GAO-03-862R Health Care Disparities

United States General Accounting Office 

Washington, DC 20548 

July 8, 2003 

The Honorable Bill Frist 

Majority Leader 

United States Senate 

Subject: Health Care: Approaches to Address Racial and Ethnic Disparities

Dear Senator Frist: 

A recent report by the Institute of Medicine, a branch of the National Academy of 

Sciences, found that racial and ethnic minority groups tend to receive a lower quality 

of health care than nonminorities, even when access-related factors such as income 

and insurance coverage are controlled.1

 It concluded that the elimination of racial and 

ethnic health care disparities is a major challenge in the United States. Racial and 

ethnic minority groups identified by the federal government—American Indians or 

Alaska Natives, Asians, Blacks or African Americans, Hispanics or Latinos, and 

Native Hawaiians or other Pacific Islanders—are expected to make up an 

increasingly large portion of the U.S. population in coming years. 

The federal government, primarily through programs under the Department of Health 

and Human Services (HHS), plays a major role in providing and financing health care 

for minority groups. HHS is also the primary federal entity involved in projects and 

research aimed at understanding and addressing disparities in health care. HHS has 

focused on racial and ethnic disparities in health access and outcomes in six areas: 

cancer screening and management, cardiovascular disease, diabetes, HIV 

infection/AIDS, immunizations, and infant mortality. HHS offices and agencies, 

researchers at philanthropic foundations, and private organizations such as 

employers and health plans have efforts under way to try to address racial and ethnic 

disparities in health care, using interventions such as disease management programs, 

disease prevention programs, health literacy and language service projects, and 

education and outreach programs. You requested that we identify approaches that 

experts view as promising to address racial and ethnic disparities in health care. The 

enclosure contains the information we provided during our July 8, 2003, briefing of 

your staff. 

 

1

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

Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003). 
2 GAO-03-862R Health Care Disparities

To respond to your request, we reviewed studies, journal articles, reports, and 

evaluations by the Institute of Medicine, federal agencies, researchers, and other 

organizations on racial and ethnic health care disparities and on potential 

interventions to reduce disparities. We also interviewed federal officials at the Office 

of Personnel Management, HHS’s Office of Minority Health, and six HHS agencies—

the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control 

and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), Health 

Resources and Services Administration (HRSA), Indian Health Service (IHS), and 

National Institutes of Health (NIH)—to learn about their programs and initiatives. In 

addition, we obtained information on relevant programs, initiatives, and promising 

approaches to address disparities from health care researchers at academic 

institutions and research organizations such as the Institute of Medicine, 

representatives from large employers and a health plan, and officials at philanthropic 

foundations and other organizations. We performed our work from April through 

June 2003 in accordance with generally accepted government auditing standards. 

In brief, identifying promising approaches to address racial and ethnic disparities in 

health care is challenging because current efforts are in early stages of 

implementation, evaluations and data are limited, and information on the 

nonfinancial causes of health care disparities is incomplete. Experts identified the 

following promising approaches that the federal government could pursue to address 

disparities: 

• Develop new demonstration projects in federal programs using the best available 

evidence to target areas of disparities and plan promising interventions. 

• Expand current efforts in programs and demonstration projects such as CDC’s 

REACH 2010 community-based coalitions. 

• Strengthen federal leadership on disparities, including prompt dissemination of 

information on successful interventions to reduce or eliminate health care 

disparities. 

• Collect complete and accurate racial and ethnic health care data in national 

surveys to better understand and target efforts to reduce health care disparities 

through steps such as ensuring the inclusion of adequate numbers of minority 

participants. 

We provided a draft of this report to officials at HHS for their technical review. We 

incorporated their comments as appropriate.

As we agreed with your office, unless you publicly announce the contents of this 

report earlier, we plan no further distribution of it until 30 days from the date of this 

letter. We will then send copies to the Secretary of HHS, the Director of the Office of 

Personnel Management, and interested congressional committees and will make 

copies available to others upon request. The report will also be available at no charge 

on the GAO Web site at http://www.gao.gov. 
3 GAO-03-862R Health Care Disparities

If you have any questions or need additional information, please contact me at (202) 

512-7119 or Kim Yamane at (206) 287-4772. Lisa A. Lusk and Elaine Swift made key 

contributions to this report. 

Sincerely yours, 

Janet Heinrich 

Director, Health Care—Public Health Issues 

Enclosure 
Enclosure Enclosure 

4 GAO-03-862R Health Care Disparities

1

Health Care: Approaches to 

Address Racial and Ethnic 

Disparities

Briefing for Congressional Staff of Senator Bill Frist 

Majority Leader 

United States Senate
Enclosure Enclosure 

5 GAO-03-862R Health Care Disparities

2

Racial and Ethnic Health Care 

Disparities Are Serious and Pervasive

“[D]isparities are associated with socioeconomic differences and tend to 

diminish significantly, and in a few cases, disappear altogether when socioeconomic factors are controlled. The majority of studies, however, find that racial and ethnic disparities remain even after adjustment for socioeconomic differences and other healthcare access-related factors.” 

(Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003)).

“Disparities in health care are among this nation’s most serious health care 

problems. Research has extensively documented the pervasiveness of racial and ethnic disparities.” (Institute of Medicine, Guidance for the National Healthcare Disparities Report (Washington, D.C.: 

National Academies Press, 2002)).
Enclosure Enclosure 

6 GAO-03-862R Health Care Disparities

3

Objective

Identify promising ways to address racial 

and ethnic disparities in health care
Enclosure Enclosure 

7 GAO-03-862R Health Care Disparities

4

Scope and Methodology

• Reviewed studies, journals, reports, and evaluations by the 

Institute of Medicine, federal agencies, researchers, and other 

organizations on racial and ethnic health care disparities and on 

potential interventions to address disparities

• Interviewed federal officials at the HHS’s Office of Minority Health 

and six HHS agencies, including AHRQ, CDC, CMS, HRSA, IHS, 

and NIH as well as at the Office of Personnel Management
Enclosure Enclosure 

8 GAO-03-862R Health Care Disparities

5

Scope and Methodology (cont.)

• Interviewed individual health care researchers knowledgeable about 

health care disparity issues, including researchers at academic institutions, 

the Institute of Medicine, and the RAND Corporation

• Interviewed representatives of organizations including philanthropic 

foundations such as the California Endowment, Commonwealth Fund, and 

Kaiser Family Foundation; large employers and a health plan affiliated with 

the Washington Business Group on Health; and other organizations, such 

as the American Medical Association, Community Service Society of New 

York, National Committee for Quality Assurance, National Health Law 

Program, and MacColl Institute for Healthcare Innovation
Enclosure Enclosure 

9 GAO-03-862R Health Care Disparities

6

Background

Racial and Ethnic Populations

HHS identifies the following racial and ethnic minority groups:

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Native Hawaiian or Other Pacific Islander
Enclosure Enclosure 

10 GAO-03-862R Health Care Disparities

7

Background

Areas of Disparities in Health Care

While disparities have been identified in many areas, HHS has 

focused on six areas where serious racial and ethnic disparities

exist in health access and outcomes:

• Cancer screening and management

• Cardiovascular disease

• Diabetes

• HIV infection/AIDS

• Immunizations

• Infant mortality
Enclosure Enclosure 

11 GAO-03-862R Health Care Disparities

8

Background

Examples of Areas with Disparities in Health 

Care

• Cancer screening and 

management: procedures (e.g., 

diagnostic procedures, surgery) 

and pain management

• Cardiovascular disease:

appropriate medication (e.g., 

thrombolytics) and procedures 

(e.g., diagnostic procedures, heart 

surgery)

• Diabetes: disease management 

(e.g., lipid testing, measurement 

of glycosylated hemoglobin)

• HIV infection/AIDS: 

appropriate medication (e.g., 

antiretroviral drugs)

• Immunizations: on-time 

delivery of recommended 

immunizations

• Infant mortality: appropriate 

prenatal treatment and 

prenatal procedures 
Enclosure Enclosure 

12 GAO-03-862R Health Care Disparities

9

Background

Examples of Disparities in Health Care

• African Americans, American Indians, Hawaiians, Indians and Pakistanis, Mexicans, 

South and Central Americans, and Puerto Ricans were 1.4 to 3.6 times more likely 

to present with advanced (stage IV) breast cancer than non-Hispanic whites. (C. I. Li and 

others, “Differences in Breast Cancer Stage, Treatment, and Survival by Race and Ethnicity,” Archives of Internal Medicine, vol. 163, no.1 (2003)).

• For early-stage lung cancer, the rates of surgery and of 5-year survival were lower for African Americans than whites. Survival rates for African Americans and whites 

who underwent surgery, however, were similar. This observation suggests that 

lower survival rates among African Americans may be explained by the lower rate of 

surgical treatment. (P.B. Bach and others, “Racial Differences in the Treatment of Early-Stage Lung Cancer,” New England Journal of Medicine, vol. 

341, no. 16 (1999)).

• Among those age 65 years and older, 69 percent of white persons received 

influenza vaccinations, compared with only 50 percent and 48 percent of older 

African American and Hispanic persons, respectively. (Based on data collected from January through September 

in the Sample Adult Core Component of the 2002 National Health Interview Survey). http://www.cdc.gov/nchs/about/major/nhis/released200303.htm

(downloaded June 11, 2003).
Enclosure Enclosure 

13 GAO-03-862R Health Care Disparities

10

Background

Factors behind Health Care Disparities

Experts have identified many factors that contribute to 

disparities in health care. These factors include: 

• Access: physical (e.g., proximity to health care sites, 

transportation); financial (e.g., health insurance, personal 

resources); and other (e.g., ability to take time off from work,

ability to navigate a complex health care system)

• Provider-patient relationships: cultural barriers, language 

barriers, literacy levels, provider bias, and unequal treatment
Enclosure Enclosure 

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11

Background

The Federal Government Plays a Major Role in 

Health Care for Minority Populations

The federal government provides or finances health care directly or jointly

with states for large numbers of minorities. For example, of the estimated 

29 million African Americans with health care insurance in 2001:

• Nearly 8 million were covered by Medicaid

• Nearly 4 million were covered by Medicare

• More than 1 million were covered by military health care, including care 

provided by the Department of Veterans Affairs and the Department of 

Defense’s TRICARE program
Enclosure Enclosure 

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12

Background

Examples of Interventions

Some efforts by the federal government and private sector to

address health care disparities include:

• Disease management, such as diabetes management programs

• Disease prevention, such as cancer screening programs for 

breast cancer

• Health literacy and language services to ensure the 

understanding of heath information

• Cultural competency, such as increasing cultural awareness to 

help providers serve a diverse population

• Education and outreach, such as programs administered by 

community and faith-based groups, targeting specific populations 
Enclosure Enclosure 

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13

Promising Approaches

Challenges to Identifying Promising Approaches 

to Address Health Care Disparities

• Incomplete understanding of nonfinancial causes of 

disparities

• Targeted programs and demonstrations in early stages of 

implementation; limited evaluations on existing programs 

and interventions

• No one overarching approach to address disparities; many 

believe that multiple approaches are needed because 

groups and subgroups experience different disparities for 

different reasons

• Limited health care data on racial and ethnic minorities
Enclosure Enclosure 

17 GAO-03-862R Health Care Disparities

14

Promising Approaches

Addressing Health Care Disparities

Health care researchers, federal officials, or other sources identified several 

ways that the federal government could address health care disparities:

• Develop new demonstration projects in federal programs

• Expand current efforts to reduce disparities in demonstration projects and 

initiatives

• Strengthen federal leadership on disparities, including prompt dissemination of 

information 

• Collect complete and accurate racial and ethnic health care data in national 

surveys to better understand and target efforts to reduce health care disparities 

through steps such as ensuring the inclusion of adequate numbers of minority 

participants
Enclosure Enclosure 

18 GAO-03-862R Health Care Disparities

15

Promising Approaches

Develop New Demonstration Projects

Experts identify new demonstration projects as a promising approach to

address disparities. Research indicates that new demonstrations

could incorporate the following features:

• The best available evidence to target areas of health care disparities and 

plan promising interventions 

• Data sufficient to evaluate a demonstration’s effectiveness, to allow 

comparisons to other approaches, and to facilitate possible expansion

• A source independent of those conducting the intervention evaluating the 

intervention
Enclosure Enclosure 

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16

Promising Approaches

Expand Current Efforts

Experts identified several current federal efforts that offer promise and

could be expanded. They include:

• CDC’s REACH 2010: a multiyear demonstration project that began in 1999 

and currently supports 42 community-based coalitions across the country 

to, for example, target cardiovascular disease and diabetes in African 

American women and cervical cancer among Vietnamese women.

• HRSA’s Community Health Center Collaboratives: a health initiative 

that involves multidisciplinary teams in community health centers and 

promotes systemic changes in health care for chronic conditions and 

prevention. For example, collaboratives provide disease management and 

education in a largely minority population for conditions such as diabetes, 

asthma, and cardiovascular disease. More than 530 of over 800 community 

health centers have participated in the collaboratives.
Enclosure Enclosure 

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17

Promising Approaches

Expand Current Efforts (cont.)

• AHRQ’s EXCEED program: nine centers that bring together teams of 

researchers to address a group of projects organized around a central 

theme, such as cultural competency. For example, the centers test 

interventions such as diabetes care and cancer screening among elderly 

American Indians/Alaska Natives and assess the extent to which doctorpatient communications contribute to disparities in health care use.
Enclosure Enclosure 

21 GAO-03-862R Health Care Disparities

18

Promising Approaches

Strengthen Federal Leadership

Experts suggest that HHS leadership is key to reducing and

eliminating racial and ethnic disparities in health care. While

HHS leadership supports activities to address this issue, experts said

stronger direction could include steps to:

• Initiate and facilitate the development of additional interagency 

initiatives on disparities

• Ensure the collection and prompt dissemination of best practices

and lessons learned on approaches to reduce or eliminate 

disparities

• Promote the expansion of programs with demonstrated track 

records of success
Enclosure Enclosure 

22 GAO-03-862R Health Care Disparities

(290284) 

19

Promising Approaches

Collect Complete and Accurate Racial and 

Ethnic Health Care Data

Experts suggest that HHS could strengthen how surveys such as

MEPS, NHANES, NHIS, and others could contribute to understanding

disparities and effective interventions by:

• Ensuring and supporting the inclusion of adequate numbers of 

minority participants in national surveys or conducting smaller scale 

surveys of specific groups

• Identifying gaps in the understanding of disparities and 

interventions and using surveys to help fill them 
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