While overall life expectancy in the United States has improved, racial and socioeconomic disparities in mortality and health status have widened. Many Americans fail to receive treatments of proven benefit -- a burden that falls most heavily on racial and ethnic minorities, and low-income populations. As numerous studies and previous Dartmouth Atlas reports have documented, income and race are important determinants of both the health care patients receive and of patients’ health care outcomes.
These disparities are particularly striking when examined across U.S. states and regions; it’s not only who you are that matters, but also where you live. Indeed, many studies that report racial disparities based on national samples do not account for the tremendous variation across regions and procedures. The rate of leg amputation -- a devastating complication of diabetes and peripheral vascular disease -- is four times greater in blacks than in whites; but rates of amputation vary nearly tenfold across regions. For evidence-based services, such as screening mammography and appropriate testing for diabetes, disparities across regions are substantially greater than the differences by race; there are some regions where blacks receive equal or better care than whites but where care for all patients is less than ideal. A recent study found that black cancer patients treated at NCI-designated cancer centers did not experience higher mortality than white patients served at the same hospitals.
Geographic variations in health care are responsible for a substantial component of the observed racial disparity in care, since blacks live disproportionately in parts of the country that have low-quality hospitals and providers. Hospitals and regions of the country also vary enormously in the extent to which disparities are present. Health care disparities are the result of both unequal treatment within a hospital or by a given provider, and unequal treatment because of where people live. These findings highlight the importance of understanding health and health care within a local context -- and of efforts to explore and address the underlying causes of disparities within and across regions.