The authors hypothesized that racial differences in use of cardiac procedures would decrease with acquisition of adequate health insurance (in this study, Medicare health insurance) when this occurs in conjunction with development of a serious illness (in this study, end stage renal disease (ESRD)).

Before the onset of ESRD in the sample patients, there were racial differences in use of cardiac procedures, even after thoroughly adjusting estimates for a range of demographic and clinical variables. Major covariates that partially, but not fully, explained the race effect included insurance coverage and marital status.

The racial comparison of the use of cardiac procedure use after patients developed ESRD and acquired Medicare health insurance showed that blacks had slightly higher use than whites. Since black patients who receive dialysis survive longer than white patients, the rates of service use were adjusted for survival time, as well as medical conditions that arose during the follow-up. This adjustment resulted in white patients being significantly more likely to use services, but to a lesser degree than at baseline. The difference at follow-up was largely due to large racial disparities in service use at baseline and during the first year of follow-up. The racial differences diminished by the second year and disappeared entirely during the third year and beyond.

The authors consider why blacks have a higher rate of services at follow-up (8.5%) than at baseline (2.8%). Change in insurance status may have played a role, but, since there was a substantial baseline disparity between black and white patients in both the privately insured and Medicare subgroups, it seems that acquisition of health insurance could not have been the only factor leading to the narrowing ethnic gap. The subgroup of patients that had Medicare coverage at baseline had no change in insurance type once they received care for ESRD, but the racial difference in procedure use disappeared with the initiation of comprehensive care for ESRD. The authors infer that “independent of or through interaction with insurance status, access to the comprehensive system of health care needed once ESRD patients undergo dialysis plays a role in increasing the receipt of cardiovascular procedures among black patients.”

There was no racial difference in service use during the 90-days after the first hospitalization. “When patients have adequate health insurance, a regular source of care, and a strong clinical indication for a cardiac procedures, equity in use of services between black and white patients can be achieved.”

There was a slightly lower rate of procedures for white patients at follow-up compared with baseline, suggesting the possibility that reduction in the use of discretionary procedures for white patients may partially explain the diminished racial difference in service use over the follow-up.

The authors conclude that “for the general population, health insurance may be necessary but not sufficient to narrow ethnic gaps in access. Combining insurance with systems that deliver comprehensive clinically appropriate care should improve the attainment of equitable access to care.”