Doctors, Patients, and the Racial Mortality Gap: What Are the Causes?

Disparities in health outcomes between white and minority Americans are a significant and well documented challenge in improving equity in health care. Two frequently cited explanations are discrimination in treatment - doctors treating minority patients differently, and unequal access to care - patients being trapped in facilities of inferior quality. I use a new dataset from the Department of Veterans Affairs and employ a novel estimation strategy to investigate the sources of the racial gap in mortality for chronic heart disease, the most expensive chronic condition in the elderly. I find that racial differences in mortality persist even when the quality of clinics and doctors is controlled for. Investigating the doctor-patient interaction, I show that doctor quality significantly influences patient outcomes. While minority patients visit slightly less competent doctors, this does not explain the large gap in survival. Individual doctors are found to treat their patients similarly regardless of race. On the patient side, I demonstrate that variation in compliance triggers a racial mortality gap. Differences in patient response to treatment significantly alter survival probabilities. Considerable reductions in medical costs could be achieved by convincing patients of the importance of strictly following the therapy regimen. I estimate that targeting compliance patterns could reduce the black-white mortality gap by at least two-thirds.