major cause of racial and ethnic disparities. Even when minority beneficiaries have the financial resources to obtain Medicare covered services (or when financial barriers are not a serious problem, as with home health or other services that require no coinsurance payments, or hospital care once the deductible is met and before covered days expire), they still often face other logistical, organizational, or systemic barriers. Providers may simply not be available in the parts of cities or towns where minorities disproportionately live. Further, the providers that serve minority communities may not offer the extensive array of services that are offered in wealthier, predominantly white communities. Minorities may also lack transportation to get to providers. Medicare Advantage (MA) plans, which are heavily subsidized by Medicare, and thus are often able to offer benefits not available to traditional Medicare beneficiaries or lower cost-sharing rates, may not have adequate provider coverage in areas where minorities disproportionately live.

Minorities who are Medicaid recipients may also have a difficult time finding providers who accept Medicaid. Many physicians set quotas as to the number of Medicaid patients they will treat; others may refuse to treat Medicaid patients altogether.  Medicaid status in many parts of the country correlates highly with minority status, thus these physicians are in effect, if not in intent, discriminating against racial minorities. Medicaid programs that offer very low physician payment rates or that refuse to cover Part B coinsurance amounts when Medicare payments exceed Medicaid rates, moreover, encourage this discrimination by discouraging physicians from accepting Medicaid recipients.

Research shows that minorities rely disproportionately on practitioners of the same racial or ethnic group.  But these practitioners may not have the access to specialist referral networks that white practitioners do; thus, minority beneficiaries may not be able to *678 get access to specialists as readily as majority white beneficiaries.  Minorities are also disproportionately dependent on hospital outpatient departments and emergency rooms (in particular those of large urban hospitals) for receiving care, and often face difficulties in negotiating these clinical bureaucracies. The safety net providers that minorities often depend on have faced increasing financial difficulties in recent years, making care even less accessible to minorities.

Finally, limited English proficiency (LEP) poses a major access barrier for many minority beneficiaries.  Providers often lack adequate translation services, and beneficiaries who lack English proficiency may have to depend on provider employees with no training in interpretation, family members, or even other patients for interpretation. Basic forms and explanatory materials, moreover, may not be available in any language other than English, imposing a further barrier to access. In particular, LEP beneficiaries may experience greater deficits in knowledge about Medicare, and have a harder time using the Medicare program.

A third cause of racial disparities in the receipt of Medicare services is professional attitudes and behavior. There is ample, though not always uncontroverted, evidence that many health care professionals treat members of racial and ethnic minority groups differently than they do white majority patients. For some professionals, this may be the result of conscious discrimination. For others it is probably the result of unarticulated beliefs or stereotypical thinking about the likelihood that minorities will benefit from certain procedures, be able to understand or comply with certain treatment regimens, or, perhaps, be able to afford certain forms of treatment.  The fact that patient race is one of the key descriptors used in clinical rounds and medical presentations, despite the fact that race is largely a social construct with limited genetic basis,  suggests that it is largely *679 used as a decision-making heuristic based on stereotypical thinking.  Physicians' expectations or suspicions concerning the ability of minority patients to comply with treatment and about complicating factors such as substance abuse, poor living conditions, or family support, may shape clinical judgments regarding diagnosis and treatment, as may unarticulated assumptions about a minority patient's lack of truthfulness, self-discipline, initiative or intelligence or assumptions about the patient's tolerance for pain.

To the extent such beliefs exist, they simply reflect beliefs generally held in the majority American culture. Studies find, for example that 44% of American whites believe that blacks are lazy and 51% believe that they are prone to violence, while only 5% of whites view whites as lazy and 15% as prone to violence,  and similar attitudes have been identified in doctors.  The conditions under which clinical encounters commonly take place-brief encounters under time pressure where complex decisions must be made in the presence of cognitive overload-encourage the use of stereotypes as heuristics for decision-making.  Cultural and language barriers may impede the physician's ability to learn of and understand the patient's symptoms and treatment preferences, while the difficulty of empathy across race, and often class, boundaries, may make it more difficult for the physician to understand the patient's hopes and fears.  The result of all of these factors is that racial and ethnic minorities tend to receive less, and less aggressive, treatment than majority whites.

A fourth and final set of factors that contribute to racial and ethnic disparities are the attitudes, knowledge, and behavior of beneficiaries. In general, Medicare beneficiaries vary widely in their *680 trust in scientific medicine, their confidence in medical professionals and institutions and in their advice, their tolerance for pain and discomfort, and their attitudes towards the short and long-term trade-offs presented by treatment decisions. To some extent these differences may be linked to racial and ethnic minority status.  More specifically, the experience of a half a life-time of segregated medical care, compounded by the collective memory of the Tuskegee experiments, undoubtedly contributes to the lack of trust that African-American beneficiaries may feel toward health care providers.  Distrust for a system that is perceived as biased may lead to a disinclination to accept aggressive treatment or treatment that has not been adequately explained.  At least as important, however, may be lack of knowledge and understanding of the health care system and of Medicare benefits. Disproportionately, minority beneficiaries were uninsured before securing Medicare coverage, and therefore, lack established connections with providers and experience as to how to find and use health care services.  Particularly important may be lack of knowledge about the preventive benefits available from Medicare, and of how to gain access to them. Patients may also simply not understand the professionals who are treating them because of their limited English proficiency or because of cultural differences that cause them to hear something other than what the professional intended to communicate.

Because there are multiple causes of racial and ethnic disparities in Medicare, no single approach to solving the problem of disparities will be effective. Rather multiple approaches, addressing each of the varied problems, will be necessary.