Cardiovascular health disparities: the next frontier

Poverty may be the critical roadblock to accomplishing health care equality.

More than twenty years ago, then Secretary of Health and Human Services Margaret Heckler called attention to the health status of African-Americans and other minorities by establishing the Task Force on Black and Minority Health. This action was stimulated by the overall health statistics for the nation, which demonstrated a continuous decline in the death rates for many of the nation’s disease categories. Unfortunately, many of the nation’s minority populations did not enjoy the same degree of mortality decline. Hence, a “health disparities gap” became apparent.

This initial report was met with skepticism, disbelief and outrage. The Task Force reported that there were 60,000 excess deaths each year in minority populations; cardiovascular disease and stroke were responsible for a large portion. The Task Force made eight recommendations, which ranged from outreach campaigns for minority populations and enhanced educational materials to improvement in availability and accessibility of health professionals for minority communities.

Cardiovascular disease has been at the forefront of the topics of debate. This is probably because it is a disease category for which there are an abundance of data and, as a consequence of the health disparities gap, it accounts for the majority of the excess mortality.

Paul L. Douglas, MD

I suspect that our two-decade old analysis of the health care disparities in the United States has convinced the majority of the health care community, the government, regulators and the general population that the health care gap does exist and results in 80,000 to 130,000 preventable deaths each year. The Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care and the congressionally mandated Assessment on Healthcare Disparities Report from the Agency for Healthcare Research and Quality further confirmed these inequities in care.

The causes of these inequities are complex and multifactorial. A report by Schulman et al. published in 2003 in the New England Journal of Medicine — featuring physicians asked to make recommendations for cardiac catheterization in patients with identical chest pain histories and risk factors that only differed by race, age and gender — demonstrated that physician bias may also play an important role in health disparities.

Reviewing the evidence

In 2002, the Henry S. Kaiser Foundation, in conjunction with the American College of Cardiology, performed a review of the cardiovascular literature in an effort to provide a scientific database for cardiovascular disparities and to critically assess whether the accusations were based on definitive scientific fact. This report found strong scientific evidence for racial disparity in the use of diagnostic cardiac procedures, thrombolytic therapy, coronary artery bypass surgery and coronary angioplasty.

Since this report, many articles have appeared, most demonstrating inequities in care whether examining single center reports, large administrative databases, registries or population-based studies. The role of physician decision-making, stereotypes of subpopulations, patient belief systems, access to care, trust in the health care enterprise and patient compliance all appear to be important components of the health care disparities issue.

The evidence appears to be consistent, persistent, pervasive, conclusive, undeniable and unacceptable in a nation that prides itself in having the best health care delivery system in the world. Recommendations on addressing the disparities gap have originated from every aspect of the health care enterprise. Despite these recommendations, the gap continues to widen for many ethnic minorities. Life expectancy is approximately 5.5 years higher in whites compared with blacks.

Our best efforts notwithstanding, we are continuously confronted with challenges in providing equitable health care for every minority community. We have made well-intentioned efforts at correcting each component that contributes to health disparities. However, the solutions thus far presented have made little impact.

Why have we failed to make a difference? Our efforts have been genuine, intensely researched and carefully crafted. However, many of the recommended solutions have not been fully implemented. We have not increased the number of underrepresented minorities in the health care work force. We have approximately 46 million uninsured people in the United States, thus creating a major barrier to access to health care.

The risk factors for cardiovascular disease continue to increase, especially obesity and diabetes. The socioeconomic gap for minorities continues to widen. These problems represent environmental, sociocultural and socioeconomic inequities that exist in the United States.

Working on solutions

President Bush has issued “Reforming Health Care for the 21st Century” as his roadmap for solving the health care crisis. He acknowledges that the cost of health care is expected to increase to 18.7% of the gross domestic product by 2014, a rate of increasing burden that is not sustainable in the United States economy. The president has offered several potential solutions, including tax incentives, health saving accounts, affordable coverage for vulnerable Americans and improved health information technology.

The Centers for Medicare and Medicaid Services have introduced Pay for Performance measures. Although on the surface these measures appear to reward quality, they may actually widen the health gap as providers “cherry pick” those patients who are the most compliant, thereby increasing the likelihood of good health outcomes and leaving the most vulnerable to those providers with eroding financial resources.

The state of Massachusetts has taken a bold initiative at providing universal coverage for all its citizens, but this is a plan that requires residents and employers to purchase medical insurance for themselves and their families. This is a noble gesture, but is it replicable in other states with smaller financial reserves and larger numbers of uninsured?

Role of poverty

In this climate of continued frustration, are we likely to meet the goals of the Department of Health and Human Services’ Healthy People 2010? I suspect not. Possibly, we need another target.

The most critical obstruction to health care equality may be our inability to reduce poverty. No one would suggest that we abandon our current proposed solutions at reducing the disparities gap. We must continue to search for answers by increasing the number of minority health care professionals, improving public education for healthy lifestyles and disease prevention, improving health care access and research, improving the quality of care for vulnerable populations, recognizing physician biases, improving patient-provider communication and awareness, and monitoring of health care disparities. These goals will require our continued focus and attention.

However, our greatest challenge — and the final and most essential hurdle — may be our ability to resolve the poverty issue. The most critical obstruction to health care equality may be our inability to reduce poverty. Poverty leads to poor education, poor access to health care, a greater likelihood of destructive behaviors, poor disease outcomes and increased mortality rates. The United States ranks as the world’s most impoverished developed nation, according to the Human Development Report to the United Nations Development Programme.

During the last 20 years, leaders in medicine, genetics, politics, economics and medical bioethics have enlightened us about the inadequacies in our health care system. Our abilities to solve the difficult, complex, multifactorial health disparities gap problem haven’t been realized though. Maybe we should expand the target and add reducing the poverty level in our country to our multiple objectives. I suspect that if we narrow the poverty gap, all others will follow.

Paul L. Douglass, MD, FACC, is chief, division of cardiology, and director of cardiovascular services, Atlanta Medical Center, and clinical assistant professor, Morehouse School of Medicine. He is also a member of Cardiology Today's Editorial Board.