Atlantic Economic Journal

, Volume 37, Issue 3, pp 279–298 | Cite as

Race, Quality of Care and Patient Outcomes: What Can We Learn from the Department of Veterans Affairs?

  • Emilia Simeonova


The large and persistent differences in health outcomes between African Americans and whites have sometimes been attributed to differences in the quality of the facilities in which they receive care. A large body of literature documents systematically worse performance by facilities which serve a larger share of black patients. However, these estimates may be biased by unobserved variables which correlate with the racial profile of the clinic and also affect outcomes. This paper uses a unique dataset from the Department of Veterans’ Affairs system to examine the relationship between the quality of health care and the racial profile of the patient population in an equal-access health care system. An instrumental variable is used to overcome the omitted variable bias in the Ordinary Least Squares (OLS) estimates. Both the OLS and IV estimates show that increasing the proportion of visits by African–American patients results in improved outcomes for all patients treated at the clinic. The OLS results significantly underestimate the effect of increasing the proportion of black patients. Holding the overall clinic load constant and adding one hundred outpatient visits by African Americans in a year would result in a 0.5 percentage point decrease in 1-year mortality for the average patient in the clinic. Thus, contrary to results from the private health care sector, increasing clinic racial integration in an equal access system would benefit all patients.


Racial segregation Health and health care markets Discrimination 




  1. American Heart Association (2009). Statistical fact sheet—miscellaneous 2009 update ( accessed on March 27th, 2009.
  2. Baicker, K., Chandra, A., Skinner, J. S., & Wennberg, J. E. (2004). Who you are and where you live: how race and geography affect the treatment of Medicare beneficiaries. Health Affairs Web Exclusive, October 7, 2004.Google Scholar
  3. Balsa, A., & McGuire, T. (2001). Statistical discrimination in health care. Journal of Health Economics, 20(5), 881–907. doi: 10.1016/S0167-6296(01)00101-1.CrossRefGoogle Scholar
  4. Balsa, A., & McGuire, T. (2003). Prejudice, clinical uncertainty and stereotyping as sources of health disparities. Journal of Health Economics, 22(1), 89–116. doi: 10.1016/S0167-6296(02)00098-X.CrossRefGoogle Scholar
  5. Barnato, A. E., Lucas, F. L., Staiger, D., Wennberg, D., & Chandra, A. (2005). Hospital-level racial disparities in acute myocardial infarction treatment and outcomes. Medical Care, 43(4), 308–319. doi: 10.1097/01.mlr.0000156848.62086.06.CrossRefGoogle Scholar
  6. Bradley, E. H., Herrin, J., Wang, Y., McNamara, R. L., Webster, T. R., Magid, D. J., et al. (2004). Racial and ethnic differences in times to acute reperfusion therapy for patients hospitalized with myocardial infarction. Journal of the American Medical Association, 292(13), 1563–1572. doi: 10.1001/jama.292.13.1563.CrossRefGoogle Scholar
  7. Chandra, A., & Skinner, J. (2003). Geography and racial health disparities. NBER Working Paper 9513, February.Google Scholar
  8. Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Diseases, 40(5), 373–383. doi: 10.1016/0021-9681(87)90171-8.CrossRefGoogle Scholar
  9. Davis, S., Liu, Y., & Gibbons, G. (2003). Disparities in trends of hospitalization for potentially preventable chronic conditions among African Americans during the 1990s: implications and benchmarks. American Journal of Public Health, 93(3), 447–455. doi: 10.2105/AJPH.93.3.447.CrossRefGoogle Scholar
  10. Gallant, M., Spitze, G., & Prohaska, T. (2007). Help or hindrance? How family and friends influence chronic illness self-management among older adults. Research on Aging, 29(5), 375–409. doi: 10.1177/0164027507303169.CrossRefGoogle Scholar
  11. GAO. (1998). VA community clinics: Networks’ efforts to improve veterans’ access to primary care vary. June (GAO/HEHS-98-116).Google Scholar
  12. Gaskin, D., & Hoffman, C. (2000). Racial and ethnic differences in preventable hospitalizations across 10 States. Medical Care Research and Review, 57(1), 85–107.Google Scholar
  13. Grabowski, D. (2004). The admission of blacks to high-deficiency nursing homes. Medical Care, 42(5), 456–464. doi: 10.1097/01.mlr.0000124307.17380.df.CrossRefGoogle Scholar
  14. Groeneveld, P., Laufer, S., & Garber, A. (2005). Technology diffusion, hospital variation, and racial disparities among elderly Medicare beneficiaries 1989–2000. Medical Care, 43(4), 320–329. doi: 10.1097/ Scholar
  15. Gurmankin, A., Polsky, D., & Volpp, K. (2004). Accounting for apparent reverse racial disparities in department of veterans’ affairs (VA)—based medical care: Influence of out-of-VA care. American Journal of Public Health, 94(12), 2076–2078. doi: 10.2105/AJPH.94.12.2076.CrossRefGoogle Scholar
  16. Institute of Medicine. (1999). Leading health indicators for healthy people 2010: Final report. Washington: National Academies Press.Google Scholar
  17. Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington: National Academies Press.Google Scholar
  18. Jessup, M., & Brozena, S. (2003). Heart failure. The New England Journal of Medicine, 348, 2007–2018. doi: 10.1056/NEJMra021498.CrossRefGoogle Scholar
  19. Joshi, A. V., D’Souza, A. O., & Madhavan, S. S. (2004). Differences in hospital length-of-stay, charges, and mortality in congestive heart failure patients. Congestive heart failure (Greenwich, Conn.), 10(2), 76–84. doi: 10.1111/j.1527-5299.2004.02008.x.CrossRefGoogle Scholar
  20. Klein, R. E. (2001). The changing veteran population, 1990–2020. Washington, DC: US Department of Veterans Affairs.Google Scholar
  21. Klein, R. E., & Stockford, D. D. (2001). Data on the socioeconomic status of veterans and VA program usage. Washington, DC: U.S. Department of Veterans Affairs.Google Scholar
  22. LaVeist, T., Nickerson, K., & Bowie, J. (2000). Attitudes about racism, medical mistrust, and satisfaction with care among African American and white cardiac patients. Medical Care Research and Review, 57(Supplement 1), 146–161.Google Scholar
  23. Muntwyler, J., Abetelb, G., Grunera, C., & Follath, F. (2002). One-year mortality among unselected outpatients with heart failure. European Heart Journal, 23(23), 1861–1866. doi: 10.1053/euhj.2002.3282.CrossRefGoogle Scholar
  24. Ordin, D. L., & Krumholz, H. M. (2003). Race, quality of care, and outcomes of elderly patients hospitalized with heart failure. Journal of the American Medical Association, 289, 2517–2524. doi: 10.1001/jama.289.19.2517.CrossRefGoogle Scholar
  25. Simeonova, E. (2008). In sickness and in health: The effect of marriage for the chronically ill. mimeo, IIES Stockholm University.Google Scholar
  26. Skinner, J., Chandra, A., Staiger, D., Lee, J., & McClellan, M. (2005). Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation, 112, 2634–2641. doi: 10.1161/CIRCULATIONAHA.105.543231.CrossRefGoogle Scholar

Copyright information

© International Atlantic Economic Society 2009

Authors and Affiliations

  1. 1.IIES Stockholm UniversityStockholmSweden

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