What has been fairly obvious for years is that disparate treatment stems in part from Medicaid, the public health insurance program. There was a time, long past, when a Medicaid card worked more or less like a Blue Cross card: It got patients into many private doctors' offices. Not anymore. Funding cuts and ever tighter restrictions (on doctors and patients) have largely turned Medicaid into a separate, unequal system for the poor. Minorities, of course, are not alone in this boat, but they are disproportionately stuck there.

But Medicaid is not the whole story. According to the Institute of Medicine, even when minority patients have decent insurance, a solid income, a college degree -- in other words, even when things are the same as for typical white patients except race or ethnicity -- treatment is different. Why? The report puts much of the blame on prejudice and stereotyping by doctors, a startling and courageous assertion when you consider that scores of researchers have documented disparities for more than a decade, and almost nobody has dared to talk about this in a forthright way until now.

The chapter title, cautious to the point of parody, is "Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter." It is no polemic on racism but, like the rest of the report, a sober, dense review of the relevant research. Most of it involves experiments and surveys aimed at teasing out physician attitudes and judgments and measuring their influence on what should be straightforward medical decisions.

In one well-known study, doctors watched videotaped vignettes of patients (really actors) with symptoms of coronary artery disease. Each video featured a different patient -- a white man, a black woman and so forth -- but the complaints were the same. According to the study, doctors were much less likely to propose cardiac catherization for blacks and women than for whites and men.

Does such bias persist even among minority doctors? In another study, medical students -- whites and minorities -- watched vignettes of patients complaining of chest pain. Overall, the students were more likely to provide a "definite" diagnosis of angina for white male patients than for black female patients. But when asked to rate the patients' overall health, the doctors split according to their own race, ethnicity and gender. White students, and male students, tended to assess the black female patients as having worse general health and a lower quality of life than the white male patients -- even though both patient groups presented the same basic information. Minority and women students tended to rate all patients the same on this score.

Studies like these have sparked hot debate in the scientific literature. On the surface, these are arcane arguments over methods: Should the investigators use odds ratios or risk ratios to calculate a patient's chances of getting a specialist referral? But it's no great stretch to assume that something deeper fuels the fire of these controversies. Doctors don't take kindly to allegations of bias. Who does? Nevertheless, the institute pulls no punches.

"Although it is reasonable to assume that the vast majority of health care providers find prejudice morally abhorrent, several studies show that even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes," says the press release on the report.

The pressures of medical practice probably exacerbate these impulses. A doctor spends just minutes with each patient, often patients he barely knows, and must make ever more complex decisions. "If physicians are having trouble making a diagnosis because the symptoms are not clear-cut, they are trained to place greater emphasis on prior expectations about the patient's condition based on age, gender, socioeconomic status, race or ethnicity," the press release said.

Of course, the patient brings baggage, too. Minorities are more likely than whites to say they mistrust doctors and nurses. (Hardly suprising in light of this research.) Suspicion does not make for an optimal doctor-patient dynamic, and it can be frustrating and insulting to a doctor who is working hard to help a seriously ill patient and likely to lose money on the effort. But as the institute notes, the doctor "is the more powerful actor" in this relationship and should bear more of the load for making sure that all patients are treated the same.

The report's first recommendation for reducing disparities is to increase awareness among the general public, doctors, insurance companies, policymakers. It's the flip side of the HHS strategy of targeting African-Americans exclusively. And it makes far more sense. Two recent polls show that a significant majority of Americans believe that blacks get the same quality of healthcare as whites. Minorities apparently know that's not true. A survey released in March by the Commonwealth Fund in New York found that blacks (and Hispanics and Asian-Americans) are more likely than whites to report difficulty communicating with doctors, to feel they are treated with disrespect when they get healthcare, and to believe they would receive better treatment if they were a different race or ethnicity.

The Institute of Medicine also recommends the elimination of two-tier healthcare: People on Medicaid should get the same services, and the same protections, as privately insured patients. (The institute noted that Congress fussed mightily last year over legislation to safeguard the rights of people in private HMOs, but not Medicaid managed care. The report said any patient's rights bill must extend to people in public programs.)

The report also urges Medicaid to bring stability to doctor-patient relationships. These have been trampled by budget cuts and other changes in the program. The institute devotes considerable ink to the importance of consistent, ongoing medical care. Against that backdrop, a one-shot go-to-the-doctor day seems not only misguided but also counterproductive.

In its meatiest recommendation, the report calls for aggressive civil rights enforcement in healthcare. The HHS Office for Civil Rights "has long abandoned proactive, investigative strategies," the report said. Although complaints have increased in recent years, the enforcement budget in fiscal year 2000 was 60 percent of the 1981 funding, adjusted for inflation.

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