Some argue that wide disparities in utilization rates across racial and ethnic groups are indicative of discrimination (see Box 9.3). Use indifference curve analysis to explain why it may be diffi cult to distinguish between discrimination and differences in socioeconomic factors such as incomes and preferences.

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BOX 9.3 Disparities A National Priority in Health Care: Disparities across racial, ethnic, and socioeconomic groups in health outcomes and health care utilization are well-documented. The Healthy People 2010 (U.S. Depart- ment of Health and Human Services, 2000) initiative placed the elimination of dispar- ities on the national agenda. Yet, the most recent report from the Agency for Healthcare Research and Quality (2015) covering 2012 indicates that disparities remain common. The Agency uses over 250 measures of quality (e.g., pregnant women receiving prena- tal care in the first trimester) and of access (e.g., people who have a specific source of ongoing care). Those in poor households had worse access than those in high-income households on all the access measures; the poor also received lower quality of care on more than half the quality measures. Blacks had worse access than whites on half the measures and they received worse care than whites on about one-third the quality measures. More disturbing, the Agency found that most access and quality disparities related to race, ethnicity, or income have not changed significantly over time despite the national attention and policy priority given to this problem. Why? Is there discrimination in health care delivery against certain population groups as some have suggested? There are no easy answers but the Institute of Medi- cine's report to Congress on the extent and sources of the disparities (Smedley, Stith, and Nelson, 2002) greatly raised awareness of the complexity of the underlying issues. The report recognized that differences in access to care are major contributors to disparities in utilization and health outcomes, but also that there are many other confounding factors including discrimination and differences in preferences and pro- pensities to seek care across groups. Economists have sought to develop methods that distinguish among the various sources that account for disparities (Balsa, Cau, and McGuire, 2007; David and Harrington, 2010; and Mahmoudi and Jensen, 2012).