Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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2 The Healthcare Environment and Its Relation to Disparities Many aspects of the healthcare environment influence the quality of care received by U.S. racial and ethnic minority groups.
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81 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES Much of the data presented in this chapter are drawn from available literature and large national data sources, such as the U.S. Census and the National Center for Vital and Health Statistics.
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82 UNEQUAL TREATMENT Americans. As depicted in Figure 2-1, African Americans have the highest rates of morbidity and mortality of any U.S.
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83 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES White Black American Indian or Alaska Native 200 Asian or Pacific Islander Hispanic 150 100 50 0 Diabetes Mellitus Diseases Cerebrovascular Malignant Diseases Neoplasms of Heart FIGURE 2-2 Age-adjusted death rates for selected causes of death by race and Hispanic origin: United States, 1950-1998. SOURCE: Health, United States 2000 (2001)
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84 UNEQUAL TREATMENT employment based coverage individually purchased public insurance no insurance 100 90 Rates of Coverage (percent) 80 44 53.1 59.1 70 65.8 72.8 60 4.2 50 4.2 20 40 6 25.7 6.6 15 30 7.5 14.2 20 10.8 35 24 22.8 10 17.5 12.7 0 Non-Hispanic Non-Hispanic Hispanic Other General White African- Population American Under Age 65 FIGURE 2-4 Sources of health insurance for population under age 65, by race and ethnicity, 1999.
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86 UNEQUAL TREATMENT generally, only 64% of API populations have job-based health insurance, compared with nearly three-fourths of whites (73%)
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87 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES Hispanic Americans Hispanic Americans face greater barriers to health insurance than all other U.S. racial and ethnic groups.
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88 UNEQUAL TREATMENT Uninsured Medicaid Job-Based 100 Health Insurance Coverage (percent) 90 80 70 60 50 40 30 20 10 0 Central and Cubans Mexicans Puerto Ricans South Americans FIGURE 2-6 Health insurance coverage among Latino subgroups (Ages 0-64)
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89 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES 30 27.3 26.8 25.8 25 20 Percent 15 10 5.2 5 3.2 1.3 1 0 All Wh Afr Am As His Oth ian ica Ho pa ite, eri er nA nic can use or Ra no Pa me ce n-H ho Ind cifi lds rica isp ian c Is n an ,E lan ic ski de mo r ,o rA leu t FIGURE 2-7 Percentage linguistically isolated households, by race and ethnicity, United States, 1990.
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90 UNEQUAL TREATMENT Korean, and Vietnamese families live in similar conditions. Figure 2-8 displays the percentage of Asian American households that are linguistically isolated.
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91 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES you'll never take them and you'll come back and tell me you're still eating pig's feet and everything…then why do I still need to write this prescription.' And I'm like ‘I don't eat pig's feet.'" (African-American patient) "My name is .
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92 UNEQUAL TREATMENT Racial attitudes and relations in recent decades have been characterized by both progress and strife. Sociologist Lawrence Bobo (2001)
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93 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES tuted half of the school enrollment, support dips to approximately threequarters of respondents. If the school is presented as "mostly black," support falls to below 50%.
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94 UNEQUAL TREATMENT tudes toward Chinese Americans. These respondents, who tended to have lower levels of education, lower incomes, and were more likely from the South, believe in large majorities -- ranging from 68% to 73% -- that Chinese Americans "don't care what happens to anyone but their own kind," and are "taking away too many jobs from Americans" (Edsall, 2001)
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95 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES with respect to major demographic data collected by the U.S. Bureau of the Census and other data sources, as outlined in this chapter.
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96 UNEQUAL TREATMENT in specific cases is not the same as statistical measures of the overall level at which discrimination exists" (Turner and Skidmore, 1999, p.
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97 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES norities residing in the geographic unit of the average minority individual) , Massey found that, on average, African Americans live in communities that are overwhelmingly African American, with dissimilarity indices averaging 77.8 in northern cities and 66.5 in southern cities (indices above 60 are considered high)
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98 UNEQUAL TREATMENT Importantly, segregation does not appear to result merely from the choices of African-American and other minority groups to live apart from white Americans. Polling data indicate that African Americans strongly endorse the idea of residential integration, and would prefer to live in racially mixed neighborhoods.
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99 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES hood of discriminatory practices. Auditors are trained to present comparable needs and desires in home purchases or rental properties, and are provided with similar socioeconomic traits.
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100 UNEQUAL TREATMENT a group's spatial position in society and its socioeconomic opportunities. For example, some communities are characterized by better schools, safer streets, better public services, fewer environmentally based health hazards, and better access to quality healthcare.
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101 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES Americans, and American Indians) constituted only about one-third of juveniles in the United States in 1997, they represent two-thirds of detained and committed youth in juvenile facilities.
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102 UNEQUAL TREATMENT dence base to better understand the contexts in which care is delivered to racial and ethnic minority patients. These data are not meant to imply that inferences can be drawn from this literature regarding possible discrimination in healthcare settings.
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103 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES sion of aspects of the history of U.S. healthcare for American Indians and Alaska Natives, see Joe, this volume)
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104 UNEQUAL TREATMENT which included segregated care for the poor (Smith, 1999)
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105 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES encing growth and financial prosperity. While on the surface these closings may have seemed like a mere shifting of service sites, they had quite profound and devastating effects in minority communities.
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106 UNEQUAL TREATMENT ulty with little scientific basis for instruction, and functioned principally as "diploma mills." These proprietary schools offered after-hours education and training, and contributed to the tension regarding the social and professional place for inexpensive medical education and primary care (Martensen, 1995)
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107 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES The Flexner report had an enormous impact on medical education and the entire healthcare delivery system. The American Medical Association and major philanthropic organizations closed ranks behind the report.
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108 UNEQUAL TREATMENT 74% of all black medical students attended Howard or Meharry (Ziem, 1977)
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109 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES care is received. Rates of health insurance vary greatly among racial and ethnic groups, as do primary sites where care is received, and who delivers this care.
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110 UNEQUAL TREATMENT in Lillie-Blanton et al., 2001)
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111 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES ethnicity insurance 20 16 16 15 15 15 Percent 10 7 6 5 0 Whites African Hispanics Private Any Uninsured Americans Medicaid FIGURE 2-11 Site of care: Other non-hospital facilities. SOURCE: Medical Expenditure Survey, 1997, as cited in Lillie-Blanton et al., 2001.
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112 UNEQUAL TREATMENT American and Latino children are more likely to receive care in these settings than their white counterparts. Racial and ethnic minority patients are also more likely to report experiencing difficulty in accessing specialists.
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TABLE 2-2 Number of Primary Care Visits Made to Primary Care Delivery Sites in the United States in 1994 Community Hospital Overall Health Centers Physician's Offices Outpatient Departments Per 100 Per 100 Per 100 Per 100 In Persons In Persons In Persons In Persons Thousands Per Year Thousands Per Year Thousands Per Year Thousands Per Year Race/Ethnicity Hispanic 28,087 (8.6)
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114 UNEQUAL TREATMENT were lower than in communities not serviced by these centers (Epstein, 2001)
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115 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES Asian American, one-fourth (24.9%) is Hispanic, and 1.8% is American Indian (AAMC, 2000)
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116 UNEQUAL TREATMENT Nurses In 2000, 12.3 percent of registered nurses were racial and ethnic minorities. Nearly 5% of all nurses self-reported as African American, 3.5% as Asian, 2% as Hispanic, 0.5% as American Indian/Alaska Native, 0.2% as Native Hawaiian/Pacific Islander, and 1.2% reported being of two or more racial backgrounds.
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TABLE 2-3 Percent Distribution of Registered Nurse Population in Each Geographic Area by Racial/Ethnic Background: March 1996 East West East West New Middle South South South North North Race/Ethnicity U.S. England Atlantic Atlantic Central Central Central Central Mountain Pacific Estimated RN population in area 2,558,874 176,951 443,846 460,460 141,705 215,200 452,080 198,952 137,739 331,941 White (non-Hispanic)
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118 UNEQUAL TREATMENT The 1967 report of the National Advisory Commission on Health Manpower (NACHM) sparked renewed efforts to recruit IMGs when it declared a national shortage of physicians (COGME, 1998)
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119 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES resident staff consisting of greater than 40% IMGs (MedPAC, 1999)
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120 UNEQUAL TREATMENT The cultural, racial, and ethnic diversity of IMG healthcare providers, who constitute more than 25% of the resident physicians in the United States, is broad. Most are new to this country and are learning to live within its vast sociocultural complexities, while also trying to learn to deal with an ambiguous welcome into the U.S healthcare delivery system with its own rigid, complex and demanding subculture (Stevens, Goodman, and Mick, 1978)
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121 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES "When I was in medical school I had a racist comment by one of the white stu dents. He said the only reason why you're here, it wasn't said to me but I overheard it, the only reason why black students are here is because they're black and this that and the other.
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122 UNEQUAL TREATMENT policies in 1995, 1996, and 1997 (notably, the Fifth District Court of Appeals finding in Hopwood v. Texas, the California Regents decision to ban race or gender-based preferences in admissions, and passage of the California Civil Rights Initiative [Proposition 209]
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123 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES • The quality of healthcare depends as much on physicians' scientific competence as on an understanding of cultural, social, and economic factors that influence the health of patients, the ways in which they seek care, and their response to medical treatment. Racial and ethnic diversity of health professions faculty and students helps to ensure that all students will develop the cultural competencies necessary for treating patients in an increasingly diverse nation (Association of American Medical Colleges, 1998)
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124 UNEQUAL TREATMENT Recommendation 2-1: Increase awareness of racial and ethnic dispari ties in healthcare among the general public and key stakeholders. Public education to increase awareness of racial and ethnic dispari ties in healthcare is an important first step toward eliminating these disparities.
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