Racial Inequities in Military Health System Less Than General Population, But Gaps Exist, Study Finds

by Braxton Taylor

The military health system has fewer racial and ethnic disparities than the U.S. civilian health care system, but inequality still exists among Black mothers and some other minority groups, according to an advisory board.

A draft report by the Defense Health Board found the military health system largely provides more equal treatment across races and ethnicities for a range of conditions like pregnancy and birth, mental health and surgeries. Still, for those who do not fare as well, the Pentagon should act to make improvements, the board said.

In places where gaps do exist, they are smaller than in the general population. Yet there are some notable areas where care could be improved for all patients, according to the draft report, intended for the assistant secretary of defense for health affairs.

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“Black female beneficiaries and their infants experience worse [maternity and birth outcomes] than white beneficiaries in the MHS,” or military health system, according to the report.

A higher infant mortality rate for non-Hispanic Black military beneficiaries, differences in cesarean delivery, ICU admission and severe complications, especially higher rates of premature births for Black parents, “needs urgent assessment and action in the military health system,” the report found.

Black mothers and their babies who are treated in the military system were still better off than those in the general population, where birth outcomes have worsened for Blacks over the past several years.

In addition to disparities in maternal care, the report found differences in other types of treatments. For example, according to the board:

  • Black and Asian beneficiaries needing a hysterectomy did not receive advanced, minimally invasive procedures at the same rate as white patients.
  • White women were more likely to get flu shots while Black patients were more likely to get mammograms or cervical cancer tests.
  • Breast cancer screening rates were similar in the military health system across races and ethnicities, but were higher for colorectal and cervical cancer for Black women than other patients.
  • Readmission rates for military beneficiaries for diabetes-related conditions were significantly higher for American Indian and Alaska Native beneficiaries compared with white patients — 18 times higher for those treated in a military hospital and roughly five times higher for those in a civilian facility under the Tricare program.

The draft report is the result of a 15-month investigation that included briefings with military and civilian physicians and health administrators, a site visit to Naval Medical Center San Diego, and interviews with providers. It was being finalized to be presented to the Pentagon in the coming months.

Defense Health Board members deliberated for hours over the report’s language during a meeting held Monday at Naval Medical Center Portsmouth, Virginia. The board was asked to study health care outcomes among the ranks following a requirement by the Biden administration to ensure racial equity in services and support across the federal government.

Research reviewed by the board included 58 studies or briefs that spanned decades, with some dating to 2000.

During the meeting, Dr. Michael-Anne Browne, chairwoman of the board subcommittee that developed the draft report, said much of the research was done by “individuals without institutional support — true heroes doing this on their own time, pulling medical records and trying to marry it with demographic information” with no institutional support from the Pentagon.

Roughly 24% of active-duty personnel identify as a racial minority, while 3% say they are multiracial and 16% report Hispanic ethnicity.

All, including dependents and retired military personnel, have access to low- or no-cost health care, which some researchers have theorized would eliminate any barriers to care for patients.

But, according to the board, universal health coverage does not mean universal access to care.

Factors that can influence the availability and quality of care include geographic location and “ineffective care,” meaning that beneficiaries may not be seeking treatment as a result of their experiences, according to the review.

The report found that while the Defense Department maintains the race and ethnicity of active-duty personnel, it lacks accurate data for spouses and children — discrepancies that make it difficult to research health disparities.

The lack of accurate data also puts the Pentagon and Defense Health Agency at odds with a new standard this year requiring civilian hospitals and health care programs to collect race and ethnicity data for all patients.

“It was astounding that we found statistically significant disparities in maternal health outcomes by race that warrant immediate action and attention … and what we really found was that race and ethnicity data for beneficiaries are often missing or inaccurate,” Browne said during a briefing to the board.

Browne noted that it is difficult if not possible for service members or beneficiaries to view or edit race or ethnicity in their official Pentagon records, and have no way of updating the data fields in the new electronic health system records.

She raised concerns that the DoD cannot adequately track or study racial disparities among all military health beneficiaries if the department has no idea of the population’s ethnic makeup.

“We have a long-term recommendation out there to replace [the Defense Enrollment Eligibility Reporting System, or DEERS] with a modern personnel and beneficiary database that communicates with the medical system and allows for beneficiary self-service updates to demographic information,” Browne said.

DEERS and MHS Genesis — the Defense Department’s new electronic health records system — are independent of one another and a change in one cannot affect the other, according to Army Col. Tom Cantilina, chief health informatics officer for the Defense Health Agency, said during the board meeting Monday.

He added that the DHA is at the forefront of demographics collections for its patients, with demographic fields now mandatory in MHS Genesis; they “must be filled out when interacting with the patient,” usually during registration, he explained.

“It’s a conversation at the front desk or with the scheduling clerk between those patients that we collect that information,” Cantilina said.

Meanwhile, Browne said the subcommittee made a conscious attempt to steer clear of diversity, equity and inclusion issues, or DEI, in the military health system. DEI has drawn the attention and ire of Republican lawmakers in Washington, who criticize it as part of Democrats’ “woke” social agenda. The report did recommend hiring a more diverse workforce of physicians and nurses to treat the diverse patient population.

“We did not believe that our tasking was DEI. It was racial and ethnic health disparities. DEI is a political football. There are some people who are wanting to defund all DEI activities, and in the military in particular, and we wanted to be sure that we didn’t give grounds for some of those folks to sweep this into that same pile,” Browne said.

The board did not vote to approve the draft report and instead sent it back to the subcommittee for changes recommended in the meeting. It plans to vote on the final report at a later date and forward it to the Defense Department for consideration.

— Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime

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