In the United States, it is not disputed that disparities in health outcomes vary (independent of clinical factors) across individuals by socioeconomic status and by the presence or absence of health care coverage. Furthermore, these disparities in the quality of care are also commonly found among individuals by race and ethnicity. In 2003, the Institute of Medicine (IOM) released its controversial report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Smedley, Stith, and Nelson 2003). As its title suggests, the report found systematic evidence that, on average, members of racial minorities receive a lower quality of health care than nonminorities. Moreover, the IOM report concluded that these persistent differences were attributable not only to differences in the level of access, but also to stereotyping and bias, conscious or unconscious, by health care professionals. This controversial conclusion has been vigorously contested both by physicians and non-physicians, many of whom are concerned both with the report's criticism of health care and its wider political and social implications.
In November 2003, the University of Chicago's MacLean Center for Clinical Medical Ethics, the Law School, and the Harris Graduate School in Public [End Page S10] Policy Studies convened scholars from a variety of disciplines, including medicine, law, economics, business, and public policy, to examine the fundamental question about the source of the differences in health outcomes and quality of care among different races. This volume includes principal papers and formal responses on three general issues. The first topic addresses global questions about the sources and extent of disparities in access to health care.The second addresses disparities in life-saving interventions, such as organ transplantation. The third examines disparities in chronic conditions, such as coronary artery disease.
The opening papers in this volume focus on the 2003 IOM report. The first three papers criticize the conclusions of the IOM report. Sally Satel and Jonathan Klick dispute whether disparities in health care are explained by any conscious or systematic discrimination on the part of physicians or other health care providers. They argue that the IOM report used retrospective data that failed to reflect individual patients' conditions and to include all relevant variables. Satel and Klick urge researchers to conduct detailed prospective studies, audits, black-white doctor comparisons, and outcome analyses.
Richard Epstein also disagrees with the IOM report's conclusion. Epstein argues that the IOM report is remiss because it fails to adopt a meaningful definition of the idea of discrimination in health care. One consequence of this decision is that the IOM report does not distinguish between discrimination based on bigotry from that based on differential cost: new providers can enter the market to improve access in the first case but cannot do so in the second. In addition, Epstein criticizes the IOM report for its failure to separate out access differentials best explained by such features as breakdowns in communication from practices of discrimination by health care professionals. He claims that the absence of any reported data on conscious discrimination makes it highly unlikely that health care workers—who are largely committed to the ethic of equal access to health care treatment—engage in potent forms of unconscious discrimination. It is far more likely that the observed differences in care are often attributable to efforts of conscientious physicians to take into account the educational and support systems of individual patients. Epstein fears that sharp criticism of current performance could have the unfortunate consequence of driving members of minority groups further away from much needed medical care.
A related paper examines geography as an explanation for the appearance of widespread disparities in outcomes. Katherine Baicker, Amitabh Chandra, and Jonathan Skinner raise the question of whether geographic factors help explain the disparities in outcome. These authors argue that because a disproportionate number of minority patients live in areas where there is worse health care, the effect appears to be the product of race. In fact, controlling for geography eliminates much of the observed disparities in health. The paper does not, however, discuss the possibility that health services are worse in some areas because they have high concentrations of racial minorities.