Where Racial Gaps In American Health Care Melt Away: Military Insurance

Past research has found a consistent pattern of racial inequality in American health care. Now, new research from Brigham and Women's Hospital finds an island of racial equality — among patients in the military health care system.

The research, published in the journal Health Affairs, looked at a common heart disease procedure among more than 8,000 patients insured by TRICARE, the military insurance for active-duty and retired personnel and their families.

Research fellow Dr. Muhammad Ali Chaudhary says black and white patients did equally well on quality measures like whether they were prescribed the right drugs — statins and beta-blockers — and whether they landed quickly back in the hospital.

"In the military, the color of your uniform matters more than the color of your skin," he says. "So I think it's that, in conjunction with the universal health care system, that's mitigating all these disparities."

TRICARE eliminated racial gaps better than expansions of state Medicaid programs, he says. Here are a few edited excerpts of our conversation:

How would you sum up what you found?

There is an absence of racial disparities, at least in the case of surgical coronary care, in the TRICARE setting. It can be related to a couple of factors, a universal and well-integrated health care system being one of them. But there are other factors, such as health care segregation [which is like residential segregation but refers to health care institutions], implicit provider bias and mistrust in the system by the patients. All of these factors are mitigated in the military health care system.

What did you set out to find?

We've done a couple of studies before this in which we found no racial disparities within the military health care system. But this time around, we wanted to look at some of the metrics for quality of care endorsed by the National Quality Forum. So that's why we can very reliably say that if these metrics don't show any racial disparities, then there is no difference in quality of care being provided to the under-served, the African American community, as compared to the white community in the military.

What did you look at?

'CABG' is an acronym that stands for coronary artery bypass grafting. It is basically a procedure that you do when you have [a] blockade in your arteries of your heart. It's a very common procedure. We looked at three measures: the prescription of statins, the prescription of beta blockers — these are two drugs that should be standard of care after a CABG procedure, the statins to reduce cholesterol and beta blockers to reduce heart rate and decrease blood pressure — and the third thing that we looked at was 30-day readmissions. And we found no significant differences between prescription patterns of statins and beta blockers and readmissions between African American and white patients.

What's the broader context?

The literature shows that African American patients have worse outcomes not just with CABG but also other surgical procedures and in other fields of medicine. This is a well-established fact.

The TRICARE system is a very integrated universal health care system with more than 9 million beneficiaries, including active duty military personnel, retired personnel and their families.

When we look at Medicaid expansions we find that yes, African American patients and other under-served communities did benefit from insurance coverage. But there is limited or lack of data that shows that they had improved outcomes or there was a decrease in racial disparities.

Our hypothesis is that it's not just the universal insurance that's mitigating disparities, but also other factors such as health care segregation, implicit provider bias and patients' mistrust in the system. In the military, all of these factors are either mitigated or completely absent.

So the military and TRICARE can serve as a good example for us to develop interventions that not only increase insurance coverage but also look at these other factors.

So why are people talking about Medicare for All instead of VA for All?

The military experience might not be completely translatable to the American public, obviously. But we can take this system, the TRICARE system, as an ideal and try to emulate it.

What policy implications do your findings have?

Number one: It is certain that a well-integrated universal health care system does mitigate racial disparities. And the second point is that if you want to completely eliminate racial disparities then you have to look at universal health care plus these other factors that might be potentiating some of these disparities. These are the two takeaways from this study.