Doctors in an operating room are wearing clinical gear and performing open heart surgery on a patient.

Black communities have a higher risk of heart disease than white communities, yet have lower access to less risky heart surgeries.
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On Wednesday, doctors from University of Rochester Medical Center in New York announced what they called the “troubling” results of a recent patient study that followed nearly 104,000 heart surgery subjects across 1,085 hospitals. 

In short, their analysis, published in the journal JAMA Network Open, offered concrete evidence that Black people don’t have the same level of access to newer, safer and minimally invasive cardiac surgeries when compared with their white counterparts. 

They had 35% lower odds of getting such procedures.

“Minimally invasive surgeries set patients up for the best outcomes,” study co-author Peter W. Knight, a distinguished professor of cardiac surgery who spearheaded the adoption of minimally invasive procedures at URMC, said in a statement. “That is why the inequities we found in this study are so troubling.”

This means Black people have a higher likelihood of getting traditional heart procedures instead of cutting-edge ones — but those traditional procedures usually involve totally opening the chest cavity, pose a substantial threat of complications and present long recovery times during which even more complications can arise. 

Therefore, the study also concluded that Black patients ultimately have a 62% higher chance than white patients of dying or experiencing major complications due to their heart condition. 

“We’ve known for 35 years that historically marginalized racial and ethnic groups tend to have less access to cardiovascular procedures,” lead author Laurent G. Glance, a professor of anesthesiology and perioperative medicine at URMC, said in a statement. “This study highlights the fact that even in 2022, if you’re not white, you don’t get the same therapies that white people do.”

To be clear, when talking about Black and white individuals, the study considered only non-Hispanic subjects. (The team found Hispanic patients were not less likely to get minimally invasive heart surgery but still had somewhat higher odds of major post-surgical complications, including death, compared with white individuals).

Another important caveat is that Black people have worse overall cardiovascular health than non-Hispanic white people, the study notes, because of historical social and structural injustices in the US. 

For instance, air pollution is higher in racially segregated areas and more likely to hold a higher quantity of toxic, cancer-causing metals. Those areas are often largely populated by Black residents because of the decades-long historic practice of redlining, which restricted where Black home buyers and businesses could establish themselves.

Economic inequality meets medical inequality

In their paper, Glance and fellow researchers also consider why their revealed racial injustice in health care might exist.

For one, they found that Black patients were more likely to seek treatment at underresourced hospitals and to be tended to by less experienced surgeons. People living in Black communities were also shown to have 31-fold higher odds of being treated at hospitals that serve a high proportion of specifically Black patients, underscoring that hospitals are still quite segregated. 

Together, these elements led to one of the team’s proposed solutions: that the Centers for Medicare and Medicaid Services should urge health care programs to stop imposing financial penalties on hospitals that serve the greatest number of vulnerable communities. 

Basically, these penalties are incurred by medical centers enrolled in what are known as value-based health care programs, which offer rewards for high quality of care. On the flip side, those programs penalize hospitals that can’t meet a certain standard, yet that’s often the consequence of being understaffed or having an increased patient load.

Second, the team says Black patients were more likely to have Medicaid insurance, in reference to the US’ public health insurance program, administered by states, for people with low incomes.

“Reducing uninsurance is important, but a big chunk of healthcare reform has been Medicaid expansion,” Glance said. “In theory, increasing the number of people who have insurance should increase access to these procedures, but in this study, we found that just getting people insurance wasn’t enough. The type of insurance also mattered.”

A paper from last year that focused on US health care, for example, suggested providers run into more obstacles when trying to bill Medicaid than they do with other insurers. 

Adding to a wealth of research on the topic, the authors of that study believe such administrative hurdles at least partially explain why Medicaid patients have a hard time getting the same high-quality care as patients with Medicare — federally backed health insurance in the US for people 65 and older — or private coverage. 

Along those lines, Glance and colleagues in their paper stress the importance of increasing access to private health insurance, and lowering the age of eligibility for Medicare, as well as creating a buy-in model for it. 

“Efforts to increase access to commercial insurance or expand Medicare coverage — as opposed to Medicaid expansion alone — may be more successful in promoting racial equity,” the authors write.

This isn’t to say Medicaid is bad

Despite Glance’s study finding a correlation between type of insurance and access to minimally invasive heart procedures, the value of Medicaid itself is more nuanced than it might seem. 

There are a multitude of crucial variables at play when it comes to who has Medicaid, Medicare or private insurance. People with private insurance, for instance, tend to be wealthier and healthier than people with Medicaid, meaning health outcome inequities are likely based on much more than just who has which insurance.

“Of note,” Wednesday’s study authors said, “even among patients with commercial or Medicare insurance, non-Hispanic Black individuals were still less likely to undergo minimally invasive surgery than non-Hispanic White individuals.”

Plus, at the end of the day, it’s better for low-income families to have some health insurance than none. Medicaid is often the only option for some households. As of August, it provided for more than 90 million people. 

For the purest results on Medicaid value as a whole, a massive randomized trial would need to be conducted. To that end, the authors of the recent study say further investigation into their proposed reasons for cardiac surgery inequities is required, but think this is a solid start to solving the problem.

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