and American Indians and Alaska Natives, overall, may receive care that is as inadequate as that for blacks, though because of small numbers and problems with racial and ethnic identification, the figures must be treated with caution. People enrolled in both Medicare and Medicaid (of any racial or ethnic group) also receive less adequate care than average, suggesting a socioeconomic dimension to poor care. However, their disadvantage is sometimes smaller than that of particular racial and ethnic groups.

Such differences in the receipt of medical procedures are consistent with a larger literature, generally for earlier years, that finds systematic racial and ethnic differences in the receipt of a broad spectrum of therapeutic interventions (Geiger, 2002; Institute of Medicine, 2002; Mayberry et al., 2000). Blacks and sometimes other minorities are less likely to receive a diverse range of procedures, ranging from high-technology interventions to basic diagnostic and treatment procedures, and they experience poorer quality medical care than whites.

Differences in patient preferences and inappropriate use by whites of some procedures may play a role in the differences. For instance, Schneider et al. (2001) show that the black-white difference in angioplasty can be explained by inappropriate or at least questionable use of the procedure for whites. However, they find that this explanation does not fully account for differences in bypass surgery. The pattern of differences between blacks and whites appears robust even when such factors are considered, and it persists in studies that adjust for differences in health insurance, socioeconomic status, stage and severity of disease, comorbidity, and the type of medical facility (Institute of Medicine, 2002).

Weighed against such evidence is one recent study of a nationwide sample of almost 30,000 Medicare patients hospitalized with heart failure in 1998 and 1999 (Rathore et al., 2003). Blacks were slightly more likely than whites to receive appropriate treatment (ACE inhibitors and measurement of left ventricular ejection fraction). They were more likely to be readmitted but had lower mortality rates up to a year after hospitalization. None of these differences, however, was significant after controlling for patient medical history and other patient, physician, and hospital characteristics. This study, drawing on the same database as Hebb et al. (2003) and reaching essentially similar conclusions in the area of treatment of congestive heart failure (see Figure 10-1), shows that even blacks, despite falling short of standard treatment more often than others, are not necessarily disadvantaged in every treatment area.

Some differences in quality of care may reflect the particular institutions and health care providers on which minorities depend. Regardless of insurance coverage, blacks and Hispanics are almost twice as likely as whites to receive care from a hospital-based provider (Institute of Medicine, 2002). In particular, they are almost 1.6 times more likely than whites to be



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