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Equal access to health care lessens racial, ethnic death rate disparities


Access to health care in the United States hinges on a number of factors, including employment status, geographic location and financial resources. Disparities in access to health care can lead to disparities in health; these disparities often fall along racial and ethnic lines.

New research shows that when people of different races and ethnicities had equal access to health care, disparities in death rates decreased as compared with the general population.

The study, published in Health Equity, took advantage of a sub-system within the American health care system – the Veterans Health Administration (VHA), which provides health care to eligible veterans without requiring them to pay insurance premiums. It also helps veterans access care through initiatives such as transportation services. (Eligibility requirements stipulate that “A person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable may qualify for VA health care benefits including qualifying Reserve and National Guard members.”)

Thus, the authors of this study suggest that the VHA offers a kind of natural experiment. They write that the agency, which they describe as “the largest equal-access system in the United States,” is “a suitable model to examine whether equal-access systems and efforts to address nonfinancial barriers to care can reduce racial/ethnic mortality disparities relative to those in the general population.”

“This study is actually part of a larger effort to identify where disparities exist in the VHA,” said lead author Michelle Wong, a research fellow at the Veterans Affairs Greater Los Angeles Healthcare System. “We are examining racial and ethnic disparities and trying to understand what factors might contribute to them.”

She added that the larger initiative that this project is part of is spearheaded by the VHA Office of Health Equity.

The researchers looked at a sample of veterans across the U.S. who went to the VHA for at least one outpatient visit between October 2008 and September 2009. The total sample comprises 5.03 million veterans.

The researchers followed this group until December 2011 and calculated death rates among the sample using national death index records linked to VHA electronic medical records. These mortality rates were compared against death rates for the general U.S. population. The researchers looked at overall death rates (“all-cause mortality”) as well as deaths caused by specific diseases: cancer and cardiovascular disease (“cause-specific mortality”).

Here’s what they found:

  • Compared to the U.S. general population, the veteran population had fewer and less severe disparities.
  • All-cause and cause-specific mortality disparities present among non-Hispanic black women in the U.S. general population did not exist for the VHA population.
  • Within the VHA sample, “Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites.”
  • Some disparities persisted. Non-Hispanic black men had higher rates of cause-specific mortality compared to non-Hispanic white adults in the VHA population, though the disparities were less pronounced than in the general population.
  • Adjusted all-cause mortality rates were higher among American Indians and Alaska Natives than for non-Hispanic white adults within the VHA population — a disparity that is not present in the general population.

“VHA’s success in delivering care to racial/ethnic groups that experience mortality disparities in the U.S. general population highlights the value of its efforts, as an equal-access system that strives to make comprehensive, integrated care available to all members, in addressing persistent racial/ethnic disparities,” the authors conclude. “Despite differences between the U.S. and VHA populations (e.g., VHA users had prior military exposure, more chronic and mental health conditions, and within this study, at least 1 health care visit), implications of this analysis extend beyond VHA to inform how equal-access systems, and broader efforts to expand access to integrated, comprehensive care, may mitigate racial/ethnic health disparities.”

Citation: Wong, Michelle S.; et al. "Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration," Health Equity, April 2019. doi: 10.1089/heq.2018.0086.