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A mixed methods study combined descriptive analysis of 2007 Medicare claims data and thematic analysis of 19 clinician interviews, 8 minority patient focus groups and 8 one-on-one interviews with minority heart patients across three communities. The disparity between White and non-White CR use ranged from 7 to 11 percentage points among study sites ( p &lt; .05). Key themes suggest disparities are driven by (a) flawed financing and reimbursement that creates disincentives to invest in CR programs, (b) a health care system whose priorities are misaligned with the needs of patients, and (c) subjective decision-making around referral processes. 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