Factors Other Than Race Explain Whether Men In Study Had Health Insurance And Received Health Care

January 19, 1999

In a group of gay and bisexual men infected with the human immunodeficiency virus (HIV) who were more highly educated, better paid, and more likely to be insured than Americans on average, researchers found that factors other than race explained whether the men had health insurance and whether they used medical and dental services.

HIV-infected whites, however, were more likely to use so-called discretionary outpatient services, such as doctor visits, when they had a minimum of symptoms. Whites were also more likely to use dental services, although blacks were more likely to have dental insurance. The study, by researchers at the Johns Hopkins School of Public Health, appeared in the January 19, 1999, issue of The Journal of the Acquired Immunodeficiency Syndromes (JAIDS).

Lead author Nancy Kass, ScD, associate professor, Health Policy and Management, Johns Hopkins School of Public Health, and Bioethics Institute, said, "Since most of these men were highly educated, highly insured, and earned medium to high incomes, we must conclude that their differences in using these services can be explained by other influences, such as environmental, social, and psychological factors."

The authors speculated that black men at early stages of infection may have chosen to forego discretionary services because they wished to hide their infection from peers, did not feel the need to seek services as readily as whites, trusted less in biomedical institutions, or felt less welcomed by the health care system.

The scientists also stressed that race and class, while often correlated, do not measure the same thing, so that it is important for researchers to be precise when using race as a variable in health services and epidemiologic research, emphasizing when racial differences truly exist as opposed to when the variable "race" is a surrogate for another factor. "There are instances when race is the true predictor of differences in health status or health service use and is not serving as a proxy," said Dr. Kass, "but race should not be used in lieu of a true predictor."

The authors studied men within the SHARE (Study to Help the AIDS Research Effort) cohort, the Baltimore contingent of the nationwide Multicenter AIDS Cohort Study (MACS). Because the black and white men in SHARE have comparable socioeconomic backgrounds and risk exposure, the scientists reasoned that their socioeconomic homogeneity would eliminate the racial differences in health insurance coverage and health service use reported by other researchers.

Three-hundred-seven (307) HIV-infected gay and bisexual men who came in for research visits every six months were studied. Thirty-eight percent had AIDS at the time of their study visit; 78 percent were white; and most were well-educated, professional, and well-insured.

There was no difference between blacks' and whites' likelihood of having health insurance, private insurance, using inpatient emergency room services, or antiretroviral medications. Even controlling for lower CD4 counts and higher incomes, HIV-infected white men remained three times as likely to have seen a doctor in the six months before their study visit than HIV-infected black men. And, among those whose immune systems were still robust, white HIV-infected men were ten times as likely to have seen a doctor in the previous six months. Similarly, controlling for other factors, whereas 62 percent of HIV-infected white men had seen a dentist in the last six months, only 45 percent of the black men had, even though black men were significantly more likely to have dental insurance.


Studies have found that African Americans have less trust in biomedical research than do whites, and that racism exists in American medicine in terms of doctors treating their African-American and white patients differently. Blacks may also be less inclined to seek health services, because of the shortage of African-American providers (under five percent of all physicians and under two percent of all dentists in the United States, in 1995).

Johns Hopkins University Bloomberg School of Public Health

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