Study shows universal health insurance may mitigate surgical disparities for African Americans

A new study from Brigham and Women's Hospital utilized claims data from more than 630,000 patients living in the state of California and found no significant differences in post-operative complications or mortality between African American patients and White patients who were treated in a universally insured military health system. Meanwhile, African Americans treated in civilian settings who were either uninsured or on Medicaid experienced significantly higher odds of mortality, complications, and readmission after surgery as compared to Whites, implying that universal insurance may mitigate disparities. The findings were published online Tuesday, August 9th, in Annals of Surgery.

"To our knowledge, the effect of universal health insurance on reducing surgical disparities for African Americans had not been examined empirically prior to this study," explained Andrew Schoenfeld, MD, MSc, associate orthopaedic surgeon and director of Spine Surgical Research at BWH, faculty member at the Center for Surgery and Public Health (CSPH) at BWH, and lead author of the study.

Schoenfeld and a team of researchers from CSPH and the Uniformed Services University of the Health Sciences looked at claims information for 502,345 patients from the California State Inpatient Database (2007-2011), and 129,212 patients from the Department of Defense's (DoD) health insurance (Tricare) system (2006-2010). Tricare is one of the largest single American health insurers, responsible for providing care to more than 8 million American military service members, retirees and their dependents. Tricare is offered through a Federal agency to eligible beneficiaries irrespective of social class, occupational status or capacity to work, and thus may better represent the anticipated American experience with a universal healthcare initiative than data derived from patients insured through Medicare or private plans.

Patients were included in the study if they were African American (non-Hispanic black) or White (non-Hispanic White); were age 18 or older; and received one of 12 surgical procedures inclusive of cardiothoracic surgery (coronary artery bypass grafting [CABG)], general surgery (appendectomy, colectomy, esophagectomy, inguinal hernia repair), orthopaedics (total knee arthroplasty, total hip arthroplasty, hip fracture repair), urology (nephrectomy, transurethral resection of the prostate [TURP], radical cystectomy) and neurosurgery (lumbar spine surgery). These procedures are considered representative of the types of major surgical interventions performed across these disciplines, include urgent and elective procedures, and are often used in surgical quality studies.

The study found that compared to privately insured Whites, African Americans with private insurance had an approximately 20 percent higher odds of experiencing complications, approximately 30 percent higher odds of being readmitted, and could expect longer hospital stays. Uninsured African Americans and those on Medicaid faced about a fourfold greater odds of dying. Their odds of experiencing complications and readmission were almost twice as high when compared to privately insured Whites. Uninsured African Americans and those on Medicaid could also expect significantly longer hospital stays (more than 12 hours longer than privately insured Whites). These disparities were absent, however, among African Americans treated directly within DoD hospitals, also known as the Tricare direct care setting. According to researchers, "This may point to the fact that in a more equitable health system paired with universal insurance, racial disparities can be eliminated."

"It's heartening to see that healthcare disparities were virtually non-existent in the Tricare direct care setting, a unique environment where the color of one's uniform likely outshines the color of one's skin," said Adil Haider, MD, MPH, Kessler Director of the Center for Surgery and Public Health at Brigham and Women's Hospital, and the senior author of the study.