Despite insurance, income and race affect health care Large federal study examines experience of Medicare patients


WASHINGTON -- Even when people are covered by Medicare, the type of care they receive and their overall mortality are influenced by race and income, according to a large federal study.

While insurance was found to be essential for obtaining good health care, the study concluded that it was not sufficient to guarantee optimum care for everyone.

The study was done by researchers at the Woodlawn-based Health Care Financing Administration, which oversees Medicare insurance coverage for the elderly.

Examining the records of doctor and hospital claims for services in 1993 for 26.3 million Medicare beneficiaries, they found that blacks and lower-income people of all races appear to get less preventive care and less optimal management of chronic diseases than do whites and upper-income people.

Similar trends have been noted before in earlier studies, but researchers, led by Marian Gornick and Paul Eggers, said their work matched the Medicare records with income data based on ZIP codes from the 1990 census.

This method allowed them to separate out the effects of income on the kind of care received. Previous studies have suggested that the lack of insurance and lower incomes were the barriers that interfered with blacks' obtaining health services.

The new report found that even when insurance coverage and income are equal among blacks and whites, blacks obtain fewer preventive services, such as mammograms or influenza immunizations, than do whites.

Comparing flu immunization rates, less-affluent whites had rates 26 percent lower than the most affluent group and less-affluent blacks had rates 39 percent lower the most well-off Medicare recipients.

And although equally covered by insurance, black male Medicare beneficiaries in 1993 had an age-adjusted mortality rate of 8 per 100, compared with 6.7 per 100 for white men, the researchers found. For women, the mortality rates for blacks were 5.2 per 100 compared with 4.5 per 100 for whites.

The report, being published today in the New England Journal of Medicine, said the racial differences were reduced by adjusting mortality and health-services use rates for differences in income, but only slightly.

For instance, the rates of getting mammograms for early detection of breast cancer are 34 percent lower for black women than white women when income was not considered. Yet adjusted for income, mammography rates for blacks still were 25 percent lower than for whites, the report noted.

"Even when insurance coverage and income are equal, barriers to getting the best care still remain for some beneficiary groups," Dr. Bruce C. Vladeck, the financing agency's administrator, said in an interview.

"This means we have to do more, such as develop special outreach programs, to make sure that black beneficiaries have better access to health services."

The poorer outcome for black patients on Medicare is partly due to the lack of health insurance and adequate care in the years before they reach age 65 and became eligible for Medicare, Vladeck said.

Dr. H. Jack Geiger, of the City University of New York Medical School, said in an editorial in the journal that results of the new study are consistent with scores of others showing that black and poor populations get less and poorer quality health care.

The study clearly shows that both race and income have effects on health care, Geiger said, but "race was the overriding determinant of disparities in care."

If racism is involved, Geiger said, it is unlikely to be overt or conscious, but rather reflects more subtle ways in which doctors view their patients.

Pub Date: 9/12/96

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