Bridging the Gap

The kind of medical care you receive could be affected by more than just your health. Racial disparities in health care — differences in the quality of care received by different racial or ethnic groups — continue to significantly impact health care outcomes, according to research conducted by John Ayanian, M.D., professor of internal medicine, of health management and policy and of public policy, and director of the Institute for Healthcare and Policy and Innovation, or IHPI, and his colleagues. Ayanian, also the Alice Hamilton Collegiate Professor of Medicine, published an article in the New England Journal of Medicine Catalyst outlining how these disparities persist, despite some favorable improvements in recent years, and why it is essential to eliminate them.

What first prompted your interest in how race and health care are related?

As an undergraduate at Duke, I was a history major and a pre-med student. Several of my U.S. history courses focused on slavery, segregation and civil rights. For my senior thesis, my interests in history and health care came together when I studied the health outcomes of African Americans in North Carolina during the first half of the 20th century. As I was beginning my career as a physician and caring for a diverse group of patients, I learned that race as a social factor continues to shape their experiences in our health care system in ways that we need to understand, so that we can eliminate health care disparities wherever they persist.

What do these disparities look like in the clinic?

Health care disparities in the past were very explicit, often related to basic health care access, with segregated hospital wards and clinics. Since the 1960s, these explicit forms of discrimination have been eliminated in the U.S., but we are left with more subtle forms of implicit bias. For example, we know that doctors often don't communicate as well with patients whose racial and ethnic backgrounds differ from their own. Some minority patients may not trust health care providers as readily because of discrimination that they or their family or friends have experienced. We also have broader socioeconomic issues in the health care system that contribute to disparities, including higher rates of uninsurance among African Americans and Latinos and inadequate funding for health care facilities in poor communities.

Why do such differences in health care outcomes and life expectancy exist? What factors in health care and the environment are at play?

These are crucial questions that many colleagues and I at IHPI are striving to answer. National data show that the gaps in life expectancy between African Americans and white Americans have been reduced by about half — from over seven years to less than four years over the past 40 years. Some of this improvement relates to better health care for conditions such as hypertension and HIV infection, as well as better opportunities in education, employment and other social determinants of health. But important racial disparities persist in infant mortality, cardiovascular disease and cancer. These disparities are often related to less-healthy social and physical environments in lower-income communities, as well as differences in insurance coverage and in access to high-quality care.

As I advocated in my NEJM Catalyst commentary, the U.S. has an ethical and economic imperative to eliminate racial and ethnic disparities in health care and health. We won't have a truly high-quality health care system until we achieve equity in health care, so that all patients and communities, regardless of race, education or income, have the opportunity to receive high-quality care that meets their needs. These efforts must be coupled with policies that promote healthy communities.

How can we continue to reduce these disparities within the rapidly changing health care environment?

Health system leaders and policymakers must continue to make eliminating health care disparities a local and national priority. Providing resources to community health centers and safety-net hospitals that serve communities where health disparities are concentrated will be essential. As we train the next generation of health care professionals at the University of Michigan, we are also working to ensure that they are well-prepared to care effectively and compassionately for patients of all backgrounds.