Healthcare is often a black and white issue.

White patients receive significantly more high-cost medical procedures than African-Americans. That disparity has been documented and discussed since the early 1990s. Now two new studies show that, in spite of national and local efforts to close the gap, there is no evidence of change.

A study published in the current New England Journal of Medicine shows that elderly white patients receive significantly more high-cost medical procedures, including coronary-artery bypass grafting, carotid endarterectomy (removal of carotid plaque), and hip replacement than African-Americans in the same age bracket. A second study published in the same issue of the journal looked at almost 600,000 patients hospitalized with myocardial infarction and found white men received the most aggressive therapy while black women received the least. This too is déjà vu. The new findings are much the same as they were in a 1994-96 study.

"We were quite surprised to see there was no change in disparity," says researcher Viola Vaccarino, an assistant professor of medicine at Emory University School of Medicine.

Why have good intentions yielded stagnant stats? Vaccarino speculates that it may be a "a health-related factor that has not changed over time." Such as? "Issues related to a patient's presentation, [symptoms in] patients who are women or a racial minority may be less clearly recognizable that for the white man. Chest pains may be not there or be as strong so it doesn't point to the heart right away. They may have nausea, back pain, sweating, fatigue, and shortness of breath," she says. "In comparisons of blacks to whites and women to men, research has shown that presentation is less clear-cut. It may say more about the patient's thought process than his heart." Patients who come from a more disadvantaged socioeconomic background may have a harder time communicating with their doctors. This may affect their risk and morbidity.

Or it may be a result of where you go and whom you see.

"Minority groups are less likely to have access to the best hospitals or physicians or specialists," Vaccarino says. "They may not have the ability of obtaining quickly important treatments when they are in the hospital. Just the way healthcare is structured, [a lesser] socioeconomic status makes some groups more vulnerable."

Ranku Sen, communications director of Applied Research Center and the Northwest Federation of Community Organizations, believes that language issues, a culture of stereotyping, and an institutional culture that accepts stereotypes, account for some of the gap. The center calls for a change in personal attitudes and public policy. On a local level, Sen says, healthcare providers should be taught to recognize and correct any unconscious biases they may harbor and to recognize cultural traditions and to make hospitals hospitable to all cultures.

The national picture can be improved by "setting clear standards for care, Sen says.

And, of course, money helps.

"People of color, trapped in low-wage jobs, have disproportionately low incomes and live in segregated neighborhoods that tend to have a higher level of health risk," Sen says. More money can mean less disease.