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AEI Report: Geography Seen as Source of Racial Health

FEBRUARY 22, 2006 -- Geography rather than race could be the central reason for health care disparities between black and white patients, according to an analysis released Wednesday by researchers at the American Enterprise Institute (AEI).

Authors of the report dismissed the notion that unequal medical treatment is the result of biased physicians during a forum at the conservative Washington research organization. In turn, they urged health care policy experts to alter their approaches to crafting solutions aimed at closing the gap.

"We acknowledge that health care certainly varies by race, but we challenge the notion that it varies because of race," said AEI fellow and psychiatrist Sally Satel, who co-authored the analysis with Florida State University law professor Jonathan Klick.

Klick explained that if the problem does not stem from discrimination, its solution should not hinge on efforts such as cultural sensitivity training for doctors. Instead, Klick said policy may need to focus on getting better care to low-income areas by placing better doctors there, funding night hours for clinics, or subsidizing transportation to more distant hospitals.

"Residence is a big—and maybe the main—part of the problem," he said.

According to its authors, the findings presented Wednesday challenged those published in a 2002 Institute of Medicine study that they concluded did not adequately account for where patients live. The IOM study recommended increasing awareness about racial disparities, based on findings that racial and ethnic minorities experience a lower quality of care and are less likely to receive routine medical procedures—even when insurance status, income, age, and the severity of medical conditions are comparable.

"At best, the IOM prescriptions are wasteful," Klick said. "We need to sort of reframe the issues that the IOM has given to us."

But health care policy experts who attended the forum did not readily accept that analysis.

"Very few social scientists would present this as an either/or," said IOM study director Brian Smedley, adding that factors such as geography, racial bias, and cultural and linguistic barriers were all considered in the 2002 study.

Likewise, Marsha Lillie-Blanton, vice president of health policy at the Kaiser Family Foundation, said, "I'm a bit discouraged by the characterization of the IOM report."

Nonetheless, Lillie-Blanton added she was startled by maps and geographical data presented during the forum that illustrated a major care disparity in the southeast United States. Panelist Christopher Foreman, who spent a decade at the Brookings Institution, gave credit to those data, saying it would consequently be conceivable for lawmakers from those areas to create a coalition and focus their efforts to close the gap in care.

Research presented by both Amitabh Chandra, assistant public policy professor at Harvard University, and Peter Bach, physician at the Memorial Sloan-Kettering Cancer Center, signaled that while geography is not the only factor in accessing good health care, it may be possible to narrowly target the disparity on hospitals that treat predominately black patients.

Bach's data illustrated that black patients are clustered around certain doctors who care mostly for other black patients, are more likely to get care from physicians who practice in low-income areas, and are less likely to see doctors that have optimal access to quality resources.

Still, University of Delaware professor Linda Gottfredson emphasized that identically treating all patients would not ensure equal results. She said patients face varied "cognitive hurdles" in following through on their health care, whether reading medicine labels and documents, calculating dosage requirements, or recognizing the symptoms of their illness.

With a broad-based consensus that a disparity indeed exists, Lillie-Blanton said the forum left her encouraged, explaining, "We are moving forward in this debate and not standing still."

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