Racial and ethnic minorities tend to receive lower-quality health care than whites, even when insurance status, income, age, and severity of conditions are comparable. These disparities, which have been thoroughly documented, represent a pressing national problem. (See the Institute of Medicine’s report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care and The California Endowment’s report, Unequal Treatment. Unequal Health. What Data Tells Us About Health Gaps in California) Even among Medicare beneficiaries, significant disparities persist in health care, although disparities in the use of health care services by race and income have diminished since Medicare’s implementation. This article briefly discusses Medicare’s historical significance in providing universal health care access, reviews the current situation of health disparities among the Medicare population, and, drawing on the work of National Academy of Social Insurance (NASI), examines Medicare’s role in moving towards a lasting solution.
Historical significance of Medicare
Even with the current situation of health disparities, Medicare has significantly improved the lives of people of color since its inception. For example, Medicare played a crucial role in desegregating hospitals by requiring that hospitals comply with the Civil Rights Act of 1964. As a result, more than 1,000 hospitals were desegregated in a period of less than four months. Medicare also provided a virtually universal entitlement to health insurance, which significantly increased access to care for all people over the age of 65 and a substantial number of disabled persons, beginning in 1972. According to a NASI report, Medicare and Communities of Color, in 1963, before Medicare was created people of color 75 years and older had an average of 4.8 visits a year to the doctor, compared with 7.5 for White people of the same age group. By 1971, however, beneficiaries of color saw the doctor at a rate comparable to White beneficiaries. In addition, Medicare currently continues to improve access to care for people of color. Thirty percent of Latino people ages 55–64 were uninsured in 2001, but after age 65 only 5 percent were uninsured. Health data shows that Asian and Black beneficiaries have also experienced similar gains in access to care after becoming eligible for Medicare.
Medicare’s comprehensive collection of data has also made invaluable contributions to documenting disparities. Derived from beneficiary claims, Medicare’s data set has a large amount of health information that researchers can use to examine differences in health care utilization by race and ethnicity. The Medicare Current Beneficiary Survey, administered to a representative sample of beneficiaries, provides a wealth of information as well. According to the NASI report, this survey “is the only comprehensive source of information on the health status, health care use and expenditures, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries.” Along with other sources, these data sets have been and continue to be crucial for evaluating the experiences of people of color in Medicare.
Yet even with all these important contributions, stark health disparities exist and persist among Medicare beneficiaries. If not effectively addressed, they will continue to grow over the next generation as Medicare’s population becomes increasingly diverse. Currently, people of color — Asian, Black, Latino, and Native American people — account for 6.5 million, or 18 percent of the Medicare population over the age of 65. By 2030, people of color will represent more than 25 percent of the population over the age of 65, or 18.6 million people. In California, this percentage will be even greater as people of color already represent 28 percent of the Medicare population. Below is a list of some examples of the current health disparity situation.
Health disparities among beneficiaries: some examples & discussion
- Nearly 70 percent of African American beneficiaries live with hypertension, compared with 50 percent of white beneficiaries. (2000 Medicare Current Beneficiary Survey)
- Rates for African Americans and Latinos over the age of 65 having diabetes are double the rate for whites (California Health Interview Survey 2001)
- 28 percent of surveyed physicians treating African American Medicare patients reported difficulty providing their patients access to high quality care, as compared with 19 percent of physicians treating white patients. (Primary Care Physicians Who Treat Blacks and Whites, New England Journal of Medicine (NEJM), 2004)
- The life expectancy for African American men and women in the United States is nearly one decade fewer years of life than compared with their white counterparts.
- Stroke mortality among African Americans is one and a half to two times higher than that of whites.
- African American Medicare beneficiaries fare worse than white beneficiaries, even when they belong to the same health plan, an indication that racial health care disparities cannot be attributed to individual, inferior doctors. (Relationship Between Quality of Care and Racial Disparities in Medicare Health Plans, Journal of the American Medical Association (JAMA), 2006)
- Over 40 percent of African American and Latino beneficiaries perceive their health status as fair or poor, compared with 28 percent of white beneficiaries.
These are just a few examples, yet clearly the list goes on. Beneficiaries of color are more likely than their white counterparts to have low incomes, often reflecting persisting inequalities in education and employment. Low-income beneficiaries are also less able to afford Medicare’s premiums and coinsurance requirements, and particularly the new low-income copayment requirements for Part D drugs.
In addition, beneficiaries of color are more likely than white beneficiaries to have Medicaid or to rely solely on Medicare coverage. They are less likely to have private supplemental coverage in the form of individually purchased Medigap or employer-sponsored retiree coverage. According to a study by the Center for Studying Health System Change, twenty-seven percent of African American beneficiaries versus just 10 percent of white beneficiaries rely solely on Medicare. This lack of supplemental insurance limits their access to and affordability of care as supplemental insurance coverage helps with Medicare premiums and cost sharing and in covering services not covered by Medicare.
Also, persisting disparities remain in preventive, primary, and surgical care for beneficiaries of color, regardless of the dramatic improvements in health care access discussed above that Medicare provides at age 65. (See NASI’s brief, Medicare and Communities of Color, 2004) For example:
- In fee-for-service Medicare, communities of color show an unequal use of medical services and experience a lower quality of care compared to white beneficiaries, even when taking insurance status and socio-economic status into account.
- Beneficiaries of color are less likely than white beneficiaries to receive common preventive measures such as mammography, prostate exams, and flu shots.
- Beneficiaries of color are less likely to report having a physician’s office as a usual source of care than their white counterparts.
- Beneficiaries of color also disproportionately rely on emergency rooms and urgent care clinics or report having no usual source of care. Beneficiaries of color are also less satisfied with their care. Fourteen percent of African American beneficiaries report being very satisfied with their general care, compared with 31 percent of white and 25 percent of Latino beneficiaries.
Delayed treatments and preventable hospitalizations for avoidable medical conditions are also more common among beneficiaries of color, whether the cause is patient lifestyle, physician attitudes, or other institutional and systemic factors. For example, among African American beneficiaries, inadequate diabetes management leads to more treatments for glaucoma, hospitalizations for hypoglycemic comas, and non-traumatic lower limb amputations. In a study of over 19,000 Medicare patients who underwent amputation or leg-sparing surgery, among those with diabetes, African Americans were 58% more likely than whites to undergo above-the-knee amputation. (The Archives of Surgery, Guadagnoli, Ayanian, Gibbons, McNeil and LoGerfo, 1995)
Beneficiaries of color are less likely to receive angioplasty, bypass surgery, and proper follow-up care after cardiac episodes. African American beneficiaries’ angioplasty rates are about 60 percent of their white counterparts, bypass surgery rates are 50 percent lower for African American beneficiaries, and African American beneficiaries receive follow-up care after hospitalizations for a cardiac problem at only 80 percent of the rate for white beneficiaries. African American beneficiaries are even less likely to receive routine therapy that restores blood flow to vital organs and tissues after a heart attack. (See Medicare and Communities of Color, 2004)
What causes these disparities? The Institute of Medicine’s 2002 report, Unequal Treatment, concluded that disparities are caused by a complex web of factors based in “historical and contemporary inequities” that involve participants throughout the many layers of the health care system, including patients, health care professionals, administrative and bureaucratic processes, and the health marketplace itself. The report found that personal bias, discrimination, and racism are powerful contributing factors to the unequal treatment of communities of color in America’s health care system.
Medicare’s role as a leader in eliminating health disparities
Given these findings, what is Medicare’s current role in addressing health disparities? In a report, Strengthening Medicare’s Role in Reducing Racial and Ethnic Health Disparities, the National Academy of Social Insurance (NASI) argues that Medicare’s dominant influence over the entire health care sector, gives it both unique opportunities to, and responsibility for, reducing racial and ethnic health disparities. Through its policies and programs, Medicare can not only improve the care provided to its 9 million minority beneficiaries, but also, with it’s leverage as the largest purchaser and regulator of health care, can influence a reduction in disparities among all age groups. NASI states that “as a social insurance program, Medicare has the responsibility to ensure that all those who have contributed to the program receive appropriate care on a fair and nondiscriminatory basis.”
The study concludes that Medicare can take the lead in reducing disparities — both for its beneficiaries and throughout the health system. It makes 17 recommendations to those who set policy for and administer the Medicare program that fall into five categories:
- Improving the quality of clinical care,
- Increasing access to care,
- Educating health professionals to improve diversity and cultural competence,
- Holding health care providers responsible for reducing disparities, and
- Making the reduction of disparities a top administrative priority and focus.
In each of these areas, Medicare has tools that it can use to help reduce disparities. For details on both the recommendations and rationale, view the study panel’s final report.
The panel also published the following papers and briefs on this subject:
- Medicare, the National Quality Infrastructure, and Health Disparities, Medicare Brief No. 14, by Lawrence P. Casalino
- Improving Medicare’s Data on Race and Ethnicity, Medicare Brief No. 15, by A. Marshall McBean
- Racial and Ethnic Disparities in Medicare: What the Department of Health and Human Services and the Center for Medicare and Medicaid Services Can, and Should, Do, by Timothy Stoltzfus Jost
- CMS’ Programs and Initiatives to Reduce Racial and Ethnic Disparities in Medicare, by Ellen O’Brien
- Individual Physicians or Organized Processes: How Can Disparities in Clinical Care be Reduced?, by Lawrence P. Casalino
- Medicare Race and Ethnicity Data, by A. Marshall McBean
- A New Strategy to Combat Racial Inequality in American Health Care Delivery by Dayna Bowen Matthew
Medicare’s historical impact on improving access to care for beneficiaries of color is unprecedented, and it has been and continues to be a leader in collecting data on racial and ethnic health disparities. In addition, over the years Medicare has made efforts to support communities of color and to address racial and ethnic health disparities in Medicare, yet significant health disparities remain in both Medicare and the U.S. health care system overall. As beneficiaries of color become an increasing part of the Medicare population, addressing their needs and reducing health disparities will become of growing importance to the program’s success. Medicare has the responsibility as well as the tools, resources, and political and economic leverage to become a dynamic leader in reducing racial and ethnic health disparities among its beneficiaries and the rest of the health system.