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Racial Disparities Played Down
By Shankar Vedantam
A federal report on racial disparities in health care was revised at
the behest of top administration officials -- and a comparison with an
earlier draft shows that the version released in December played down
the imbalances and was less critical of the lack of equality.
Government officials acknowledged and defended the changes yesterday,
even as critics charged that the Department of Health and Human
Services rewrote what was to be a scientific road map for change to put a
positive spin on a public health crisis: Minorities receive less care, and
less high-quality care, than whites, across a broad range of diseases.
The earlier draft of the report's executive summary, for example,
described in detail the problems faced by minorities and the societal costs
of the disparities, and it called such gaps "national problems."
The final report's executive summary interspersed examples of
disparities with success stories and emphasized the role of geography and
socioeconomic factors -- rather than just race -- in producing different
outcomes. It dropped the reference to "national problems."
Government officials agreed that the tone of the report had been
changed, saying the revisions reflected HHS Secretary Tommy G. Thompson's
strategy of triggering improvement by focusing on the positive.
"That's just the way Secretary Thompson wants to create change," said
Karen Migdail, a spokeswoman at the Agency for Healthcare Research and
Quality, the HHS unit that drafted the report. "The idea is not to say,
'We failed, we failed, we failed,' but to say, 'We improved, we
improved, we improved.' "
The National Healthcare Disparities Report was intended by HHS to be a
comprehensive look at the scope and reasons for inequalities in health
care. A number of studies have shown that even among people with
identical diseases and the same income level, minorities are less likely to
be diagnosed promptly and more likely to receive sub-optimal care.
Documented disparities exist in the diagnosis and treatment of cancer, heart
disease, AIDS, diabetes, pediatric illness, mental disorders and other
conditions. They also exist in surgical procedures and nursing home
services.
The report was based on an earlier study by the Institute of Medicine
(IOM), a branch of the National Academy of Sciences, an independent
institution that advises the government on scientific questions.
An IOM report suggested last year that widespread racial differences
in health care "are rooted in historic and contemporary inequities" and
asserted that stereotyping and bias by doctors, hospitals and other
care providers may be at fault -- a much stronger critique than the HHS
report.
"The final report was much more positive and upbeat" than the
draft, said Donald Steinwachs, a member of the IOM committee. The final
version, he said, "does not really help people focus on the major
problem areas."
"One of the missions of public health is to identify public health
problems," said Steinwachs, chairman of the department of health policy
and management at the Bloomberg School of Public Health at Johns Hopkins
University in Baltimore. "If you don't identify the problems, then
people don't address them."
The earlier draft of the executive summary was obtained by Rep. Henry
A. Waxman (D-Calif.), who charged that the changes were part of a broad
effort by the Bush administration to politicize science.
"In effect, they whitewashed the issue away, even though they were
told that health care disparities are a national problem and pervasive and
carry a significant personal and societal price," he said. "It's hard
not to reach the obvious result that HHS is wishing the problem away."
The earlier version of the executive summary defined "disparity" and
mentioned it 30 times in the "key findings" section, Waxman said. The
final version mentioned the word only twice in that section and left it
undefined.
In what they called "a case study in politics and science," Waxman and
four other members of Congress said the final version "drops findings
on the societal costs of disparities, and replaces them with a
discussion of 'successes.' "
The final report cited positive examples such as these: that Asians or
Pacific Islanders have lower death rates from cancer; that black and
Hispanic patients are "more likely to report that their provider usually
asks about medications from other doctors"; and that Hispanics and
Asians or Pacific Islanders have "lower rates of hospitalization from
influenza."
Bill Pierce, a spokesman at HHS, said the department is well aware of
the importance of disparities and that the changes made to the
executive summary were only a matter of seeing the glass "half empty" or "half
full." No statistics or tables were changed in the final report, he
said.
Pierce said the Bush administration has launched public health
initiatives in minority communities such as "Take a Loved One to the Doctor
Day," created eight centers to study the issue of disparities, and
started programs to screen low-income women for breast and cervical cancer.
Focusing on the positive was a better approach, he said, "versus
saying, 'We don't do this well, and it is these people's fault.' "
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