How deeply does our health care system discriminate?

Even the safest hospitals still display wide gaps in health outcomes based on patients’ skin color

By Mark Kreidler, Capital & Main

This story is produced by the award-winning journalism nonprofit Capital & Main and co-published here with permission.

Since before the country’s formation, unequal health based on race, from inferior care and treatment to shorter life spans, has been part and parcel of American history. Surveys in recent decades have enabled researchers to bring those disparities into sharper and sometimes harrowing focus.

But identifying these issues hasn’t brought the country much closer to resolving them. And a new report underscores how truly intractable those problems are — because it brings race-based disparities right into the safest hospitals in the United States.

According to the report, which was released this month by the Leapfrog Group, America’s A-graded hospitals — so denoted because of their superior record of keeping patients safe from preventable harm — do no better at reducing racial health disparities than hospitals at the bottom of the scale.

Would you rather be a patient in an A-graded hospital than, say, a D-graded one? Of course — and that is true regardless of a person’s color or ethnicity. Yet even the safest hospitals in the country still reflect wide differences in health outcomes based on patients’ skin color.

“The disappointing finding is that A-graded hospitals don’t do better, for the most part,” said Matt Austin, a Johns Hopkins medical school faculty member who provides strategic guidance to Leapfrog on its annual hospital survey. “We really don’t touch on the why, and I’m not sure we understand the why at this point — other than the obvious, which is that these inequities in our U.S. health system have always been present.”

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For more than a decade, Leapfrog, a nonprofit watchdog group dedicated to transparency in health care, has compiled and measured data from U.S. hospitals and used it to issue safety grades to hospitals on a traditional A through F scale. The most recent survey, undertaken in partnership with the Urban Institute, mined the results of millions of patients, including those in California.

Leapfrog closely studied what it calls “adverse safety events,” which are problems or complications in both general hospital and surgery-specific settings, and then looked at the racial and ethnic breakdowns of those events in three safety-grade cohorts: A, B and C/D/F.

Across 11 such categories at all hospitals, Black patients had significantly higher rates of adverse events than white patients in five, and lower rates in only two. Of particular note was the difference in surgery-related complications; Blacks experienced rates of postoperative sepsis infections, pulmonary embolisms during surgery and postoperative respiratory failure that were 34%, 51% and 17% higher than the rates for whites, respectively.

Latino patients experienced higher rates of adverse outcomes than white patients in two of 11 categories and lower rates in four, the report found.

Most significantly, the disparities didn’t vary much no matter how well a hospital was graded for safety. “These findings suggest that the hospitals most adept at achieving safe care overall are no better at identifying and narrowing inequities in the delivery of that care,” the report’s authors wrote.

Further, patients with public insurance were more likely to receive unsafe care than those with private insurance. Medicare patients had significantly higher rates of adverse events in 10 of the 11 categories studied; for Medicaid patients, it was eight of 11. And while any number of factors — inferior access to care, difficulty finding regular doctors — might contribute to the overall health issues of someone relying on a program like Medi-Cal, even the safest-graded facilities didn’t make it less likely that they’d receive unsafe care when they were actually in the hospital.

The results suggest a double whammy for Black patients. According to the Kaiser Family Foundation, Black residents of the U.S. are more likely to have public health insurance than either white or Latino residents.

Austin noted that although the subject has been discussed for decades, studies such as this one are relatively few. Patients in the A and B graded hospitals received safer care overall, with fewer adverse outcomes — but those hospitals’ inability to close the racial and ethnic disparity gap was glaring.

“There’s certainly a lot of literature out there about some of the causes of the disparities in general, including cultural competency (in understanding race-based health differences) among health care providers,” Austin said in a telephone interview. “The primary question we wanted to examine was whether the higher-graded hospitals were able to reduce those disparities. They weren’t.”

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The Leapfrog report, though new and focused on hospital care, follows a long pattern of previous findings on race and health, including those specific to California. The most recent survey by the California Health Care Foundation, released in February, found that Black and Latino patients were far more likely than either white or Asian Californians to report having had a negative health care experience in the last few years. Among Black residents who took the survey, meanwhile, 98% said that making health care more affordable was “extremely” or “very” important and said that money concerns are one reason they sometimes don’t see a doctor.

And racism in health care is, sadly, a well-worn topic. Some 20 years after the publication of the landmark report “Unequal Treatment,” which highlighted deeply entrenched racial disparities in health coverage in the U.S., many of those involved in producing it told the health site STAT that little has changed.

“There hasn’t been a lot of progress in 20 years,” Brian Smedley, a health equity and policy researcher with the Urban Institute who served as the report’s lead editor, said last year. “We are still largely seeing what some would call medical apartheid.”

The stakes have never been more evident. A report published in May by the Journal of the American Medical Association put it starkly: From 1999 through 2020, the first year of the pandemic, Black Americans experienced 1.63 million “excess deaths” compared with whites, representing 80 million years of potential life lost.

Health disparities in the U.S. remain all too real, and as the Leapfrog report makes clear, they persist even among the highest-regarded facilities. In searching for answers, both California and the nation might begin by asking why their safest hospitals do no better at reducing race-based inequities than anyone else.

Copyright 2023 Capital & Main

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