Health Care: Approaches to Address Racial and Ethnic Disparities 
(08-JUL-03, GAO-03-862R).					 
                                                                 
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. 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. Congress requested that we identify approaches
that experts view as promising to address racial and ethnic	 
disparities in health care.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-862R					        
    ACCNO:   A07476						        
  TITLE:     Health Care: Approaches to Address Racial and Ethnic     
Disparities							 
     DATE:   07/08/2003 
  SUBJECT:   Health care services				 
	     Racial discrimination				 
	     Health care cost control				 
	     Health care costs					 
	     Minorities 					 
	     Strategic planning 				 

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GAO-03-862R

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).

GAO- 03- 862R Health Care Disparities 2 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.

GAO- 03- 862R Health Care Disparities 3 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

GAO- 03- 862R Health Care Disparities 5

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

GAO- 03- 862R Health Care Disparities 6

3

Objective Identify promising ways to address racial and ethnic disparities
in health care

Enclosure Enclosure

GAO- 03- 862R Health Care Disparities 7

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

GAO- 03- 862R Health Care Disparities 8

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

GAO- 03- 862R Health Care Disparities 9

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

GAO- 03- 862R Health Care Disparities 10

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

GAO- 03- 862R Health Care Disparities 11

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

GAO- 03- 862R Health Care Disparities 12

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

GAO- 03- 862R Health Care Disparities 13

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

GAO- 03- 862R Health Care Disparities 14

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

GAO- 03- 862R Health Care Disparities 15

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

GAO- 03- 862R Health Care Disparities 16

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

GAO- 03- 862R Health Care Disparities 17

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

GAO- 03- 862R Health Care Disparities 18

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

GAO- 03- 862R Health Care Disparities 19

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

GAO- 03- 862R Health Care Disparities 20

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

GAO- 03- 862R Health Care Disparities 21

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

GAO- 03- 862R Health Care Disparities 22 (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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