Understanding America's Health Care Inequality

DECEMBER 19, 2018
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Hi, I’m Dr. Keith C. Ferdinand, cardiologist at the Tulane [University] School of Medicine and professor of medicine at the Tulane Heart and Vascular Institute.

Today I would like to address disparities in racial and ethnic minorities. First I will talk about some of the current data on disparities specifically related to hypertension and cardiovascular disease. I then will address the socioeconomic factors, also known as the social determinants of health, and how these impact disparities. And finally I will give some practical solutions on how we, as providers, can address these disparities.

Health and overall wellness has improved for all Americans over the last 2 decades. As health has improved, however, there’s a real gap. Since the 1960s, there’s a gap in mortality—whites versus blacks—driven mainly by cardiovascular disease. African Americans have more hypertension; diabetes; obesity, especially in black females; chronic kidney disease; end-stage renal disease; heart failure; premature heart attacks; and an increased death from strokes. These drive these disparities.

In July of 1964, Martin Luther King Jr looked over the shoulder of [President] Lyndon Johnson as they addressed social and economic disparities and access to public accommodations. The Civil Rights Act was landmarked. But as we’ve gone forward—specifically, as it relates to health, probably more than biology or genetics—these social factors now have to be addressed as they relate to the disparities in cardiovascular health. If you look at some of the latest data as they relate to cardiovascular health, you will see that African Americans have more hypertension, earlier onset, more premature hypertension, death from heart failure, premature myocardial infarction, and death from strokes.

These are not driven as much by biology but by the fact that the social determinants of health—where people live, where they play, where they work—all affect these outcomes. Furthermore, going forward, we know that race and even ethnicity are social terms without really true biologic factors. Nevertheless, if we don’t address these social determinants—universal health care, access to a primary care provider, appropriate referral to specialists—we are doomed to see these disparities persist.

The Institute of Medicine in 1960 suggested that there were real disparities in cardiovascular care. Now in 2018 and going forward, we need to do more to address these disparities. In fact, the social determinants of health probably have more of an impact than any biology or genetics as it relates to race and ethnicity and outcomes in cardiovascular disease. Now, if you look across the United States, the Southeastern Conference is good for football but bad for cardiovascular disease. In those areas starting in East Texas, Louisiana, Mississippi, Alabama, Georgia, into the panhandle of Florida, North and South Carolina, parts of Tennessee and Kentucky, and even into Appalachia, there are high rates of cardiovascular disease, including heart attacks and strokes.

In these areas, you have a large number of persons who are uninsured. This uninsured status leads to poorer outcomes. People who cannot afford medications cannot have access to care.

Now, 1 realistic component of this is a large proportion of African Americans who live in these areas. The legacy of slavery was overcome by the civil rights legislation, but perhaps some of the downside of what we have seen for centuries in the United States are disparities in health care. If you look at the map, you will also see that those persons who are uninsured have an increase in nonadherence—that is, in those areas where people don’t have means, they’re less able to afford care, not only including medications but also simple access to primary care providers and specialists. Those persons will get care, but their primary source of care will be the emergency department. When do you go to the doctor? When you’re sick. What doctor? The emergency department, when you have chest pains, shortness of breath, leg swelling.

A landmark study was done decades ago that’s called the Eight Americas. Chris Murray, MD, from the University of Washington, cut Americans into certain segments, looking at real-life expectancy and longevity. Inner-city urban blacks had a shorter life expectancy than people in other parts of America by as much as 10 years or more. This was found both for men and for women.

Transcript edited for clarity.

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