Academic journal article Health Care Financing Review

Disparities in Medicare Services: Potential Causes, Plausible Explanations, and Recommendations

Academic journal article Health Care Financing Review

Disparities in Medicare Services: Potential Causes, Plausible Explanations, and Recommendations

Article excerpt

INTRODUCTION

The purpose of this article is to provide information for health policy experts to use in considering a research agenda to study and experiment with approaches that have the potential for ameliorating disparities in health care. First, I provide information on disparities in various measures of health for vulnerable subgroups of the elderly, focusing on the three leading causes of death: heart disease, cancer, and stroke. Then, disparities in health are considered along with disparities found in the use of Medicare services. Finally, I examine potential explanations for disparities in Medicare utilization and offer a set of recommendations for change.

The fundamental issue addressed is whether differences in the use of Medicare services signify unequal access to health care. On one dimension of access--potential access--all of the elderly included in the study were insured by Medicare (although some differences may exist in supplemental coverage.) The arguments made in this article revolve around realized access--use of Medicare services--and focus on persistent disparities in Medicare utilization rates that appear inconsistent with the health care needs of vulnerable subgroups of the elderly (Aday, Fleming, and Anderson, 1984).

There are two major limitations to this article. First, health data systems in the United States often contain information broken out by race and ethnicity but rarely by income, education, or occupation, which makes it difficult to analyze the separate influences of race, ethnicity, and SES on health and health care. The lack of information on SES frequently leads analysts to use race and ethnicity as proxies for SES, under the assumptions that race and ethnicity are highly correlated with SES and that social and economic factors are the primary influences on health (alternatively referred to as "health status" or "health outcomes") and health care (use of health care services) (Montgomery and Carter-Pokras, 1993). However, studies that have been able to control for SES often find that disparities by race persist, at least in part, indicating that SES, race, and ethnicity are likely to have separate influences on health and health care. Despite the limitations in the data, striking disparities can often be shown in health and health care, by race, ethnicity, and SES. A second limitation is the lack of published studies testing possible causes and explanations for disparities in Medicare utilization (Mayberry et al., 1999). Thus, I can only explore potential explanations, looking for those that do not fit the data and those that do.

DEMOGRAPHIC FACTORS

Race and Ethnicity

Race and ethnicity in the United States are associated with health status. Every major health measure (mortality, morbidity, and disability) indicates that black persons have poorer health than white persons (National Center for Health Statistics, 1998). Less consistency is found for other subgroups. For example, among those age 65 or over, morbidity rates are generally higher for Hispanic persons than for white persons; however, mortality rates are lower for Hispanic persons than for white persons, which is notable because of the relatively low incomes among Hispanic persons. Similarly notable are mortality rates for the elderly of Asian/Pacific Island origin, which are lower than the rates for elderly Hispanic, white, and black persons, as well as American Indians/Native Alaskans (National Center for Health Statistics, 1998). The favorable death rates for older Hispanic persons and Asian/Pacific Islanders may reflect certain cultural attributes, such as dietary habits and family support, that persist after immigrating to the United States and that are associated with positive health outcomes.

Although these associations are generally consistent over time (Dutton and Levine, 1989), certain relationships have been seen to change, suggesting that acculturation can erode the protective factors associated with an individual's country of origin. …

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