U.S. Commission on Civil Rights

The U.S. Commission on Civil Rights is an independent, bipartisan agency established by 

Congress in 1957. It is directed to

Investigate complaints alleging that citizens are being deprived of their right to vote by 

reason of their race, color, religion, sex, age, disability, or national origin, or by reason of 

fraudulent practices.

Study and collect information relating to discrimination or a denial of equal protection of 

the laws under the Constitution because of race, color, religion, sex, age, disability, or 

national origin, or in the administration of justice.

Appraise federal laws and policies with respect to discrimination or denial of equal 

protection of the laws because of race, color, religion, sex, age, disability, or national 

origin, or in the administration of justice.

Serve as a national clearinghouse for information in respect to discrimination or denial of 

equal protection of the laws because of race, color, religion, sex, age, disability, or 

national origin.

Submit reports, findings, and recommendations to the President and Congress. 

Issue public service announcements to discourage discrimination or denial of equal 

protection of the laws.

Members of the Commission

Gerald A. Reynolds, Chairman

Abigail Thernstrom, Vice Chair

Todd Gaziano

Gail Heriot

Peter N. Kirsanow

Arlan D. Melendez

Ashley L. Taylor, Jr.

Michael Yaki

Martin Dannenfelser, Staff Director

U.S. Commission on Civil Rights

624 Ninth Street, NW

Washington, DC 20425

(202) 376-8128

(202) 376-8116 TTY

www.usccr.gov

This report is available on disk in ASCII Text and Microsoft Word 2003 for persons with visual 

impairments. Please call (202) 376-8110.
 

Health Care 

Disparities

A Briefing Before

The United States Commission on Civil Rights 

Held in Washington, DC

Briefing Report

Table of Contents v

Table of Contents 

Executive Summary.................................................................................................................. 1

Panelist Statements: First Panel................................................................................................ 3

Louis W. Sullivan ................................................................................................................. 3

Causes of Health Disparities..................................................................................................... 8

Current Research and Actions to Eliminate Health Care Disparities....................................... 9

Rubens J. Pamies ................................................................................................................ 12

Amitabh Chandra................................................................................................................ 21

Peter Bach ........................................................................................................................... 35

Statements: Second Panel ....................................................................................................... 39

William R. Lewis................................................................................................................ 39

Herman A. Taylor............................................................................................................... 48

Strong Heart Study (SHS) 1989-2000 .................................................................................... 58

Stop Atherosclerosis in Native Diabetics (SANDS Trial) 2002-2007.................................... 58

Strong Heart Family Study (SHFS) 2000-2010...................................................................... 59

The Message ........................................................................................................................... 60

Bruce Siegel........................................................................................................................ 61

Public Comments.................................................................................................................... 73

Peter Bach ........................................................................................................................... 75

Amitabh Chandra................................................................................................................ 75

Garth N. Graham................................................................................................................. 75

Barbara V. Howard ............................................................................................................. 76

William R. Lewis................................................................................................................ 77

Rubens J. Pamies ................................................................................................................ 77

Sally L. Satel....................................................................................................................... 78

Bruce Siegel........................................................................................................................ 78

Louis W. Sullivan ............................................................................................................... 79

Herman A. Taylor............................................................................................................... 79

Commissioner Statements....................................................................................................... 81

Statement of Abigail Thernstrom, Vice Chair.................................................................... 81

Statement of Commissioner Todd Gaziano ........................................................................ 83
vi Health Care Disparities

Statement and Rebuttal of Commissioner Gail Heriot ....................................................... 87
Executive Summary 1

Executive Summary

The federal government defines health care disparities as the persistent gaps between the 

health status of minorities and non-minorities in the United States. According to the National 

Partnership for Action to End Health Disparities (a division of the Department of Health and 

Human Services), despite continued advances in health care and technology, racial and ethnic 

minorities continue to have more disease, disability, and premature death than nonminorities.

In a briefing held on June 12, 2009, the Commissioners chose to examine health disparities 

through the microcosm of cardiovascular disease and the related condition of hypertension. 

Conditions arising from cardiovascular disease are the leading cause of death in America, 

cutting across all racial and ethnic groups, socioeconomic levels, and affecting both men and 

women. Within this context, the Commissioners heard experts discuss relevant data and their 

conclusions as to why disparities persist, possibly flawed conclusions resulting from 

omission of important variables in earlier studies such as the 2002 Institute of Medicine 

report, health care delivery system differences, recent and ongoing research, access to care 

and quality of care, patient behavior, and other aspects of differences between population 

groups in terms of cardiac/hypertension health and cardiac/hypertension care.

Panelists did not agree on the causes of disparities in both health status and health care.

Factors included receiving care from health care providers who were not Board-certified; 

bias resulting from insufficient numbers of minorities in the health care workforce; 

inadequate health insurance coverage and the high cost of healthcare; lack of data available 

for specific populations; differences in provider expertise and use of diagnostic and treatment 

resources; and geographic and demographic distributions.

The American Heart Association testified that its prepared guidelines help doctors improve 

diagnosis and treatment for coronary artery disease, heart failure and stroke. The Jackson 

Heart Study, a single-site longitudinal study of African-American cardiovascular health, 

examines psychosocial, nutritional, metabolic, and genetic effects on cardiovascular disease. 

The Strong Heart Study, a population-based survey and the first to highlight the higher rates 

of cardiovascular disease among American Indians and other populations with high rates of 

diabetes, focuses on American Indian communities and has trained non-physician providers 

to offer certain medical services. Expecting Success, the first collaborative undertaking by a 

group of hospitals to eliminate disparities, concentrates on improving cardiac care for 

African-Americans and Latinos.

At the completion of their testimony, the panelists fielded questions from the Commissioners 

on such issues as how problems with data collection in the 1990 and 2000 census skewed 

results for Native Americans; the percentage of the health care disparities caused by factors 

outside the health care delivery system; the portion of health care disparities related to 

possible bias; the extent to which linguistic and cultural competency affect access to and the 

quality of treatment in health care; research that attempts to explain disparities existing 

between rural, suburban and urban areas; the lack of public awareness as to the differences in 
2 Health Care Disparities 

quality among various medical facilities with respect to high-quality health care; the quality 

of health care received in inner-city hospitals; success in developing procedures and training 

for non-physicians who can work in underserved communities; and why the gap in disparities 

continues for some minorities but has closed for others.

Panelists were the Honorable Louis W. Sullivan, Chairman, Sullivan Alliance to Transform 

America‘s Health Professions; Dr. Garth Graham, Deputy Assistant Secretary for Minority 

Health, U.S. Department of Health and Human Services; Dr. Rubens Pamies, Professor of 

Medicine, University of Nebraska Medical Center; Dr. Amitabh Chandra, Professor of Public 

Policy, John F. Kennedy School of Government at Harvard University; Dr. Sally L. Satel, 

Resident Scholar at the American Enterprise Institute; Dr. Peter Bach, Assistant Attending 

Physician, Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering 

Cancer Center; Dr. William Lewis, Cardiologist, American Heart Association; Dr. Herman 

Taylor, Professor of Medicine, Jackson Heart Study, Jackson Medical Mall; Dr. Barbara V. 

Howard, Senior Scientist, Medstar Research Institute; and Dr. Bruce Siegel, Director, Center 

for Health Care Quality, George Washington University School of Public Health and Health 

Services.

A transcript of this briefing is available on the Commission‘s Web site, www.usccr.gov, and 

by request from the Publications Office, U.S. Commission on Civil Rights, 624 Ninth Street, 

NW, Suite 600, Washington, DC, 20425, (202) 376-8128, TTY (202) 376-8116, or via e-mail 

at publications@usccr.gov.
Panelist Statements: First Panel 3

Panelist Statements: First Panel

Note: Statements are unedited by the Commission and are the sole work of the author.

Louis W. Sullivan

Background

The Sullivan Alliance to Transform America‘s Health Professions is a national effort to 

enhance health workforce diversity initiatives around the country. The Sullivan Alliance was 

organized in January of 2005 to act on the reports and recommendations of the Sullivan 

Commission (Missing Persons: Minorities in the Health Professions, September, 2004), and 

the Institute of Medicine Committee on Institutional and Policy-Level Strategies for 

Increasing the Diversity of the U.S. Healthcare Workforce (In the Nation‘s Compelling 

Interest Ensuring Diversity in the Healthcare Workforce, February, 2004). In its report, the 

Sullivan Commission described the current situation: ―. . . Too many Americans are suffering 

life or death consequences . . .The time is right and our citizens are anxious for action.‖ The 

report further concluded ―the fact that the nation‘s health professions have not kept pace with 

changing demographics may be an even greater cause of disparities in health access and 

outcomes than the persistent lack of health insurance for tens of thousands of Americans.‖

The Nation’s Health Workforce

The strength of our health workforce is central to the capacity of our healthcare system.

The PriceWaterhouseCoopers Health Research Institute predicts a shortage of 24,000 

physicians by 2020 (5) supporting a call by the Association of American Medical Colleges

for a 30 percent increase in medical school enrollment and an expansion of graduate medical 

education positions by the year 2015 (4, 6). A severe nursing shortage has been reported by 

the vast majority of U.S. hospitals, and the U.S Department of Health and Human Services 

projects that by 2020 the shortage of nurses will be between 400,000 and 1 million (5). The 

Association of Schools of Public Health estimates that by the year 2020, 250,000 more public 

health workers will be needed in the nation (7). Lastly, a shortfall of more than 150,000 

pharmacists is projected by 2020 (8, 9).

The current shortage of health professionals is exacerbated by a misdistribution of physicians 

by geography and specialty. It is well documented that there is a critical shortage of primary 

care and family physicians (5, 10-12). In addition there is a dearth of health providers in rural 

and inner city areas which have been designated by the U.S. Public Health Service as health 

professions shortage areas (HPSA). As of 2005 there were more than 5,500 HPSA

throughout the United States (13). In 2008, more than 35 million Americans lived in areas 

that were designated as underserved – lacking primary care physicians, dentists and mental 

health professionals (14).

The 2007 data from the U.S. Census Bureau indicate that one third of the U.S. population (34

percent) is a racial or ethnic minority (15). More than 50 million Americans speak a language 

other than English at home (16). Furthermore, U.S. census projections show that racial and 

ethnic minorities will become the majority of the U.S. population by 2042 (3). Today, 
4 Health Care Disparities

African-Americans, Hispanic Americans, and American Indians make up (sic) of the U.S. 

population. In 2004, according to the Sullivan Commission report ―Missing Persons: 

Minorities in the Health Professions,‖ minorities made up only 9.4 percent of nurses, 6.1

percent of physicians, (sic) of dentists and 6.9 percent of psychologists (17).

There are a host of barriers impeding access to a health professions career by ethnic and 

racial minorities. These include poor awareness of health professions careers and their 

academic requirements, financial barriers, academic preparation, and lack of role models and 

mentors (22-28).

The Case for Health Workforce Diversity

At this time, when the U.S. supply of health professionals is not keeping pace with growing 

needs, the U.S. population is increasingly diverse racially and ethnically. Today, minorities 

account for 43 percent of Americans under 20 (2) and it is projected that over the next two 

decades minority student enrollment in our nation‘s colleges will reach nearly 40 percent 

(29). Considering these population trends, Cohen and Steinecke (30) state that ―increasing 

physician supply and increasing diversity [in the health professions] are both critically 

important and are inseparable goals.‖

The dearth of minorities in the nation‘s health workforce is a major factor contributing to 

health disparities. Achieving greater racial and ethnic diversity of the nation‘s health 

professionals has distinct benefits (21). First, minority physicians are more likely to practice 

in medically underserved areas and care for patients regardless of their ability to pay (21, 31-

34). Secondly, minority physicians are more likely to choose primary care practices (11) and 

minority registered nurses are more likely to be employed in nursing and work full time (20), 

thus improving the care of vulnerable populations. Finally, a diverse health workforce 

encourages a greater number of minorities to enroll in clinical trials designed to alleviate 

health disparities (35).

There is evidence that the intellectual, cultural sensitivity and professional competency of all 

students is enhanced by learning in an ethnically and racially diverse educational 

environment (31, 36-38). And, also there is evidence that a workforce equipped to serve 

culturally and linguistically diverse individuals increases the number of initial visits, results 

in higher utilization of care, enhances high quality encounters, lowers medical errors and 

reduces emergency room admissions (39-41).

There is also an ethical issue with the U.S. importing foreign medical graduates and nurses 

from poor third world countries to address the needs of the U.S. healthcare system. These 

foreign-trained health workers provide a ―band aid‖ approach to a lingering crisis, while 

depleting third world countries of valuable human resources needed for their own 

populations.

Discussions

The reforms needed to improve the nation‘s health system, the health status of our citizens 

and to provide leadership in global health are a significant challenge.
Panelist Statements: First Panel 5

Healthcare reform is a prominent focus for the Obama administration and the new Congress.

They have the challenge and the opportunity to develop a successful model for health reform.

By addressing the central issue – the health care workforce – the administration and the 

Congress can lead the effort for needed changes in our healthcare system.

Such an effort must not only address the lack of health insurance and/or underinsurance of 

more than 47 million U.S. citizens and the high costs of health care, it must also focus on the 

current – and increasing – shortage and misdistribution of health professionals and the need 

for more racial and ethnic diversity among the nation‘s health professionals.

All of these factors have a significant impact on access to health care, protecting and 

improving the health of Americans, and eliminating disparities in health status of the nation‘s 

racial and ethnic minorities. The Sullivan alliance and the nation‘s health professions 

associations are committed to working with the Obama administration and with the Congress 

in efforts to reform the nation‘s health system.

I thank you for this opportunity to present these issues to the U.S. Commission on Civil 

Rights. I look forward to your questions, and your comments and your support in these 

efforts to achieve our goal of eliminating disparities in health status and in access to health 

care.

Bibliography

1. Association of Academic Health Centers. Out of Order Out of Time: The State of the Nation's Health 

Workforce. Washington, DC 2008.

2. Roberts S. Minorities Often a majority of the Population Under 20. The New York Times, 2008.

3. U.S. Census Bureau. An Older and More Diverse Nation by Midcentury. http://www.census.gov/PressRelease/www/releases/archives/population/012496.html. Accessed 10/22/08.

4. Association of American Medical Colleges. The Come of Physician Supply and Demand: Projections 

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6. Association of American Medical Colleges. AAMC Statement on the Physician Workforce.

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7. Association of Schools of Public Health. Confronting the Public Health Workforce Crisis.

http://www.asph.org/document.cfm?page=1038. Accessed 5/21/08.

8. Pal S. Pharmacist Shortage to Worsen in 2020. U.S. Pharmacist. 2002; 27(12).

9. American Association of Colleges of Pharmacy. Dramatic Rise in Need for Pharmacists Projected.

http://www.aacp.org/site/tertiary.asp?TRACKID=&VID=2&CID=577&DID=4638. Accessed 11/11/08.

10. Aagaard EM, Julian K, Dedier J, Soloman I, Tillisch J, Perez-Stable EJ. Factors affecting medical students' 

selection of an internal medicine residency program. J Natl Med Assoc. Sep 2005; 97(9):1264-1270.

11. Corbie-Smith G, Frank E, Nickens H. The intersection of race, gender, and primary care: results from the 

Women Physicians' Health Study. J Natl Med Assoc. Oct 2000; 92(10):472-480.

12. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing 

the evidence. Health Aff (Millwood). Jan-Jun 2005;Suppl Web Exclusives:W5-97-W95-107.

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primary Care Shortage Area Designation System October, 2006.

14. Dininny S. WA Medical School Celebrates opening. The Seattle Times. July, 2008.

15. U.S. Census Bureau. Selected Characteristics of the Native and Foreign-Born Populations (S0501).

http://factfinder.census.gov/servlet/STTable?_bm=y&-geo_id=01000US&-
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16. Progressive Policy Institute. 50 Million Americans Speak Languages Other Than English At Home 2008.

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Professions. Washington, DC September, 2004.

18. American Dental Association. Member Demographics; 2008.

19. American Medical Association. Total Physicians by Race/Ethnicity - 2006. http://www.amaassn.org/ama/pub/category/12930.html.

20. HRSA. The Registered Nurse Population: Findings From the March 2004 National Sample Survey of 

Registered Nurses. ftp://ftp.hrsa.gov/bhpr/workforce/0306mss.pdf.

21. Grumbach K, Mendoza R. Disparities in human resources: addressing the lack of diversity in the health 

professions. Health Aff (Millwood). Mar-Apr 2008;27(2):413-422.

22. Cohen J. Increasing Diversity in the Workforce is One Solid Way to Prevent Disparities in Health Care.

http://www.medscape.com/viewarticle/514893. Accessed 4/21/06.

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24. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood). 

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25. Fletcher A, Williams PR, Beacham T, et al. Recruitment, retention and matriculation of ethnic minority 

nursing students: a University of Mississippi School of Nursing approach. J Cult Divers. Winter 

2003;10(4):128-133.

26. Foundation TCW. Reflections on Increasing Diversity in the Health Professions December, 2005.

27. Gardner J. Barriers influencing the success of racial and ethnic minority students in nursing programs. J 

Transcult Nurs. Apr 2005;16(2):155-162.

28. Gardner JD. A successful Minority Retention Project. J Nurs Educ. Dec 2005;44(12):566-568.

29. Cole D. Do interracial interactions matter? An examination of student-faculty contact and intellectual selfconcept. The Journal of Higher Education. 2007;78(3):249-281.

30. Cohen JJ, Steinecke A. Building a diverse physician workforce. Jama. Sep 6 2006;296(9):1135-1137.

31. Cohen J, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood). 

Sep-Oct 2002;21(5):90-102.

32. HRSA. The Rationale for Diversity in the Health Professions: A Review of the Evidence 2006.

33. Komaromy M, Grumbach K, Drake M, et al. The role of black and Hispanic physicians in providing health 

care for underserved populations. N Engl J Med. May 16 1996;334(20):1305-1310.

34. Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. Jama. May 17 

1995;273(19):1515-1520.

35. Association of American Medical Colleges. Diversity in Medical Education: Facts and Figures 2008.

Washington, D.C. 2008.

36. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversityrelated outcomes in US medical schools. Jama. Sep 10 2008;300(10):1135-1145.

37. Fischer MJ. Does campus diversity promote friendship diversity? A look at interracial friendships in 

college. Social Science Quarterly. 2008;89(3):631-655.

38. Friedman AL. Enhancing the diversity of the pediatrician workforce. Pediatrics. Apr 2007;119(4):833-837.

39. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, 

ratings of care, and concordance of patient and physician race. Ann Intern Med. Dec 2 2003;139(11):907-

915.

40. LaVeist TA, Nuru-Jeter A, Jones KE. The association of doctor-patient race concordance with health 

services utilization. J Public Health Policy. 2003;24(3-4):312-323.

41. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health 

Aff (Millwood). Jul-Aug 2000;19(4):76-83.
Panelist Statements: First Panel 7

Garth N. Graham

It is a pleasure to present to the Commission on Civil Rights on the causes of Health Care 

Disparities, populations most affected by these disparities, and actions needed to eliminate 

them.

The mission of the Office of Minority Health (OMH) is to improve the health of racial and 

ethnic minority populations through the development of health policies and programs that 

will help eliminate health disparities. OMH is located in the Office of the Secretary, Office of 

Public Health and Science. OMH advises the Secretary, Deputy Secretary, and the Assistant 

Secretary of Health on public health policies and programs that impact racial/ethnic 

minorities, and coordinates HHS-wide efforts that address minority health issues.

Health disparities can be defined as significant gaps or differences in the overall rate of 

disease incidence, prevalence, morbidity, mortality, or survival rates in the population as 

compared to the health status of the general population. The Institute of Medicine defines 

disparities in health care as racial or ethnic differences in the quality of health care that are 

not caused by differences in clinical need, patient preferences, or appropriateness of 

intervention (Unequal Treatment, Institute of Medicine, 2002).

Overall health status in the U.S. has improved significantly as demonstrated by the dramatic 

increase in life expectancy for whites (from 47.6 to 77 years) and blacks (from 33 to 72.2 

years). However, in spite of the many improvements in health over several decades, 

significant gaps still exist by race, ethnicity, gender, disabilities, and other related sub 

populations with respect to premature death and preventable disease. These gaps may in part 

be related to demographic changes in the U.S. population. According to the 2000 census data 

(U.S. Census Bureau, 2000), the population of the U.S. grew by 13 percent over the last 

decade, and has increased in diversity at even a greater rate. Racial and ethnic minorities are 

among the fastest growing of all communities in the country, and today comprise 

approximately 34 percent of the total U.S. population. It is projected that by 2030, 40 percent 

of the population will be non-white (U.S, Census Bureau, 2004). Consequently the U.S. is 

not only experiencing greater diversity, but people are living longer, experiencing rising costs

of health care, and emerging new diseases pose additional challenges to efforts to eliminate 

health disparities.

While racial and ethnic diversity is increasing, minorities tend to die sooner from a wide 

variety of acute and chronic conditions. Racial and ethnic minorities receive lower quality of 

health care compared to whites across a wide range of preventive, diagnostic, and therapeutic 

services. These conditions in health care contribute to continuing racial-ethnic differences in 

the burden of illness and death. For example, an estimated 15.8 million people in the United 

States are living with Coronary Heart Disease (CHD) and more than 5.7 million with the 

effects of stroke, which is the second leading cause of dementia after Alzheimer‘s disease 

(Healthy People 2010 Midcourse Review, 2007. African-Americans continue to experience a 

higher rate of stroke, have more severe strokes, and continue to be twice as likely to die from 

stroke as white Americans. Disparities in cardiovascular disease are among the most serious 

public health problems.
8 Health Care Disparities

About 70 million Americans fall into the newly recognized blood pressure risk category of 

―pre hypertension‖ and are in danger of developing hypertension (high blood pressure) and 

its associated complications. Hypertension leads to more than half of all heart attacks, 

strokes, and heart failure cases in the United States each year and increases the risk of kidney 

failure and blindness. The prevalence of high blood pressure—a major risk factor for 

coronary heart disease, stroke, kidney disease, and hear failure—is nearly 40 percent greater 

in African-Americans than in whites. (An estimated 6.4 million African-Americans have 

hypertension; Mexican-Americans also experience a high prevalence of hypertension (HHS, 

2000a, G-2).

The rate of congestive heart failure hospitalizations in black non-Hispanics 64-75 years was 

more than twice the rate of that for white non-Hispanics. In addition to heart disease 

disparities, African-Americans are 30 percent more likely to develop cancer and 30 percent

more likely than whites to die from it. Hispanics in the U.S. are 50 percent more likely than 

whites to suffer from diabetes, and the incidence of diabetes among Native Americans is 

more than twice that for whites. Moreover, African-American and American Indian infant 

morality rates are 2.5 and 1.5 times higher, respectively, than that of whites.

Causes of Health Disparities

The cause of health disparities is certainly multi-factorial. It is related to the interplay 

between individual/personal factors, socioeconomic, neighborhood/environmental, 

institutional and other social determinants of health that occur in certain sub populations. 

Individual factors. Individual factors include behavior, language, literacy, poverty, low 

education, lack of health insurance or under insurance, and or lack of a regular source of 

care. 

System factors. System factors that can contribute to health care disparities include

limited clinic hours and lack of availability of cultural and linguistic appropriate materials.

These factors can contribute to patient dissatisfaction, poor comprehension, compliance, and 

low quality of care.

Disparities in health care have significant implications for health professionals, 

administration, policymakers, and health care consumers and present a significant challenge 

to the health system. Strategies to eliminate health care disparities will require intervening on 

multiple levels within the various factors that contribute to disparities.

Individual level changes include improving knowledge and awareness of diseases, changing 

behavior related to smoking, exercise, nutrition, monitoring blood pressure, and adhering to 

medical advice. Societal level changes include improving access to quality health care, 

reducing health care costs, and making health care more affordable for those with low or no 

income. 

Systems level changes include changing the organization of care, improving the degree to 

which systems are culturally appropriate for patient population being served, providing 

practice staff with Cultural and Linguistic Competence Training, improving language access 
Panelist Statements: First Panel 9

including the availability of interpreters, making changes in the physical environment and 

diversity in the health professions.

Current Research and Actions to Eliminate Health Care Disparities

Several recent initiatives included under the Recovery Act have potential to affect health care 

disparities. Among them are:

Evidence-based and Community Based Prevention and Wellness Strategies Recovery Plan.

Will help to reduce risk factors and prevent/delay chronic disease, promote wellness, and 

better manage chronic conditions. This program will deliver specific, measurable health 

outcomes that address chronic disease rates.

Comparative Effectiveness Research. Includes $400 million allocated to the Office of the 

Secretary to conduct a rigorous evaluation of the impact of different options that are 

available for treating a given medical condition for a particular set of patients. It involves 

comparing clinical outcomes, effectiveness, and appropriateness of items, services, and 

procedures to prevent, diagnose, or treat diseases, disorders, and other health conditions.

Several Initiatives currently in place at OMH are also devoted to reducing and eliminating 

health and health care disparities:

Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating 

Racial/Ethnic Health Disparities

National Partnership to End Health Disparities

Federal Collaboration on Health Disparities Research

Culturally Competence Curriculum Modules (CCCM) 

OMH Grant Programs to Eliminate Health Disparities

HIV/AIDS Health Improvement for Re-entering Ex-Offenders Initiative (HIRE Program)

National Health Information Technology Collaborative for the Underserved (NHIT-UP)

The Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating 

Racial/Ethnic Health Disparities, developed by OMH, is intended to help guide, organize, 

and coordinate the systematic planning, implementation, and evaluation of efforts within 

OMH, HHS and across the nation to achieve better results relative to minority health 

improvement and health disparity reduction.

The National Partnership to End Health Disparities, created in 2006, provides opportunities 

for leadership, ownership, and accountability at all levels of involvement, not just within the 

federal government. NPA was created to work across the country to create a nation free of 

health disparities, with quality health outcomes for all people. NPA has five action-oriented 

objectives for ending health disparities; 1) awareness; 2) leadership; 3) health and healthy 

system experience; 4) cultural and linguistic competency; and 5) research and evaluation.

The Federal Collaboration on Health Disparities Research (FCHDR), led by the HHS Health 

Disparities Council and the Interagency Committee on Disability Research in the Department 

of Education, was created to identify and support research priorities for cross-agency 

collaboration to hasten the elimination of health disparities. FCHDR is currently working on 
10 Health Care Disparities

collaborative research focused on obesity, built environment, co-morbidities, and culturally 

appropriate mental health care. Seven federal departments and 14 agencies are currently 

involved.

Culturally Competence Curriculum Modules (CCCM) were specifically designed by OMH to 

focus on medical providers and to deliver concepts, tools, and case studies that illustrate both 

the need and the benefit of providing culturally competent care in a clinical setting. CCCM 

targets client/patient and health care provider knowledge on health disparities, and 

improvement of health care professional practices and institutional policies that support 

delivery of care.

OMH Division of Program Operations (DPO) is the focal point within OMH for grant 

programs eliminate health disparities. It uses various mechanisms to conduct programs that 

support public and private community-based practices and innovative models to improve 

information dissemination, education, prevention, and service delivery to minority 

communities. DPO develops, implements and monitors programs and activities in response 

to new program direction and policy, and facilitates the involvement of other Department 

agencies in areas of mutual interest and concern. DPO currently administers a number of 

grants programs aimed at eliminating disparities. 

HIV/AIDS Health Improvement for Re-entering Ex-Offenders Initiative (HIRE Program) is a 

new initiative created in 2009 to provide access to HIV/AIDS prevention and treatment 

services to ex-offenders‘ to ensure their successful transition from state or federal 

incarceration back to their communities. HIRE focuses on the three states with the highest 

incidence of inmates known to be infected with HIV or to have confirmed AIDS in state 

prisons at year end 2006: New York (4,000), Florida (3,412), and Texas (2,693). Through 

this new initiative, community-based and faith-based organizations will deliver 

comprehensive HIV/AIDS-related services and transition assistance including prescription 

drug assistance, substance abuse, and mental health services, and will address ex offender 

issues related to employment, family, education, housing, and community involvement.

The National Health Information Technology Collaborative for the Underserved (NHIT-UP) 

is a public/private partnership formed in 2008 to study and propose solutions to reduce and 

ultimately eliminate health disparities experienced by medically underserved areas and 

populations through the use of advances in health IT. Activities include convening meetings 

to discuss advances in the field, documenting models and strategies to inform and engage the 

underserved in the use of Health Information Technology (HIT) for health self-management 

and empowerment, and making recommendations on infrastructural and training needs. 

Health IT applications are expected to lead to a richer set of data from which population 

health care trends can be assessed. Health IT also enables greater communication between 

patients and providers and better tracking of care delivered and outcomes achieved. In 

addition to changes at the multifactorial levels described earlier, workforce diversity will also 

be key. Despite making up almost 28 percent of the nation‘s populations, African-Americans, 

Native Americans, and Latinos make up only 3 percent of the medical school faculty, fewer 

than 16 percent of public health school faculty, and only 17 percent of all city and county 

health officers (Collins from Betancourt paper). This lack of diversity is believed to 
Panelist Statements: First Panel 11

contribute to structural policies, procedures, and delivery system that are inappropriately 

designed or poorly suited to serve diverse patient populations.

Ultimately, interdisciplinary approaches carried out collaboratively with all partner sectors 

will be instrumental to eliminating health care disparities. Such an approach will need to 

include policy makers, federal, state, and local partners; health care systems, health care 

professionals, health care professional associations, community based organizations, faithbased institutions, and a broad spectrum of the public.

Strategies and solutions to eliminate health care disparities also will need to be mindful of 

the socioeconomic inequality, concentrated poverty, inequitable and segregated housing, 

and education and the role these upstream factors play in health and disease. In the end, 

issues related to health disparities in racial and ethnic minorities are not a minority problem;

it is an American problem and will take the collective efforts of all of us working together 

to solve these issues and bring true quality health care to all.
12 Health Care Disparities

Rubens J. Pamies

Martin Luther King, Jr. once said, ―Of all the forms of inequality, injustice in health care is 

the most shocking and inhumane.‖

Greetings. Thank you for the opportunity to speak today about health disparities. I am 

Rubens Pamies, Vice Chancellor of Academic Affairs and Dean of Graduate Studies and 

Professor of Internal Medicine at the University of Nebraska Medical Center in Omaha, 

Nebraska. As a physician and researcher, identifying and addressing health disparities are 

issues I have studied for over 20 years.

Diversity

To best understand health disparities, it is important to look at the diversity of America. 

(Slide #1) Over the past 20 years, the proportion of white Americans has decreased from 83

percent in 1970 to 69 percent in 2000, while the proportion of African-Americans has 

increased slightly from 11 percent to 12 percent, and the proportion of Hispanics jumped 

from nearly 5 percent to 12.5 percent.

1 Our country is becoming increasingly diverse, making 

our healthcare issues uniquely different from other comparable nations around the world. The 

U.S. Census Bureau had originally estimated that by the year 2050, nearly one in two 

Americans will be a member of a racial or ethnic minority.2Projections indicate this could 

occur as early as 2037. Currently, four states and the District of Columbia have majority 

minority populations.3

 

2 U.S Interim Projections by Age, Sex, Race, and Hispanic Origin. Washington, DC: US Census Bureau, 

Population Division, Population Projections Branch, US Dept of Commerce; 2004. Available at: 

http://www.census.gov/ipc.www.usinterimproj/.

3 U.S. Census Bureau Press Release. Available at: http://www.census.gov/PressRelease/www/releases/archives/population/013734.html.

Proportional Representation of U.S. Population 

by Race

White African American Hispanic

0

10

20

30

40

50

60

70

80

90

1970

2000

Slide #1
Panelist Statements: First Panel 13

Workforce

Currently, the health care workforce is not representative of minorities in the general 

population. According to the U.S. Census, Hispanics comprise 12 percent of the population, 

but only 2 percent of registered nurses, 3.4 percent of psychologists, and 3.5 percent of 

physicians.4Similarly, African-Americans constituted 12 percent of the total population in 

2000, but only 5 percent of physicians, 9 percent of registered nurses, and 4 percent of 

dentists.5(Slide #2) In the last 10 years, the percentage of African-Americans in health care 

careers has actually dropped in nursing and pharmacy, while slight increases were seen in 

optometry, dentistry and physicians. (Slide #3) In total, underrepresented minorities comprise 

less than 8 percent of physicians nationwide, and only 4 percent of medical school faculty, 

with almost 20 percent of these minority faculty coming from Historically Black Colleges 

and Universities.6

Proportional representation is important for a variety of reasons, not only for patient care, but 

also for showing underrepresented students they can enter healthcare fields, and for

enhancing the cultural competency and learning environment in the workforce. A landmark 

Institute of Medicine Report, entitled, ―Unequal Treatment: Confronting Racial and Ethnic 

Disparities in Healthcare,‖ articulated the need for increasing diversity in healthcare. The 

report drew four conclusions. First, underrepresented minority health care professionals are

significantly more likely to serve in medically underserved communities, which often include 

urban and disadvantaged areas.7Second, studies have shown that patients are more likely to 

seek care from a physician of their own race or ethnicity and report being more satisfied 

when doing so. Third, minorities considering health care professions are more likely to 

 

4 US Census Bureau, EEO Tool. Employment by Occupation, Sex, Age, and Race for U.S. Total. Available at: 

http://www.census.gov/eeo2000/index.html.

5

Id.

6 Association of American Medical Colleges, Faculty Roster System. Available at: 

http://www.aamc.org/data/facultyroster/usmsf03/start.htm.

7

Satcher & Pamies, supra at 406.

Slide #2

African American Health Professionals 

1990 Vs. 2000

Unites States Census 

Registered

Nurse

Optometrist Pharmacist Dentist Physician

1990

2000

1990 2000

2000

2000 1990 1990

1990

2000

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

1990

2000
14 Health Care Disparities

pursue fields where they see minority role models.8The final reason concerns medical 

research. Minorities are more likely to participate in research studies when the research is 

conducted by a health care provider of the same minority group.9 Consequently, 

underrepresented minority health care professionals are more likely to have research interest 

in diseases which disproportionately affect minority patient populations, thereby helping to 

solve the mysteries regarding why certain conditions disproportionately produce poorer 

outcomes for minorities. Because these researchers often see first-hand the effects of various 

diseases on their communities and families, they become interested in learning more about 

the disease and dedicate their professional careers to treatment solutions. Clinical research 

studies are vital to understanding why certain racial and ethnic groups are affected differently 

by diseases and treatments. It is essential that data related to minority health care continue to 

be collected.

Mortality, Morbidity and Disease Incidence

It has been said that the U.S. health care system is wonderful if you are healthy.

Unfortunately, that is not the case for many individuals. Despite overall health improvements 

in the U.S. population, racial and ethnic minorities experience higher rates of morbidity and 

mortality than non-minorities.10 This point is proven simply by looking at life expectancies.

(Slide #4) African-American men have a shorter life expectancy at 66 years than white men, 

who, on average, live until age 74. Compare that with American Indian men, who in some 

areas can only expect to live into their mid-50s. While life expectancies for most groups have 

 

8

Id.

9

Id.

10Id at 3.

Black, 4,091 

(3.9%) Hispanic, 3,305 

(3.1%)

Asian, 12,531 

(11.9%)

Native American, 

108 (0.1%)

White, 

79,450 

(75.3%)

Slide 3: Racial and Ethnic Composition

of Medical Faculty 2002-2003 (Full-Time Faculty)

(12% of the Blacks are at Howard, Meharry, and Morehouse)
Panelist Statements: First Panel 15

risen, the life expectancy gap between white and African-American males has not changed 

significantly in 40 years. Even though our country can tout major health and technological 

advances in the last 60 years, African-Americans‘ mortality rate -- at 1.6 times higher than

whites -- is identical to the ratio in 1950. (Slide #5) Infant mortality rates are just as dismal as 

rates for African-Americans and American Indians are 2.5 and 1.5 times higher than whites.11

Examining the prevalence of certain diseases and conditions in racial and ethnic minorities 

reveals further evidence of health disparities. African-Americans have the highest rates of 

mortality from heart disease, cancer, cerebrovascular disease, and HIV/AIDS than any other 

U.S. racial/ethnic group.12 In fact, the HIV rate is reaching epidemic levels, particularly for 

African-American females. More than 80 percent of women who have HIV and AIDS are 

 

11 Id at 10-12.

12 Institute of Medicine of the National Academies, Unequal Treatment: Confronting Racial and Ethnic 

Disparities in Health Care 29 (2003).

Life Expectancies

African Americans and Whites

Men Women

75 80

74

66

0

10

20

30

40

50

60

70

80 Years

White

African American

Slide # 4 Slide # 5

13.5

5.7

0

2

4

6

8

10

12

14

African American White NCHS 2003

Racial and Ethnic Disparities Infant Mortality 

Deaths per 1,000 Live Births
16 Health Care Disparities

either African-American or Hispanic.13 American Indians have higher rates of diabetes and 

liver disease, and Hispanics are more likely than whites to die from diabetes, which modern 

medicine has made increasingly manageable. Asian-American subpopulations experience 

rates of stomach, liver and cervical cancers that are well above national averages.14

The disparate burden of cardiovascular and hypertensive disease is particularly concerning.

Hypertension in African-Americans leads to an 80 percent higher stroke mortality rate, a 50

percent higher heart disease mortality rate, and a 32 percent higher rate of renal disease than 

the general population.15 Half of African-Americans aged 40 through 59 are hypertensive 

compared with 30 percent of whites.16 Initially, access to care was suspected as the primary 

cause. However, even in Veterans Affairs hospitals, where access is not an issue, major 

health disparities still exist. Studies there have shown that physicians are less likely to refer 

African-American patients for cardiac catheterization, and African-Americans are less likely 

to undergo invasive cardiac procedures.17 Current theories on cardiovascular health 

disparities center on a variety of factors, including racial discrimination in treatment, 

genetics, environment, and demographics.18

There are new theories emerging about the burgeoning cardiovascular health disparities 

affecting African-Americans in greater numbers than any other race. The first theory is 

epigenetics, or changes to the DNA caused by environmental agents such as diet or stress, 

that can actually be passed on from one generation to the next. Epigenetics underscores the 

cumulative effects of poor socioeconomic conditions, discrimination, and inequality in 

education and other opportunities. The second theory is the Allostatic Load, which declares 

that the body experiences biological changes in response to stress. Specifically, cortical 

releasing hormones are higher in those that have experienced prolonged stress, suggesting 

that years of feeling unequal or experiencing discrimination can worsen cardiovascular 

health.

The current economic situation has resulted in reports that fewer prescription drugs are being 

refilled. The concern is that individuals who have been successful at maintaining healthy 

blood pressures and other cardiovascular conditions with medication may no longer be able 

to afford them, which will result in higher blood pressures, increased stress and hypertension, 

and a number of other dangerous conditions. We may see a shift from health maintenance 

with medications at a modest cost to emergency room treatment at a much higher cost.

Causes of Health Disparities

The disproportionate burden of health disparities has been well documented in the United 

States for the last two centuries. There are several contributing factors, including 

socioeconomics, racism and discrimination, limited access to health care, the quality of 

services provided, patient and provider behavioral factors, as well as many others. These 

 

13 U.S. Center for Disease Control, Available at: 

http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/slides/Women.pdf

14 Satcher & Pamies, supra at 10-12, 209-210.

15 Id at 168.

16 Id at 167.

17 Id at 169.

18 Id at 170.
Panelist Statements: First Panel 17

factors tend to compound one another and create a cycle of problems. Despite increases in 

access to care and immunizations, the differences between many minority groups compared 

to whites are either stagnant or getting worse.

Socioeconomics

Being in a lower socioeconomic class usually means having substandard housing conditions, 

fewer opportunities for higher education, less health insurance coverage, and limited access 

to health care.19 The environmental health risks, which include everything from air and water 

quality to soil contaminants and other pollutants, tend to be more prevalent in low-income 

communities. Lower socioeconomic groups often live in more segregated areas, where there 

are higher poverty levels and more drug and alcohol abuse. Missing from these environments 

are: green space, access to healthy foods, job opportunities, and access to healthcare. More 

than any other racial group, African-Americans tend to live in segregated neighborhoods.

(Slide #6) In fact, some major urban areas of the United States are as segregated as apartheidera South Africa.20 In 2000, an index measuring black and white housing segregation showed 

that two-thirds of African-Americans would have to relocate in order to achieve a statistically 

random distribution of black and white households in America. Individuals living in 

segregated areas typically do not have the resources to transfer wealth to the next generation; 

instead, kids inherit a lifetime of poverty, a lack of educational opportunities, and typically a 

lifetime of poor health.

Educational Inequality

Low-income, segregated areas of communities have a lower tax base and less philanthropic 

ability to support education. As a result, racial and ethnic minorities have fewer educational 

opportunities, and fewer role models, and they tend to limit their goals to low-paying and in 

some cases hazardous occupations. For many minority children, others‘ expectations of them

are set so low, they never reach their full potential.

 

19 Id at 18.

20 Douglas Massey & Nancy Denton, American Apartheid: Segregation and the Making of the Underclass.

(1998).

American Apartheid:

South Africa (de jure) in 1991 & U.S. (de facto) in 2000

Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001 Slide # 6
18 Health Care Disparities

For these children, achieving the American dream is not even a dream. (Slide #7) To 

illustrate this point, consider 1,000 African-American students starting kindergarten. Of those 

1,000 students, over half (580) will graduate from high school. Of those, slightly more than

half will enter college. Seventy percent of those who enter college will drop out before 

finishing, leaving less than 10% who actually graduate from college. Three times as many 

who graduate from college will enter prison.

The inequalities in science education programs serve as barriers that prevent minority 

students from considering health care careers. Additionally, daily headlines announcing an 

end to affirmative action programs may also play a role in discouraging prospective students 

from pursuing a health care career. Other obstacles include: fewer pipeline programs that 

encourage professional careers, financial disadvantages, standardized admissions tests and 

higher education admissions policies.

Limited Access to Care

Racial and ethnic minorities are less likely to have health insurance,

21 and those that do often 

face high copayments and transportation accessibility issues to the local clinic or hospital.

There are fewer minority primary care physicians in neighborhoods where minorities reside, 

resulting in individuals being forced to take more time off of work and to find transportation 

to and from the health care facility that is usually farther away. When health care is received, 

it is often reactive rather than preventative, fragmented and uncoordinated, so the health 

conditions are more chronic and take more time, money and resources to treat. Individuals 

without health insurance have more difficulty getting appropriate care, as low provider 

 

21 Satcher and Pamies, supra at 21.

1,000

580

324

97

333

Kindergarten High School 

Grads

Enter College College Grad Prison

Slide 7. African-American Students

Projected Path in Omaha Based on Trends
Panelist Statements: First Panel 19

reimbursements have reduced the number of physicians willing to serve low-income 

populations.

Quality of Services

Studies conclude that racial and ethnic minorities receive a lower quality of health care and 

diagnostic services than non-minorities.22 Even at equivalent levels of access to care, racial 

and ethnic minorities are less likely to receive routine medical procedures than white 

Americans. For example, African-Americans with advanced renal disease are less likely to 

receive dialysis and kidney transplantation.23 Similarly, one study found that blacks, AfricanAmericans and Hispanics with bone fractures seen in emergency rooms were less likely than 

whites to receive pain control medications.24 Lower quality of services can be attributed to 

provider bias, prejudice, and stereotypes, language barriers, and cultural ineptitude. Providers 

may make assumptions about the type of treatment or medication patients can afford, and 

may even provide fewer services to patients based on their insurance plan or ability to pay. 

This causes stress, which can intensify other health problems. Providers and patients must 

also address the language barrier, as many minorities live in linguistically-isolated 

households where no one speaks or understands English proficiently. As a result, many 

patients do not understand their diagnosis, medications, and plans for follow-up care, which 

are critically important to improving health.

Patient Variables

While there are external factors that influence health disparities, patients play a major role as 

well. Studies show that minority patients are more likely to refuse recommended services, 

adhere poorly to treatment regimens, and delay seeking care. Health literacy continues to be a 

concern with minority patients. Patients may not understand provider instructions, further 

complicating or prolonging their recovery. Lastly, based on past experiences, patients may 

have a general mistrust of health care providers and the medical establishment, making them 

unwilling to seek timely treatment.

Healthcare Reform

As the U.S. Congress crafts a health care plan, now is an appropriate time to begin 

addressing the barriers and disparities that exist in health care. Minorities would be best 

served by the creation of subcommittees to address disparities in health care and workforce 

diversity. As many studies have demonstrated, more progress needs to be made in attracting 

minorities to health care professions. The health care workforce must be representative and 

reflective of the communities served. Health care reform should also include more K-12 

science programs in minority-populated areas, which will prepare our youth to consider 

health care careers. Lastly, comprehensive recommendations to improve housing, green 

space, poverty conditions and the educational system in urban areas are needed to remove 

barriers for minority students considering health care careers.

It is undeniable that socioeconomic factors contribute to health disparities. A comprehensive 

health care reform plan must address these social and environmental factors. Policies should 

 

22 Id at 21-22.

23 MMHD 16

24 Id.
20 Health Care Disparities

address providing adequate primary care, health education and preventative care for healthy 

lifestyles, which will all help control costs. The cumulative effect of unhealthy behaviors and 

unsafe living environments is poor health outcomes and higher costs.

Another important inclusion is the creation and support of an electronic health record. This 

will enable clinics and hospitals to have instant access to patient records, medical histories, 

and insurance information, all of which are important to ensure a seamless continuum of 

care. Since many vulnerable populations tend to use emergency rooms or community health 

clinics rather than primary care physicians for routine care, it is essential to electronically 

link these entities into the system to improve coordination of care. Electronic health records 

should promote quality assurance, and the data extracted from them is vital to effectively 

identify and address health disparities.

Another important step to reducing health disparities is to require employers to provide 

employees paid time off for health-related appointments. Many workers fear they will lose 

their jobs if they miss work. Sick workers reduce productivity as they infect others, do not 

receive critical preventative care and treatment, and their illnesses escalate in severity.

Providing paid time off reduces the cost to insurance providers and the health care system.

Based on the Institute of Medicine Report highlighting provider bias and differences in 

treatment options offered to minority patients, and given that the U.S. population is becoming 

more diverse, it is critical that health care workers receive additional cultural competency 

training. This will improve health care providers‘ ability to understand cultural differences 

and beliefs in treatment options, help them become more comfortable working with medical 

translators and increase the quality of care for vulnerable patients.

Many federal programs and initiatives have increased awareness of health disparities, but 

more can and should be done. America would benefit by the formation of a federal 

commission on health disparities, which could develop and analyze recommendations for 

improving the health of racial and ethnic minorities.

Conclusion

The health disparities in America are clear. Large gaps in life expectancies exist; infant 

mortality rates remain too high; and some statistics, such as the African-American/white 

mortality ratio, have not improved in 60 years. Many minorities face several issues affecting 

their health including living in unhealthy environments with fewer health care facilities, 

fewer health care professionals and less emphasis on general wellness.

As the Institute of Medicine study concluded, people tend to seek treatment from physicians 

who most resemble them. Increasing minority physicians and faculty members will address 

the health care workforce shortages and will reduce health care costs if more minorities seek 

care. Putting more emphasis on cultural competency will improve healthcare quality.

I‘d like to conclude with an appropriate quote that says, ―In the end, it‘s not what we don‘t 

know that will destroy us, but rather the failure to respond appropriately to what we do 

know.‖ Thank you.
Panelist Statements: First Panel 21

Amitabh Chandra 

My name is Amitabh Chandra, and I am a professor at Harvard University‘s Kennedy School 

of Government and a fellow with the Dartmouth Institute for Health Policy. Thank you for 

inviting me to the Commission to discuss the role of healthcare providers in racial and ethnic 

disparities in healthcare. (Note: I acknowledge support from National Institute of Aging P01 

AG19783‐02. This briefing draws from my article ―Who you are and where you Live: Race 

and the Geography of Healthcare‖ Medical Care 47(2), February 2009.)

We are all aware of the stubborn persistence of racial disparities in treatment over time, even 

in the fully insured Medicare population.25 What explains this phenomenon? Unequal 

Treatment, the Institute of Medicine‘s encyclopedic survey of these disparities, offers several 

explanations ‐‐ differences in socioeconomic status, patient behaviors, provider quality, and 

differential treatment of minority patients in the clinical encounter.26 Many advocates believe 

that the most odious of these, differential treatment in the clinical encounter, is also the most 

pernicious source of treatment disparities. My first point this morning is that we are unlikely 

to make great strides in improving minority health by prioritizing action on this channel. Its 

importance is dominated by other shortcomings, which are far more injurious to minority 

health.

That racial disparities in health care emanate principally from the clinical encounter 

embodies the idea that a provider treats two identical patients, one white and the other black, 

differently. More precisely, treatment differences in the clinical encounter may occur because 

there is explicit discrimination where a provider consciously withholds valuable care from 

minority patients. This is the most malfeasant of explanations for disparities in the clinical 

encounter, and is perhaps one reason for why there is so much interest in this mechanism.

But disparities may arise from implicit discrimination, where a harried provider operating in 

a time‐sensitive environment makes unconscious mental decisions that are detrimental to 

minorities. Stereotyping is the one manifestation of this indiscretion and it occurs when a 

provider uses a patient‘s race to deduce information about the benefit of treatment. If 

African-American patients are on average less likely to be compliant, then a physician may 

assume that her African-American patient is less compliant. Such reasoning will worsen 

outcomes for that patient if he is different from the typical African-American, and worsen 

outcomes for all African-Americans if the stereotype about them is wrong. Such biases are 

compounded by poor communication between providers and their patients, which may create 

enormous psychological barriers to minority patients seeking care. Finally, there may be 

genetic or physiological differences between patients that affect the benefit of treatment by 

race. My training as an economist precludes me from commenting on the magnitude of this 

channel, and I will leave it to others to discuss its relevance.

Have we conclusively established the role of the clinical encounter in affecting racial 

disparities in health care? Answering this simple question carefully poses a formidable 

 

25 Jha A, Fisher ES, Li Z, Orav EJ, Epstein AM. Racial trends in the use of major procedures among the elderly. 

New England Journal of Medicine 2005;353.

26 Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 

Washington, D.C.: National Academy Press; 2002.
22 Health Care Disparities

empirical challenge, perhaps one of the greatest empirical challenges in science: we would 

need to observe the same provider treating two patients with the same economic and social 

resources, physiology, clinical history, severity, preferences, compliance, and future 

prognosis. The first problem we confront is that because of patterns of neighborhood 

segregation, the same provider is rarely observed treating both black and white patients. 

Ignoring this problem as many researchers have done causes us to attribute differences in 

neighborhoods, referral patterns, and the quality of providers that serve different 

communities to the clinical encounter. But differences in provider quality are a distinct 

explanation from the same provider treating patients differently, and the two explanations 

require unconnected policy responses. I will return to this point again.

The second challenge to measuring the size of the clinical encounter is that it is difficult, if 

not impossible, for observational studies to fully adjust for other relevant factors that affect 

clinical decision making: patient preferences, severity, social support, and potential 

compliance affect the benefit from treatment and should affect treatment decisions. These 

variables are routinely observed by providers treating patients but not by social scientists 

observing providers. The fact that multiple studies all note that minority patients get less care 

is interpreted by some to be evidence of pervasive bias in the clinical encounter, and by 

others of pervasive shortcomings in all observational studies to control for the key 

determinants of treatment that are correlated with race. I reiterate that many of these 

determinants may not be physiological.

Researchers have made progress on both these challenges: we have measured disparities for 

treatments where the role of preferences, follow-up care, communication, and physiology 

should be less relevant—for example, by studying the receipt of beta‐blockers or reperfusion 

within hours of being admitted for a heart attack. But for these treatments, we found no 

disparities in the clinical encounter—a finding that undermines the primacy of the clinical 

encounter explanation. We have also used patient actors and Implicit Association Tests 

(IATs) to evaluate the role of provider prejudice directly. In these more  ̳controlled‘ 

environments, physicians and the researchers studying them observe the same information. 

This is an exciting and promising area of research, but its findings still nascent for the 

purpose of informing policy and legislation. Our ability to generalize from these studies is 

dependent upon whether the self‐selected physicians who participated in these laboratory 

studies are representative of physicians who take care of minority populations.27 28

The final challenge for the focus on the clinical encounter is that we don‘t have a policy lever 

to eliminate it. One often‐touted prescription is to encourage cultural competency training for 

physicians and expansions in the numbers of minority physicians. But this view is grounded 

more in hope than science. Direct evidence that such policies will improve minority health

care remains absent. In fact, one study in the New England J. Medicine found that racial 

 

27 Green, Alexander, Dana Carney, Daniel Pallin, Long Ngo, Kristal Paymond, Lisa Iezzoni, Mahzarin Banaji, 

―Implicit Bias among Physicians and its Predictions of Thrombolysis for Blacks and Whites Patients,‖ Journal 

of General Internal Medicine, June 2007.

28 Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians‘ recommendations for 

cardiac catheterization. N Engl J Med. 1999;340(8):618–26.
Panelist Statements: First Panel 23

differences in treatment were similar among patients treated by white and black physicians.29

Indeed, we could even damage minority health further if these interventions alienate or 

displace the least prejudicial physicians—those who have devoted their lives to treating 

minority patients.

My second point is to elaborate on how providers influence minority health, but through a 

different dimension than I have just discussed. A new explanation for racial disparities in 

care is that they are partially the consequence of differences in where minorities and whites 

receive care.306 If different providers treat blacks and whites, then perhaps one reason for 

racial disparities in care is not only who you are—your race—but also where you live.31 32

Both sources of disparities are injurious to minority health care. The first type of variation, 

"within provider variation,‖ highlights the role of explicit and implicit discrimination in the 

clinical encounter. The second, ―between provider variation,‖ relates less to race per se and 

more to geographical variations in the quality of treatment patterns of all patients.33 34 It 

contributes to racial disparities in treatment because minorities are more likely to be cared for 

by lower quality providers. (Some large academic centers are an exception to this statement, 

but the link between such centers and quality is by no means automatic.)

35 Differences in 

where minorities are treated have to do with factors such as lower socio‐economic status, but 

historical patterns of discrimination and neighborhood segregation surely exacerbate this 

variation.36 37 Confronted with these realities, we should be cautious in concluding that 

malfeasance and nonfeasance are the sole purview of the medical profession.

So what is the evidence in favor of the role of geography as a determinant of racial disparities 

in health care? Peter Bach and his colleagues has demonstrated that blacks and whites have 

different providers, and those providers who treat minorities are often less clinically trained 

and have fewer resources.38 This finding challenges much of the emphasis on the individual 

 

29 Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM. Racial difference in the use of cardiac 

catheterization after acute myocardial infarction. N Engl J Med 2001;344:1443‐1449.

30 Wennberg JE, Cooper MM. eds., The Dartmouth Atlas of Health Care 1999 (Chicago: American Hospital 

Association, 1999). 

31 Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee 

arthroplasty among Medicare patients. N Engl J Med 2003;349:1350‐9.

32 Chandra A, Skinner J. Geography and Health Disparities. In: Anderson NB, Bulatao R, Cohen B, eds. Critical 

Perspectives on Racial and Ethnic Differences in Health in Late Life. Washington D.C.: National Research 

Council of the National Academies; 2004.

33 Baicker K, Chandra A, Skinner JS. Geographic variation in health care and the problem of measuring racial 

disparities. Perspectives in biology and medicine 2005;48:S42‐53.

34 Baicker K, Chandra A, Skinner JS, Wennberg JE. Who you are and where you live: how race and geography 

affect the treatment of Medicare beneficiaries. Health affairs (Project Hope) 2004;Suppl Web Exclusives: 

33‐44.

35 Yasaitis, Laura, Elliott S. Fisher, Jonathan S. Skinner, and Amitabh Chandra. Hospital Quality And Intensity 

Of Spending: Is There An Association? Health Affairs Web Exclusive, May 21, 2009.

36 Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. 

Public Health Rep. 2001 Sep–Oct; 116(5): 404–416.

37 Williams DR, Jackson PB. Social Sources Of Racial Disparities In Health. Health Affairs, March/April 2005; 

24(2): 325‐334.

38 Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. 

N Engl J Med 2004;351:575‐84.
24 Health Care Disparities

clinical encounter, for key to that argument is the requirement that the same provider treats 

minority and majority patients differently. To understand the geography explanation further, 

consider how segregated the treatment of heart attacks is today: My collaborators and I have 

demonstrated that 85 percent of all black heart attack patients are treated by only 1,000 

hospitals.39 By contrast, 60 percent of whites receive their care in hospitals that treat no black 

heart attack patients. Because blacks and whites go to different hospitals for AMI care, 

differences across hospital in their ability to provide rapid reperfusion will play an important 

role in observed racial disparities in outcomes for heart attacks. Within hospitals, we found 

that there were no black–white disparities in the use of effective medical treatments such as 

aspirin and beta‐blockers during hospitalization. But there were substantial racial differences 

in treatments if one ignored where one was treated. In other work we found that AMI patients 

admitted to hospitals that disproportionately served blacks have been found to experience a 

risk‐adjusted 90‐day mortality rate that is almost 40 percent higher than that of non‐minority 

serving hospitals.40 These patients had similar co‐morbidities and disease severity, suggesting 

that the difference in survival may be attributed to differences in the quality of treatment. For 

heart attack treatments, over half of the gap in survival can be explained by differences in 

where patients received care. Others have noted similar findings for the performance of 

NICUs in minority serving hospitals.41 Forty years after the passage of Civil Rights Act, 

minority health care is de facto separate and unequal. Ironically, a close cousin of this 

embarrassment, segregated hospitals, was the original motivation for Title VI legislation.

The new focus on the geography of minority health care should not be viewed as taking 

attention away from reforming the clinical encounter. Rather, it notes that even if we could 

fully eliminate disparities in the clinical encounter, the health care of blacks would improve 

but still lag behind that of whites because of differences in the quality of where the two 

groups receive care. For many of us, this is simply not good enough. I believe that we can do 

better, much better. In the context of ambulatory diabetes care, my collaborators at 

Dartmouth and I estimate that aggressively improving the performance of the 500 largest 

minority serving networks would improve minority health care more than the complete 

elimination of racial disparities within every provider in the U.S. Because a small group of 

providers treat minority patients, targeting quality improvements towards minority serving

providers will dramatically reduce black‐white disparities in care more generally. Such 

interventions would improve the health of both minority and white patients, but the gains 

would disproportionately accrue to minority patients whose care is concentrated in such 

providers. Indeed, given the greater reliance on ambulatory care, one may want to think 

about expanding the reach of Title VI of Civil Rights legislation to go beyond the reach of 

hospital care and encompass care that is delivered in office visits and by managed care plans.

 

39 Barnato AE, Lucas FL, Staiger D, Wennberg DE, Chandra A. Hospital‐level Racial Disparities in Acute 

Myocardial Infarction Treatment and Outcomes. Med Care. 2005;43(4):308‐19.

40 Skinner J, Chandra A, Staiger D, Lee J, McClellan M. Mortality After Acute Myocardial Infarction in 

Hospitals That Disproportionately Treat Black Patients. Circulation. 2005;112(17):2634‐2641.

41 Morales, Leo S., Staiger, Douglas, Horbar, Jeffrey D., Carpenter, Joseph, Kenny, Michael, Geppert, Jeffrey, 

Rogowski, Jeannette. Mortality Among Very Low‐Birthweight Infants in Hospitals Serving Minority 

Populations. Am J Public Health 2005 95: 2206‐2212.
Panelist Statements: First Panel 25

Finally, in closing let me make one simple point: the determinants of racial disparities in 

health are not the same as the determinants of disparities in health care. The principal 

determinants of health are genes, behaviors, schooling, neighborhoods, and economic 

circumstance. Health is secondarily affected by health care, but more likely to be influenced 

by prevention including the quality of ambulatory care, which can check the progression of 

diabetes, hypertension and chronic disease, and through this protection, the incidence of heart

attacks and strokes. Of tertiary importance, at the very end of the causal chain is the role of 

disparities in the care encounter; the quality of that encounter matters much more than the 

disparity within it. So the 6.5 year racial gap in life expectancy for men and the 4.5 year 

racial gap for women, which are surely larger when one accounts for the condition of that 

life, are unlikely to be affected by the focus on treatment disparities.42 The preoccupation 

with treatment disparities in the endgame misses the fact that minority patients find 

themselves confronting the endgame sooner and more often than anyone else.

 

42 Harper, Sam, John Lynch; Scott Burris; George Davey Smith. Trends in the Black‐White Life Expectancy 

Gap in the United States, 1983‐2003. JAMA. 2007;297(11):1224‐1232.
26 Health Care Disparities

Sally L. Satel

Chairman Reynolds, Vice-Chairman Thernstrom, and other esteemed members of the 

Commission, thank you for the invitation to address you on the nature of health disparities.

My name is Sally Satel. I am a resident scholar at the American Enterprise Institute and a 

physician practicing part time at a local methadone clinic. At AEI, much of my work has 

focused on the interface of medicine and culture and the politicization of science. I have 

been particularly interested in the manifestation of identity politics within medicine. Until 

several years ago, the subject of health disparities has been an exceptionally rich example 

of this phenomenon.

Today I would like to present an overview of health disparities as a discrete topic within the 

domain of health policy. I will briefly trace the evolution of the conceptual underpinnings 

of the health disparities issue from its origins as a epidemiological phenomenon with no 

posited cause, to a civil rights problem presumably driven by bias among physicians, and 

then to a public health concern stemming from socio-economic factors. Unsurprising, as the 

causal orientation shifts from civil rights to public health, proposed remedies must realign 

as well. The themes in this statement are elaborated in greater depth in The Health 

Disparities Myth – Closing the Treatment Gap (AEI Press 2006) which has been distributed 

to all members of the Commission and is available online at: 

http://www.aei.org/docLib/20080630_HealthDisparitiesMyth.pdf.

Health Disparities Emerges as a Policy Issue

One of the earliest appearances of the term ―health disparity‖ was in the 1985 Report of the 

Secretary’s Task Force on Black and Minority Health, published by the U.S. Department of 

Health, Education, and Welfare (now HHS). There the term referred to ―excess deaths‖—

that is, the difference between the number of deaths observed in a racial/ethnic group and the 

number of deaths that would have occurred in that group if it had the same death rate as the 

non-Hispanic white population. This definition of ―disparity‖ was purely descriptive; it was 

silent on the question of what produces these differences.

In 1999, the National Institutes of Health devised a similar definition of health disparities: 

―Differences in the incidence, prevalence, mortality, and burden of diseases and other 

adverse health conditions that exist among specific population groups in the United States.‖ 

Similarly agnostic definitions have been issued by other government agencies and offices.

Although allusions to ―racism‖ in the health care system had been made during the 1990s, the 

idea was catapulted into public consciousness by a much-cited 2002 report from the Institute 

of Medicine (IOM), part of the National Academy of Sciences, called Unequal Treatment: 

Confronting Racial and Ethnic Disparities in Health Care. The report defined disparities as, 

―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.‖ 43 Emphasis was 

placed on the doctor-patient relationship, which, the report said, is marked by ―bias,‖ 

 

43 Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: Confronting Racial and 

Ethnic Disparities in Health Care. 4. (Washington, D.C.: National Academy of Sciences, 2002)
Panelist Statements: First Panel 27

―prejudice,‖ and ―discrimination.‖ The report claimed that the clinical encounter itself – more 

specifically, the inferior treatment that white doctors gave minority patients -- fueled the 

treatment differential and, by extension, the poorer health of minorities.

Media coverage of the IOM report was extensive and sensational: ―Color-Blind Care . . . Is 

Not What Minorities Are Getting‖ (Newsday); ―Fed Report Cites  ̳Prejudice‘ in White, 

Minority Health Care Gap‖ (Boston Herald); and ―Separate and Unequal‖ (St. Louis PostDispatch). The IOM report was a watershed event. It transformed the concept of ―disparity‖ 

from an epidemiological phenomenon into a civil rights matter. The word disparity now 

connoted unfair difference due to a patient‘s race or ethnicity. As epidemiologist Olivia 

Carter-Pokras at the University of Maryland observed, the word disparity ―has begun to take 

on the implication of injustice.‖ Accordingly, remedies proposed by the IOM experts and 

others have emphasized race-based prescriptions -- most prominently, workforce diversity 

initiatives and cultural competence training. I will begin by focusing on the questionable 

rationales behind these initiatives.

Assumptions of the Health Disparities Project

Three bedrock assumptions of the health disparities project warrant mention.

Assumption #1: “Bias” Can Be Proven

A key premise of disparities research is that the existence of bias can be established through 

retrospective research. Yet the myriad factors that contribute to doctors‘ thinking cannot be 

inferred from large databases. Nuanced research on physician behavior requires prospective 

work conducted in the clinical setting; it cannot be divined from after-the-fact inferences 

about how doctors behave or sterile questionnaires that do not (cannot) capture the 

complexity of the clinical decision-making process. Quantitatively trained sociologists would 

need to play a larger role in these investigations.

Assumption #2: Measuring the Relative Health of Groups Is an Optimal Strategy

The health disparities project is concerned primarily with relative health. A fundamental 

research query is whether certain ethnic groups are receiving more or less health care than 

other groups. While this approach may have an intuitive appeal, it is problematic for several 

reasons and should thus be only one of many metrics for measuring improvement in minority 

health.

First, it can mask absolute improvements in care.44Consider this illustrative example:

Black patients with diabetes who attended a Bronx clinic were tested for diabetic 

control 53 percent of the time; whites were tested 57 percent of the time. This 

difference of four percentage points was smaller than the testing differential of 14

percentage points found at a Washington, D.C., clinic. The smaller gap could be 

seen as indicative of a better overall situation. But a closer look shows that 59 

percent of blacks in the Washington clinic were tested, versus 73 percent of 

whites.

 

44 David Mechanic, ―Policy Challenges in Addressing Racial Disparities and Improving Population Health,‖ 

Health Affairs 24, no. 2 (2005): 336.
28 Health Care Disparities

In absolute terms, the D.C. diabetics—both black and white—received better care than their 

Bronx counterparts, but a narrow judgment based on racial comparison alone would conceal 

this reality. Indeed, absolute improvements in treatment—if they occur in all groups—will 

not close a gap but should still be recognized as valuable.

Second, focusing on narrowing disparities can obscure deficiencies in care.

Amal Trivedi and colleagues at Harvard found greater improvements in black 

patients than whites in the receipt of necessary tests and treatments (for example, 

eye exams for diabetics or beta-blockers after heart attacks) over a six-year 

period. Just looking at the narrowed black-white differentials would conceal the 

fact that both white and black patients, all of whom were enrolled in Medicare 

managed-care plans, received the tests with sub-optimal regularity.

Assumption #3: Health Gaps Can Be Closed

Pragmatically, it will be impossible to eliminate health differences without first eliminating 

the other disparities in society (e.g., early education, family stability, income, and so on) that 

are linked with health status. Though some public health experts would argue otherwise, 

reorganizing the socioeconomic sphere of our nation is a mission that transcends the purview 

of the public health profession. The questions about societal leveling: how to execute it; 

whether to pursue it at all and, if so, in which domains -- are best left to politicians, voters, 

and social welfare policy experts. Nonetheless, if eliminating disparities is the goal of the 

health disparities project, it will be an elusive one indeed.

Do Minority Patients Fare Better with Minority Physicians?

Considerable emphasis is placed on the importance of physician workforce diversity (based 

upon the notion that race concordance between patient and doctor will improve minority 

health) and cultural competence training as ways to close the health gap. This contention has 

weak empirical basis, however. Perhaps more data will prove their virtues, but at present, 

they seem driven more by intuition than fact.

Do the data support the claims that minority patients fare better with physicians of their own

race?

Only a handful of studies have been devoted to the question of whether patients‘ outcomes 

are better if they and their clinicians are of the same race. Some of these were conducted with 

psychiatric patients, and most showed that clinician race had a minimal impact on how black 

patients fared in their treatment and recovery. One large study that appeared in the journal 

Psychiatric Services involved more than 1,700 homeless individuals participating in an 

intensive services program. Each person was randomly assigned a case manager with whom 

he worked closely. Over the course of a year, improvement in dimensions like the number of 

days a patient worked at a job, whether he had drug problems, and the number of days he 

spent homeless bore no relationship to whether he and the case manager were of the same 

race. A 2005 study from the University of North Carolina found that physician race had little 

effect on the successful management of high blood pressure in elderly black and white 

patients. Seeing the same physician, however, was a key factor in attaining good outcomes.
Panelist Statements: First Panel 29

What do patients want?

A comprehensive review of the literature published in the Journal of Health Politics, Policy 

and Law found that ―racial/ethnic concordance holdslittle salience in the minds of most 

black and Latino patients and that discordance has little effect.‖ 45 This is consistent with a 

poll of 4,000 respondents published by The Commonwealth Fund – one of the largest, most 

detailed and most ethnically diverse surveys ever conducted. In that survey, the main 

complaint of almost every patient, regardless of ethnic or racial group, was the doctor‘s 

―failure to spend enough time with me.‖ When asked to cite the factors that ―influence your 

choice of doctor,‖ the physician‘s ―nationality/race/ethnicity‖ ranked 12th out of 13 possible 

options.

Other data reinforce the importance of adequate physician-patient contact. A number of 

studies show that patients report having more say in their treatment (and, presumably, have 

better compliance with treatment although the studies did not address that question) when the 

doctor, regardless of race, spent more time with them. A study by Lisa Cooper-Patrick and 

others found that the amount of time the doctor spent with the patient was a stronger 

determinant of patients‘ ―participatory‖ ratings -- indicating patients‘ perceptions of how 

involved they were in treatment decisions -- than was racial concordance. Thus, it appears 

that the length of doctor-patient contact overwhelms whatever concordance effect may exist 

in leading to patients‘ enhanced sense of participation.

Sherrie Kaplan and her colleagues also observed that the amount of time the patient spent 

with the doctor helped determine the participation score. In the one study, visits of less than 

20 minutes were found to be too brief to involve patients in treatment decisions. In another 

analysis, physicians who had ―high-volume‖ practices were rated as less participatory than 

those who saw fewer patients but spent more time with each. Given the value patients place 

on face-to-face time with their physician, irrespective of the physician‘s race, the real 

problem seems to be that an average primary care visit is 15 minutes for everyone—rather 

than its being a few minutes shorter for black patients.

It is important to note, however, that the Cooper-Patrick study is widely cited as support for 

doctor-patient race concordance. But a closer reading is repaid. Cooper-Patrick reported that 

black patients rated their visits to doctors as more participatory when their doctors were

black.46 Yet the clinical significance of this is hard to interpret in light of the fact that patients 

rated their interactions with same-race physicians (a participation score of 62.6 out of a 

possible 120) as barely different from interactions with different-race physicians (60.4 out of 

120). What‘s more, when Sherrie Kaplan and her colleagues employed the same survey

instrument, they discovered that minority patients who saw minority doctors had lower 

scores on the questions of participation that those who saw white doctors. The small volume 

of evidence on this topic indicates that race concordance between patient and physician has 

no reliable relationship to doctor-patient interactions, let alone to the quality of patient care 

as a function of race.

 

45 Jason Schnittker and Ka Liang, “The Promise and Limits of Racial/Ethnic Concordance in Physician-Patient 

Interaction,‖ Journal of Health Politics, Policy and Law, 31 (2006): 811-838. 

46 Lisa Cooper-Patrick and others, ―Race, Gender and Partnership in the Patient-Physician Relationship,‖ The 

Journal of the American Medical Association, 282, no. 6 (1999): 583–89.
30 Health Care Disparities

The Limits of Unequal Treatment

In view of the deference accorded the IOM report, Unequal Treatment, as a ―landmark‖ 

document, it is important to ask whether the evidence put forth by the report justifies its 

conclusions about the significance of physician bias in generating health differentials.

The Health Disparities Myth presents a lengthy critique. (Note that ―myth‖ refers to the 

allegation of bias as a major cause of disparities, not to the existence of differentials 

themselves.) Consider one major limitation of the report: the fact that it did not have enough 

information to rule out other important determinants of treatment differentials between black 

and white patients.

This is because most of the studies reviewed by the IOM experts were retrospective, relying 

upon chart review or large Medicare administrative databases that do not capture many 

variables that influence the type and frequency of care given. As the IOM report itself 

acknowledged, the more confounding variables were identified, the smaller the differential 

between whites and minorities became: ―Almost all of the studies reviewed here find that as 

more potentially confounding variables are controlled, the magnitude of racial and ethnic 

differentials in care decreases.‖ Some studies were more scrupulous than others in 

accounting for confounding determinants of treatment, but even so, a treatment differential 

often remained.

Cardiovascular illness is one of the most commonly studied conditions because it is a major 

cause of morbidity and mortality among African-Americans. The studies of cardiovascular 

care described in the IOM report were generally able to account for co-morbid conditions and 

severity of disease at the time care was sought. But a number of important clinical variables 

that influence physician decision-making were often missing from administrative

databases—for instance, EKG subtleties, position of occlusion in carotid and coronary 

vessels, coronary ejection fraction, and pulmonary function test performance. Further, 

variables such as patient preference and enrollment in supplemental insurance (which can 

influence whether a certain procedure is administered) are rarely recorded.

Moreover—and this is key—the unrecorded variables tend to vary by race and ethnicity. 

Consider, again, an example from cardiac care. Much evidence and experience confirms that 

coronary angiograms of black patients often show less anatomical suitability for intervention 

than in their white counterparts—either lesions in their vessels are too diffuse for 

angioplasty, or the patients have a higher incidence of normal-appearing vessels—despite the 

clinical appearance of having suffered acute myocardial infarction (heart attack). An 

examination of records, therefore, could suggest a racial bias in treatment simply because 

coronary angiograms are less often given to black patients. Detailed rationales for treatment 

choices could explain the differential but these nuances are not reliably indicated in the 

records themselves.
Panelist Statements: First Panel 31

After Unequal Treatment

In the years following the IOM report, a cascade of studies has demonstrated the vital 

importance of key variables in health differentials. The result has been less overt talk of 

―racism‖ and less insistence that the doctor‘s office is a particularly promising place to find a 

significant cause of health differentials. The current view is that wider, systemic factors 

underlie health differentials. These factors -- the role of geography, hospital quality, and 

physician quality -- overwhelm the influence of bias, to the extent it meaningfully exists at 

all, within the clinical encounter.

Geography

Health care varies a great deal depending on where people live, and because blacks are 

overrepresented in regions of the United States that are burdened with poorer health facilities,

disparities are destined to be, at least in part, a function of residence.47

Hospital Quality

Minority patients are more likely to receive care in lower-performing hospitals than are white 

patients. Hospitals that treat greater numbers of minority patients generally offer poorerquality service than those that treat fewer minorities. Yet, within hospitals, the quality of care 

is generally comparable between whites and minorities when they are admitted for the same 

reason or receive the same procedure.48

Physician Quality

White and black patients, on average, do not visit the same population of physicians—

making the idea of preferential treatment by individual doctors an improbable explanation for 

disparities. Doctors whom black patients tend to see may not be in a position to provide 

optimal care. For example, they report having less access to high-quality colleaguespecialists, such as cardiologists or gastroenterologists, to whom they could refer their 

patients, or to nonemergency hospital services, diagnostic imaging, and ancillary services, 

such as home health aid. In addition, physicians of any race who disproportionately treat 

black patients are less likely to have passed a demanding certification exam in their specialty 

than physicians treating white patients.49

Identity Politics Linger

The concept of ―cultural competence‖ is fundamental to the health disparities project. Most 

medical schools have some kind of cultural competency training. New Jersey was the first 

state to pass a law requiring doctors to receive so-called ―cultural competency‖ training as a 

 

47 R. Hasnain-Wynia, DW Baker, D. Nerenz, J. Feinglass, AC Beal, MB Landrum, R. Behal, JS Weissman, 

―Disparities in health care are driven by where minority patients seek care: Examination of the hospital quality 

alliance measures.‖ Archives of Internal Medicine 167, no. 12 (2007): 1233-1239; Katherine Baicker, Amitabh 

Chandra, and Jonathan S. Skinner, ―Geographic Variation in Health Care and the Problem of Measuring Racial 

Disparities,‖ Perspectives in Biology and Medicine 48, no. 1, supp. (2005): S42–53.

48 Katherine Baicker and Amitabh Chandra, ―Myths and Misconceptions About Health Insurance,‖ Health 

Affairs 27, no. 6 (2008): w533-w543.

49 Peter B. Bach and others, ―Primary Care Physicians Who Treat Blacks and Whites,‖ New England Journal of 

Medicine 351, no. 6 (2004): 575–84; JD Reschovsky, AS O‘Malley, ―Do Primary Care Physicians Treating 

Minority Patients Report Problems Delivering High-Quality Care?‖ Health Affairs 23, no. 3 (2008): 222-231

(Web Exclusive).
32 Health Care Disparities

condition of obtaining or renewing their licenses to practice medicine; California and 

Washington followed. All major agencies within HHS have offices of minority health that, 

among other things, champion cultural competence. Over 40 states have an office dedicated 

to health disparities, minority health, or multicultural health. The Health Equity and 

Accountability Act of 2007 and the Minority Improvement and Health Disparity Elimination 

Act (neither has been re-introduced this session) contained ambitious cultural competence 

initiatives.

But what exactly is cultural competence? Consider the sprawling definition from the 

Department of Health and Human Services.

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and 

policies that come together in a system, agency, or among professionals that 

enables effective work in cross-cultural situations.  ̳Culture‘ refers to integrated 

patterns of human behavior that include the language, thoughts, communications, 

actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or 

social groups. Competence‘ implies having the capacity to function effectively as 

an individual and an organization within the context of the cultural beliefs, 

behaviors, and needs presented by consumers and their communities.

-- CLAS Standards Report (U.S. Department of Health and Human Services 

Office of the Secretary, 2000)

In practice, cultural competence refers to a range of interventions. It can include useful, 

practical accommodations intended to help health providers care for unacculturated or 

immigrant populations—such as translation services or education of medical staff about local 

healing customs and commonly used remedies. But it can also entail blatant, patronizing 

racial sensitivity training. Accordingly, some observers worry that cultural competence could 

deteriorate into an oversimplified, stereotyped, paint-by numbers affair that purports to teach 

students and physicians ―how to treat‖ African-Americans, Asians, Latinos, and others. 

Others recoil at the specter of a clinical milieu in which black patients will be assigned to 

black doctors, gay patients to gay doctors, and so on.

At its most constructive, cultural competence is a variant of standard training in doctorpatient communication—a course that is required by all medical schools within the first two 

years of study. Joseph Betancourt, a physician at Harvard Medical School, describes an 

universal form of cultural competence that has ―evolved from the making of assumptions 

about patients on the basis of their background to the implementation of the principles of 

patient-centered care, including exploration, empathy, and responsiveness to patients‘ needs, 

values, and preferences.‖50 In the end, Betancourt is simply describing competent care—one 

wonders why this requires a separate course.

 

50 Joseph R. Betancourt, ―Cultural Competence—Marginal or Mainstream Movement?‖ New England Journal 

of Medicine 351, no. 10 (2004):953.
Panelist Statements: First Panel 33

Does cultural competence training have any effect on disparities? A literature search revealed 

no rigorous evaluations of cultural competency training that attempted to answer whether it 

improves quality of care, let alone reduces disparities.51

Conclusion

The health disparities discussion has matured over the years as volumes of data on 

geographical and economic factors accumulate. Though the bias theme lingers in academic 

quarters it appears to play a much less dominant part in the discussion of minority health than 

it in the years following the IOM report. This is a welcome development.

Not only are charges of bias divisive, pursuing them as a priority siphons energy and

resources from endeavors targeting system factors that are more relevant to improving 

minority health: expanding access to high-quality care and facilitating changes in 

individuals‘ lifestyles and their capacity to manage chronic disease.

From this perspective, proposed race-based remedies for the treatment gap -- such as racial 

preferences in admission to medical school to increase diversity, and racial sensitivity 

training for doctors -- become trivial or irrelevant at best, and potentially harmful at worst.

A true public health solution to inadequate care—one that seeks to maximize the health of all 

Americans—would more properly target all underserved populations, irrespective of group 

membership. Success would be reflected in the improved health of these communities; and, 

because many of them happen to comprise large numbers of minorities, racial and ethnic care 

differentials would diminish as well.

Selected Endnotes (For version of this statement with full citations see sallysatelmd.com)

Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: 

Confronting Racial and Ethnic Disparities in Health Care. 4. (Washington, D.C.: National 

Academy of Sciences, 2002)

David Mechanic, ―Policy Challenges in Addressing Racial Disparities and Improving 

Population Health,‖ Health Affairs 24, no. 2 (2005): 336.

Jason Schnittker and Ka Liang, “The Promise and Limits of Racial/Ethnic Concordance in 

Physician-Patient Interaction,‖ Journal of Health Politics, Policy and Law, 31 (2006): 811-

838. 

Lisa Cooper-Patrick and others, ―Race, Gender and Partnership in the Patient-Physician 

Relationship,‖ The Journal of the American Medical Association 282, no. 6 (1999): 583–

89.

R. Hasnain-Wynia, DW Baker, D. Nerenz, J. Feinglass, AC Beal, MB Landrum, R. Behal, JS 

Weissman, ―Disparities in health care are driven by where minority patients seek care: 

Examination of the hospital quality alliance measures.‖ Archives of Internal Medicine 167, 

no. 12 (2007): 1233-1239; Katherine Baicker, Amitabh Chandra, and Jonathan S. Skinner, 

 

51 ―Does Cultural Competency Training Improve Quality of Care?‖ MDNG New Media, June 11, 2008 

http://www.hcplive.com/mdnglive/webexclusives/Cultural_Competency_Training. 
34 Health Care Disparities

―Geographic Variation in Health Care and the Problem of Measuring Racial Disparities,‖ 

Perspectives in Biology and Medicine 48, no. 1, supp. (2005): S42–53.

Katherine Baicker and Amitabh Chandra, ―Myths and Misconceptions About Health

Insurance,‖ Health Affairs 27, no. 6 (2008): w533-w543.

Peter B. Bach and others, ―Primary Care Physicians Who Treat Blacks and Whites,‖ New 

England Journal of Medicine 351, no. 6 (2004): 575–84; JD Reschovsky, AS O‘Malley, 

―Do Primary Care Physicians Treating Minority Patients Report Problems Delivering 

High-Quality Care?‖ Health Affairs 23, no. 3 (2008): 222-231 (Web Exclusive).

Joseph R. Betancourt, ―Cultural Competence—Marginal or Mainstream Movement?‖ New 

England Journal of Medicine 351, no. 10 (2004):953.

―Does Cultural Competency Training Improve Quality of Care?‖ MDNG New Media, June 

11, 2008,

http://www.hcplive.com/mdnglive/webexclusives/Cultural_Competency_Training.
Panelist Statements: First Panel 35

Peter Bach

Chairman Reynolds, Vice-Chairman Thernstrom, and other esteemed members of the 

Commission. 

My name is Peter Bach. I am a physician at Memorial Sloan Kettering cancer center in New 

York City, where I do health services research. My research discipline uses a hybrid set of 

techniques from economics, epidemiology and statistics in order to gain a representative 

understanding of the health care delivery system. For more than a decade one of my main 

research interests has been in the field of health disparities.

I bring to this hearing a few other relevant pieces of experience. For one, I have served in a 

number of capacities for the government, both as an external advisor and internally. I served 

as an advisor to the trans-HHS working group on health disparities - a group that crafted a 

long set of important recommendations for both research and implementation regarding the 

reduction of health disparities.

I also served internally as the Senior Adviser to the Administrator of the Centers for 

Medicare and Medicaid Services. During my time Mark McClellan was the Administrator, 

and among other duties, he tasked me with helping coordinate and communicate Medicare‘s 

activities regarding disparities among our beneficiaries.

Prior to today my work has led to other opportunities to both testify before Congress and to 

speak with the media regarding the important questions of both the origins and the potential 

approaches to health disparities.

I would like to express my gratitude for this invitation to speak with you today. I am humbled 

by the opportunity, and flattered by the notion that I can add to the discussions that you are 

having. I also want to thank the funders who have supported my and my colleagues‘ work 

over the years, including the National Cancer Institute, the National Institute of Aging, The 

Commonwealth fund, and the Robert Wood Johnson foundation. I also must specifically 

credit my colleagues Colin Begg and Deborah Schrag at Memorial Sloan-Kettering, and 

Hoangmai H Pham at the Center for Studying Health System Change. Although my name 

might appear as the lead author on some of our group‘s work, it has all been a highly 

collaborative effort.

I would like to use my time to reflect on some of the work in which I have been involved, 

and place the findings from it in context. About a decade ago my colleagues and I began to 

wonder if the higher rates of mortality from cancer seen among blacks when compared to 

whites could be due to blacks receiving less effective treatments after diagnosis. We knew 

that higher rates of blacks getting cancer could not explain the gap, because that gap was 

only 10 percent, while the cancer death rate in blacks was 33 percent higher than it was in 

whites.

So we chose a single cancer procedure to study - surgery for early stage lung cancer. We 

focused on this procedure because it treats the number one cancer killer, is enormously 
36 Health Care Disparities

effective, and we knew that in an analysis, it would be relatively easy to determine if a given 

patient did or did not receive it. In an analysis published in the New England Journal of 

Medicine in 1999 we showed that in Medicare, blacks with a curable diagnosis received this 

surgery 13 percent less often than whites with the same diagnosis. We showed that this was 

not due to greater co-morbidity, or even due to poverty. We also showed that we believed 

that this treatment gap was the explanation for black patients‘ poorer outcomes.

The study is personally memorable. It was one of the first major analyses published using the 

NCI‘s Seer-Medicare database, which has since become a cornerstone of studies of cancer 

care. It was also one of the few studies that had demonstrated that treatment gaps were 

important in terms of disease outcomes. That has since been shown in numerous other 

settings.

We were unable to determine in our study why treatment rates were lower for blacks. Our 

study wasn‘t designed with that question in mind, and the data we used was insufficient to 

address this sort of granular patient level question. Parenthetically, there is nearly always a 

tradeoff between wishing to have a study that is broadly representative of the population and 

wanting to have a study that has tremendous detail about each patient or care setting.

Ours used national data covering many years, and tens of thousands of patients, but had little 

individual level information. Other work in disparities is notably the opposite, sometimes 

covering just a few patients and doctors in a single practice setting, from which a lot can be 

learned about that setting, but less about the ―universe‖ of care settings.

The fallout from the publication was educational for me. A number of pundits used our

findings as a platform, to decry the health care system as racist, and by extension, doctors as 

racists. In fact there was a story in the New York Times Week In Review about our study 

titled ―Not just another case of health racism.‖

Too many people concluded too quickly that the explanation for our findings, and many 

other similar findings, was that doctors discriminated against their minority patients, 

providing them less good care than their white patients. I noted in an essay in the New 

England Journal of Medicine that the invocation of racism as the cause of treatment 

disparities moved the problem from one of health care system quality to one of health care 

provider moral failure.

Our research group saw in some studies the potential for another explanation for treatment 

gaps. One that, if you will, ―blamed‖ the system rather than the doctor. We hypothesized that 

a key reason why blacks received lower quality care than whites could be that they went to 

doctors who, for a variety of reasons, were less able to provide the higher quality care 

routinely received by whites. This could be the case because the doctors were less well 

trained, or less well resourced, or simply less knowledgeable.

In 2004 we published a study in the New England Journal of Medicine that provided some 

evidence supporting our explanation. In it, we documented the presence of two conditions 

that supported our theory.
Panelist Statements: First Panel 37

The first was that we demonstrated that the key precondition for our hypothesis existed. 

Blacks and whites were indeed not treated by the same doctors. By looking at Medicare 

patients we were able to show that the care of black patients was heavily clustered among a 

small group of doctors - it took only 20 percent of these doctors to account for 80 percent of 

the care blacks received. Whites were different. Their care was mostly with other doctors.

Then we compared the doctors at the level of the individual patient visits, to ask the question 

"If I'm a typical Medicare patient who is black, what are the features of my doctor?‖ Then we 

asked that question again, for a typical white patient.

We found that the doctors were different. A black patient was less likely to have a doctor 

who was board certified than a white patient. We thought that was important because having 

board certification is one predictor of delivering high quality care. We also found that the 

primary care doctors who treated blacks had fewer resources to direct at the care of their 

patients. They had a harder time making referrals, or electively admitting patients to the 

hospital, or getting imaging tests.

Most interesting, although we didn‘t realize the importance fully at the time, the financing of 

the practices was different. It‘s not surprising in retrospect, but blacks went more often to 

doctors who provided free care or care reimbursed through low-paying Medicaid. This meant 

that the doctors who treated blacks were just less well financed, and so probably less well 

staffed with ancillary support services, and more hurried.

Although we could not link these doctor differences to care disparities, our findings provided 

support to the idea that care setting matters and adversely affects blacks. Around the time of 

this paper, and over the years since, this finding has been reproduced numerous times. Be it 

doctors or hospitals or surgeons or dialysis centers or managed care insurance companies, 

lower quality overall seems to be associated with having more black patients and fewer 

whites.

Recently colleagues of mine looked at some more detailed aspects of practices that treat large 

numbers of minority patients, and estimated that the impact of low payment rates from 

Medicaid were a sizable contributor to access problems, and led to shorter patient visits too.

My colleagues and I have also recently finished an analysis that is not yet published, so I can 

only present the general findings. We are finding that for Medicare patients who are black 

and white, the important predictors of getting lower quality care are your socio-economic 

status, and how good the quality of care is that your doctor gives his or her other patients. We 

were unable to detect any consistent evidence that doctors are treating their black and white 

patients differently per se.

My colleagues and I are in general agreement that these findings are consistent with the 

plausible hypothesis that first and foremost care for blacks is of lower quality because blacks 

are accessing a part of the system that is poorly functioning. Little if any of the undertreatment appears to be due to doctors singling out minorities for lower quality care.
38 Health Care Disparities

None of us take the challenges posed by this alternative explanation for health disparities 

lightly. In ways, it will be harder to ameliorate this problem. But the payoff will be more 

durable and robust.

So, you have asked me here today to talk about health disparities and what our research 

suggests about their origins. That research rests in a social context in which many people 

arrived early at a conclusion that discrimination (conscious or unconscious) lay at the heart of 

treatment disparities.

Our work has provided a different explanation. One in which we have a poorly distributed 

health care system, in which the lowest quality resources are in the neighborhoods with the 

most needy individuals. If correct, the mechanism suggests that an approach that targets these 

high risk areas will be the best way to improve care and outcomes for patients.

Thank you again for inviting me. I look forward to your questions.
39 Panelist Statements: Second Panel 

Statements: Second Panel

William R. Lewis 

On behalf of the American Heart Association, its American Stroke Association division, and 

our more than 22 million volunteers and supporters, I want to express our appreciation for the 

opportunity to address the U.S. Commission on Civil Rights and to share information 

regarding our efforts to reduce health disparities involving cardiovascular disease and stroke. 

Addressing health disparities and improving health care quality are high priorities for the 

American Heart Association. Importantly, eliminating health care disparities represents one 

of the tenets of our recent Association statement of principles for health care reform. My 

name is Bill Lewis, and I am a cardiologist practicing at MetroHealth Medical Center. 

MetroHealth Medical Center serves as the county hospital in Cleveland, Ohio and is 

affiliated with Case Western Reserve University. I am an associate professor of medicine at 

Case Western Reserve and serve as the chief of clinical cardiology for MetroHealth Medical 

Center. I am a volunteer for the American Heart Association and I am actively involved with 

the AHA‘s Get With the Guidelines Quality Improvement Program. The presence of 

disparities in health care has been recognized for decades. The challenge is to identify and 

implement effective strategies for translating our scientific knowledge into daily practice for 

all Americans without regard to race, ethnicity, gender or socioeconomic status. We know 

scientifically how to reduce the risk and incidence of cardiovascular disease and stroke and 

improve outcomes for individuals with cardiovascular disease and stroke. However, as a 

nation, we continue to struggle with how best to implement this knowledge into daily 

practice at large.

In our time together today, I will provide an overview of the American Heart Association‘s 

approach to bridging the gaps in health and health care disparities involving cardiovascular 

disease and stroke. In addition, I will highlight and provide additional details regarding an 

innovative program that the American Heart Association developed to tackle these difficult 

challenges.

There is good news. Although we face significant challenges in addressing health disparities 

in the United States and additional research is needed, we have identified some concrete 

strategies for improving the quality of care for all Americans.

Overview on Disparities for Individuals with Cardiovascular Disease and Stroke

There is no question that significant and unacceptable levels of health disparities have existed 

for many years across the spectrum of medical conditions, including cardiovascular disease 

and stroke. The groundbreaking 1985 report of the U.S. Secretary of Health and Human 

Services‘ Task Force on Black and Minority Health found that there were nearly 60,000 

more deaths in minority populations than would have been expected between 1979 and 1981 

based on the rate in the non-minority population. About one-third of these excess deaths were 

due to heart disease and stroke.52

 

52 U.S. Department of Health and Human Services. 1985 Report of the Secretary‘s Task force on Black and 

Minority Health. Washington, DC: US Department of Health and Human Services; 1985.
40 Health Care Disparities

These disparities continue to persist. For example, in 2000, the U.S. Department of Health 

and Human Services reported that heart disease death rates were more than 40 percent higher 

for African-Americans than for whites.53 Racial and ethnic minority populations confront 

more barriers to cardiovascular disease diagnosis and care, receive lower quality treatment 

and experience more communication barriers.54 Numerous studies have demonstrated 

disparities in heart disease and stroke risk factor management on the basis of race, ethnicity 

and gender, including blood pressure control, cholesterol management and the treatment of 

diabetes and obesity.55

In short, racial and ethnic minority populations are at greater risk of cardiovascular disease 

and stroke, may receive more sub-optimal care, and subsequently experience worse 

outcomes, including death. As a group, these individuals have less access to health care 

services than the rest of the population, and the health care received is lower in quality. At 

the same time, there are fewer minority physicians in the health care workforce. Among 

cardiologists in 2001, only 2 percent were black, 3.8 percent were Hispanic, and 12.7 percent 

were Asian. There is also limited awareness among cardiovascular practitioners about health 

disparities. For example, only 35 percent of cardiologists recently surveyed agreed that 

disparities in overall care exist in the United States, and only 5 percent believed that 

disparities exist among the patients receiving care from them.56

Bridging Health Disparities is a Priority for the American Heart Association

In 2003, the American Heart Association convened a three-day summit to examine health 

disparities related to cardiovascular disease and to assist in developing the next phase of the 

American Heart Association‘s scientific, programmatic and advocacy efforts to address these 

important issues. 

The participants in the summit identified a number of important recommendations that are

guiding the American Heart Association in its ongoing efforts. These recommendations 

include, but certainly are not limited to, the following:

Stratify and report data by racial/ethnic groups, and when possible, report data in the

primary language that patients speak;

Improve minority access to quality care;

Increase screening and prevention of cardiovascular disease;

Increase the number of racial/ethnic minorities who work in health care and improve 

cultural competency among health care providers;

 

53 U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health.

Washington, DC: US Government Printing Office; 2000.

54 Yancy CW, Benjamin EJ, Fabunmi RP, Bonow RO. Discovering the Full Spectrum of Cardiovascular 

Disease: Minority Health Summit 2003. Executive Summary. Circulation. 2005;111;1339-1349. [hereinafter 

Yancy et al. 2005]

55 Lloyd-Jones D, Adams R, Carnethon M, De Simone G, et al. Heart disease and stroke statistics—2009 

update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. 

Circulation.2009; 119: 480–486, e21–e181.

56 Lurie, N, Fremont A, Jain AK, Taylor SL, McLaughlin R, Peterson E, Kong W, Ferguson TB. Racial and 

Ethnic Disparities in Care: The Perspectives of Cardiologists. Circulation. 2005;111:1264-1269.
Panelist Statements: Second Panel 41

Increase research on the genetic and environmental factors that contribute to racial/ethnic 

health disparities and increase the participation of minorities in research and as 

investigators; and

Provide patients and the public with culturally and linguistically appropriate health care 

and educational materials.57

In its federal advocacy efforts, the American Heart Association has recognized that the 

collection of data about health disparities is a pivotal first step in better identifying and 

eliminating disparities in care and has therefore prioritized the better collection of data 

related to race, ethnicity, gender, and where appropriate, primary language. For instance, the 

Association worked to secure a provision in the Medicare Improvements for Patients and 

Providers Act of 2008 that helps identify and eliminate disparities in the quality of health 

services for minorities and women enrolled in the Medicare program. The Association also 

supported adding health disparities language to the health information technology provisions 

of the economic stimulus law passed by Congress in February, 2009.

The American Heart Association has also continued to pursue and refine a number of

programmatic interventions to address health disparities, such as its Power To End Stroke 

movement to raise awareness among African-Americans about their increased risk of stroke. 

In particular, however, I would like to highlight the promising developments involving the 

American Heart Association‘s Get With The Guidelines program.

The American Heart Association’s Get With The Guidelines Program: A Model for 

Improving Quality and Addressing Health Disparities

In 2000, the American Heart Association launched a program called Get With The 

Guidelines that currently focuses on quality improvement for three conditions: coronary 

artery disease, heart failure and stroke. The program provides multiple interventions to help 

improve the care provided to patients by helping providers adhere to the evidence-based 

guidelines for treating these common conditions and preventing subsequent acute events. 

Providers obviously remain free to customize the care provided to each patient, but the 

evidence-based recommendations for these diseases reflect non-controversial aspects of care 

that are supported by a wealth of scientific evidence.

The Get With The Guidelines program focuses on acute hospitalizations as an opportunity to 

ensure that important clinical strategies for avoiding subsequent acute events (so-called 

―secondary prevention‖) are implemented immediately, educational efforts are initiated to 

help patients manage their disease and steps are taken to coordinate the transition of each 

patient‘s care to the community setting. These are critical building blocks to improving 

patient outcomes and ensuring that all patients receive the full scope of care recommended by 

the evidence-based clinical guidelines.

The components of the Get With The Guidelines program include the following:

A web-based patient management tool that permits the real-time input of data regarding

each patient;

 

57 Yancy et al. 2005.
42 Health Care Disparities

A clinical decision support function, which prompts providers to ensure that they 

consider all of the recommended aspects of care for each patient. In a health system in 

which multiple providers care for patients in a variety of settings, this tool helps the 

hospital team ensure that all of the fundamental aspects of care, including the transition to 

the community setting, are addressed for each patient.

A real-time benchmarking function, in which individual physicians and hospitals can 

compare their performance on a variety of quality of care measures against a large 

database providing statistical averages for a variety of provider types and regions. The 

ability to evaluate this information on a timely basis may help individual providers 

identify opportunities for improving patient care and identifying ways to do so on an 

ongoing basis.

Educational materials are provided for use by physicians, nurses, patients, family 

members and other caregivers. The American Heart Association provides targeted 

educational materials for individuals from a variety of cultural backgrounds written in a 

variety of languages.

Tools are offered to help hospital providers communicate with community-based 

providers regarding each patient‘s care and any recommendations for follow-up.

The program also functions as a robust clinical registry that permits further scientific 

evaluation of the effectiveness of specific interventions and the progress made in 

improving care, including the analysis of the rate of uptake of new scientific knowledge 

at the community level, the quality of care provided, and the clinical outcomes for 

individuals belonging to the various race, ethnicity and gender based subgroups.

Recognition for high quality care is also provided to hospitals that consistently follow 

treatment guidelines. This may enhance a hospital‘s status within the community, and 

hospitals may use this data in negotiations with insurance companies as evidence of high 

quality care.

Taken in combination, these elements form a program that has been shown – through 

extensive scientific study – to improve adherence to evidence-based guidelines and to reduce 

disparities among various subgroups of patients. To date, more than 1.7 million patients have 

been enrolled in Get With The Guidelines. This has given clinicians and researchers a great 

opportunity to address quality cardiovascular and stroke care for all patients, including those 

in special populations.

In particular, I will highlight four observations from the clinical data on Get With The

Guidelines, followed by an overview of some of the latest literature affirming these 

observations.

1. Get With The Guidelines has demonstrated substantial narrowing or elimination in racial 

and ethnic disparities for health services provided within hospitals and upon hospital 

discharge for patients with coronary artery disease, heart failure and stroke. In fact, the 

clinical outcomes for minority patients in hospitals participating in Get With The 

Guidelines are equal when compared to their white counterparts.

2. Get with the Guidelines has enhanced the transparency of issues involving disparities in 

health on the basis of race, ethnicity and gender. At the micro-level, these data help 

individual physicians and hospitals address disparities in care on a case-by-case basis. At 
Panelist Statements: Second Panel 43

a macro-level, the Get With The Guidelines clinical registry is now providing a rich 

source of data that highlights the ongoing need to address disparities in care. These data 

on health disparities among patients with coronary artery disease, heart failure and stroke 

are reported in the American Heart Association‘s 2009 Statistical Update and will be 

published in future articles and updates. Such data represent a critical step forward in 

defining and eradicating health disparities.

3. Get with the Guidelines has permitted the study of health disparities involving 

interventions and technologies that go beyond the core performance measures. For 

example, this registry has been used to study and identify significant disparities in the use 

of cardiac resynchronization therapy and implantable cardioverter-defibrillators, devices 

that have been shown to improve survival in patients with heart failure. Women and 

minorities are approximately 50 percent less likely to receive an implantable defibrillator 

as treatment for heart failure despite having the same indications for therapy. The 

availability of these data now allow for further investigation into explanations for these 

differences and strategies that may close these treatment gaps.

4. Participation in the Get With The Guidelines program has been embraced by many 

hospitals throughout the United States. These hospitals value the significant benefits of 

participating in this quality improvement program. Currently, there are 1,525 hospitals 

using Get With The Guidelines programs. The largest number of hospitals, 1,304, 

participates in the stroke program. Approximately 1,000 hospitals participate in the 

coronary artery disease and heart failure programs. This is about a third of all hospitals in 

the United States. Participating hospitals represent a diverse group comprising large and 

small, academic and non-academic, and urban and rural hospitals located in every state.

To help illustrate the ways in which Get With The Guidelines is being used to address health 

disparities, I will provide you with a brief survey of the most recent literature involving Get 

With The Guidelines in the context of heart failure, stroke, and coronary artery disease. I am 

pleased to report that all of this information has been or will soon be published in the peerreviewed literature, and additional studies are currently underway that will help further guide 

our efforts to address health disparities.

Before describing some of this literature in more detail, it is important to note that, although 

this briefing is focused on racial and ethnic disparities, large disparities also exist among 

women, compared to men. Therefore, I will also share some data related to gender-based 

differences and disparities.

Get With The Guidelines—Heart Failure

Heart failure (HF) is the leading cause of hospitalization and re-hospitalization for the 

Medicare population. Black and possibly Hispanic populations are at an increased risk for 

developing HF, do so at an earlier age, experience greater disability, and possibly higher risk 

of death at younger ages.

In a report from the OPTIMIZE-HF registry, a precursor to Get With The Guidelines-HF, 

inpatient outcomes and adherence to inpatient quality measures are at least similar and in-
44 Health Care Disparities

patient mortality is in fact better for black than white patients.58 Preliminary analysis of data 

from the Get With The Guidelines-HF database confirms this finding among more than 

78,000 patients in about 250 hospitals participating in the program.59 This study, whose final 

findings will be published soon, demonstrates that among participating hospitals in the Get 

With The Guidelines-HF program, equitable quality care is attainable across major racial and 

ethnic groups. There was also consistent improvement in the delivery of equitable quality 

care among all heart failure patients in the Get With The Guidelines-HF program. These 

findings support the notion that quality improvement initiatives may be an important 

instrument in reducing or eliminating racial/ethnic differences in the delivery of 

cardiovascular care.

Another study reviewed the frequency and characterizations of heart failure patients treated 

with cardiac resynchronization therapy (CRT), an emerging therapy supported by the clinical 

guidelines, by various factors, including race. In this study of 33,898 patients admitted to 228 

hospitals between 2005 and 2007 using the Get With The Guidelines-HF program, the use of 

CRT was analyzed.60 One of the major findings of this study was that cardiac 

resynchronization therapy (a form of pacemaker therapy) use varies by age, race, hospital site 

and geographic region. CRT use was less common in black patients compared with white 

patients. This disparity is particularly concerning because black patients have a higher 

incidence of nonischemic cardiomyopathy, which has been shown to be associated with 

greater rates of clinical response to CRT. Also, black patients are more likely to develop 

advanced symptomatic heart failure and to have a higher rate of re-hospitalization.61 This 

study highlights an example of Get With The Guidelines helping researchers to identify 

where significant racial disparities exist in the use of treatments that go beyond the core 

performance measures. Further research is needed to understand the reasons for the 

variations in CRT use at the patient, physician and hospital levels and to implement programs 

to improve the awareness and promotion of evidence-based use of medical devices in heart 

failure.

Get With The Guidelines—Stroke

Stroke is the third-leading cause of death and a leading cause of morbidity and long-term 

functional disability. An estimated 700,000 strokes occur each year in the United States, and 

200,000 of these events are recurrent strokes. Blacks have almost twice the risk of first-ever 

stroke compared with whites. Despite widely available evidence supporting clinical 

interventions that improve health outcomes for patients hospitalized due to stroke, many 

patients do not receive recommended interventions.

 

58 Yancy CW, Abraham W, Albert N, et al. Quality of Care and Outcomes for African Americans Hospitalized 

with Heart Failure: Findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in 

Hospitalized Patients with Heart Failure) Registry. J. Am. Coll. Cardiol. 2008;51:1675-1684.

59 Yancy CW, Fonarow GC, LaBresh KA, Albert NM, Ellrodt G, Hernandez AF, Yu Y, Peterson ED. Disparate

quality of care for black and Hispanic heart failure patients: a report from Get With The Guidelines – Heart 

Failure. J Card Fail. 2007;13:S157.

60 Piccini JP, Hernandez AF, Dai D, Thomas KL, Lewis WR, Yancy CW, Peterson ED, Fonarow GC. Use of

Cardiac Resynchronization Therapy in Patients Hospitalized with Heart Failure. Circulation. 2008;118:926-933.

61 Thomas KL, East MA, Velaquez EJ, Tuttle RH, Shaw LK, O‘Connor CM, Peterson ED. Outcomes by Race 

and Etiology of Patients with Left Ventricular Systolic Dysfunction. Am J Cardiol. 2005;96:956-963.
Panelist Statements: Second Panel 45

In preliminary analysis of nearly 400,000 ischemic stroke patients at approximately 1,100 

hospitals participating in Get With The Guidelines-Stroke, researchers have found that, after 

adjusting for risk, black patients received lower rates of guideline-based care, while Hispanic 

patients received care similar to whites for all measures. However, the quality of care 

improved over time for all three racial/ethnic groups.62

In another, recently published study, data from 790 hospitals participating in the Get With 

The Guidelines-Stroke program demonstrated that participation in the program resulted in 

sustained and substantial improvements on seven measures of stroke care regardless of size, 

geography and teaching status of the hospitals.63 Performance improvement varied across 

measures, with intravenous tPA use, lipid lowering, and smoking cessation showing the 

highest absolute percent change. Antithrombotic use and anticoagulation for atrial fibrillation 

showed smaller absolute improvements. An increase in the intravenous tPA treatment rate of 

30 percent across the participating sites translates into a substantial expected decrease in 

functional disability in the population served.

This study has important implications for public policy. The data show that focused quality 

improvement efforts, coupled with data reporting in a structured learning environment, can 

produce dramatic results. Such a program can be used to bring equity across different 

subpopulations that address disparities in care.

As a result of such data, the proposed adoption of stroke measures by the Centers for 

Medicare & Medicaid Services (CMS) into the Medicare hospital quality reporting program 

has the potential to greatly expand the efforts to improve stroke care. The American Heart 

Association is strongly urging CMS to implement the stroke measures as quickly as possible.

Researchers also have examined the quality of care that women receive after strokes using 

data from the Get With The Guidelines-Stroke program.64 Although sex differences on 

individual performance measures were relatively modest, women consistently are less likely 

to receive evidence-based care for stroke compared to men. Further study is necessary to 

identify the causes and consequences of these sex-based differences in care. 

Get With The Guidelines—Coronary Artery Disease (CAD)

Studies have also examined whether participation in the Get With The Guidelines program 

results in greater adherence to guidelines for coronary artery disease.65 In general, adherence 

to published guidelines is known to be variable even among top hospitals.66

 

62 Lloyd-Jones D, Adams R, Carnethon M, De Simone G, et al. Heart disease and stroke statistics—2009 

update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. 

Circulation.2009; 119: 480–486, e21–e181.

63 Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, Ellrodt G, Cannon CP, Liang L,

Peterson E, LaBresh KA. Get With the Guidelines Stroke is Associated with Sustained Improvement in Care for

Patients Hospitalized with Acute Stroke or Transient Ischemic Attack. Circulation. 2009;119:107-115.

64 Reeves MJ, Fonarow GC, Zhao X, Smith EE, Schwamm LH. Quality of Care in Women with Ischemic 

Stroke in the GWTG Program. Stroke. 2009;40:1127-1133.

65 Lewis WR, Peterson ED, Cannon CP, Super DM, LaBresh KA, Quealy K, Liang L, Fonarow GC. Results 

with the Get With the Guidelines Quality Improvement Program. Arch Inter Med. 2008;168(16):1813-1819.

66 McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The Quality of Health Care

Delivered to Adults in the United States. N Engl J Med. 2003;348(26):2635-2645.
46 Health Care Disparities

Hospitals participating in the Get With The Guidelines-CAD program were compared with 

other hospitals for a fixed period of time, using the publicly available CMS Hospital 

Compare database. This study found that participation in the Get With The Guidelines-CAD 

program was associated with improved guideline adherence. This is one of the first studies to 

demonstrate that a quality improvement program is independently associated with increased 

adherence using an external, concurrent national database.

Although the improvements in adherence observed in this study were all in absolute terms, 

with more than 1 million patients hospitalized with acute myocardial infarction each year, 

these differences in performance would translate to tens of thousands more patients treated 

with recommended therapies each year if all hospitals provided the same level of 

performance as those participating in the Get With The Guidelines-CAD program.

In another example of the use of Get With The Guidelines to examine disparities in

cardiovascular care, investigators addressed sex differences in medical care after acute 

myocardial infarction.67 In this study, 78,254 patients with acute myocardial infarction in 420 

hospitals between 2001 and 2006 were examined. Compared with men, women were less 

likely to receive early aspirin treatment, early treatment with beta-blockers, reperfusion 

therapy or timely reperfusion and a door-to-balloon time equal to or less than 90 minutes. 

Women also experienced lower use of cardiac catheterization and revascularization 

procedures after acute myocardial infarction. There may be multiple reasons for the observed 

differences in the use of these therapies, such as differences in baseline risk, multiple comorbidities or other modifiable factors and contributing etiologies. These factors are worth 

examining in future analyses of race and sex disparities and adherence to guideline 

recommended treatments.

Get With The Guidelines-Office of Minority Health Pilot Project

Through collaboration with the U.S. Department of Health and Human Services Office of 

Minority Health, Get With The Guidelines launched a quality improvement initiative 

targeting health care disparities with the goal being to use a quality approach to narrow 

treatment differences. The University of Mississippi was recruited as a test site. Data were 

collected serially over time to assess the core measures of quality for coronary artery disease 

and heart failure, and additional other measures of heart failure quality were involved.

That pilot study has demonstrated that at baseline, blacks and whites receive similar care 

when assessing the most well-established markers of quality. When examining emerging 

markers of heart failure quality, we demonstrated that for a novel therapy that is uniquely 

appropriate for blacks with heart failure, there was a nearly three-fold increase in the 

appropriate use of this therapy over time. Regarding the use of an implantable defibrillator, 

we noted that use increased from 35 percent to nearly 50 percent of those with an indication 

for the device—a rate similar to its use in all patients. It is our finding that a quality-driven 

approach represents at least one potential strategy that may narrow treatment gaps between 

groups and help to reduce health care disparities. Much work remains.

 

67 Jneid H, Fonarow GC, Cannon CP, Hernandez AF, Palacios IF, Maree AO, Wells Q, Bozkurt B, LaBresh 

KA, Liang L, Hong Y, Newby LK, Fletcher G, Peterson E, Wexler L. Sex Differences in Medical Care and 

Early Death After Acute Myocardial Infarction. Circulation. 2008;118:2803-2810.
Panelist Statements: Second Panel 47

Summary Remarks

At the American Heart Association, we believe strongly that each person in the United States 

should always receive high quality care regardless of race, ethnicity, gender or other factors 

and that the promotion of evidence-based clinical practice guidelines will help to ensure that 

patients receive the appropriate care. The use of continuous quality improvement tools that 

include clinical decision support, such as Get With The Guidelines, help to translate practice 

guidelines into consistent use at the patient bedside and minimize clinician bias that can lead 

to disparities. As has been demonstrated by research, the Get With The Guidelines program 

is a powerful tool to improve patient care at the bedside. Using the registry function of this 

program, we are also able to bring greater transparency to the issues of health disparities in 

cardiovascular disease and stroke with meaningful scientific evidence from high impact 

publications using Get With The Guidelines registry data. As we extend our focus on quality, 

the opportunity exists to use quality as a gender-blind, race and ethnicity blind, and age-blind 

strategy to reduce treatment gaps between groups of patients and to optimize outcomes for 

patients with cardiovascular disease and stroke.

Thank you, and I would be pleased to answer any questions you may have.
48 Health Care Disparities

Herman A. Taylor 

Thank you, Commissioner.

Since the larger terrain of the topic ―health disparities‖ has been well covered by several 

speakers on the panel, I will restrict my brief remarks to specific results of my group‘s 

research, principally from The Jackson Heart Study (JHS), and reasonable implications of 

that research.

The JHS is the largest longitudinal study of African-American cardiovascular health ever 

undertaken. Our study is unique in that it will ultimately allow us to analyze the impact of a 

wide variety of factors -- psychological, social, nutritional, metabolic, and genetic – on 

cardiovascular disease (CVD). The cohort of African-American adults who comprise the JHS 

is notable for its diversity in socioeconomic status; such diversity offers the opportunity to 

look at the possible health consequences of differences in social position within the AfricanAmerican community, a community which is all too often looked on monolithically without 

attention to the vast heterogeneity of the African-American experience. We will also be able 

to compare our data with suitably designed studies in other ethnic groups.

The JHS is a work in progress; so much of what I will say today will describe early results.

(Note: JHS does NOT treat its participants; it is an observational study.) My main points will 

be the following:

1. Early results from the JHS dramatically confirm the high risk for CVD among the 

African-American community;

2. In the specific instance of hypertension, a leading CVD risk factor, increased levels of 

awareness, treatment and control of hypertension have been achieved within the Jackson 

African-American community;

3. The improvement in treatment outcomes and control of hypertension is encouraging; 

however, because of the much higher occurrence of hypertension (and other CVD risk 

factors) in blacks compared to other groups in the U.S., disparities in hypertensionrelated morbidity and mortality will persist;

4. Efforts to prevent hypertension (and other CVD risk factors) are a critical part of a 

strategy to eliminate disparities in cardiovascular disease and death.

Ominous levels of Risk

Obesity

We compared the rates of obesity in the Framingham Heart Study—a long-running renowned 

study of CVD in a white American population---with rates in the JHS (African-American) 

cohort. The overall prevalence of obesity in JHS and FHS was 53.3 percent and 27.1 percent

respectively. JHS participants were more likely to be obese whereas FHS participants were 

more likely to be normal weight or overweight. The prevalence of stage 2 obesity (i.e., ―very 

obese‖ status; BMI>35) was almost three times higher in JHS 35-54-year-olds compared to 

FHS (26.5 percent vs. 9.1 percent), whereas the adjusted prevalence of normal weight was 

2.5 times higher in FHS (36.7 percent vs. 13.9 percent). The pattern of much higher levels of 

obesity among blacks was also seen in the older comparison groups.
Panelist Statements: Second Panel 49

Hypertension increased with increasing BMI in both Jackson and Framingham and was 

higher in the JHS at each BMI group. Among normal weight participants the proportion with 

hypertension was more than 3.5 times greater in Jackson (31.2 percent) compared to 

Framingham (8.6 percent). Notably, among normal weight participants, the proportion with 

diabetes was 6 times higher in Jackson (blacks) compared to Framingham (whites).

Metabolic Syndrome

Metabolic syndrome has become a subject of great interest. It is associated with three major 

disease epidemics in the U.S.: obesity, type 2 diabetes, and continued high rates of CVD. 

Metabolic syndrome is diagnosed when three or more metabolic disorders, including 

abdominal obesity, elevated plasma triglyceride concentration, low plasma HDL cholesterol 

concentration, elevated blood pressure, and elevated fasting glucose, are present.

Our analyses of data from JHS demonstrate extraordinarily high metabolic syndrome 

prevalence. Among those aged 35–84 the prevalence was 44.8 percent in women and 33.4

percent in men, far above corresponding national rates (e.g., latest NHANES rate <25%). 

Metabolic syndrome prevalence in the JHS is among the highest reported for populationbased cohorts worldwide and is significantly associated with increased risk for heart disease 

and stroke. Both in men and women, the prevalence significantly decreases with higher 

household income and educational attainment.

Hypertension

Hypertension is likely the single most important treatable and controllable risk factor for 

CVD, however, controlling hypertension is a problem for many Americans, particularly 

blacks. There are national reports of widening disparities in the success rate of hypertension 

treatment between blacks and whites.

Encouraging Control Rates Possible

The data from the JHS stand in contrast to the national data. Percent of participants with 

controlled hypertension in the Jackson Heart Study (All African-American):

~70% Blacks (the same as white control rates nationally)

To summarize: national data show a persistent disparity in hypertension control rates for 

African-Americans despite levels of awareness and treatment that are similar or higher than 

those for whites. However, the JHS may carry a hopeful message: that under some 

circumstances, such as those represented by the JHS cohort, equal rates of hypertension 

control are possible for blacks and whites.

What is different about the Jackson Heart Study participants? Is something different in 

Jackson, MS?

Although the comparisons above were not adjusted for risk factors or study design 

differences, our findings are consistent with the other research, where better treatment and 

control were suggested in the ―stroke belt‖ compared with other parts of the country. This 

indicates that higher rates of control are achievable than customarily assumed.
50 Health Care Disparities

Possible contributors to favorable control rates in the JHS:

high levels of physician motivation;

education surrounding hypertension; 

positive effects of being in a study on heart disease (JHS is observational only); 

the regular flow of public messages about the study and heart health delivered to the 

black community

Discouraging Disparities Despite High Treatment Rates

But is attaining equally good hypertension control rates between blacks and whites enough to 

eliminate the disparity in hypertension-related disease and death?

Despite favorable rates of control in Jackson, high levels of CVD morbidity and mortality 

persist. Wide ethnic differences in stroke, heart failure and moderate differences in heart 

attack rates – all contributed to by hypertension -- are still seen in the Jackson area, according 

to surveillance data from a sister study of the JHS, Atherosclerosis Risk in Communities

(ARIC). (Data to be quoted during briefing.)

Disparities in cardiovascular health cannot be eliminated without preventing the emergence

of differences in the rates of the risk factors for CVD. Treating disease is obviously important 

and can be life saving, but most often it does not completely return people to normal health. 

The situation is akin to a car damaged in an accident: many things can be restored or 

replaced, but the vehicle cannot be returned to original condition. When disease becomes 

established, the trajectory of health is altered, and the health outcomes between a person who 

is treated for a disease and one who has never had the disease are disparate. We must 

increase our understanding of why there are disparate rates of risk factor onset, and act upon 

that knowledge. While we continue to search for answers to physiological risk factors related 
Panelist Statements: Second Panel 51

to excess CVD, at minimum we must address the identified societal factors that contribute to 

the problem. Most important to this effort is prevention.

Much of the expertise in these areas of prevention lies in the fields of nutrition, behavior, 

psychology and social epidemiology, and I refer you to experts whom I will mention during 

my presentation. However, some general areas of focus are clear:

Food supply characteristics (caloric intake; salt intake; fast foods; other eating outside the 

home)

Physical activity levels (school, workplace, neighborhood, built environment)

The burden of persistent discrimination (interpersonal, institutional, environmental)

Conclusion

The bottom line -- to reduce disparities in hypertension and CVD, we must decrease the 

number of African-Americans that ever become hypertensive. Our research and that of others 

strongly suggest that a multi-pronged approach is imperative:

1. equalization of awareness, access, and appropriate utilization of care;

2. investment in research to further define the basis of higher risk factor levels among ethnic 

minorities; and

3. use of evidence-based prevention efforts that go beyond health care institutions into the 

societal milieu are critical to resolving America‘s ethnic health disparities.

Health equity cannot be achieved without balanced attention to risk prevention and 

treatment.

U.S. Commission on Civil Rights

Briefing on Health Disparities

Washington, D.C.

June 12, 2009

Herman A. Taylor, Jr. MD, MPH, FACC

Professor of Medicine and Shirley Professor for the Study of Health Disparities

Jackson Heart Study Principal Investigator
52 Health Care Disparities

0

5

10

15

20

25

30

35

40

45

18.5-24.9 25 - 29.9 30 - 34.9 35 - 50

BMI Group

Prevalence (%)

JHS FHS

9%

12%

37%

27%

Obesity by Age and Race: 

Younger Adults

0

10

20

30

40

50

60

Diabetes Hypertension High LDLc High

Triglycerides

Low HDLc

Prevalence (%)

Prevalence of CVD risk factors in participants 35-54 years of age by BMI group 

and Study. Adjusted for age, sex, current smoking, and education.

Jackson

Normal BMI

Overweight

Overweight

Stage 1 Obesity

Stage 1 Obesity

Stage 2 Obesity

Stage 2 Obesity

Normal BMI

Framingham

(similar pattern for participants 55-74 years of age)
Panelist Statements: Second Panel 53

Metabolic Syndrome Patterns in the 

JHS
54 Health Care Disparities

HTN Control by Age and Sex

60

69

51

77

59

73

61 66

0

20

40

60

80

100

%

All Ages 21-39 40-59 ≥ 60

Age

Men

Women

n=1753

Overall HTN Control = 66.4%

Wyatt, et al: Hypertension 2008

MS Black Males

US White Males

MS White Males 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

600

700

800

900

1000

1100

1200

Racial Disparity Trends in 

Cardiovascular Mortality for MS Males

Age-Adjusted Cardiovascular Mortality Rates (Ages 35 Years and Over) utilizing Compressed Mortality File 

and CDC Wonder.
Panelist Statements: Second Panel 55

Jackson Heart Study

• A Major strength

• “...the simultaneous examination of a comprehensive, 

theory-driven set of social, ethnoracial, psychological, and 

environmental variables alongside traditional and 

nontraditional biological measures” (Payne et al., 2005, p. 

S6-38). 

Psychosocial/Sociocultural Measures

• CES-D

• Global Stress

• Weekly Stress Inventory

• Daily Hassles

• Religion

• Socio-economic Status

• Violence

• Anger (CHOST, Anger In & Out)

• Hostility

• Coping Racism & Discrimination

• Social Support

• Optimism

• John Henryism

• Job Strain

Psychosocial/Sociocultural Measures

• CES-D

• Global Stress

• Weekly Stress Inventory

• Daily Hassles

• Religion

• Socio-economic Status

• Violence

• Anger (CHOST, Anger In & Out)

• Hostility

• Coping Racism & Discrimination

• Social Support

• Optimism

• John Henryism

• Job Strain
56 Health Care Disparities
57 Panelist Statements: Second Panel 

Table 1. Dimensions of everyday, lifetime, and burden of discrimination among African Americans by age and sex in the Jackson Heart Study, 2000-2004

Total, 21-34 years 35-44 years 45-64 years >/=65 years X2 P Female Male X2 P

% (n=244), % (n=991), % (n=2688), % (n=1277), % value (n=3329), % (n=1871), % value

Treated with less courtesy 64.8 70.9 73.8 68.2 49.6 <.001 66.0 62.8 0.02

Treated with less respect 61.0 69.1 72.6 64.5 43.2 <.001 61.2 60.7 0.72

Poor service at restaurant 56.5 67.9 72.4 61.1 32.4 <.001 56.7 56.2 0.76

People think you are not smart 59.1 70.0 68.5 61.2 45.3 <.001 60.3 57.1 0.02

People are afraid of you 39.5 58.0 52.2 42.1 20.8 <.001 35.4 46.9 <.001

People think you are dishonest 33.6 46.9 45.8 34.8 19.2 <.001 29.8 40.4 <.001

People think you are not as good 59.6 68.7 69.2 62.3 44.4 <.001 58.8 60.9 0.13

Called names or insulted 34.7 44.9 44.4 35.8 22.6 <.001 33.0 37.6 0.001

Threatened or harassed 25.3 26.8 31.1 28.1 14.5 <.001 23.6 28.2 <.001

At School (n=2250) 43.3 37.0 49.2 45.9 34.6 <.001 43.1 43.8 0.65

Getting a job (n=2310) 44.5 30.5 51.6 48.7 32.7 <.001 41.6 49.6 <.001

At Work (n=3336) 64.3 61.3 69.5 67.5 54.1 <.001 64.1 64.6 0.28

Get Housing (n=673) 13.0 8.23 15.5 14.0 9.7 <.001 11.3 16.0 <.001

Getting Resources (n=1950) 37.6 24.4 42.0 42.0 27.5 <.001 33.9 44.3 <.001

Getting Medical Care (n=715) 13.8 4.9 13.1 14.6 14.1 0.004 15.6 10.6 <.001

Public Places (n=1826) 35.2 38.7 39.3 38.3 25.0 <.001 30.7 43.4 <.001

Getting Services (n=1927) 37.2 32.9 42.4 38.9 30.3 <.001 36.5 38.4 0.17

Other Ways (n=279) 5.4 4.1 6.2 5.5 4.9 0.47 5.2 5.9 0.23

Discrimination was more frequent 

(n=520) 10.74 21.8 14.6 9.0 9.2 <.001 11.8 8.9 0.004

Discrimination made life very 

stressful (n=1098) 22.7 14.1 19.4 24.1 23.7 <.001 25.0 18.6 <.001

Discrimination interfered w/having 

full life some to a lot (n=1793) 35.7 20.1 32.3 37.6 37.5 <.001 33.3 40.1 <.001

Discrimination made life hard some 

to a lot (n=1996) 39.8 23.5 36.4 42.2 40.5 <.001 38.2 42.7 <.001

Because of skin color, treatment by 

Whites was worse (n=674) 13.1 15.4 15.1 13.8 9.7 <.001 11.3 16.3 <.001

Because of skin color, treatment by 

Blacks was worse (n=773) 14.2 14.5 14.4 14.3 14.0 0.42 15.1 12.7 0.02

Source: Jackson Heart Study, baseline data 2000-2004.

c. Burden and Skin-Color Determinants of Lifetime (Major Life) Discrimination

Age Sex

a. Occurrence of Everyday Discrimination

b. Occurrence of Lifetime (Major Life) Discrimination
58 Health Care Disparities

Barbara V. Howard

This document summarizes a major research project funded by the National Heart Lung and 

Blood Institute of the NIH called the Strong Heart Study that has worked with American 

Indian communities to understand cardiovascular disease and its risk factors.

Goal and Principles

In partnership with community leaders and members to conduct excellent scientific studies to learn 

information that will help to treat or prevent cardiovascular diseases (CVD – heart diseases, stroke, 

and circulation problems) in Indian communities:

Almost all staff members in the three centers (AZ, OK and DK) are community members. 

Thirty-one American Indian MDs, PhDs and advanced-degree candidates have been 

investigators.

No measures are made or analyses performed that are not in the consent forms that are 

approved by all 13 communities and signed by all participants. All data and samples are stored 

without personal identifiers either in our data-coordinating Center in OK or in our laboratories 

in DC or San Antonio. No data or samples are released without full approvals. 

Strong Heart Study (SHS) 1989-2000

Four thousand, five hundred and forty-nine men and women 45-74 years old (1,500 from 

GRIC, SRIC and AkChin) underwent three exams to measure risk factors (blood pressure, blood 

measures, lifestyle questionnaires) and indicators of CVD (ECG, ultrasound of neck, heart and 

legs). Results were provided to each participant and summaries to their communities.

What We Have Found

Results demonstrated for the first time an increasing rate of CVD in Indian communities,

mainly in persons with diabetes. Rates of coronary heart disease and stroke are both higher 

than other ethnic groups in the U.S. We measured preclinical disease using carotid ultrasound 

and echocardiography and found that there is much evidence of accumulating atherosclerosis 

and abnormalities in heart function. We also evaluated several important risk factors and 

determined that, in addition to age, male sex and diabetes, LDL cholesterol, blood pressure, 

and measures of kidney disease are important predictors.

Community Benefits

Revision of IHS guidelines for treatment of cholesterol.

An Indian -specific calculator to help providers estimate CVD risk in Indian patients.

Increased attention to the importance of urine protein or serum creatinine measures in 

predicting CVD and the need for careful blood pressure control.

Current continued follow-up of the participants will emphasize learning more about strokes and 

heart failure that occur as people age.

Stop Atherosclerosis in Native Diabetics (SANDS Trial) 2002-2007

This is the first trial in Indian communities to test prevention strategies for CVD in persons with 

diabetes. Four hundred and ninety-nine diabetic men and women participated for three years (137 

from AZ).
Panelist Statements: Second Panel 59

Their blood pressure and cholesterol were treated either to current guidelines or to lower targets.

Study staff worked closely with care providers. Targets for LDL cholesterol and blood pressure 

were reached and maintained in the majority of participants, showing that proper algorithms and 

careful training can substantially improve delivery of care.

There was marked improvement in ultrasound measures of atherosclerosis (hardening of the 

arteries) in those with lower targets, and fewer CVD events in both groups

What We Have Learned

The results established the value of controlling blood pressure and blood fats in all persons 

with diabetes.

Lower targets can be safely reached in Indian patients and may be needed in those at high risk.

Community Benefits

Data now available in American Indian patients on safety and effectiveness in of medications 

that control blood pressure and cholesterol.

Increased awareness of the benefits of controlling blood pressure and blood fats in people with 

diabetes.

Strong Heart Family Study (SHFS) 2000-2010

Three thousand, seven hundred and seventy-six men and women over 15 yrs of age who were 

members of 94 families were examined (1,279 in AZ, 31 families) using the same methods as 

SHS. Results are provided to each participant and summaries to their communities.

A genetic map was made (no cells were grown and no genomes were multiplied) and a search is 

ongoing to identify genes that determine CVD risk factors or are related to the ultrasound measures 

of the heart and of neck vessels. Continuous education on the meaning and value of genetic studies 

has resulted in this being well received by participants.

What We Have Learned

Overweight in young people is already accompanied by increases in risk factors such as blood 

pressure and blood fats and also by abnormalities in the ultrasound measures of the heart.

Depression is occurring in persons with diabetes and this may interfere with controlling blood 

sugar.

The genetic maps have shown some promising areas that seem to control blood pressure and 

blood fats and may be related to body weight.

Community Benefits

The findings in overweight young people have led to increasing attention to measuring CVD 

risk factors in young people who are overweight or have diabetes.

Our work on depression is stimulating care providers to learn to identify and help persons who 

are depressed so that they can care for themselves better.

Genetic work takes a long time to get to the point where exact genes and proteins are identified 

that can be turned into new treatments or ways to identify persons at risk, but this is our 

ultimate goal.
60 Health Care Disparities

Current work is focusing on better understanding changes in risk factors and heart function 

throughout the lifespan, and analyzing the relations of lifestyle changes to CVD risk.

The Message

Emphasis has been on doing high quality science to obtain valid information that will be useful to 

care providers or for the development of new prevention and treatment regimens. Findings --

because this has been done in partnership with the community -- result in increased awareness and 

understanding of health problems. Communities will then be better equipped to plan health 

programs. The trial demonstrated that appropriate CVD risk factor control can be achieved and 

maintained in primary care settings mediated by intermediate level providers who are members of 

the community. Our studies also point to the importance of identifying barriers to adherence to 

prevention and treatment regimens and developing community based programs to address these 

barriers.
Panelist Statements: Second Panel 61

Bruce Siegel

Quality of Heart Care Can Be Improved – and Disparities Reduced

The United States spends twice as much money per person on health care than anywhere on 

earth, but the U.S. ranks 18th worldwide in average life expectancy – behind Australia, 

Canada, France, Japan and others. Given that America spends so much more money on 

health care, one would hope that Americans have better health outcomes than anyone else, so 

why the gap?

Most experts say that the answer lies in the quality of care Americans receive. Unfortunately, 

more care doesn‘t always mean better care or the right care. Americans receive a lot of health 

care treatments, but far too often, they are not the treatments that are proven to be most 

effective for the most people when applied at the right time, without mistakes.

Although the quality of health care is poor for many Americans, certain racial and ethnic 

groups continually experience worse quality care than white patients. While quality 

sometimes differs depending on the patient‘s geographic location, education level or health 

insurance status, repeated research has shown that African-Americans and Hispanics 

consistently receive a lower quality of care than their white counterparts, even when all 

demographic and socioeconomic factors are equal.

It‘s also proven that disparities in care don‘t stop once patients leave the hospital. Data 

suggest that gaps in health status emerge after patients of different racial and ethnic groups 

are discharged. Clearly, there is much to be done to improve the quality of care that 

minorities receive in and out of the hospital.

Identifying and reducing disparities in the quality of U.S. health care is a matter of some 

urgency – and survival for many hospital systems. The U.S. Census Bureau recently reported 

that minority populations in the U.S. will collectively outnumber whites in less than 35 years.

Experts say that if hospitals are going to remain cutting edge and competitive in the future, 

they will need to be able to document that all patients receive the same care, regardless of 

skin color or background.

Cardiac Care – An Excellent Starting Point

In 2002, the well-respected Institute of Medicine‘s groundbreaking report, Unequal

Treatment: Confronting Racial and Ethnic Disparities in Health Care, provided evidence that 

racial and ethnic disparities in care were especially likely to occur in the treatment of cancer 

and heart disease. It‘s well documented, for example, that African-Americans and Hispanics 

are less likely than whites to receive life-saving cardiac diagnostic procedures,

revascularization and thrombolytic therapy.

While a growing body of evidence documents potential underlying causes of disparities in 

care, little has been done to date to implement and test possible interventions to reduce or 

eliminate these gaps. Many experts believe that cardiac care is an excellent starting point. 

Whether experiencing a heart attack, heart failure or other conditions, the recommended 

standard of care for cardiac patients is clear and accepted among medical professionals

nationwide, meaning that ―the right thing to do‖ for most cardiac patients is widely
62 Health Care Disparities

understood. Additionally, the measurement tools to determine whether cardiac patients

received the recommended standard of care have been developed and thoroughly tested, so

it‘s possible to tell if patients received the right care at the right time.

The Project: Expecting Success

In response to the lack of potential disparities solutions, the Robert Wood Johnson

Foundation introduced a 29-month-long pilot program in late 2005, aimed at analyzing racial 

and ethnic disparities in cardiac care at select hospitals across the country. Called Expecting 

Success: Excellence in Cardiac Care, the program selected 10 pilot hospitals (from a 

competitive applicant pool of more than 120) to develop and share tools for improving 

cardiac care for African-American and Hispanic patients with acute myocardial infarction

(AMI) or congestive heart failure (HF). The 10 general, acute-care facilities were

intentionally diverse in terms of size, geographic location and hospital type – so as to ensure 

that their learnings would be adaptable and adoptable by hospitals nationwide. What they 

held in common was: a large base of African-American and/or Hispanic patients, a 

willingness to discover where and how disparities may be occurring, a proven track record in 

quality improvement initiatives, a readiness to serve as ―learning laboratories‖ for other

institutions nationwide and leadership committed to improving cardiovascular care for all 

patients, particularly minorities.

The Expecting Success participating hospitals focused on the continuum of cardiovascular 

care with four goals:

1. To improve cardiovascular care for African-Americans and Latinos;

2. To develop effective, replicable quality-improvement strategies, models and resources;

3. To encourage the spread of those strategies and models to clinical areas outside of cardiac 

care; and

4. To share relevant lessons with health care providers and policy makers.

The participating hospitals‘ multidisciplinary teams worked together via a collaborative 

―Learning Network‖ managed by a National Program Office that operated from The George 

Washington University Medical Center‘s School of Public Health and Health Services. Each

hospital‘s efforts were led by a core team representing a wide variety of backgrounds – from 

chiefs of cardiology to frontline nurses to directors of quality improvement. The hospitals 

received modest grants for their participation and ongoing technical assistance. Over time, 

while simultaneously working to improve the quality of care for all of their heart patients, the 

hospitals were able to identify if there were racial and ethnic disparities in the care they were 

providing.

Hospitals Tracked Care Quality with Performance Measures

Throughout the Expecting Success project, the hospital teams provided monthly reports on

23 different care performance measures – all stratified by patient race, ethnicity and primary 

language. These included the eight core measures of care for heart attacks or acute

myocardial infarction (AMI), and four core measures for heart failure (HF) that the U.S. 

Centers for Medicare and Medicaid Services collects and publicly reports. In addition, the 

hospitals reported on key composite measures – known as Measures of Ideal Care – showing
Panelist Statements: Second Panel 63

whether a given patient receives all of the core components of care they are eligible to 

receive as prescribed by the American College of Cardiology and the American Heart

Association as evidence-based guidelines for the treatment of heart failure or heart attack.

Most of the measures reflected the quality of inpatient care, but because Expecting Success 

was simultaneously focused on improving outpatient cardiac care, participating hospitals also 

reported their 30-day readmission rates as an additional performance measure.

Hospitals Measured Care by Patient Race, Ethnicity and Language

All hospital leaders like to believe that their institutions provide equal care regardless of a 

patient‘s race, ethnicity or primary language, but few know for certain. Without uniform 

standards for collecting this information (most registration staff simply ―eyeball‖ patients and 

make a determination) and without tracking patient race and ethnicity data against quality 

measurements, there is no way of knowing if all patients receive the same level of care.

The Expecting Success hospitals each utilized the Health Research and Educational Trust 

toolkit to establish standardized collection of race, ethnicity and language patient data. Some 

of the hospitals made select modifications to tailor the tools for their staff. The cornerstone of 

each involved directly asking patients to self-report their race, ethnicity and language so that 

all of the patient‘s care could ultimately be compared with these demographics. At first, staff 

registration management and even senior hospital leadership expressed anxiety about 

whether collecting such data was legal, whether their computer registration systems would 

need to be completely overhauled and how patients would react to such questions about their 

race and ethnicity.

The process went considerably more smoothly than anticipated. The hospitals soon found 

that such data collection is legal; information technology departments were engaged early; 

and people are relatively accustomed to being asked demographic questions in many aspects 

of their everyday lives.

For the first time ever, the hospitals analyzed 23 cardiac care quality indicators by patient 

race, ethnicity and language. They faced the tough reality that disparities in care might exist 

in their institutions, but armed with this information, have made tremendous progress toward

reducing these gaps in care.

Hospitals Designed Interventions to Improve Quality of Care

For the first year of the program – while a significant amount of data on race, ethnicity and 

language preferences of patients was being generated – the hospitals focused on developing 

interventions and putting systems in place to ensure that their heart patients would

consistently receive all of the recommended care for their condition. Comparing data on the 

core measures before and after interventions were applied helped hospitals gauge how

effective their interventions were and gave them the momentum to continue their work as 

planned, or adapt the intervention to be more effective.

Transitions in Care

Transitions in care for minority patients were closely tied to many of the disparities

encountered during Expecting Success. As part of the program, hospitals realized the great 
64 Health Care Disparities

benefits of inpatient and outpatient centers coming together to learn form each other. Moving 

between the hospital and ambulatory care settings, minority patients were more likely to 

experience serious lapses in their path to recovery. Expecting Success promoted a

disintegration of silos between the care settings and challenged them to work together.

Since many factors inhibit patients from following and managing their care once discharged, 

leaders at Expecting Success hospitals are now taking more time to talk with cardiac patients 

about their transition care plan long before discharge, so potential problems are identified

prior to discharge and to prevent readmission. Hospitals often found that their ambulatory 

care centers had very successful programs in place that could be leveraged and used with 

patients in the hospital prior to discharge. Successful improvements to transitions in care 

include:

Assess the transition points in the hospital.

Ensure that existing transition procedures are being consistently followed.

Assess if other procedures or resources exist to improve transitions.

Coordinate the transition with all relevant inpatient staff.

Discuss the transition and care plan with patients before discharge.

Develop patient-centered, take-home resources to provide support during transitions.

Proactively check on the status of patients after discharge and during transition.

Interpreting the Results

Final data from Expecting Success awaits peer-reviewed publication, but preliminary results 

show that the program had a remarkable effect in a short period of time. Key results show:

The all-hospital median heart failure Measure of Ideal Care, an indicator that a patient 

received all the recommended standards of heart failure care eligible to receive in the 

hospital, had a significant increase from 41 percent to 78 percent over two years.

The all-hospital median Measure of Ideal Care score for heart attack patients, an indicator 

that a patient received all the recommended standards of heart attack care eligible to 

receive in the hospital, increased from 74 percent to 86 percent over two years.

The hospitals participating in the pilot phase of Expecting Success achieved core goals of the 

program, and many are actively applying the program‘s principles to areas of care for other 

conditions. Among their accomplishments:

Recognized disparity in disease treatment. Through the Expecting Success program, 

hospital management and clinicians became increasingly aware that the potential for 

racial and ethnic disparities existed at their institution and became more firmly committed

to identifying whether disparities existed and addressing them promptly. Recognizing 

that black and Hispanic patients appear to face a greater burden in consistently receiving 

high-quality care in their institutions was a huge eye opener for some participants.

Improved quality; reduced disparities. Within one year, every hospital that participated in

the program was increasing its percentage of patients receiving all core measures of care 

recommended for heart attacks and heart failure. The successes continued throughout the 

program.

Hardwired uniform collection of patient race, ethnicity and language data. For the first 

time, participating hospitals tracked data on core measures of care for patients with heart 

failure or who had a heart attack by race, ethnicity and primary language. While 
Panelist Statements: Second Panel 65

simultaneously working to improve the quality of care for all their heart patients, the 

hospitals were able to identify if there were racial and ethnic disparities in their care.

Implemented targeted quality improvements based on data. The hospitals identified and 

implemented ways to ensure that patients consistently received the right care developing 

standard order sets, creating documentation systems, etc. At each hospital, this required a 

team approach to identify where proven quality standards were being missed, and to 

redesign systems accordingly.

Implemented targeted quality improvements based on data. The hospitals identified and 

implemented ways to ensure that patients consistently received the right care –

developing standard order sets, creating documentation systems, etc. At each hospital, 

this required a team approach to identify where proven quality standards were being 

missed, and to redesign systems accordingly.

Became more engaged in discharge and outpatient care to reduce readmissions. Quality 

of care after hospital discharge proved to be dramatically different for patients of 

different races/ethnicities. Expecting Success hospitals all recognized that they have 

considerable work to do with providers and clinics in their communities to better manage 

their cardiac patients after they leave the hospital, in order to prevent unnecessary 

readmissions and emergency department visits.

Spreading the Success to Other Institutions

Working together, the Expecting Success collaborative helped participating hospitals

improve the overall quality of their cardiac care, explore whether disparities in their care

exist and summon the courage and tools to address the findings. Success was contingent 

upon the hospitals knowing exactly who their patients were and identifying whether these 

patients received the same care regardless of race, ethnicity or language.

Hospitals that participated in the pilot program, along with staff from the National Program 

Office, believe key factors to implementing the program include:

Recognize the importance of talking about disparities. No one wants to consider that their 

institution may have disparities, but acknowledgement that inequities may exist is the

first step to gathering and following the data.

Garner executive buy-in for improving quality. Develop a compelling case for 

management‘s support by showing that the hospital does not always meet evidence-based 

care metrics.

Engage all stakeholders. Include senior leadership, information technology, quality 

improvement staff, all levels of clinical staff, frontline registration staff and others in 

planning the program.

Build community awareness. Tell the community what you‘re undertaking to showcase 

efforts and increase support.

Data collection is essential. A consistent process for collecting patient data by race, 

ethnicity and primary language with everyone is instrumental to the success of the effort.

Creativity counts when improving quality. All hospitals tried out a wide range of 

interventions in their effort to improve their progress on meeting core measures.
66 Health Care Disparities

AMI and HF Measures

Expecting Success: 

Excellence in Cardiac Care 

Bruce Siegel, MD, MPH

Director

Center For Health Care Quality

United States Commission on Civil Rights Briefing

June 12, 2009

2

A hospital collaborative to eliminate disparities

 Expecting Success: Robert Wood Johnson Foundation-funded

 Built on IOM’s Unequal Treatment:

 Evidence-based care to promote equity; reduce disparities

 Focused on improving cardiac care for African-Americans and 

Latinos

 Heart attack and heart failure

 Major elements

 Standardized collection of patient race/ethnicity/language data using 

HRET Toolkit 

 Quality improvement

 Measurement: 23 quality measures reported monthly by patient race, 

ethnicity and language

 Core measures, all-or-none measures, CHF 30 day-readmission rate
Panelist Statements: Second Panel 67

3

Expecting Success Partners

Duke University 

Hospital

Durham, NC

Mount Sinai Hospital

Chicago, IL

Sinai-Grace Hospital

Detroit, MI

Montefiore Medical Center

New York, NY

Memorial Regional 

Hospital

Hollywood, FL

University of Mississippi 

Medical Center

Delta Regional Medical Center Jackson, MS

Greenville, MS

University Health System

San Antonio, TX

Del Sol Medical Center

El Paso, TX

Washington 

Hospital Center

Washington, DC

4

First step:

Collecting accurate data on patient race, 

ethnicity and language

 No more “eyeballing”: Ask at registration

 Change information systems to capture data

 Lots of anxiety

 First time done in multi-hospital setting

 These hospitals now know who their patients are

 One hospital and Hispanic patients
68 Health Care Disparities

5

6

Quality focus

 Three major improvement “themes”

 Ensuring evidence-based care

 Standard order use

 Redesigned Processes

 “Code Heart” to reduce time to care for heart 

attack patients

 Discharge and transition

 Heart failure educators
Panelist Statements: Second Panel 69

7

Hospital Y

Percent of Heart Failure Patients Receiving Discharge Instructions by Ethnicity

2005 Q4 - 2007 Q3

75%

100% 100%

97%

91% 99%

88%

66%

100% 100%

93%

100%

90%

93%

86%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2005Q4 2006Q1 2006Q2 2006Q3 2006Q4 2007Q1 2007Q2 2007Q3

Year/Quarter Percent of Patients

Hispanic

patients

Not Hispanic

patients

Closing the gap

76.4

(n=687)

86

(n=534)

87.5

(n=1108)

93.4

(n=846)

0

10

20

30

40

50

60

70

80

90

100

Jan.-June 2006 July-Dec. 2007

Percent

Slide 8. All Expecting Success Hospitals

Percent of Patients Receiving All Recommended AMI Care

Black White
70 Health Care Disparities

69.6

(n=280)

88.1

(n=327) 80.3

(n=1195)

90.4

(n=1266)

0

10

20

30

40

50

60

70

80

90

100

Jan.-June 2006 July-Dec. 2007

Percent

Slide 9. All Expecting Success Hospitals

Percent of Patients Receiving All Recommended AMI Care

Hispanic Not Hispanic

66.2

(n=1879)

81

(n=1369) 72.8

(n=1032)

87.1

(n=835)

0

10

20

30

40

50

60

70

80

90

100

Jan.-June 2006 July-Dec. 2007

Percent

Slide 10. All Expecting Success Hospitals

Percent of Patients Receving All Recommended Heart Failure Care

Black White
Panelist Statements: Second Panel 71

46.4

(n=440)

82.1

(n=430)

61.8

(n=1945)

82.2

(n=2006)

0

10

20

30

40

50

60

70

80

90

100

Jan.-June 2006 July-Dec. 2007

Percent

Slide 11. All Expecting Success Hospitals

Percent of Patients Receiving All Recommended Heart Failure Care

Hispanic Not Hispanic

12

The bottom line:

 Gaps can be closed

 High-minority hospitals can dramatically 

improve care

 A journey of self-examination

 One hospital’s experience with black/white 

disparities

 But what happens after the patient goes 

home?
72 Health Care Disparities

13

R/E/L data collection and the law

 An increasing number of states mandate the collection 

and reporting of R/E/L data from certain providers or 

plans.

 Medicare will begin collecting quality data by race, 

ethnicity, and gender from providers within 2 years.1

 It is legal to report de-identified data by R/E/L for 

quality improvement purposes

 It is legal for providers and plans to collect this data in 

most circumstances 

 Some states (CA, MD, NH, NJ, CT, MN, SD) 

prevent some types of insurance plans from 

collecting this data at the time of application for 

insurance coverage

1. Medicare Improvements for Patients and Providers Act of 

2008 (MIPPA), Public Law 110-275, July 15, 2008

14

American Recovery and Reinvestment 

Act of 2009

 HIT provisions are incorporated as the Health Information 

Technology for Economic and Clinical Health (HITECH) Act 

 Creates Office of the National Coordinator for Health Information 

Technology (ONCHIT) to develop and oversee a nationwide HIT 

infrastructure that improves health care quality and transparency of 

health information, and reduces costs, errors, and disparities

 HIT Policy Committee to make recommendations regarding the 

collection of race, ethnicity, primary language, and gender data

 HIT Standards Committee to recommend standards, implementation 

specifications, and certification criteria consistent with policy 

recommendations
Public Comments 73

Public Comments

In addition to the written and oral testimony presented at the briefing, some individuals and 

organizations contributed statements to the Commission for inclusion in the public record.

Below is a summary of the highlights of the public record outside of the testimony of the 

panelists.

Minority Lawmakers Want Bill To Close Health Gaps

Ben Evans

The Washington Post 

Tuesday, June 9, 2009

Racial and ethnic minority lawmakers warned Democratic leaders that any health care 

legislation that does not address health gaps between whites and minorities will be opposed. 

Republicans are resisting a government health insurance program that would compete with 

private insurance companies, arguing that the companies would be put at a competitive 

disadvantage.

Members of the Asian, Congressional Black and Congressional Hispanic Caucuses plan to 

introduce legislation this week that would broaden health care reform beyond those plans 

already floating in the House and Senate. The three minority caucuses have a total of 91 

members, most of whom are Democrats, which is enough to help mold the final piece of 

legislation. Because of higher rates of cancer, diabetes, heart disease and infant mortality 

among minorities, minority lawmakers want more funds for community health centers that 

provide care in poor neighborhoods. They also want to expand a National Institute of Health 

center to focus on minority health concerns, work to improve workforce diversity in the 

medical industry and collect additional data to better track disparities in health care.

Health and Human Services Secretary Kathleen Sebelius said the Obama administration is 

committed to addressing the ―alarming disparity in the delivery of quality health care,‖ which 

is critical to lowering health care costs. According to Secretary Sebelius, 75 percent of the 

nation‘s $2.2 trillion health care expenses go toward treating chronic diseases, which are 

more prevalent among minorities. She noted that increasing rates of HIV/AIDS among 

African-Americans is one of the most disturbing events in U.S. health care.

Secretary Sebelius also noted that not only are minorities more likely to be uninsured, but are 

also less likely to receive quality care. According to a White House issued summary report 

on minority health care, one in three Hispanics and American Indians, and roughly one in 

five African-Americans as compared to one in eight whites lack health insurance. The report 

also shows that African-Americans are seven times more likely than whites to have 

HIV/AIDS, that blacks and Hispanics have diabetes rates nearly twice as high as whites, and 

that black men are 50 percent more likely than their white counterparts to develop prostrate 

cancer.
74 Health Care Disparities

Racial Disparities in Illness Highlighted – Study Finds Alarmingly High Rates Among 

Black Women

Darryl Fears

The Washington Post

June 10, 2009

According to a Kaiser Family Foundation study released today, black women in Washington, 

D.C. are more likely than their white counterparts to suffer from obesity, diabetes, heart 

disease and poor health in general at alarming rates. The study was based on 2004 to 2006 

data compiled by the Centers for Disease Control and Prevention and the Current Population 

Survey. Unless otherwise stated the statistics in this story pertains to Washington, D.C. The 

study also found wide gaps between black and white women in incidences of cancer and 

HIV/AIDS and noted that black women‘s poor health is associated with low educational 

attainment, poverty, unemployment, stress, bad living conditions and inadequate health care 

coverage. Twenty-five percent of black women live below the poverty line, which was 

defined as $19,000 a year for a family of four at the time of the study, and nearly 14 percent 

of black women had no high school diploma.

The study showed that black women‘s health also compared unfavorably with that of other 

minority women. For example, 36 percent of black women compared with 10 percent of 

Hispanic and Asian women were overweight or obese; and more than 7 percent of black 

women suffered from diabetes as compared with only 2 percent of Hispanic and 3 percent of 

Asian women. Less than 1 percent of white women suffered from diabetes and only 7 percent 

were overweight or obese. Cara James, a senior policy analyst at the Kaiser Foundation,

acknowledged that comparing black women‘s health with that of white women in 

Washington, D.C. is rather unfair because the city‘s white women tend to be among the 

healthiest and wealthiest in the nation.

According to the Kaiser Foundation study, the health disparities between black and white 

women were narrower in Maryland and Virginia. In Maryland, 37 percent of black woman 

compared with 21 percent of white women were overweight or obese. In Virginia, the rate 

was 36 percent for black women and 17 percent for white women. In the District, the cancer 

mortality rate was 204 per 100,000 black women and 137 per 100,000 white women. In 

Maryland, the cancer mortality rate was 191 per 100,000 black women compared with 166 

per 100,000 white women. In the District, the incidence of new HIV/AIDS infection for 

black women, 176 per 100,000, was far larger than for any other group of women. The rate 

for Hispanic women was 48 per 100,000.

According to a District of Columbia study, the city‘s overall AIDS prevalence rate was 3 

percent, the highest in the nation. In Virginia and Maryland the rates were 31 per 100,000 

and 68 per 100,000, respectively. The District of Columbia‘s health director, Pierre Vigilance 

said the city is working to address the disparities and more is being done to address access to 

more health care for women, and especially mothers.
Speaker Biographies 75

Speaker Biographies

Peter Bach

Peter Bach is a member of the Health Outcomes Research Group in the Department of 

Epidemiology and Biostatistics, and a pulmonary and critical care physician in the 

Department of Medicine in Memorial Sloan-Kettering Cancer Center. His work has focused 

on improving the quality of care for African-American patients in Medicare, including cancer 

care. Dr. Bach is also engaged in health care policy work. In 2005 and 2006, he served as 

senior adviser to the administrator of the Centers for Medicare and Medicaid Services (CMS) 

in Washington, DC, where he oversaw the agency‘s cancer initiatives, evidenced 

development work through conditional coverage, and data policy. He is the recipient of the 

Boyer award for clinical research, was the previous incumbent of the Frederick Adler faculty 

chair, and has been the recipient of grants from the National Cancer Institute, the National 

Institute of Aging, and the American Lung Association. Dr. Bach is a graduate of Harvard 

College, the University of Minnesota Medical School, and the University of Chicago School 

for Public Policy.

Amitabh Chandra

Amitabh Chandra is an economist and a professor of public policy at the Harvard Kennedy 

School of Government. He is a research fellow at the IZA Institute in Bonn, Germany, and at 

the National Bureau of Economic Research (NBER). His research focuses on productivity 

and cost-growth in health care and racial disparities in health care. His research has been 

supported by the National Institute of Aging, the National Institute of Child Health and 

Development, the Robert Wood Johnson Foundation, and has been published in the 

American Economic Review, the Journal of Political Economy, the New England Journal of 

Medicine, and Health Affairs. He is an editor of the Journal of Human Resources, Economics 

Letters, and the American Economic Journal. Professor Chandra has testified to the United 

States Senate, the National Academy of Science, the Institute of Medicine and the United 

States Commission on Civil Rights. His research has been featured in the New York Times, 

the Washington Post, CNN, Newsweek, and on National Public Radio. He is the recipient of 

an Outstanding Teacher Award, the first-prize recipient of the Upjohn Institute's International 

Dissertation Research Award, the Kenneth Arrow Award for best paper in health economics, 

and the Eugene Garfield Award for the impact of medical research.

Garth N. Graham

Garth Graham is the deputy assistant secretary for minority health in the Office of Minority 

Health at the Department of Health and Human Services (HHS). He also serves as the 

executive director of the HHS Council on Health Disparities. The Council is comprised of 

senior leadership across the department, which coordinates and tracks progress on disparities 

related projects undertaken by the department. He was previously appointed a White House 

Fellow and special assistant to former Secretary Tommy G. Thompson at the Department of 

Health and Human Services.
76 Health Care Disparities

Dr. Graham founded the Boston Men‘s Cardiovascular Health Project, a project designed to 

identify behavioral explanations for decreased adherence to adequate diet and exercise by 

African-American men. Dr. Graham was the Founding Senior Editorial Board Member of the 

Yale Journal of Health, Law, Policy, and Ethics, served on the Editorial Board of the Yale 

Journal of Biology and Science, and was a reviewer for the Journal of Health Services 

Research. He also served on the Public Health Executive Council of the Massachusetts 

Medical Society, the Board of Directors of Physicians for Human Rights, chairman of the 

American Medical Association/MSS National Minority Issues Committee and on the 

Steering Committee of the Boston Men‘s Health Coalition. Dr. Graham has taught on the 

Faculty of the Observed Structured Clinical Exam at Harvard Medical School and has 

authored scientific articles and presentations on cardiovascular disease, HIV/AIDS, and 

community medicine and medical education.

Dr. Graham earned an M.D. from the Yale School of Medicine, where he graduated cum 

laude. He also earned an M.P.H. from the Yale School of Epidemiology and Public Health 

with a focus in health policy administration. Dr. Graham completed his residency in Internal 

Medicine at Massachusetts General Hospital and was also a Clinical Fellow at Harvard 

Medical School.

Barbara V. Howard

Barbara Howard is the senior scientist and former president of MedStar Research Institute. 

She was formerly the associate chief of the Phoenix Clinical Diabetes and Nutrition Section, 

NIDDK, National Institutes of Health. She is the past chair of the American Heart 

Association Council on Nutrition, Physical Activity, and Metabolism, past chair of the 

Nutrition Committee of the American Heart Association, and past chair of the Nutrition 

Study Section of the National Institutes of Health. She has served as a member of the NIH 

Expert Panel on Obesity that developed guidelines for the treatment and prevention of 

obesity, on ADA advisory panels to develop recommendations for management of lipids and 

glucose, and as a member of editorial boards for several scientific journals.

Dr. Howard has received the Bolton Corson Medal from the Franklin Institute for research in 

nutrition and atherosclerosis and the Special Recognition Award from the Arteriosclerosis 

Council of the American Heart Association. She was a Bierman lecturer for the American 

Diabetes Association, a Levy lecturer for the American Heart Association, and has received 

the Kelly West Award from the American Diabetes Association. Her major research interests 

are in cardiovascular disease, particularly in relation to diabetes and its occurrence in diverse 

ethnic groups. Her current research projects include the Strong Heart Study, a multi-center 

study of cardiovascular disease and its risk factors in American Indians; the Women‘s Health 

Initiative, a multi-center study of postmenopausal women and their health; GOCADAN, a 

study of the genetics of coronary artery disease in Alaska Eskimos; and the SANDS study, a 

multi-center study to examine strategies for reducing atherosclerosis in people with diabetes.

Dr. Howard received her Ph.D. in Microbiology from the University of Pennsylvania in 

1968, and currently holds faculty appointments in the Department of Medicine at 

Georgetown University and the Department of Biochemistry at Howard University.
Speaker Biographies 77

William R. Lewis

William Lewis is an attending physician at MetroHealth Medical Center, an affiliate of Case 

Western Reserve University, where he is also an associate professor of medicine and chief of 

clinical cardiology. He has served on the board of trustees of the Ohio Chapter of the 

American College of Cardiology and represented Ohio on the Board of Governors of the 

ACC. He is former president of the Cleveland Metro Division of the American Heart 

Association.

Dr. Lewis‘ main research interest is in health care quality. He has served on various ad hoc 

committees for the ACC and the Heart Rhythm Society and is a Fellow for the National 

Association of Public Hospitals Program. He also serves on the national Steering Committee 

for the American Heart Association‘s Get with the Guidelines program and has been a 

speaker for the program on a regional and national level.

Dr. Lewis received a Bachelor of Arts in economics and his medical degree from Ohio State 

University. He was inducted into the Gamma Chapter of the Alpha Omega Alpha honorary 

medical society, and for his research efforts, was inducted into the Landacre Society. He 

received his internal medicine training at University Hospitals of Cleveland and Case 

Western Reserve University. He is board certified in internal medicine, cardiology and 

clinical cardiac electrophysiology.

Rubens J. Pamies

Rubens Pamies is the vice chancellor for academic affairs, dean for graduate studies and 

professor of internal medicine at the University of Nebraska Medical Center (UNMC). Prior 

to that, he was chairman of the department of internal medicine and The Edward S. Harkness 

Professor of Medicine at Meharry Medical College School of Medicine. He was chief of 

service in the department of internal medicine at the Metropolitan Nashville General 

Hospital, and he was a professor of medicine in the School of Medicine at Vanderbilt 

University Medical Center. Dr. Pamies was recently selected as a new member and chair of 

the Advisory Committee on Minority Health for the U.S. Department of Health and Human 

Services‘ Office of Minority Health. He collaborated with former United States Surgeon 

General, Dr. David Satcher, to author and edit one of the first textbooks addressing 

inequalities in health care titled, ―Multicultural Medicine and Health Disparities.‖ Dedicating 

his academic medical career to minority health issues, Dr. Pamies created the first office of 

minority affairs at the University of South Florida College of Medicine in 1991. He also 

served as chief of the general internal medicine division at Mount Sinai Medical Center in 

Cleveland.

Dr. Pamies is a contributor to the Institute of Medicine‘s report for research and reducing 

health disparities. He is a test committee representative for the National Board of Medical 

Examiners, chairman of the Building Bright Futures adolescent behavioral health task force 

in Omaha, and a formal member of the Public Health Advisory committee for the 

Congressional Black Caucus Foundation, Inc.
78 Health Care Disparities

Dr. Pamies received his baccalaureate degree in 1981 from St. John‘s University and his 

medical degree in 1986 from the State University of New York at Buffalo. He completed his 

residency at Cornell-North Shore University Hospital in the internal medicine primary care 

track.

Sally L. Satel

Sally Satel is a resident scholar at the American Enterprise Institute and former W.H. Brady 

Fellow. She is also a staff psychiatrist at the Oasis Clinic in Washington, D.C., and a lecturer 

and assistant professor of psychiatry at Yale University School of Medicine. Dr. Satel was 

professional staff on the U.S. Senate Veteran‘s Affairs Committee. She has also held 

positions as a staff psychiatrist with the District of Columbia Superior Court Pretrial Program 

and West Haven VA Medical Center, Yale University School of Medicine. She is a former 

member of the Advisory Council at the U.S. Department of Health and Human Services, 

Center for Mental Health Services and the U.S. Department of Defense, Panel to Investigate 

Sexual Misconduct at the U.S. Air Force Academy.

Dr. Satel has authored several books and monographs, including Drug Treatment: The Case 

for Coercion (AEI Press, 1999); PC M.D. - How Political Correctness is Corrupting 

Medicine. (Basic Books, 2001); Health and the Income Inequality Hypothesis: A Doctrine in 

Search of Data (AEI Press, 2004) with N. Eberstadt; The Health Disparities Myth: 

Diagnosing the Treatment Gap (AEI Press, 2006) with J. Klick; One Nation under Therapy 

How the Helping Culture Is Eroding Self-Reliance (St. Martin's, 2005) with C. Sommers; and 

When Altruism Isn't Enough: The Case for Compensating Kidney Donors (AEI Press, 2008).

Dr. Satel received her Bachelors of Science degree from Cornell University; Masters of 

Science degree from the University of Chicago, and M.D. from Brown University, 

Providence.

Bruce Siegel

Bruce Siegel is a research professor and director of the Center for Health Care Quality in the 

Department of Health Policy at the George Washington University School of Public Health 

and Health Services. There he oversees the Aligning Forces for Quality Initiative of the 

Robert Wood Johnson Foundation. Much of his work has sought to measure and improve the 

quality of health care received by Americans, with focus on its most vulnerable populations. 

His contributions have included developing innovation in reducing crowding and improving 

hospital patient flow, eliminating ethnic and racial disparities in care, and supporting the 

safety net. Dr. Siegel‘s research projects have included work with the Commonwealth Fund, 

the California Endowment, the Agency for Healthcare Research and Quality, the District of 

Columbia and others on quality and equity.

Dr. Siegel has previously held the positions of New Jersey Commissioner of Health, 

president of the New York City Health and Hospitals Corporation, and president of Tampa 

General Healthcare. In addition, he served as a director of the Accreditation Council for 

Graduate Medical Education, as a senior fellow at New School University, and as an advisor
Speaker Biographies 79

to the Institute of Medicine, the World Bank, hospitals, hospital associations, philanthropies, 

count and state governments, and pharmaceutical firms. He is a member of the Board of 

Stewardship Trustees of Catholic Health Initiatives.

Dr. Siegel received his AB degree from Princeton University, MD from Cornell University 

medical College, and MPH from Johns Hopkins School of Hygiene and Public Health. He is 

board certified in Preventive Medicine. He has written and spoken extensively on health care 

management, policy and public health issues.

Louis W. Sullivan

Louis Sullivan is chairman of the board of the National Health Museum in Atlanta, Georgia, 

and is also chairman of the Washington, D.C., based Sullivan Alliance to Transform 

America‘s Health Professions. Additionally, he serves as chair of the President‘s 

Commission on Historically Black Colleges and Universities, and was co-chair of the 

President‘s Commission on HIV and AIDS from 2001-2006. Dr. Sullivan is the founding

dean and first president of Morehouse School of Medicine (MSM). On July 1, 2002, he 

retired and was appointed president emeritus. In addition, he is former secretary of the U.S. 

Department of Health and Human Services (1989-1993).

Dr. Sullivan was an instructor of medicine at Harvard Medical School and assistant professor 

of medicine at Seton Hall College of Medicine and was co-director of hematology at Boston 

University Medical Center where he founded the Boston University Hematology Service at 

Boston City Hospital.

Dr. Sullivan received his undergraduate degree from Morehouse College and earned his 

medical degree, cum laude, from Boston University School of Medicine. He is certified in 

internal medicine and hematology, holds a mastership from the American College of 

Physicians and is a member of Phi Beta Kappa and Alpha Omega Alpha academic honor 

societies. Dr. Sullivan is the recipient of more than 55 honorary degrees, including an 

honorary doctor of medicine degree from the University of Pretoria in South Africa.

Herman A. Taylor

Herman Taylor holds positions at the three institutions that are partners in the Jackson Heart 

Study (JHS). In 1998, Dr. Taylor came to Jackson, Mississippi, to lead the JHS, the largest 

population-based study of heart and related diseases ever undertaken in African-Americans.

While the study seeks to answer questions about cardiovascular disease risk in the AfricanAmerican population, it also provides historically black colleges and universities experience 

in large-scale epidemiological research. Dr. Taylor attended Princeton University and then 

Harvard Medical School. After a year‘s internship at Harvard‘s Mount Auburn Hospital, he 

spent two years in the Miami, Florida, Liberty City neighborhood with the National Health 

Service Corps. After completing a residency in internal medicine at the University of North 

Carolina at Chapel Hill and a cardiology fellowship at the University of Alabama in 

Birmingham (UAB), he was appointed to the UAB faculty and served as attending 

cardiologist at the University Hospital, the Birmingham Veterans Medical Center, and the 
80 Health Care Disparities

Cooper Green Hospital. At UAB, Taylor was the first African-American chief cardiology 

fellow and the first black cardiologist on the faculty. He was the founding Medical Director 

of the UAB Hospital Cardiopulmonary Rehabilitation Service and was lead investigator on 

several studies funded by the National Institutes of Health (NIH). He also founded Heart to 

Heart (HTH), a non-profit organization that provides cardiac surgical services for children 

from the developing world. Dr. Taylor is listed as one of the Best Doctors in America, and in 

2005, he was named the first Aaron Shirley chair for the Study of Health Disparities at the 

University of Mississippi Medical Center.
Commissioner Statements 81

Commissioner Statements 

Statement of Abigail Thernstrom, Vice Chair

Are Differences in Health Care Due to Racial Discrimination?

Many Americans do not enjoy good health care. And when the data on quality of care and 

health outcomes are sorted by race, ethnicity, geography, income, education, as well as a host 

of other variables, it becomes clear that some groups are served less well than others by the 

American health care system. But are the disparities in quality care due to racial 

discrimination? Our briefing did not definitively answer that question.

As our panelists pointed out, if we are to improve the health care system, we need to consider 

the many factors that contribute to the troubling group differences. 

Americans deserve the best medical care possible without regard to race, gender, or ethnicity. 

It is within the purview of our civil rights enforcement agencies to protect all Americans 

against racially discriminatory practices. But disparities, in and of themselves, are not evident 

of illegal discrimination.

During our briefing the subject of cultural competence training for medical professionals was 

raised by two panelists,1and it was addressed again by me2during our Q & A. 

Dr. Sally Satel described the definitions of cultural competence as mind numbingly vague.3

In her testimony she echoed my biggest concern:

At its worst, cultural competency training devolves into a version of racial 

sensitivity training with the stereotypes intact. I‘ve always wondered how I‘m 

supposed to treat black patients differently than white ones.4

Dr. Peter B. Bach added:

We should appreciate that medical education is a zero sum game...every layer of 

demand [such as adding cultural competence training] we put on [medical 

students] academically to enrich their ability in one area necessarily takes away 

from some other area.5

 

1

Prepared statements submitted for the 6/12/2009 USCCR briefing by both Dr. Sally Satel and by Dr. Graham 

Garth. 

2 Vice Chair Abigail Thernstrom questions about cultural competence 6/12/2009 at USCCR draft briefing 

transcript pp. 88-98, with responses from various panelists. 

3 Dr. Sally Satel testimony 6/12/2009, USCCR draft briefing transcript at p. 96.

4 Dr. Sally Satel testimony 6/12/2009, USCCR draft briefing transcript at p. 96.

5 Dr. Peter Bach testimony 6/12/2009, USCCR draft briefing transcript at p. 85.
82 Health Care Disparities

Dr. Satel, citing the work of Joseph Betancourt, delivered the simplest, most cogent 

definition of ―cultural competence‖ in the medical setting:

This is about universal factors in dealing with other human beings, in this case 

within the medical setting, and it‘s a very short quotation where [Betancourt] says 

that an enlightened form of cultural competence...has ―evolved from 

implementing the principles of patient center[ed] care, including exploration, 

empathy, responsiveness to patients‘ needs, values and preferences.‖6

Dr. Satel also made a very useful distinction between linguistic competence and 

anthropological competence. The first involves overcoming language barriers, while the 

second involves awareness of the differences in custom and practice between the health care 

provider and the patient. The latter might include, for example, knowing that kinds of home 

remedies a particular patient from a different culture might be using, or the unique dietary 

habits of patients from that culture.7

In her prepared statement, Dr. Satel also remarked on the waning focus on classic 

discrimination – on group prejudice. ―It is my impression,‖ she said

that the tenor of the discussion surrounding health disparities has softened in the 

media, especially with respect to the notion that physicians themselves are 

prejudiced. Nowadays, the more generally accepted view is that wider, more 

systemic factors underlie health differentials. There is less overt talk of ―racism‖ or 

―bias.‖8

Of course some physicians are undoubtedly prejudiced against members of certain groups, 

but their numbers are surely small, and it would seem more useful to focus training on 

bridging the linguistic and cultural gaps that can interfere with the practices of good 

medicine.

Finally, our panelists identified many intervening variables affecting the quality of health 

care that should be addressed in a systematic fashion. In addition to addressing problems 

created by cultural and linguistic barriers, these variables included: Resources (facilities, the 

number of board certified doctors, budgets); lifestyle problems that span cultures (poor 

dietary and exercise habits, for instance); inadequate patient education and outreach; and 

poor quality health care in rural areas. 

 

6 Dr. Sally Satel testimony 6/12/2009, USCCR draft briefing transcript at p. 97.

7 Dr. Sally Satel testimony 6/12/2009, USCCR draft briefing transcript at p. 96.

8 Dr. Sally Satel prepared statement 6/12/2009, at page 4.
Commissioner Statements 83

Statement of Commissioner Todd Gaziano

I am pleased to join the concurring Statement of Commissioner Gail Heriot.1 Her

statement provides an excellent summary of the evidence gathered by the Commission 

refuting the claim that individual doctors treat their white patients differently than their 

minority patients; the principal reason for health care disparities relates to differences in the 

quality of care in different areas of the country. Commissioner Heriot‘s statement also 

powerfully explains why well-meaning efforts to artificially increase the number of minority 

health care providers and promote ―cultural competency‖ training are likely to backfire.

My separate effort attempts to explain the central finding of the research she 

discusses with some simple examples and to briefly summarize the legal consequences that 

flow from that research. My focus is as follows: (1) among the many complex causes of 

health (and health care) disparities, intentional or subconscious discrimination based on race 

or ethnicity does not appear to be a measurable component—it appears not to exist; and (2) 

the absence of racial or ethnic discrimination renders most attempts by government to 

legislate preferences for minority health care professionals both counterproductive and 

unconstitutional.

In parts of southern West Virginia, not too far from where I grew up and my father 

still practices medicine, the health status and treatment options for many poor residents are

heartbreaking. The grim situation these residents face is caused by a mix of factors: increased

stress from poverty and high unemployment; significantly higher levels of obesity, caused in 

part by cultural influences and low income (obesity and an unhealthy diet tend to be 

inversely related to income); lower quality health care facilities and fewer means to obtain 

health care; a slight fatalism from previous generations of isolation and hardship that causes 

them to seek preventative care or early medical intervention less frequently; and other 

conditions prevalent in the area (such as occupational lung disease from a deadly 

combination of smoking and decades of work in underground coal mines).

Appalachia has some unique problems, but similar factors that influence health 

outcomes are not evenly distributed among racial and ethnic groups throughout America. 

Apart from some rare genetic predispositions to diseases that correlate with race, most causes 

of health disparities are not related to the race or ethnicity of the patients themselves or their 

doctors, but to the conditions in which they grow up and live. Unfortunately, some racial and 

ethnic populations are more poorly situated than others. Thus, aggregate statistics about 

differences in relative health measured by race or ethnicity don‘t communicate much that is 

helpful, and probably do much to mask the real causes of the disparities.

 

1

See also Letter from the U.S. Commission on Civil Rights to President Barack Obama and Distinguished 

Member of Congress, October 9, 2009, available at 

www.usccr.gov/correspd/CommissionHealthCareBill100909.pdf, regarding similar issues relating to the then 

pending health reform bill (the letter was signed by Commission Chairman Gerald Reynolds and 

Commissioners Pete Kirsanow, Ashley Taylor, Gail Heriot, and myself).
84 Health Care Disparities

With regard to health treatment disparities, it should surprise no one that medical 

treatment options are based at least in part on the quality of the health care facilities and 

providers in a given community. Practitioners in many suburban and urban areas are better 

credentialed, have more advanced equipment, and have more specialized practices, on 

average, than elsewhere. Moreover, certain advanced procedures are pioneered in teaching 

hospitals and have the highest success rate when administered by physicians who perform 

them regularly. Residents served by many rural health care facilities simply have fewer 

health care options.

As Commissioner Heriot‘s statement explains, there is little evidence that 

individual doctors (regardless of race) treat their minority patients worse than their white 

patients.2There are many factors that contribute to health treatment disparities, but 

intentional or subconscious discrimination does not seem to be one of them. The best 

evidence shows that there is little or no difference in treatment by race or ethnicity within a 

particular health care facility. Unfortunately, minority populations are overrepresented in the 

regions of the country with poorer health facilities.3Similarly, minority patients are more 

likely to be served by lower-performing hospitals than are white patients.4The best way to 

improve health care for minority patients would be to improve the quality of the facilities and 

professionals in areas where they live.

These findings have significant legal consequences for policymakers. The starting 

point for any analysis of race-conscious policies is that all race-conscious policies of any 

kind, including those that attempt to mitigate health disparities, are presumptively 

unconstitutional. As the Commission noted in its October 9, 2009 letter on the health care 

bill, all governmental racial classifications (whether well-meaning or not) trigger strict 

scrutiny, the most intensive type of judicial review.5To survive strict scrutiny, a regulation 

must be necessary to achieve a compelling government purpose and must be the most 

narrowly tailored means to accomplish that end.6It is very unlikely that any race-conscious 

policy could overcome the strong presumption of unconstitutionality because the factors 

discussed above would cause any conceivable race-based policy to flunk the Supreme 

Court‘s strict-scrutiny test.

 

2

Statement of Amitabh Chandra; Statement of Sally L. Satel (describing studies showing physician‘s race had 

little to do with how black patients fared).

3

Statement of Sally L. Satel (citing R. Hasnain-Wynia, DW Baker, D. Nerenz, J. Feinglass, AC Beal, MB 

Landrum, R. Behal, JS Weissman, Archives of Internal Medicine 167, no. 12 (2007): 1233-1239; Katherine 

Baicker, Amitabh Chandra, and Jonathan S. Skinner, ―Geographic Variation in Health Care and the Problem of 

Measuring Racial Disparities,‖ Perspectives in Biology and Medicine 48, no. 1, supp. (2005): S42-53).

4

Satel Statement (citing Katherine Baicker and Amitabh Chandra, ―Myths and Misconceptions About Health

Insurance,‖ Health Affairs 27, no. 6 (2008) w533-w543).

5

See, e.g., Adarand v. Pena, 515 U.S. 200, 237 (1995). Justice O‘Connor, writing for the majority in Adarand, 

declared that it was not true that the test was ―strict in theory, but fatal in fact.‖ Id. That the Court‘s majority 

had to offer that assurance, however, shows that a proper application of the test almost always is fatal. Indeed, 

there was not a single forward-looking preference plan (as opposed to a remedial decree) approved by the High 

Court between 1950 and 2003. Grutter v. Bollinger, 539 U.S. 306 (2003), is the first exception, and I am not 

alone in thinking it resulted from an erroneous application of the test.

6 Adarand, 515 U.S. at 235.
Commissioner Statements 85

There is no compelling government interest that justifies favoring the medical 

training of students of some races over others. Remedying instances of actual government 

discrimination is a compelling government interest, but there is no evidence that health 

disparities are caused by past or present government discrimination. What other justifications 

might exist? The Supreme Court has squarely held that the role-model justification for racial 

preferences is not compelling,7and it has never held that equalizing societal outcomes or 

benefits by race is a compelling government interest that justifies conscious government 

discrimination.

Even if Congress had a compelling government interest in equalizing health 

treatment or outcomes among racial populations, it would fail in showing that racial 

favoritism among medical students or nurses is narrowly tailored to achieve that end. That is 

because such race-conscious preferences will not improve health outcomes for anyone and 

are more likely to be counterproductive to that end. There is simply no sound evidence that 

race-conscious policies—such as programs designed to increase the number of minority 

doctors (most likely by lowering admission standards for minority applicants) or by adding 

cultural competency classes to medical and nursing school curricula—will improve anyone‘s 

health care or reduce health disparities. (Even assuming minority doctors are more likely to 

practice in under-served areas, which is a contested claim, it is a leap of faith to assume that 

will result in better outcomes overall.)

Witnesses cited studies showing that the race of the doctor had almost no impact 

on the level of health care received by minority patients.8 One study in the New England 

Journal of Medicine ―found that racial differences in treatment were similar among patients 

treated by white and black physicians.‖9The view that either increasing the number of 

minority physicians or increasing cultural competency training can mitigate health disparities 

―is grounded more in hope than science.‖10 One of our witnesses stated that a literature search 

found ―no rigorous evaluations of cultural competency training that attempted to answer 

whether it improves quality of care, let alone reduces disparities.‖11 Ineffectual policies are 

obviously not tailored, narrowly or otherwise, to achieve the policy goal of reducing racial 

disparities and therefore cannot pass the strict-scrutiny test.

Stripping away the noble but unsupported hunches of those who want to help 

minority patients, what is left are racial preferences for the sake of helping aspiring health 

care providers of certain races at the expense of aspiring health care providers of all other 

races. Whether such a policy is well meaning or not, it is unconstitutional. And lowering the 

admissions standards for any group of medical students, especially on the theory that they 

will more likely practice in under-served areas, may only make matters worse for their future 

patients.

 

7 Wygant v. Jackson Bd. of Educ., 476 U.S. 267, 275-76 (1986).

8

See Chandra and Satel Statements.

9

Chandra Statement (citing Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM, ―Racial difference in 

the use of cardiac catheritization after acute myocardial infarction,‖ New England Journal of Medicine 2001; 

344: 1443-1449).

10 Chandra Statement.

11 Satel Statement.
86 Health Care Disparities

Sometimes sound public policy research and constitutional rules point in opposite

directions, but much more often they point in the same direction. They point very much in 

the same direction in evaluating government proposals to artificially increase the number of 

minority health care providers. Race-based policies that are ineffective or counterproductive 

are bad in themselves, and they can never pass the constitutional strict scrutiny test. That test 

was explicitly designed in the mid-twentieth century to smoke out race-conscious policies 

that are based on little more than racial stereotypes, false beliefs, and erroneous assumptions. 

Without a solid scientific foundation, government race-conscious policies in medical 

education, training, and treatment should be rejected as both counterproductive and 

unconstitutional.
Commissioner Statements 87

Statement and Rebuttal of Commissioner Gail Heriot

In our letter of October 9, 2009 to President Barack Obama and Congressional leaders 

on pending health-care legislation, we noted the need to better understand the complex reasons 

behind racial differences in life expectancy and rates of morbidity.1

Some of these differences are almost certainly are the result of diet, exercise and other 

differences in life style. Genetic factors may also be at work. In both situations, knowledge can 

be useful. Individuals who understand how their own behavior influences their health and 

longevity can often change that conduct. And while genetic factors may be difficult or impossible 

to change, an individual who is aware of the possibility that his genetic inheritance predisposes 

him and his children toward particular risks may be able to guard against those risks with extra 

vigilance. 

There is also evidence that some of the differences are the result of different medical 

treatment, and it is this evidence that tends to draw the greatest concern as a matter of civil rights. 

A good example is the likelihood that a patient will undergo cardiac catheterization after acute 

myocardial infarction. Several empirical studies have now concluded that white patients are more 

likely to receive this treatment than black patients (certain other medical indications being the 

same).2

The letter pointed out that some observers--misguidedly in my opinion--believe these 

differences in treatment to be the result of ―conscious or unconscious discrimination.‖ The 

solutions these observers offer have been two-fold: ―expanding the number of minority 

physicians (even if that means lowering academic standards in medical school) and ensuring that 

all health care professionals receive 'cultural competency' training.‖3 The Commission's letter, 

however, made it clear that these solutions probably have little to do with the actual problem. As 

Dr. Amitabh Chandra of Harvard University put it at the briefing before the Commission, they 

are "grounded more in hope than science."4

 

1

For example, the prevalence of high blood pressure – a risk factor for coronary heart disease, stroke, kidney 

disease, and heart failure – is nearly 40% greater in African-Americans than in whites (Graham Statement at 

11.) Hispanics in the U.S. are 50% more likely than whites to suffer from diabetes and the incidence of diabetes 

among Native Americans is more than twice that for whites. 

2

Letter from the United States Commission on Civil Rights to President Barack Obama and Distinguished 

Members of Congress, October 9, 2009, available at 

http://www.usccr.gov/correspd/CommissionHealthCareBill100909.pdf. See Jersey Chen, Saif S. Rathmore, 

Martha J. Redford, Yun Wang, & Harlan M. Krumholz, Racial Difference in the Use of Cardiac 

Catheterization After Acute Myocardial Infarction, 344 N. ENGL. J.MED. 1443, 1444 n. 1-9 (May 10, 2001.) 

3

Id. Vice Chair Thernstrom states in her Draft Statement that our briefing did not ―definitively‖ answer the 

question of whether health disparities are due to racial discrimination. Draft Statement at 1. While in some 

sense this is surely correct, no result in social science or in medicine is ever definitive. There are always other 

variables for which to control and always other studies to be done. As I explain in greater detail infra, our 

briefing did provide ample evidence indicating that doctors discriminating between their black and white 

patients is not a significant cause of the disparities, and it would be unfair for anyone to suggest that because the 

evidence is not "definitive," that evidence should not be relied upon. Policymakers must always depend on lessthan-perfect evidence. This research is very strong relative to that which policymakers ordinarily rely upon in 

analogous situations. 

4

See Transcript, Briefing Before the U.S. Commission on Civil Rights (June 12, 2009), 

http://www.usccr.gov/calendar/trnscrpt/061209ccr2.pdf. 
88 Health Care Disparities

The evidence presented to the Commission indicates that the disparate treatment problem

is "not the result of individual physicians treating their white patients differently from their black 

patients or of non-black physicians' lack of familiarity with African-American culture." Instead, 

the problem exists largely because African-American patients use different doctors, clinics and 

hospitals than white patients.5 Our letter stated: 

"On the whole, the doctors who treat black patients with frequency are less likely to be 

highly credentialed and more likely to report obstacles in gaining access to high-quality 

service for their patients. As one might expect, these circumstances can lead to poorer 

health outcomes."6

Geography accounts for a good deal of the problem.7For example, the Deep South is one 

of the poorest regions of the country, and correspondingly it has one of the poorest health care 

delivery systems. It also has one of the largest African-American populations. In a carepeerreviewed, empirical study—Geographic Variation in Health Care and the Problem of Measuring 

Racial Disparities—the authors wrote that ―blacks tend to live in parts of the country that have a 

disproportionate share of low-quality providers.‖ ―Within those hospitals, both whites and blacks 

tend to receive low-quality care,‖ they wrote, ―but since blacks are over-represented in such 

areas, the quality of the hospital will cause an overstatement of the role that race plays ....‖8 The 

doctors are not discriminators. They may on average be less well-equipped than their peers 

practicing in wealthier parts of the country or on average less qualified. But they are not treating 

patients differently based on their race. 

If all this is true, the critics who blame the problem on lack of black doctors or a lack of 

cultural sensitivity among non-black doctors are off the track. Under their theory, one would 

expect those doctors who treat black patients most frequently on average to provide the best care 

to those black patients. Their experience with black patients would, on average, make them more 

culturally competent than doctors who seldom see black patients. Yet, if anything, precisely the 

opposite seems to be the case. 

Similarly, if the lack of black doctors were the source of the problem, one would expect 

that black patients being treated by black doctors would fare better than black patients treated by 

 

5 Letter from the United States Commission on Civil Rights to President Barack Obama and Distinguished 

Members of Congress, October 9, 2009, available at 

http://www.usccr.gov/correspd/CommissionHealthCareBill100909.pdf. 

6

Id. See Peter B. Bach, Hoangmi H. Pham, Deborah Schrag, Ramsey C. Tait, J. Lee Hargraves, Primary Care 

Physicians Who Treat blacks and Whites, 351 N. ENGL. J. MED. 6 (August 6, 2004.) The contrast under study 

was not between white doctors and black doctors, but rather between doctors who treat white patients and 

doctors who treat black patients. Both groups of doctors were majority white, although the degree of racial 

diversity among treating physicians who treat black patients was greater than it was among those who treat 

white patients. Many doctors, of course, treat large numbers of both black and white patients. See also Jonathan 

Skinner, Ambitabh Chandra, Douglas Staiger, Julie Lee & Mark McClellan, Mortality After Acute Myocardial 

Infarction in Hospitals That Disproportionately Treat Black Patients, 112 CIRCULATION 2634, 2634 

(2005)(―Risk-adjusted mortality after AMI is significantly higher in US hospitals that disproportionately serve 

blacks. A reduction in overall mortality at these hospitals could dramatically reduce black-white disparities in 

health care outcomes‖). 

7

Id.

8 Katherine Baicker, Amitabh Chandra & Jonathan S. Skinner, Geographic Variation in Health Care and the 

Problem of Measuring Racial Disparities, 48 Perspectives in Biology and Med. S42, 43 (Winter 2005.) 
Commissioner Statements 89

white doctors. Yet, again, this is not so. In Racial Differences in the Use of Cardiac 

Catheterization After Acute Myocardial Infarction,9the authors wrote: 

―We found that black patients were significantly less likely than white patients 

to undergo cardiac catheterization within 60 days after admission, regardless of 

whether the attending physicians were white or black .... The rate of cardiac 

catheterization among white patients did not differ significantly according to 

whether their physicians were white or black (45.7 percent and 49.6 percent, 

respectively ...). Similarly, the rate of cardiac catheterization among black 

patients did not differ significantly according to whether their physicians were 

white or black (38.4 percent and 38.2 percent, respectively ...).‖10

Nevertheless, the recently enacted Patient Protection and Affordable Care Act follows 

precisely the approach that these diversity advocates have supported. It contains provisions that

appear to be designed to ensure that medical schools, dental schools, and other institutions that 

train health care professionals will give preferential treatment to members of underrepresented 

minorities. Failure to do so could cause these institutions to be ineligible for federal grants and 

contracts.11 Another provision of the new law seems designed to ensure the flourishing of cultural 

competency programs in medical schools.12 California and New Jersey already mandate cultural 

competency programs for doctors. And other states are seriously considering such a requirement.

 

9

See Jersey Chen, Saif S. Rathmore, Martha J. Redford, Yun Wang, & Harlan M. Krumholz, Racial Difference 

in the Use of Cardiac Catheterization After Acute Myocardial Infarction, 344 N. ENGL. J.MED. 1443, 1444 

(May 10, 2001.) 

10 Id. at 1445. 

11 For a summary of the relevant provisions of the health care legislation, please see Letter From the United 

States Commission on Civil Rights to President Barack Obama and Distinguished Members of Congress, 

October 9, 2009, available at http://www.usccr.gov/correspd/CommissionHealthCareBill100909.pdf. 

12Sec. 5307 of the PPHACA (codified at 124 Stat. 628) amends 42 U.S.C. 293e, ―Grants for health professions 

education‖ to read: a) Cultural competency, prevention, and public health and individuals with disability grants. 

(1) In general. The Secretary, acting through the Administrator of the Health Resources and Services 

Administration, may make awards of grants, contracts, or cooperative agreements to public and nonprofit 

private entities (including tribal entities) for the development, evaluation, and dissemination of research, 

demonstration projects, and model curricula for cultural competency, prevention, public health proficiency, 

reducing health disparities, and aptitude for working with individuals with disabilities training for use in health 

professions schools and continuing education programs, and for other purposes determined as appropriate by 

the Secretary. (2) Eligible entities. Unless specifically required otherwise in this title, the Secretary shall accept 

applications for grants or contracts under this section from health professions schools, academic health centers, 

State or local governments, or other appropriate public or private nonprofit entities (or consortia of entities, 

including entities promoting multidisciplinary approaches) for funding and participation in health professions 

training activities. The Secretary may accept applications from for-profit private entities as determined 

appropriate by the Secretary. (b) Collaboration. In carrying out subsection (a), the Secretary shall collaborate 

with health professional societies, licensing and accreditation entities, health professions schools, and experts in 

minority health and cultural competency, prevention, and public health and disability groups, community-based 

organizations, and other organizations as determined appropriate by the Secretary. The Secretary shall 

coordinate with curricula and research and demonstration projects developed under section 807 [42 USCS § 

296e-1]. (c) Dissemination. (1) In general. Model curricula developed under this section shall be disseminated 

through the Internet Clearinghouse under section 270 and such other means as determined appropriate by the 

Secretary. (2) Evaluation. The Secretary shall evaluate the adoption and the implementation of cultural 

competency, prevention, and public health, and working with individuals with a disability training curricula, 

and the facilitate inclusion of these competency measures in quality measurement systems as appropriate. (d) 

Authorization of appropriations. There is authorized to be appropriated to carry out this section such sums as 

may be necessary for each of fiscal years 2010 through 2015. 
90 Health Care Disparities

It isn‘t just that these new laws fail to solve the problem. Despite the good intentions of those 

who passed them, they may well make the situation worse. By encouraging medical schools to 

relax admissions standards for members of certain racial groups, and inasmuch as physician 

quality is correlated with academic achievement, these programs may actually decrease the 

number of high-quality doctors that graduate from medical schools each year.13

Similarly, as we stated in our letter, ―Emphasizing cultural competency when the lack 

of such competency does not appear to be the crux of the problem is not harmless. The medical 

school curriculum is not infinitely elastic. There are only so many hours in the day for instruction 

and study. Emphasizing one subject necessarily implies that another subject will not be 

emphasized.‖14

Moreover, under the guise of cultural sensitivity, these programs are often training 

healthcare professionals to think in terms of clumsy stereotypes that in any other context would 

be regarded as silly or downright offensive. Consider the Guide to Culturally Competent Health 

Care, a popular text of this genre.15 It declares that Irish Americans ―are not known for being 

overly modest‖ and that ―[t]ruth is seen as a relative concept‖ by Mexican Americans. The same 

text delicately tells the reader that ―most‖ African Americans are ―present-‖ rather than ―futureoriented,‖ apparently in contrast to whites, who are thus better able to plan their lives. Italian 

Americans, the reader is informed, tend to have superstitious beliefs. If, for example, a pregnant 

woman spills coffee on herself, she may believe her baby will be born ―with a birth mark where 

the coffee was spilled.‖ 

Other texts, like Cultural Competence in Health Care, contain similarly overdrawn 

stereotypes: Latinos are said to ―generally believe that health is controlled by the environment, by 

fate (distino) and by the will of God (manos de dios)‖ and to be inclined to seek alternative care 

from ―witches (brujos).‖ American Indians are portrayed as resentful for modern medicine as ―an 

extension of prior colonialism.‖16

Training health care professionals to communicate in their patients‘ native language 

can surely help provide them with the proper care. And basic knowledge of patients‘ culture and 

 

13 Indeed, racial preferences in undergraduate admissions may have had the unintended consequence of 

lowering the number of racial minority physicians. To be a doctor, one must first complete undergraduate level 

pre-medical courses. Black and Hispanic students are just as likely, if not slightly more likely, than whites to 

plan to major in science in college. But they are much less likely to follow through on that ambition than are 

white students. Evidence presented before the Commission at another briefing indicates that students of all 

racial and ethnic groups whose entering credentials put them in the bottom third of their class are less likely to 

persist in science than students with identical credentials attending less competitive schools at which their 

credentials put them in the top third. Majoring in science is difficult, and it is easy to give up if others are 

getting the material more quickly. Because of racial preferences in admissions, minority students are 

disproportionately in the bottom third of their entering undergraduate classes, which means that they 

disproportionately give up on science. The result is that fewer minority students will be qualified to attend 

medical school after graduating college. See U.S. Commission on Civil Rights, Encouraging Minority Students 

in Science Careers (Statement of Commissioner Gail Heriot describing research on these points), available on 

the Commission‘s website at http://www.usccr.gov/. 

14 See Testimony of Peter B. Bach, M.D., Briefing on Healthcare Disparities, U.S. Commission on Civil Rights 

at 85 (June 12, 2009). 

15 Larry Purnell and Betty Paulanka, Guide to Culturally Competent Health Care (2004). 

16 Wen-Shing Tseng and Jon Streltzer, Cultural Competence in Health Care (2010). See also Statement of Sally 

Satel at 93. 
Commissioner Statements 91

circumstances can also be important—though it is generally knowledge gained by experience and 

not by classroom learning. The cultural competency movement, however, is less about real 

cultural competency than it is about political indoctrination, patronage and paying tribute to the 

forces of political correctness. It has all the hallmarks of a politically correct boondoggle.