Disparate CV health: A variance that refuses to disappear

Issue: November 2011

ByPaul L. Douglass, MD

In 1994, I wrote two editorials in the Association of Black Cardiologists’ Digest of Urban Cardiology, titled “Healthcare Reform” and “Healthcare Discrepancies in Minorities.” At the time, I was convinced that with a consistent, energized and committed effort, the CV community would soon recognize the negative impact of the multitude of inequities that resulted in poorer CV outcomes for underrepresented minorities and women. I was also convinced that once enlightened, our community of providers would accept the challenge and provide the necessary tools, leadership and resources required to resolve the disparities gap.

The first acknowledgement of the disparities gap in CV health was met with much skepticism and disbelief. Many of our colleagues trusted that we had overcome the legacy of our troubled US history of inequities in medical care. Many refused to believe that in today’s world, there could be a systematic or institutional etiology for disparate health care. Rather, if such a disparity exists, it must be biological. Many were appalled at the notion that they, as individual practitioners, could be contributors to such a disparate outcome in their patients. We all prided ourselves on our ability to treat every patient with compassion, empathy and fairness. Thus began a quest to disprove what many who served the disenfranchised and women already suspected: an inherent bias in our health care delivery system. A bias that was the manifestation of a multitude of complex realities that, as a consequence, resulted in the inequitable treatment of a well-defined demographic.

Paul L. Douglass, MD
Paul L. Douglass

So began our need to fully examine and analyze this most serious accusation: that despite similar degrees of severity of disease, despite similar levels of access and similar resources, blacks, lower socioeconomic groups and women had disparate CV health outcomes when compared with white men. The indictment was harsh, but the analysis was careful, thorough and complete. During almost 2 decades, the results have been irrefutable, consistent and reproducible. Blacks at every age level are two to three times more likely to die of CVD when compared with whites. In 2006, the average lifespan for whites was 78.2 years compared with 73.2 years for blacks, according to the US Census Bureau. From 1950 to 2006, there was a significant decline in age-adjusted all-cause mortality rates, but blacks benefited less in the decline. The fact that blacks have a greater concentration of cardiac risk factors alone does not fully explain the disparity gap. Many studies have demonstrated that cohorts with similar risks, severity of disease, access and financial resources still have disparate CV outcomes.

Complex problem

Despite the seriousness and depth of our analysis of this complex problem, we have failed to resolve the health care gap. There have been gallant efforts and tool development by many of our medical societies, but change has been slow in coming. After erudite studies, few have argued the fact that our health care system is poorly integrated; difficult to navigate; has a nonsustainable cost growth curve; and provides unequal outcomes. The US population and our legislators have started to question the value of our delivery system. It is the most expensive in the world, but lacks superiority in overall health statistics. The health of a nation is certainly dependent on more than its health care delivery system. Rates of sedentary lifestyles, obesity and poor nutrition play an integral role in the health quality of a nation.

However, recent studies have demonstrated that among 16 industrialized countries, the United States ranked sixth highest for CHD mortality for men and fourth highest for women. When compared with the United States, nine of 13 industrialized countries have shown a steeper average decline in CHD mortality in women. So many have questioned whether the cost of our health care system is justified by its perceived value. Some would argue that we have the best health care system in the world. This would be true, if one has access, finance and the educational skills necessary to navigate our disjointed networks of care. State-of-the-art care is available disproportionately, and we continue to be blind to the fact that millions of Americans lack adequate health care insurance and that this creates a major barrier to quality care. These facts define our reality. But, I submit that if we were to eliminate the disparities gap, the health care cost burden and the overall health of our nation would be exceedingly better and worth our sizeable investment.

The past 100 years are littered with attempts at transforming our health care delivery system. However, on March 23, 2010, President Barack Obama signed legislation that would extend medical insurance to approximately 30 million Americans, primarily through the expansion of Medicaid and providing subsidies for middle- and low-income individuals to purchase coverage. The law creates insurance exchanges for those buying individual policies and forbids using pre-existing conditions as a cause for denial of insurance. It attempts to lower the rising cost of Medicare by creating an expert panel that would limit government reimbursement for only scientifically proven effective therapies.

Irrespective of which side of the political spectrum you belong, this legislation was a monumental step to resolve a fundamental yet poorly acknowledged reality: No insurance equals no or poor-quality care. The legislation, despite its misgivings, courageously attempts to level the playing field regarding access to health care. This legislation became the needed catalyst for a meaningful dialogue among all stakeholders in the health enterprise. It is far from being fully implemented, as we attempt to fine-tune the bill to make it as beneficial as it can be. Already, there are more than 20 challenges to the bill, and it appears that the Supreme Court has been requested to rule on the constitutionality of the centerpiece of the legislation, the individual mandate. Although we argue the means and methods of the bill, we should not lose sight of the intended goal: providing health care that is quality-driven, affordable, accessible and delivered in a culturally competent environment for every American.

Widespread responsibility

The debate over the Patient Protection and Affordable Care Act will likely continue, but the disparate care and its reality in this country should not. The elimination of health care disparity becomes the responsibility of all who participate in the system: providers, insurers, regulators, legislators and patients. The solutions are difficult to achieve, primarily because of the complexity and enormity of the problem.

However, President Obama has provided us with a workable framework from which to begin. The solutions will need to come from every component of the health care enterprise. The solutions have been difficult to attain, but can be achieved. The rising cost of health care will continue to fuel the debate, but obtaining equity and justice in our health care delivery system should be our sustaining principles.

Now is the time to act bravely. We have not taken that bold step necessary to reconcile and transform our delivery system. The debate over the Patient Protection and Affordable Care Act hopefully will provide the proper forum in which to achieve this needed transformation. We have debated this fundamental question for almost 2 decades and have little to show for our efforts, other than the realization that health care disparities exist. Patients should be empowered with health knowledge, disease avoidance and illness prevention. Now is the time to enact policies that eliminate health disparities and promote equitable health care and outcomes.

Paul L. Douglass, MD, practices clinical and interventional cardiology at Metropolitan Atlanta Cardiology Consults and is chief of the division of cardiology and director of Cardiovascular Services at Atlanta Medical Center. He is also a member of the CHD and Prevention section of the Cardiology Today Editorial Board.

Disclosure: Dr. Douglass reports no relevant financial disclosures.