Race and Medicine: The Harm That Comes From Mistrust: Racial bias still affects many aspects of health care.

Good overview of the data and issues:

Racial discrimination has shaped so many American institutions that perhaps it should be no surprise that health care is among them. Put simply, people of color receive less care — and often worse care — than white Americans.

Reasons includes lower rates of health coverage; communication barriers; and racial stereotyping based on false beliefs.

Predictably, their health outcomes are worse than those of whites.

African-American patients tend to receive lower-quality health services, including for cancer, H.I.V., prenatal care and preventive care, vast research shows. They are also less likely to receive treatment for cardiovascular disease, and they are more likely to have unnecessary limb amputations.

As part of “The 1619 Project,” Evelynn Hammonds, a historian of science at Harvard, told Jeneen Interlandi of The New York Times: “There has never been any period in American history where the health of blacks was equal to that of whites. Disparity is built into the system.”

African-American men, in particular, have the worst health outcomes of any major demographic group. In part, research shows, this is a result of mistrust from a legacy of discrimination.

At age 45, the life expectancy of black men is more than three years less than that of non-Hispanic Caucasian men. According to a study in the Quarterly Journal of Economics, part of the historical black-white mortality difference can be attributed to a 40-year experiment by the U.S. Public Health Service that shook African-Americans’ confidence in the nation’s health system.

From 1932 to 1972, the Public Health Service tracked about 600 hundred low-income African-American men in Tuskegee, Ala., about 400 of whom had syphilis. The stated purpose was to better understand the natural course of the disease. To do so, the men were lied to about the study and provided sham treatments. Many needlessly passed the disease on to family members, suffered and died.

As one scholar put it, the Tuskegee study “revealed more about the pathology of racism than it did about the pathology of syphilis.” In fact, the natural course of syphilis was already largely understood.

The study was publicized in 1972 and immediately halted. To this day, it is frequently cited as a driver of documented distrust in the health system by African-Americans. That distrust has helped compromise many public health efforts — including those to slow the spread of H.I.V., contain tuberculosis outbreaks and broadenprovision of preventive care.

According to work by the economists Marcella Alsan and Marianne Wanamaker, black men are less likely than white men to seek health care and more likely to die at younger ages. Their analysis suggests that one-third of the black-white gap in male life expectancy in the immediate aftermath of the study could be attributed to the legacy of distrust connected to the Tuskegee study.

Their study relies on interpreting observational data, not a randomized trial, so there is room for skepticism about the specific findings and interpretation. Nevertheless, the findings are consistent with lots of other work that reveals African-Americans’ distrust of the health system, their receipt of less care, and their worse health outcomes.

The Tuskegee study is far from the only unjust treatment of nonwhite groups in health care. Thousands of nonwhite women have been sterilized without consent. For instance, between the 1930s and 1970s, one-third of Puerto Rican women of childbearing age were sterilized, many under coercion.

Likewise, in the 1960s and 1970s, thousands of Native American women were sterilized without consent, and a California eugenics law forced or coerced thousands of sterilizations of women (and men) of Mexican descent in the 20th century. (Thirty-two other states have had such laws, which were applied disproportionatelyto people of color.)

For decades, sickle cell disease, which mostly affects African-Americans, received less attention than other diseases, raisingquestions about the role of race in how medical research priorities are established.

A ‘Rare Case Where Racial Biases’ Protected African-Americans

Outside of research, routine medical practice continues to treat black and white patients differently. This has been documented in countless ways, including how practitioners view pain. Racial bias in health care and over-prescription of opioid painkillers accidentally spared some African-Americans from the level of mortality from opioid medications observed in white populations.

“While African-Americans may not have died at similar rates from opioid misuse, we can be sure needless suffering and, perhaps even death, occurred because provider racism prevented them from receiving appropriate care and pain medication,” said Linda Goler Blount, president and chief executive of the Black Women’s Health Imperative.

Of course, health outcomes are a result of much more than health care. The health of people of color is also unequal to that of whites because of differences in health behaviors, education and income, to name a few factors. But there is no doubt that the health system plays a role, too. Nor is there question that a history of discrimination and structural racism underlies racial differences in all these drivers of health.

Reinforcing the fact of racial bias in health care, a recent studyfound that care for black patients is better when they see black doctors. The study randomly assigned 1,300 African-Americans to black or nonblack primary care physicians. Those who saw black doctors received 34 percent more preventive services. One reason for this, supported by the study, is increased trust and communication.

The study findings are large. If all black men received the same increase in preventive services as those in the study (and received appropriate follow-up care), it would reduce the black-white cardiovascular mortality rate by 19 percent and shrink the total black-white male life expectancy gap by 8 percent, the researchers said.

But it is unlikely all black men could see black doctors even if they wished to. Although African-Americans make up 13 percent of the U.S. population, only 4 percent of current physicians — and less than 7 percent of recent medical school graduates — are black.

This study does not stand alone. A systematic review found that racially matched pairs of patients and doctors achieved better communication. Other studies found that many nonwhite patientsprefer practitioners who share their racial identity and that they receive better care from them. They view them as better than white physicians in communicating, providing respectful treatment and being available.

Racial bias in health care, as in other American institutions, is as old or older than the republic itself.

Title VI of the 1964 Civil Rights Act stipulates that neither race, color nor national origin may be used as a means of denying the “benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” As nearly every facet of the American health system receives federal financing and support, well-documented and present-day discrimination in health care suggests the law has not yet had its intended effect.

Source: Race and Medicine: The Harm That Comes From Mistrust

Public Services and Administration: What does the Census Say?

To what extent do public services and administration reflect and represent the population they serve? 

To start with, representation matters. The degree to which visible minority populations see themselves in public institutions both fosters and reflects integration, and facilitates how these institutions serve their citizens. This article uses census 2016 data to review how effectively education, healthcare, social services, police services and public administration at the national and provincial levels reflect diversity. Police services and public administration are also reviewed at the municipal level.

Overall, the analysis presents a mixed picture of visible minority representation, whether by area or government:

  • Significant under-representation at the elementary and secondary levels of education in contrast to comparable representation at the university level. Given that visible minorities are less likely to have degrees in education (only 7 percent of all 25-34 year olds are Canadian-born visible minority education graduates), this trend is unlikely to change quickly.
  • Healthcare and social services are broadly representative of the populations they serve. While median income data indicates most groups are reasonable well-represented at the professional level, with the exception of Filipinos, Blacks and Latin Americans, Canadian-born 25-34 year old visible minorities form 16.6 percent of those having healthcare degrees in this age cohort.
  • There is serious under-representation in the police of visible minorities among junior and senior officers, particularly of note in our largest cities. Of particular concern is the low level of “except commissioned” officers in Montreal, Edmonton, Calgary and Ottawa-Gatineau, indicating that under-representation is unlikely to be addressed soon. This under-representation likely contributes to some of the tensions between communities (i.e., Black Canadians) and police. The lack of effective employment equity reporting by most police forces is symptomatic of a lack of attention to this issue.
  • The federal public service is reasonably representative of the number of visible minorities who are also citizens, while the provinces and municipalities are less so in most provinces. Median income data shows considerable variation by level of government and visible minority group, particularly for Blacks, Filipinos and Arabs.

Charts and analysis 

Chart 1

Chart 1 provides the gender breakdown in education, healthcare and social services using the North American Industry Classification System (NAICS). The percentage of women declines as the level of education increases; the percentage of women is similar in ambulatory services (doctors and dentist offices) and hospitals, and somewhat greater in nursing homes. For social services (individual and family services), the percentage of women is similar to healthcare but childcare is 92 percent women.

Chart 2

Chart 2 illustrates the median employment incomes for all generations of visible minorities  working in these sectors. Given standard public sector pay scales, the variation reflects a combination of whether visible minorities are professionals or in support positions along with seniority (ambulatory excepted). The relatively low median inco mes of visible minorities compared to not visible minority (NVM) in all levels of education is striking, as is the higher median incomes in hospitals and nursing homes in healthcare. Median income of visible minorities in social services is largely comparable to NVM, likely reflecting relatively low salary bands and classification levels.

Chart 3

Chart 3 takes a closer look at visible minority representation in the education sector, contrasted  with the overall diversity of the population. 792,000 persons work in elementary and high schools, by far the largest area (11.7 percent visible minority), 92,000 in community colleges and CEGEPS (13.7 percent visible minority), and 224,000 in universities (23.7 percent visible minority). Women comprise the majority at all three levels: elementary and secondary schools (73.6%), community colleges and CEGEPs (57.9%) and universities (54.1%).

 In essence, students at the elementary and college levels are less likely to be taught by visible minority educators. In all provinces, the higher the level of education, the greater the number of visible minorities, with Canada-wide university representation (professors and support staff) reflecting the overall population levels.

Median income data provides insights on the extent to which visible minority groups are in professional or support positions. For elementary and secondary schools, all groups, save Chinese (8% lower) and Japanese Canadians (8 percent higher), have a disproportionate share of support positions and/or lower seniority (10 percent difference) compared to not visible minority (NVM). For community colleges and CEGEPs, all groups have significantly lower median incomes than NVM with Japanese Canadians having the least difference (6 percent). For universities, despite the overall greater diversity, median income data suggest that visible minorities are concentrated in more junior positions and support staff.

Chart 4

Chart 4 provides the provincial breakdown, once again contrasting provincial populations with representation in the education sector where the overall pattern of greater university level representation and relative under-representation at the elementary and secondary levels can be  seen. In the largest provinces, university representation is broadly reflective of the population; in smaller provinces, university representation is significantly greater than the population.

Chart 5

Chart 5 compares the overall visible minority population with those working in healthcare and  social services. 

Approximately 1.5 million persons work in healthcare: 564,000 in ambulatory services, 632,000 in hospitals and 328,000 in nursing homes. About 344,000 work in social services, of which 149,000 in individual and family services and 194,000 in childcare.

Starting with healthcare, group representation varies by sector. The major visible minority groups are represented in all sectors shown with some relative over-representation of Chinese in ambulatory services, Blacks in hospitals, nursing homes, and social services, Filipinos in all sectors and Arabs dramatically so in childcare.

Median income data indicate that South Asians, Chinese, Arabs and Southeast Asians are more likely to be in professional positions in doctor offices; Chinese, Southeast Asians, Korean and Japanese in dental offices. Hospital median income data highlight that South Asians, Chinese, West Asians, Korean and Japanese are more likely to be in professional positions. Groups that tend to be more in support positions are Filipino, Black and Latin American.

Chinese, Arab, West Asian and Korean are over-represented by men compared to not visible minority (10 percent difference), with the relative gender gap particularly high for Arabs (23 percent).

Chart 6

Chart 6 provides the healthcare visible minority representation by province, reflecting the overall pattern of representation comparable to the visible minority population, with noticeable over-representation of visible minorities in nursing homes.

Visible minorities are over-represented in Manitoba and Saskatchewan (hospitals and nursing homes only), and the under-representation in Quebec ambulatory services likely reflects the low visible minority population outside of Montreal and environs. 

Chart 7

Chart 7 contrasts the visible minority workers in social services and childcare, again reflecting the overall  national pattern, with the striking over-representation of visible minorities in childcare in most provinces.

Chart 8

Chart 8 provides the national breakdown of visible minority police officers, separated out by commissioned (senior) and “except commissioned” (junior) officers, again contrasted with the overall visible minority population. There are 2,015 commissioned officers and 75,670 non-commissioned officers. Given mixed to limited reporting by police forces, this provides the best measure of police force diversity.

As one would expect, not commissioned officer diversity is greater than the senior ranks, providing a feeder group to increase commissioned officer diversity over time.

Chart 9

Chart 9 looks at the diversity of police forces in six of Canada’s largest cities. It is a mixed picture: while the overall pattern of under-representation remains, in some cities the percentage of visible minority commissioned officers is greater than not commissioned, suggesting a conscious decision to ensure greater representation at senior levels (e.g., Toronto, Edmonton).

Equally striking is the relative lack of visible minority police in Montreal (both commissioned and except commissioned), Calgary (no visible minority commissioned officers) and Edmonton (except commissioned). 

The integrated numbers for Ottawa Gatineau disguise significant differences: whereas in Ottawa visible minority commissioned officers form 8.7 percent, except commissioned 8.5 percent, in Gatineau there are no visible minority commissioned officers and only 2.9 percent of except commissioned officers are visible minorities

Chart 10

Census data provide a useful counterpoint to the annual Treasury Board Secretariat (TBS) employment equity reports. TBS reports have a richer dataset than the Census (regional, occupational group, salary, age and other breakdowns) but they only cover Schedule 1 bodies and do not include Schedule 2 bodies (e.g., CRA, CFIA, CSIS, NRCE, Parks Canada) or Schedule 3 (Crown corporations) and do not provide a breakdown by visible minority groups. Census data also provide consistent data at the provincial and municipal levels. The population benchmark used is that of visible minorities who are also Canadian citizens, given the preference in hiring citizens.

Chart 10 not only provides the overall visible minority representation, but breaks this down by the different visible minority groups. About 317,000 persons work in federal public administration (all except defence), 269,000 in provincial public administration and 340,000 in municipal. Significantly more women than men work in federal and provincial public administration (55.6 and 58.9 percent respectively) whereas municipal public administration is majority male (60.6 percent), reflecting the nature of municipal services (e.g., garbage collection, road maintenance).

At the federal level, only Chinese, Arabs and Japanese public servants reflect or are greater than the overall visible minority citizen population. All other groups are under-represented by 10 percent or more. 

Chart 11

Chart 11 contrasts provincial and municipal public administrations with the overall number of visible minority citizens. Provincial visible minority public servants largely mirror the overall number of visible minorities with the notable under-representation in British Columbia and slight overrepresentation in Alberta, Manitoba, and Saskatchewan. Municipal pu blic administration visible minority public servants are under represented in all provinces save Saskatchewan and Atlantic Canada, and in some cases, significantly as is the case in Ontario, Quebec and British Columbia.

All groups, save Black, are underrepresented at the provincial level and all groups save Japanese are under-represented at the municipal level.

Chart 12

Chart 12 compares the median income of visible minority groups compared to not visible minority for each level of government, providing an indication of whether groups are in more senior or junior positions.

Only Chinese and Japanese public servants have higher median incomes for all three levels of government. South Asian provincial public servants, Black and West Asian municipal public servants and Korean provincial public servants also have higher median incomes. The greatest gaps in median incomes are for Black (save municipal), Filipino, Latin American and Arab (save federal). 

Addiction Kills More Blacks, But Treatment Is Prescribed Mostly To Whites

Yet another study on the disparities in healthcare:

White drug users addicted to heroin, fentanyl and other opioids have had near exclusive access to buprenorphine, a drug that curbs the craving for opioids and reduces the chance of a fatal overdose. That’s according to a study out Wednesday from the University of Michigan. It appears in JAMA Psychiatry.

Researchers reviewed two national surveys of physician-reported prescriptions. Between 2012 and 2015, as overdose deaths surged in many states, so did the number of visits during which a doctor or nurse practitioner prescribed buprenorphine, often referred to by its brand name, Suboxone. The researchers assessed 13.4 million medical encounters involving the drug but found no increase in prescriptions written for African Americans and other minorities.

“White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,” says Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and the study’s corresponding author.

The dominant use of buprenorphine to treat whites occurred at the same time opioid overdose deaths were rising faster for blacks than for whites.

“This epidemic over the last few years has been framed by many as largely a white epidemic, but we know now that’s not true,” Lagisetty says.

What is true, Lagisetty added, is that most of the white patients either paid cash (40%) or relied on private insurance (35%) to fund their buprenorphine treatment. The fact that just 25% of the visits were paid for through Medicaid and Medicare “does highlight that many of these visits could be very costly for persons of low income,” Lagisetty says.

Doctors and nurse practitioners can demand cash payments because there’s a shortage of clinicians who can prescribe buprenorphine, according to Dr. Andrew Kolodny, co-director of Opioid Policy Research at Brandeis University. Only about 5% of physicians have taken the special training required to prescribe buprenorphine.

“The few that are doing it are really able to name their price, and that’s what we’re seeing here and that’s the reason why individuals with more resources — who are more likely to be white — are more likely to access treatment with buprenorphine,” says Kolodny, who was not involved in the study.

Kolodny wants the federal government to eliminate the required special training for buprenorphine and a related cap on the number of patients a doctor can manage on the drug.

Some physicians who have studied racial disparities in addiction treatment say the root causes go back to 2000, when buprenorphine was approved. At that time, proponents argued that buprenorphine was needed to help treat suburban youth, says Dr. Helena Hansen at New York University. Those young patients didn’t see themselves as addicted to heroin in the same way as hard-core urban heroin users who went to methadone clinics for treatment, she says.

“Buprenorphine was introduced as private office treatment, for a private market, with the means to pay,” says Hansen, an associate professor of psychiatry and anthropology. “So the unequal dissemination of buprenorphine for opioid dependence is not accidental.”

Hansen added that the fix must include universal access to treatment in a primary care setting, an end to the criminalization of opioid dependence (which puts more blacks in prison for drug use than whites), and more federal funding to expand access to buprenorphine for all patients.

Several leaders in the fight to reduce opioid overdose deaths say the study results are disturbing.

“It really demands for us to be looking at equitable treatment for addiction for African Americans as we do for white Americans,” says Michael Botticelli, director of the Grayken Center for Addiction at Boston Medical Center and the former director of the Office of National Drug Control Policy.

Botticelli identified some key issues that may be contributing to the racial treatment gap that deserve further investigation. For example, he wants to know whether Medicaid reimbursement rates are simply too low to entice more doctors to work with low-income patients, or there are too few inner-city doctors prescribing buprenorphine, or African Americans themselves are somehow reluctant to seek this form of treatment.

Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, called the findings surprising and disturbing. Surprising because the disparity is so large, and disturbing because her agency has prioritized educating doctors about the value of prescribing buprenorphine.

Volkow also expressed disappointment that federal parity laws, which are supposed to guarantee equal access to all types of medications, don’t seem to be working for buprenorphine. “We need to ensure that we have capacity to provide these treatments,” Volkow says. “Because if you say you have to pay for them, but there are no services that can provide the treatments, then the issue of paying for them is secondary.”

Volkow has noted that fewer than half of Americans with an opioid use disorder have access to buprenorphine or the two other medications used to treat opioid addiction: methadone and naltrexone. Volkow said she is glad that the use of buprenorphine is on the rise, but the U.S. needs to understand why this lifesaving treatment isn’t benefiting all patients who need it.

Source: Addiction Kills More Blacks, But Treatment Is Prescribed Mostly To Whites

Doctors and Racial Bias: Still a Long Way to Go

Of note:

The racist photo in the medical school yearbook page of Gov. Ralph Northam of Virginia has probably caused many physicians to re-examine their past.

We hope we are better today, but the research is not as encouraging as you might think: There is still a long way to go in how the medical field treats minority patients, especially African-Americans.

A systematic review published in Academic Emergency Medicinegathered all the research on physicians that measured implicit bias with the Implicit Association Test and included some assessment of clinical decision making. Most of the nine studies used vignettes to test what physicians would do in certain situations.

The majority of studies found an implicit preference for white patients, especially among white physicians. Two found a relationship between this bias and clinical decision making. One found that this bias was associated with a greater chance that whites would be treated for myocardial infarction than African-Americans.

This study was published in 2017.

The Implicit Association Test has its flaws. Although its authors maintain that it measures external influences, it’s not clear how well it predicts individual behavior. Another, bigger systematic review of implicit bias in health care professionals was published in BMC Ethics, also in 2017. The researchers gathered 42 studies, only 15 of which used the Implicit Association Test, and concluded that physicians are just like everyone else. Their biases are consistent with those of the general population.

The researchers also cautioned that these biases are likely to affect diagnosis and care.

A study published three years earlier in the Journal of the American Board of Family Medicine surveyed 543 internal medicine and family physicians who had been presented with vignettes of patients with severe osteoarthritis. The survey asked the doctors about the medical cooperativeness of the patients, and whether they would recommend a total knee replacement.

Even though the descriptions of the cases were identical except for the race of the patients (African-Americans and whites), participants reported that they believed the white patients were being more medically cooperative than the African-American ones. These beliefs did not translate into different treatment recommendations in this study, but they were clearly there.

In 2003, the Institute of Medicine released a landmark report on disparities in health care. The evidence for their existence was enormous. The research available at that time showed that even after controlling for socioeconomic factors, disparities remained.

There’s significant literature documenting that African-American patients are treated differently than white patients when it comes to cardiovascular procedures. There were differences in whether they received optimal care with respect to a cancer diagnosis and treatment. African-Americans were less likely to receive appropriate care when they were infected with H.I.V. They were also more likely to die from these illnesses even after adjusting for age, sex, insurance, education and the severity of the disease.

Disparities existed for patients with diabetes, kidney disease, mental health problems, and for those who were pregnant or were children.

The report cited some systems-level factors that contributed to this problem. Good care may be unavailable in some poor neighborhoods, and easily obtained in others. Differences in insurance access and coverage can also vary by race.

But the report’s authors spent much more time on issues at the level of care, in which some physicians treated patients differently based on their race.

Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers. Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes.

Of course, there’s the issue of mistrust on the patient side. African-American patients have good reason to mistrust the health care system; the infamous Tuskegee Study is just one example.

In its report, the Institute of Medicine recommended strengthening health plans so that minorities were not disproportionately denied access. It urged that more underrepresented minorities be trained as health care professionals, and that more resources be directed toward enforcing civil rights laws.

In practice, it endorsed more evidence-based care across the board. It noted the importance of interpreters, community health workers, patient education programs and cross-cultural education for those who care for patients.

All of this has met with limited success.

In 2017, the Agency for Healthcare Research and Quality issued its 15th yearly report on health care quality and disparities, as called for by the medical institute in 2002. It found that while some disparities had gotten better, many remained. The most recent data available showed that 40 percent of the quality measures were still worse for blacks than whites. Other groups fared worse as well. Measures were worse for 20 percent of Asian-Americans, 30 percent of Native Americans, and one third of Pacific Islanders and Hispanics.

Of the 21 access measures tracked from 2000 to 2016, nine were improving. Nine were unchanged. Three were worsening.

It would be easy to look at a racist photo from the 1980s and conclude that it was a different time and that things have changed. Many things have not. We know that racism, explicit and implicit, was pervasive in medical care back then. Many studies show that it’s still pervasive today. The recommendations from the medical institute in 2003 still hold. Any fair assessment of the evidence suggests much work remains to be done.

USA: Immigrants’ Health Premiums Far Exceed What Plans Pay For Their Care

While not necessarily a perfect analysis as some of the comments indicate, far closer to the truth than the Trump administration political rhetoric. Same likely applies in Canada save for the parents and grandparents category:

President Donald Trump has repeatedly condemned U.S. immigration policy, arguing that many immigrants pose a threat to the nation and drain U.S. resources. But a study released Monday about health insurance challenges the president’s portrayal.

The study in the journal Health Affairs found that immigrants covered by private health insurance and their employers contributed nearly $25 billion more in premiums in 2014 than was spent on their care. Those in the country without legal status contributed nearly $8 billion toward the surplus.

In contrast, U.S.-born enrollees spent nearly $25 billion more than they paid for in premiums.

These findings surface as the Trump administration’s immigration policies — including a plan to tie migrants’ efforts to get permission for permanent residency to their use of federal benefit programs — have come under scrutiny.

Earlier studies also found that immigrants contribute more to Medicare than they receive in benefits, but the authors of this study say it is the first to look at the effect in private insurance plans.

Leah Zallman, assistant professor of medicine at Harvard Medical School and lead author of the study, said her findings allude to the potentially negative consequences that tighter immigration policies could have on the health care industry.

“I think in today’s era … there’s so much concern about immigrants and immigration really sort of draining our resources in the U.S.,” Zallman said. “This really points to the critical role that immigrants have in actually subsidizing and maintaining our current systems.”

Researchers calculated the financial contributions and expenses of enrollees and their employers using two surveys created by the federal government. Plans sold on the federal health law’s insurance exchanges were not included because they “differ from other private insurance in important ways and are unavailable to undocumented people,” the study authors noted.

Anyone born outside of the United States was categorized as an immigrant. However, the surveys did not ask non-citizens with private coverage about their legal status. Researchers used national data on undocumented immigrants to estimate how many people in the study group illegally resided in the country.

In 2014, immigrants and their employers contributed $88.7 billion in private insurance premiums, but spent only $64 billion for care, according to the study’s findings. Of that group, undocumented immigrants alone paid more than $17 billion to private insurers but used only $9.4 billion.

Native-born consumers paid $616 billion in premiums and received nearly $641 billion in insurers’ payments for care. They also consistently outspent immigrants across all age groups. Among enrollees 65 and older, the U.S.-born made a net contribution of nearly $10,000 more toward their care than those born overseas, according to the study.

The researchers reported that, on average, individual immigrants paid $1,123 more for premiums in 2014 than they received in insurance-covered care. U.S. natives instead cost insurers $163 on average.

Leighton Ku, director of the Center for Health Policy Research at George Washington University who was not involved in the study, said several factors contribute to immigrants’ low health care expenses. The group tends to be healthier and younger when they arrive in the United States. Cultural and language differences also hinder them from accessing care.

The study noted that immigrants’ health care expenditures increased the longer they remained in the country. But it added that since their premiums also increased at the same time, they continued to make a net contribution to their private health plans.

The findings come about a week after the Department of Homeland Security proposed redefining how it would determine “public charge,” a term used to describe a person likely to become dependent on the government for assistance. The proposal would make it harder for immigrants to live and work permanently in the U.S. if they receive certain types of federal assistance, such as Medicaid, food stamps and housing subsidies.

Trump has vowed to be tough on immigration standards. During his campaign, he berated U.S. health expenditures on immigrants, arguing that the U.S. spent $11 billion for care to people who were in the country without authorization, the study’s authors note.

But they point out that earlier research shows that immigrants have low rates of health care use and spending, compared with native residents. Their payments to private plans and Medicare in essence prop up care for patients who are U.S.-born, the authors say.

A study Zallman published earlier showed unauthorized immigrants contributed $35.1 billion more to Medicare from 2000 to 2011 than they used in services.

Benedic Ippolito, an economist at the American Enterprise Institute, cautioned using the study’s findings to draw conclusions on a large scale about immigrants and their role in health insurance. An estimated 20 percent of immigrants — including nearly half of the undocumented population — are uninsured, according to the study. Ippolito said the cost of their uncompensated care affects whether immigrants’ financial contributions actually lead to surpluses for health care overall.

“I would be careful about how much I extrapolate these results to a) other parts of the health insurance market and b) even further to what this means for immigration policy,” Ippolito said. “This paper alone does not tell us everything we need to know.”

Ku echoed the uncertainty. He said he is not certain how the Trump administration’s latest actions will affect immigrants enrolled in private insurance. Having a private plan may suggest they are employed with a certain income stability. However, if enough immigrants leave the insurance market, he added, it may have the unintended consequence of making health plans more expensive for everyone else.

“That does have the following implication that to the extent that we do things to suppress immigrants or make it harder for them to purchase insurance then in that case we may do harm to the citizens,” he said.

Source: Immigrants’ Health Premiums Far Exceed What Plans Pay For Their Care

The Studies Behind Canadian Health Care Seem To Have Forgotten Us

Valid points. Studies need to reflect the increased diversity of our population:

One of the most important campaigns in Canada has nothing to do with politics. Choosing Wisely Canada is an initiative that aims to curtail the unnecessary tests and treatments in our health-care system. Started in 2014 by a team from the University of Toronto, Canadian Medical Association and St. Michael’s Hospital, Choosing Wisely is part of a global movement that first began in the United States by the American Board of Internal Medicine Foundation. It now spans 20 countries across five continents and includes the majority of medical societies and associations, including those in Canada​​​​​.

The evidence to support a reduction in wasteful diagnostic and therapeutic resources is clear and uncontroversial. The Canadian Institute for Health Information estimates that 30 per cent of health care, or nearly 1 million tests and treatments annually, is unnecessary. This is a staggering figure, and especially worrisome given Canada’s growing health-care expenditure, which totaled $228 billion dollars — or 11 per cent of its gross domestic product — in 2016. A national effort to curb unnecessary testing and treatment not only makes medical sense, but is also economically prudent in the context of ballooning health care utilization.

Choosing Wisely hopes to achieve its goals through grassroots advocacy by publishing a series of practice recommendations for physicians based on peer-reviewed research. These recommendations, organized by specific specialties, are often based on meta-analyses of research already conducted in different areas of clinical medicine. Interestingly, many of the studies used to ultimately guide these recommendations did not collect data or outcomes on minority populations. In studies that did, most of the patientsanalyzed were Caucasian. It begs the question, is Canadian health care choosing wisely or merely choosing whitely?

Inexplicably, research data on minority and female populations is not collected in Canada — seemingly a theme in this country.

This is why it matters. The medical community has long ignored minority, female and low socioeconomic communities in its research initiatives. In order to combat this trend, the National Institutes of Health (NIH) passed the Revitalization Act in 1993 that mandated the appropriate inclusion of women and minorities as subjects in clinical research. Inexplicably, research data on minority and female populations is not collected in Canada — seemingly a theme in this country. Despite the lofty goals of the NIH, however, the research community has fallen well short of its intended demographic targets.

Clinically, this has significant implications. Studies have shown that a patient’s race and gender play a large role in disease screening, diagnosis and management. For example, the Framingham Risk Score, which is considered the gold standard algorithm to predict a patient’s 10-year risk of having a cardiovascular event, was primarily validated in the Caucasian population. Unfortunately, clinicians still rely on this tool and often apply it to minority populations despite it not accurately estimating their risk.

Similarly, research has shown that African American women suffer higher mortality ratesfrom breast cancer relative to Caucasian American women. It has been hypothesized that they may be at higher risk from early onset disease, which may put them at a disadvantage when considering current screening guidelines. These illustrations demonstrate that our medical research infrastructure has focused on promoting the health of patients who are most often male, Caucasian and well-heeled.

These research biases are hard to shake because research is notoriously hard to conduct. It first involves identifying a clinical question, generating an hypothesis, developing an experimental protocol and securing funding. Subsequently, researchers need to navigate the important but Byzantine institutional review processes before addressing the challenges associated with subject recruitment, data collection and analysis. Ideal research patients are those who have the luxury of time and who are able to travel to downtown research hospitals for repeated evaluation. It is easy to see how this is unlikely to include a minority single mother working multiple jobs in Scarborough.

Our society will migrate away from a one-size-fits-all health-care paradigm.

Canada’s Minister of Science, Kirsty Duncan, has recently called science sexist, but sadly stopped short of also calling it racist. She, did however, recently introduce the Equity, Diversity and Inclusion Action Plan in order to address the chronic under-representation of women, First Nations, visible minorities and persons with disabilities among Canada Research Chairs. This laudable effort should also dovetail with the minister’s insistence — along with support from the newly installed chief science advisor — that taxpayer-funded medical research focus on all communities represented in our country and not just select groups. She could make significant strides in this area by following the NIH’s lead with a Canadian version of the Revitalization Act.

In an era that will be increasingly dominated by big data genomics, artificial intelligenceand personalized medicine, our society will migrate away from a one-size-fits-all health-care paradigm. Choosing Wisely will continue being an essential and vital initiative in helping to reduce unnecessary tests and streamline medical care in this country. Future iterations of its recommendations, along with any practice guidelines created, should endeavour to more comprehensively apply to and represent the great diversity of Canada.

Source: The Studies Behind Canadian Health Care Seem To Have Forgotten Us

Minorities Get Less Pain Treatment in E.R. – The New York Times

Highlights a problem, with a large gap in treatment:

White patients receive more pain treatment in emergency rooms than African-Americans and other minorities, a new study reports.

Researchers studied four years of data collected nationwide by the Centers for Disease Control and Prevention. They used a sample of 6,710 visits to 350 emergency rooms by patients 18 and older with acute abdominal pain.

White and black patients reported severe pain with the same frequency — about 59 percent. But after controlling for age, insurance status, income, degree of pain and other variables, the researchers found that compared with non-Hispanic white people, non-Hispanic blacks and other minorities were 22 percent to 30 percent less likely to receive pain medication. Patients were also less likely to receive pain medicine if they were over 75 or male, lacked private insurance or were treated at a hospital with numerous minority patients. The study is in the journal Medical Care.

The senior author, Dr. Adil H. Haider, the director of the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston, said: “It may be that different people communicate differently with their providers. If we as providers could improve our ability to better communicate with patients so that we could provide more patient-centered care, we’ll be making several steps toward reducing and hopefully eliminating these disparities.”

Source: Minorities Get Less Pain Treatment in E.R. – The New York Times

Hospitals to query patients on race, sexual orientation

Balancing the need for better information to inform care decisions and concerns about people being asked to provide information is always a challenge.

But my bias is towards better information, and the few times that it has come up with my doctors, their line is “nothing is more costly than ignorance.”

More specialized information and linkages than from the Census and NHS:

Marylin Kanee, director of human rights and health equity at Mount Sinai, said properly training staff is key to ensuring patients feel comfortable with the survey and understand the information will be used to improve medical care. Researchers will not be given names of patients. Responses will be aggregated and analyzed to detect differences in health outcomes connected to variables such as race, language and poverty.

“This is information that will help us to tailor the care that we provide to our patients,” Ms. Kanee said. “It will give us information about who are patients are and it will help us to really understand where the inequities are.”

At St. Michael’s Hospital, Fok-Han Leung has experienced the benefits of having greater demographic information at his fingertips. Data collection was tested at the hospital’s family medicine outpatient clinic, with responses gathered on tablets. The information was then instantly linked to a patient’s file.

Seeing a patient’s income, for example, helped inform Dr. Leung’s prescription decisions. In some cases, a shorter medication supply and monitoring the drug’s effectiveness was more prudent than a costly 90-day prescription.

“It can sometimes help with diagnosis, but it very much helps with [care] management,” Dr. Leung said.

Patient participation in Toronto Central’s questionnaire has been strong so far: 85 per cent. At St. Joseph’s, Mike Heenan, vice-president responsible for quality and patient experience, said he’s heard from a few staff opposed to the hospital participating in the project. But he notes 95 per cent of 14,954 presurgery patients have answered the questionnaire, while only eight have registered concerns.

Hospitals to query patients on race, sexual orientation – The Globe and Mail.

Toronto’s diverse population requires multilingual health care: Goar | Toronto Star

Good overview by Carol Goar on an initiative to provide interpretation services in healthcare:

Patients using the service no longer have to bring a relative or friend to medical appointments. They don’t have to disclose sensitive information domestic abuse, mental health issues, sexual problems to their families to get help. They don’t have to impose the burden of being a go-between on young children. And according the Centre for Inner City Health, they believe the quality of the care is better when they can communicate without fear of being misinterpreted by their health-care provider.

Health-care providers have more confidence in the information they are getting from patients. They don’t have to deal with difficult family dynamics. They can involve patients in their own treatment. And they can be sure their instructions are being conveyed to the patient accurately. “It has fundamentally changed who we are able to offer services to,” one health-care provider said.

The researchers did find a few gaps and weaknesses:

  • Elderly patients often don’t like — and won’t use — the technology. The special dial-in code and the delays patching everybody into the conversation frustrate them.
  • The service is inappropriate for people with dementia or paranoia. For them, disembodied voices can be confusing or threatening.
  • It is obviously unsuitable for hard-of-hearing patients.
  • The interpreter’s gender can make some conversations difficult.
  • The cost is a barrier for certain community agencies.
  • And some patients prefer the old method.

On balance, however, the evaluation team gives the program high marks and recommends expansion with a few adjustments.

With the face of urban Canada rapidly changing, it is heartening to see Toronto take the lead in keeping medicare open and equitable.

Toronto’s diverse population requires multilingual health care: Goar | Toronto Star.

Religion and Healthcare

From UofT’s student newspaper, The Varsity, a lengthy piece on religion, accommodation and healthcare. My favourite part is the care taken to have an inclusive interfaith space:

The creation of the spiritual oasis of Mount Sinai, for example, was done by a committee.

“We actually pulled together staff who were interested in designing that space from a wide range of religious groups, including atheists, so we had everybody at the table,” says Kanee. “We worked together to figure out what we needed in that space, but also how we could build a space that wouldn’t be accommodating to the needs of one religion, and offend others.”

The room has prayer mats and kneelers, and a small table that can serve as an altar, and is attached to a wudu room. Each element was carefully considered before its inclusion; for example, no artifact could dominate the room.

“So it’s very plain,” Kanee explains, “but everything you need is in there, you just need to access it and pull it out.”

Shifting intersections: The evolving relationship between religion and medicine in Toronto’s public sphere