There are many reasons for the long-standing health disparities between racial and ethnic groups in the United States. The quality of care that patients receive is an important factor. Even though physicians and other healthcare professionals say they want to treat all patients equally, it doesn't always happen.

That's the word from the Agency for Healthcare Research and Quality (AHRQ), which has been tracking America's medical care disparities for the past two decades. AHRQ analyzes more than 200 medical care measures every year. Some progress has been made, but its 2021 report tells an unsettling story:

• Black populations received worse care than White populations in 43% of the quality measures that AHRQ tracks.

• American Indian/Alaska Native populations received worse care than White populations in 40% of quality measures.

• Hispanic populations received worse care than non-Hispanic White populations in 36% of the measures.

• Asian and Native Hawaiian/Pacific Islander populations received worse care than White populations in about 30% of quality measures.

Here's a few ways that plays out in people's lives:

• Fewer than 84% of American Indian/Alaska Native patients with colon cancer received surgical resection that included examining at least 12 lymph nodes, compared with 93% of White people.

• More than 91% of White adults reported that home health providers always treated them as gently as possible, compared with less than 81% of Asian adults.

• The rate of hospital admissions for hypertension was 212.9 per 100,000 population for Black adults in 2018; for White adults, it was just 38.4.

• Hispanic populations have had higher rates of end-stage renal disease due to diabetes than White people in every year AHRQ has looked at the measure.

Health disparities, according to Healthy People 2020, adversely affect groups of people who have systematically experienced greater obstacles to medical care based on their:

• Racial or ethnic group

• Religion

• Socioeconomic status

• Gender

• Age

• Mental health

• Cognitive, sensory, or physical disability

• Sexual orientation or gender identity

• Geographic location

• Other characteristics historically linked to discrimination or exclusion

Healthcare disparities are differences in health insurance coverage, access to and use of care, and quality of care between groups of people.

Many healthcare disparities persist even though we've known about them for a long time. Before the COVID-19 pandemic, Kaiser Family Foundation (KFF) reported that people of color had worse outcomes than their White counterparts in infant mortality, pregnancy-related deaths, prevalence of chronic conditions, and overall physical and mental health status. As of 2018, Black Americans' life expectancy was 4 years lower than that of White people.

Of course, the COVID-19 pandemic put a spotlight on disparities. In analyses accounting for age, Black people are about twice as likely to die from COVID-19 as Whites. Other populations of color also have higher rates of infection, hospitalization, and deaths from COVID-19 compared with White people.

KFF's analysis found that health disparities are driven by inequities in six domains, with racism and discrimination a thread that weaves through all of them.

• Economic instability, including employment, income, and debt

• Neighborhood and physical environment, including housing and transportation

• Education, ranging from early childhood education and literacy to higher education

• Food insecurity (not being able to access a sufficient amount of affordable, nutritious food)

• Safety and social factors, such as stress and lack of community engagement

• Healthcare delivery, with problems that include:

  • Access to culturally appropriate care in a patient's language

  • Respectful care

  • Quality of care

  • Insurance coverage

  • Access to providers and pharmacies

Medical practices that promote DE&I can improve patient care by addressing several problems.

Unconscious bias. As pointed out in Chapter 1, physicians and other medical care professionals — just like everyone else — have unconscious, or implicit, biases against certain groups of people. These beliefs, even if we are not aware of them, can influence the things we say and the decisions we make.

DE&I programs must help medical care providers at all levels recognize their unconscious biases and work to overcome them.

Lack of trust. Until federal legislation created the Medicare and Medicaid programs in 1965, US medical care was segregated by race, with separate — but not necessarily equal — hospitals and providers. In Alabama, a 1915 state law prohibited White female nurses from treating Black male patients. In Mississippi, a law that required Black patients to enter the hospital via a separate entrance from White patients also required physicians to treat White patients before Black patients. In some states, Black physicians were not allowed to practice in White-majority hospitals.

The most infamous atrocity of racism in healthcare is the Tuskegee syphilis experiment, described in Chapter 1. But many people from marginalized groups have personal or family experiences with medical care providers in which they felt mistreated, misunderstood, and marginalized.

On top of that, health disparities are in plain sight in our everyday lives. African American persons are 30% more likely than White persons to die prematurely from heart disease. Black men are 70% more likely than White men to die from a stroke.

Black women are three times more likely than White women to die during or immediately after pregnancy. In addition, the infant mortality rate is 2.3 times greater among Black persons than among White persons. Anyone who has lost a baby at birth — or a loved one from any potentially preventable situation — wonders whether they received appropriate care.

Because of that, people of color and those from other marginalized groups often distrust hospitals and medical care providers.

To cite one example, a study published in the American Journal of Public Health found that elderly Black persons reported less trust in their physician than did elderly White persons. The level of trust in one's own physician correlated with the likelihood of receiving routine checkups, prostate-specific antigen tests, and mammograms.

Those primary care services, of course, head off late-stage cancer diagnoses and other serious problems. The fact that Black persons are more likely to eschew these services may help explain some health disparities between Black persons and White persons.

"This finding is consistent with previous research indicating that trust in physicians matters in the use of health services," the researchers wrote. "Much research suggests that for minority populations, trust can be built through increasing the cultural sensitivity of medical professionals and institutions."

Insufficient diversity among the physician workforce. Only one third of US physicians are women, although that is changing. Currently, a slim majority of medical school students are female. But some other groups have much less representation. For example, only 4% of physicians — and fewer than 7% of recent medical school graduates — are Black, although Black persons account for about 13% of the US population.

Why physician diversity affects health disparities is not yet well understood, but it's getting a lot of attention. Two recent studies are worth a look.

Black men and preventive services. Black men, on average, live 4.5 fewer years than non-Hispanic White men, giving them the lowest life expectancy of any major demographic group in the US. About 60% of the difference in life expectancy between the two groups can be attributed to chronic diseases, which should be addressed through primary or secondary prevention.

Researchers have documented that Black men have higher levels of medical mistrust than White men. This mistrust leads to delays in care, lower use of healthcare services, and worse health outcomes.

A team of physicians and economists set out to answer this question: Does a physician's race influence Black men's use of preventive care services?

The researchers recruited more than 1300 Black men from barbershops and flea markets in Oakland, California, telling them that the study was to learn how to improve the use of preventive care by Black men. A clinic set up to provide preventive services to the men was staffed with both Black and non-Black male physicians.

Each patient was randomly assigned a physician. As each patient waited for the visit to begin, he was introduced to his physician via a tablet that provided text and a photo. Patients were then asked to choose which, if any, of four cardiovascular screening services — body mass index measurement, blood pressure measurement, diabetes screening, and cholesterol screening — they would like to receive. They were then told they could receive a flu shot, administered by their assigned physician.

When patients met their physician, they could revise their choices. After the physician administered the selected services and left the room, the patient filled out a feedback form.

The researchers found that, when choosing services after knowing the physician's race but before meeting him, the physician's race did not affect how many services were chosen. But after meeting the physician, patients assigned to a Black physician were more likely to increase the number of services than were those assigned to a White physician. The biggest difference was in "invasive" services — cholesterol and diabetes screenings, both of which required a fingerstick.

We all know that screenings save lives, and the researchers concluded that the increased uptake of screenings induced by Black physicians could go a long way to reducing health disparities. Specifically, the researchers calculated that increased screenings could prompt a 19% reduction in the cardiovascular mortality gap between Black and White men and an 8% decline in the life expectancy gap between the two groups.

Black infant mortality. Black newborns are more than twice as likely to die during their first year than White newborns. Do Black babies fare better if they are cared for by Black pediatricians?

Health researchers analyzed data about 1.8 million births in Florida hospitals between 1992 and 2015 and found the answer to that question: Yes.

They found:

• When Black newborns are cared for by Black physicians, the "mortality penalty" they suffer comparison with White infants is halved.

• The benefit for Black babies is even stronger in more complicated cases.

• The benefit is also strong in hospitals that deliver a large percentage of Black babies.

In both the Black men preventive services study and the Black infant mortality study, researchers could not parse out why Black patients fared better with physicians of their same race. But the studies do help us understand why patients may prefer physicians who share some identifying features.

"For families giving birth to a Black baby, the desire to minimize risk and seek care from a Black physician would be understandable," the researchers noted. "However, the disproportionately White physician workforce makes this untenable because there are too few Black physicians to service the entire population."

It is therefore essential that physicians do their best to overcome biases; augment trust by relating well to patients of color; and, as promised when they became physicians, make every effort to do no harm.