The situation with regards to American Indians and Alaska Natives is somewhat unique because of the existence of the Indian Health Service (IHS), which operates its own network of inpatient and ambulatory care facilities. While insurance coverage is an issue—24 percent of American Indians do not have health insurance (Brown et al., 2000)—it does not factor into matters of access to care in the same manner as for other subpopulations. The tripartite system of the IHS, tribally operated clinics, and urban Indian clinics represent a unique ecology within which American Indians seek help for physical, mental, alcohol, and drug problems. This is particularly relevant when discussing health care challenges for American Indian elderly since the emphasis of the IHS system is on acute rather than chronic health problems (Baldridge, 2001). Although the IHS is intended, legally, to be a residual provider, a large fraction of the IHS-eligible population depends on it (Cunningham, 1996).

QUALITY OF CARE

Research reveals systematic racial differences in the kind and quality of medical care received by Medicare beneficiaries (Escarce et al., 1993; McBean and Gornick, 1994). In 1992, black Medicare beneficiaries were less likely than their white counterparts to receive any of the 16 most commonly performed hospital procedures (McBean and Gornick, 1994). The differences were largest for referral-sensitive procedures. The Medicare files showed only four nonelective procedures that black Medicare beneficiaries received more frequently than whites—all procedures (such as the amputation of a lower limb and the removal of both testes) that reflect delayed diagnosis or initial failure in the management of chronic disease. Since a greater percentage of black than white Medicare beneficiaries make out-of-pocket payments for deductibles and copayments (McBean and Gornick, 1994), this burden could contribute to less use of ambulatory medical care and to the postponement or avoidance of treatment.

Contrasts among different groups are evident if one focuses on a few procedures that alleviate some major sources of morbidity and mortality, procedures supported by strong scientific evidence and practitioner consensus. Jencks et al. (2000) identified 24 such measures that they labeled measures of the quality of care for Medicare beneficiaries, and 21 of these have been compared across racial and ethnic groups (Hebb et al., 2003), including such inpatient measures as warfarin for patients with atrial fibrillation and such outpatient measures as mammograms at least every 2 years. Receipt of appropriate treatment by each racial or ethnic group is compared with the percentage receiving appropriate treatment overall in Figure 10-1. Racial and ethnic minorities appear to be at some disadvantage, particularly for outpatient rather than inpatient procedures. Hispanics



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