Leveling the Field — Ensuring Equity through National Health Care Reform (New Eng Jour Med)

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http://healthcarereform.nejm.org/?p=2461&query=TOC#

Leveling the Field — Ensuring Equity through National Health Care Reform
December 2nd, 2009
Bruce Siegel, M.D., and Lea Nolan, M.A.

The United States is in the midst of a profound demographic transition. By 2050, non-Hispanic whites will account for less than half the U.S. population and members of racial and ethnic minority groups will be in the majority. This shift is also reflected in the fact that the United States is now home to at least 20 million people who have low proficiency in the English language. Although there are differences among minority groups, all these populations face special challenges. Members of minority groups have higher rates of disease, poorer health, and more limited access to care than their white counterparts. They account for half of the uninsured population1 and 58% of the low-income uninsured population. Even when they have coverage, minority patients are at risk for receiving lower-quality medical and surgical care than white patients. The factors underlying these inequities are complex and go far beyond the health care system, but any meaningful reform must, at a minimum, confront disparities in care.

The major reform proposals aim to dramatically increase coverage. The result might be a lessening of racial and ethnic disparities, given that lack of insurance has tangible effects on health and health care. But it is not the entire solution. For instance, although Medicare has been instrumental in improving equity, marked ethnic and racial disparities in care persist within the program. We could be faced with an influx of millions of newly insured members of minority groups into a health care system that is unable or unwilling to provide them with high-quality care. Without an explicit focus on equity, reform will leave millions of Americans behind.

To begin with, the health care system must be given the tools to measure and improve the quality of care that minorities receive. Today, most doctors, hospitals, and health plans do not analyze the quality of care delivered according to patients’ race, ethnic group, or primary language. This lack of data makes it impossible to identify harmful variation or to develop strategies to reduce disparities. But models now exist for such action, and reform can build on these efforts.

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These laws have set the stage for pending efforts. Congress is currently considering health care reform proposals that have implications for ensuring equity for minority patients. Both the House bill, the Affordable Health Care for America Act, and the Senate bill, the Patient Protection and Affordable Care Act, propose the development and implementation of improved quality measures and the collection and analysis of data on race, ethnic group, and language as part of efforts to reduce disparities. However, these proposals apply only to federally funded programs (Medicare, Medicaid, and the Children’s Health Insurance Program, as well as any new public insurance plan) and the health plans that contract with them. In addition, other elements of these proposals could have unintended consequences that would make it harder for minority patients to obtain the best health care. The bills would accelerate pay-for-performance and transparency programs that are designed to promote quality improvement, but without thoughtful design, such programs could boomerang: doctors, hospitals, or health plans could discover that it is in their interest to avoid high-risk patients (who are often members of minority groups) whose outcomes could adversely affect their performance ratings. If decreased rates of re-hospitalization were a performance goal, for instance, providers might wish to avoid poor, sick minority patients who are likely to lack access to good primary care. Public hospitals and clinics, which already have inadequate resources, could also face funding cuts if the quality of their care did not reach certain thresholds; such cuts would further undermine quality. Reform should include incentives for improvement, not just penalties for poor performance.

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Health care reform provides a unique opportunity to reverse a legacy of inequality in health and health care. This chance should not be squandered.

Source Information

From the Center for Health Care Quality, George Washington University School of Public Health and Health Services, Washington, DC. The opinions expressed here are solely those of the authors.

The New England Journal of Medicine is owned, published, and copyrighted © 2009 Massachusetts Medical Society. All rights reserved.


http://healthcarereform.nejm.org/?p=2461&query=TOC#

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