AAMC Division of Community and Minority Programs Minority Faculty Career Development Seminar

1
Department of Health and Mental Hygiene
Health Disparities Conference
Do All Americans Receive the Same Quality
Health Care? Does It Matter?

Donald E. Wilson, MD, MACP Vice President for
Medical Affairs, University of Maryland John Z.
and Akiko K. Bowers Distinguished
Professor, Dean, School of Medicine Tuesday,
June 8, 2004 University of Maryland Baltimore
County
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Some of the Systems Assets

• A well-trained, highly motivated health workforce
• An abundance of technically sophisticated and
  (usually) luxurious healthcare facilities
• A highly adaptable and innovative system
• The worlds center of cutting edge biomedical
  research

Source How Much Responsibility Do Providers of
Health Care have for the Flaws in Our Health
System, Uwe Reinhardt, March 10, 2004.
4
Life Expectancy at Birth by Gender and Ranked by
Selected Countries, 1995
5
U.S. Life Expectancy
80
74.9
74.8
Ages
68.2
White Men Black Men
White Women Black Women
Source K. Whitfield, M. Hayward, Public Policy
Aging Report The Landscape of Health
Disparities Among Older Adults, National Academy
on an Aging Society, 2003.
6
Maternal Mortality in 2000 Estimates Developed
by WHO, UNICEF and UNFPA
Based on vital registration data available at
WHO. Source Maternal Mortality in 2000
Estimates developed by WHO, UNICEF and UNFPA.
7
Infant Mortality Rate, 2003
Source U.S. Census Bureau, International
Database.
8
Infant Mortality Rates for Mothers Age 20, By
Race/Ethnicity and Education, 1998-2000
Data National Center for Health Statistics,
National Vital Statistics System, National Linked
Birth/Infant Death Data. Source Health,
United States, 2002, Table 21.
9
Health

• The overall condition of an organism at a given
  time.
• Soundness, especially of body or mind freedom
  from disease or abnormality.
• A condition of optimal well-being.

Source The American Heritage Dictionary, Third
Edition, 1996, pg. 833.
10
National Health Expenditures (NHE)Selected
Calendar Years 1970-2002
Billions
Source Centers for Medicare and Medicaid
Services, Office of the Actuary, National Health
Statistics Group.
11
Health Spending Per Capita, Selected OECD
Countries, 2001 (in purchasing power parity U.S.
)


57 of U.S. Level
Source Organization for Economic Cooperation
and Development Data, 2003.
12
Average Annual Growth Rates
NHE
Percent
CPI
Note Health spending refers to National Health
Expenditures (NHE). Source Centers for Medicare
and Medicaid Services (CMS), Office of the
Actuary Bureau of Labor Statistics (Consumer
Price Index-U, U.S. city average, annual figures).
13
National Health Expenditures as Percent of Gross
Domestic Product (GDP)Selected Calendar Years
1970-2013
Percent
Estimated Source Centers for Medicare and
Medicaid Services, Office of the Actuary,
National Health Statistics Group and U.S.
Department of Commerce, Bureau of Economic
Analysis and Bureau of Census.
14
General Clinical Research Factors Accounting For
Growth in Personal Health Care ExpendituresSelect
ed Calendar Years 1993-2002
8.8
8.5
6.6
5.4
Average Annual Percentage Change
Source Centers for Medicare and Medicaid
Services, Office of the Actuary.
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In return for their higher health spending, the
85 of Americans who are well insured have easy
and prompt access to health care facilities that
are as luxurious by world standards as they are
technologically sophisticated.A sizeable body
of cross-national research, however, has shown
that these advantages do not translate themselves
into

• Superior health status indicators (on the
  contrary, they tend to be relatively poor albeit
  for reasons that may have little to do with
  medical care proper).
• Higher satisfaction scores among the citizenry
  (on the contrary, the U.S. ranks at the bottom of
  the OECD on this score).
• Higher satisfaction scores among physicians and
  hospital executives (on which the U.S. also
  scores relatively poorly).

Source How Much Responsibility Do Providers of
Health Care have for the Flaws in Our Health
System, Uwe Reinhardt, March 10, 2004.
16

• Modern medicine is one of those extraordinary
  works of reason an elaborate system of
  specialized knowledge, technical procedures, and
  rules of behavior.
• But medicine is also, unmistakably, a world of
  power where some are more likely to receive the
  rewards of reason than are others.
• Medicine has become a sprawling system of
  hospitals, clinics, health plans, insurance
  companies, and myriad other organizations
  employing a vast labor force.

Source The Social Transformation of American
Medicine, Paul Starr, 1982, pg. 3-4.
17
Percent of the Population by Race/Ethnicity2000
and 2030

Percent
Source U.S. Bureau of the Census, 2004, U.S.
Interim Projections by Age, Sex, Race, and
Hispanic Origin.
18
Race Opportunity SurveyPercent Who Say
...African Americans Have More or About the Same
Opportunities in Life Than Whites Have
Among
Whites
71
African Americans
24
There is A Lot of Discrimination Against African
Americans in Our Society Today
Among
20
Whites
48
African Americans
Source The Washington Post, The Henry J. Kaiser
Family Foundation Harvard University, 200.1.
19
Access to Health Care
Race Opportunity Survey
Education
Source The Washington Post, The Henry J. Kaiser
Family Foundation Harvard University, 2001.
20
Poll Do Minorities Receive Higher, the Same, or
Lower Quality Care as Whites?
Race/Ethnicity of Respondents
Source Harvard Forums on Health, 2003.
21
Fair or Poor Health, by Race/Ethnicity, 2000
Percent With Fair or Poor Health
Data National Center for Health Statistics,
National Health Interview Survey, 2000.
Source Health, United States, 2002, Table 59.
22
Members of minority groups have been the
invisible people in the health care delivery
and education systems in this country. This is
witnessed by the scarcity of health care services
and practitioners in minority group community and
the differential in health status between
minority people and Caucasians.
Source Journal of Medical Education, A Survey
of Ethnic and Sociocultural Issues in Medical
School Education, 1978.
23
To Err Is HumanBuilding a Safer Health System

• Institute of Medicine Report
• 1999

24
Unequal TreatmentConfronting Racial and
EthnicDisparities in Health Care

• Institute of Medicine Report
• 2002

25
Health Care Disparities in the United States
26
Factors in Health Disparities

• Access
• Insurance
• Poverty
• Education
• Lack of diversity among practitioners
• Geographic location
• Unequal treatment

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Health Disparities

• Racial or ethnic differences in the quality of
  health care that are not due to access-related
  factors or clinical needs, preferences, and
  appropriateness of intervention.

Source Unequal Treatment Report, Institute of
Medicine, 2002, Pg. 4.
28
Differences, Disparities and Discrimination
Populations with Equal Access to Healthcare
Difference
Non-Minority
Disparity
Quality of Healthcare
Minority
Source Gomes and McGuire, 2001.
29
Age-Adjusted Prevalence Trends for High Blood
Pressure in Americans
Age 20-74 by Race/Ethnicity, Sex and Survey
NHANES II IV
1999-2000
41.0
38.0
28.9
24.7
Percent of Population
Source CDC/NCHS. Health, United States, 2003.
30
Extent of Awareness, Treatment and Control of
High Blood Pressure by Race/EthnicityNHANES IV
1999-2000
73.9
69.5
63.0
60.1
55.6
44.6
33.4
28.1
Source JAMA, 2003 290199-206.
31
Quality of Care Among Medicare Beneficiaries in
Managed Care Plans
Source Schneider et al., JAMA, March 13, 2002.
32
Percent Of Persons 65 And Over Who Received
Influenza Vaccine In Past Year, By Ethnicity
Source Agency for Healthcare Research and
Quality, National Health Interview Survey, 2001.
33
Percentage Of Adult Diabetics Who Had Retinal Eye
Exam In Past Year, By Race
Retinal eye exam
Source Agency for Healthcare Research and
Quality, Medical Expenditures Panel Survey, 2000.
34
Admissions For Diabetes With Long-term
Complications Per 100,000 Population, By Race
Source Agency for Healthcare Research and
Quality, Healthcare Cost and Utilization Project,
2000.
35
Avoidable Admissions For Bacterial Pneumonia Per
100,000 Population, By Race/Ethnicity
Source Agency for Healthcare Research and
Quality, Healthcare Cost and Utilization Project,
2000.
36
Facts do not cease to exist because they are
ignored.

• Aldous Huxley

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National Healthcare Disparities Report

• Agency for Healthcare Research and Quality
• 2003

38
National Healthcare Disparities ReportKey
Findings

• Inequality in quality persists
• Disparities come at a personal and societal price
• Differential access may lead to disparities in
  quality
• Opportunities to provide preventive care are
  frequently missed
• Knowledge of why disparities exist is limited
• Improvement is possible
• Data limitations hinder targeted improvement
  efforts

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• Overarching Goal
• Reduction of disparities in health.
• Promote development and implementation of an
  increased number of effective interventions that
  would address health disparities and ensure
  equity in health outcomes.

Source Health and Health Care 2010 The
Forecast, the Challenge, The Institute for the
Future, funded by The Robert Wood Johnson
Foundation, January, 2000.
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Important to Eliminate Health Disparities Studies
show that certain health problems such as
diabetes, heart disease and infant mortality
happen more often among citizens with lower
incomes and minorities. How important do you
feel it is to conduct medical or health research
to understand and eliminate these differences?
Source Taking Our Pulse, conducted by
Research!America Health Poll, Charlton Research
Company, 2004.
41
One of the greatest national challenges for the
foreseeable future is the elimination of racial
and ethnic health disparities and the continued
improvement of health for all who live in the
U.S. While the general health of the nation has
improved over the past two decades, racial and
ethnic minorities continue to suffer from a
disproportionate burden of preventable illness
and death .

• John E. Maupin, DDS, MBA,
• President, Meharry Medical College
• April, 2004

42
Underrepresented Minorities as a Percent of
Medical School Matriculants and U.S. Population
URMs in US Population
Percent
URM Matriculants
Source Association of American Medical
Colleges, Minority Graduates of U. S. Medical
Schools Trends, 1950-1998, 25, AAMC Data Book
Statistical Information Related to Medical
Schools and Teaching Hospitals (Washington
AAMC, January, 2001), 21 U.S. Census Bureau,
Population Division.
43
Underrepresented Minorities as a Percent of
Medical School Matriculants and U.S. Population
URMs in US Population
Percent
URM Matriculants
Source Association of American Medical
Colleges, Minority Graduates of U. S. Medical
Schools Trends, 1950-1998, 25, AAMC Data
Book Statistical Information Related to Medical
Schools and Teaching Hospitals (Washington
AAMC, January, 2001), 21 U.S. Census Bureau,
Population Division.

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Underrepresented Minorities as a Percent of
Medical School Matriculants and U.S. Population
URMs in US Population
Percent
URM Matriculants
Source Association of American Medical
Colleges, Minority Graduates of U. S. Medical
Schools Trends, 1950-1998, 25 AAMC Data Book
Statistical Information Related to Medical
Schools and Teaching Hospitals (Washington
AAMC, January, 2001), 21 U.S. Census Bureau,
Population Division.
45
U.S. Medical School Matriculants by Race, 2003
Total 16,538
Source AAMC Data Warehouse Applicant
matriculant file as of 11/6/2003.
46
Physicians and Surgeons by Race/Ethnicity and
Hispanic Origin in the United States, 2000
Total 700,846
4.4
Source U.S. Census Bureau, 2000.
47
If we dont change direction soon, well end up
where were going.

• Professor Irwin Corey

48
Uninsured in the U.S. and Maryland
49
Nearly one out of three people in the United
States under the age of 65 went without health
insurance for all or part of the two-year period
2001-2002.
Source Going Without Health Insurance, Report
released by The Robert Wood Johnson Foundation,
prepared by Families USA for Cover
the Uninsured Week, March 10-16, 2003.
50
Uninsured in the United States
43.3 Million
Millions
17.2
Source U.S. Census Bureau, 2003.
51

Percent of People Without Health Insurance by
State (3-Year Average) 2000-2003

24.1
18.7

14.7
12
Percent
Source U.S. Census Bureau, Current Population
Survey, 2001, 2002, and 2003 Annual social and
Economic Supplements.
52
People Under Age 65 Without Health Insurance
During 2001-2002, by Employment Status
The table reflects the employment status as
projected for December 2002. For adults (ages 18
to 64), employment status reflects the
individuals employment status. For children
(under age 18), if one parent is employed, then
the child is counted as employed or as a member
of an employed family. Source Going Without
Health Insurance, Report released by The Robert
Wood Johnson Foundation, prepared by Families USA
for Cover the Uninsured Week, March 10-16, 2003.
Estimates based on the Census Bureaus most
recent CPS and SIPP data.
53
People Under 65 Without Health Insurance During
2001-2002, by Age
Source Going Without Health Insurance, Report
released by The Robert Wood Johnson Foundation,
prepared by Families USA for Cover the Uninsured
Week, March 10-16, 2003. Estimates based on the
Census Bureaus most recent CPS and SIPP data.
54
People Under 65 Without Health Insurance During
2001-2002, by Race and Hispanic Origin
Source Going Without Health Insurance, Report
released by The Robert Wood Johnson Foundation,
prepared by Families USA for Cover the Uninsured
Week, March 10-16, 2003. Estimates based on the
Census Bureaus most recent CPS and SIPP data.
55
Sources of Health Insurance Coverage and Number
of Uninsured Persons for Population Under Age 65
Years, 1987-2002
17.2
16.5
17
16.1
16.2
16.4
16.9
16.1
16
15.9
15.7
15.1
14.9
14.5
14.4
13.7
Estimated Number (millions)
Note Coverage reported as military (i.e.,
Tricare, CHAMPVA) is counted as employment-based.
Estimates for 2000, 2001 and 2002 use census
2000-bases weights. Precise estimates do not add
to 100 percent due to rounding and because
respondents may report more than one source of
coverage within a year.
Source Fronstin, 2002, Mills and Bhandari, 2003.
56
Changes in the Number Percent of Uninsured
Children Adults in Maryland, 2000-2002
150,000 150,000 450,000
540,000
Source Health Insurance Coverage in Maryland
Through 2002, Maryland Health Care Commission,
November, 2003.
57
Nonelderly Uninsured by Poverty Level
in Maryland, 2001-2002
Source Health Insurance Coverage in Maryland
Through 2002, Maryland Health Care Commission,
November, 2003.
58
Nonelderly Health Insurance Coverage by Highest
Educational Level in Family in Maryland, 2001-2002
(2000-01)
(uninsured 19)
(uninsured 37)
Source Health Insurance Coverage in Maryland
Through 2002, Maryland Health Care Commission,
November, 2003.
59
Nonelderly Health Insurance Coverage by
Race/Ethnicity in Maryland, 2001-2002
Source Health Insurance Coverage in Maryland
Through 2002, Maryland Health Care Commission,
November 2003.
60
Summary

• A significant number of the uninsured are not low
  income and do not lack access to employer-based
  coverage
• e.g., 29 of uninsured adult employees work for
  the government or firms with 100, and have
  families incomes above 200 of the poverty level
• This makes attaining universal coverage more
  complex than subsidization expanded access
• Lack of knowledge/understanding of the system
• The decision not to purchase insurance can be an
  economically rational decision
• Different valuation of health insurance
  attitudes toward risk
• Experiences, expectations of the health care
  system differ by cultural background
  socioeconomic class

Source Health Insurance Coverage in Maryland
Through 2002, Maryland Health Care Commission,
November, 2003.
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This will not be a good nation for any of us
unless we learn how to make it a better nation
for all of us.

• Theodore Roosevelt

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Knowing is not enough we must apply. Willing
is not enough we must do.
Goethe
64
Total Tax Revenues (All Taxes) as a Percent of
GDP OECD Countries, 2000
?
Source Organization for Economic Cooperation and
Development, Revenue Statistics 1965-2001, Table
3, p. 74.
65
Source How Much Responsibility Do Providers of
Health Care have for the Flaws in Our Health
System, Uwe Reinhardt, March 10, 2004.
66
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