Pursuing Equity: Contact With Primary Care and Specialist Clinicians by Demographics, Insurance, and Health Status

In his recent article (“Pursuing Equity”), Dr. Ferrer makes the very important point that primary care clinicians (especially family physicians) are a critical source of care for those who are disadvantaged. As such, primary care clinicians are an essential buffer that improves homeostasis in a fragmented and dysfunctional health care system by reducing extreme inequities. The converse is also compelling – our nation’s failure to support primary care as a national priority may exacerbate health care inequities and worsen health outcomes for our diverse U.S. population. One caution about this type of study -- there is a tendency to think of “poor, black, and uninsured” all in one breath, without recognizing the heterogeneity within each racial or ethnic group. Instead, it is important to make a distinction in this type of analysis between modifiable predictors of access and equity (poverty, uninsurance, residential segregation, access to affordable and culturally-relevant care, etc.), vs. risk factors (race, ethnicity, gender, etc.) that are not modifiable either by patients or by society. We published just such an analysis(1) of MEPS data in 2004, looking at advantaged vs. disadvantaged individuals (uninsured, poor, and no usual source of care) solely within the African-American population, to demonstrate the powerful impact of these modifiable risks on utilization even within a minority population characterized by a high level of adverse outcomes attributable to racial health disparities(2). We found up to six-fold variation in utilization of office visits and prescription medicines when comparing well-insured, middle & upper-income African American respondents vs. African Americans who were poor and uninsured, as well as dramatic differences in the ratio of ED visit rates to hospital admission rates. Bottom line? Racial disparities in patterns of health utilization are often closely related to factors we as a society could fix, if we so chose. From Dr. Ferrer’s analysis, we can add primary care access to the list, along with previously known factors such as uninsurance, individual and neighborhood poverty, residential segregation, and education(3). 1. Rust G, Fryer GE, Strothers H, Daniels E, McCann J, Satcher D. Modifiable Determinants of Health Care Utilization within the African-American population. J National Medical Assoc, Sept. 2004; 96(9):1169-1177. 2. Satcher D, Fryer GE, McCann J, Troutman A, Woolf S, Rust G. What If We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000. Health Affairs, March 2005. 3. Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff (Millwood). 2005 Mar-Apr;24(2):325-34.

Competing interests:   None declared