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
2. The Healthcare Environment and Its Relation to Disparities
Pages 80-124
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From page 80... ...
the health, health insurance, and linguistic status of these groups, and by racial attitudes and patterns of segregation and discrimination in various sectors of American life. The third section reviews the history of segregated healthcare and contemporary settings in which racial and ethnic minorities receive healthcare, including the influence and importance of community health centers.
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THE HEALTH, HEALTH INSURANCE, AND LANGUAGE STATUS OF RACIAL AND ETHNIC MINORITY POPULATIONS This section provides an overview of factors that influence healthcare and healthcare needs of minority populations including their health and insurance status, and linguistic barriers to care. Health Status Some racial and ethnic minorities experience higher rates of chronic and disabling illnesses, infectious diseases, and mortality than white
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From page 82... ...
American Indians and Alaska Natives also experience higher mortality rates than whites, accompanied by low life expectancy. And while other racial and ethnic minorities experience lower overall mortality rates than whites, these data mask both inter-group variation (e.g., among Hispanics, Puerto Ricans experience higher infant mortality rates than whites [National Center for Health Statistics, 2000~)
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. Insurance Status Racial and ethnic minority Americans are significantly less likely than white Americans to possess health insurance (see Figures 2-3 and 2-4~.
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. African Americans African Americans are less likely to possess private or employmentbased health insurance relative to white Americans, and are more likely to be covered via Medicaid or other publicly funded insurance (see Figure
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lack health insurance, compared with 17.5% in the general population. Slightly less than half of American Indians and Alaska Natives have job-based health insurance, while one quarter receive Medicaid insurance and a similar proportion are uninsured or report only IHS coverage (The Henry I
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Generally, rates of public insurance are lower for Asian Americans and Pacific Islanders, except for some Southeast-Asian subpopulations (Brown et al., 2000~. Within API subgroups, Korean Americans are least likely to have health insurance.
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These data are displayed in Figure 2-6. Linguistic Barriers Many racial and ethnic minority Americans experience language barriers.
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Kaiser Family Foundation, 2000b. (data from the 2000 Census are not available as of this writing)
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speak Navajo. Nearly 170,000 American Indians or Alaska Natives do not speak English "very well," and over 32,000 American Indian or Alaska Native households are linguistically isolated (U.S.
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He said, 'I need to write this prescriptionfor these pills, but 1 7.2 8.1 11.2 I I HI al al n ~~ ~0~ ~~ S~ ~e 1 4.8 26.6 34.8 35.1 51.5 54.7 59 8 1 n 1 n ~ ~ ~ ~ T . T T T T T 1 1 ~ O~'~e ~0~e ~~e v~ ~06 ~0 REV In' ~~ w d27FIGURE 2-8 Percentage of Asian Americans that are linguistically isolated, by subgroup.
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In particular, to understand the question of whether discrimination occurs in healthcare, it is necessary to review what is known about racial attitudes and racial discrimination in other aspects of American life. This section reviews this evidence, with the goals of: · illuminating trends in racial attitudes that may be assumed to carry over into healthcare settings; and · understanding the persistence and pervasive quality of discrimination that has characterized the American racial and ethnic minority experience.
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From page 92... ...
Third, white Americans continue to express support for negative stereotypes of minority groups in surprisingly large numbers, even though few of these individuals would identify themselves as bigoted or racist. Fourth, white and non-white Americans differ significantly in their perception of the prevalence of racial discrimination in the United States.
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A recent survey commissioned by the Committee of 100 to study Americans' attitudes toward Asian Americans found that at least 1 in 4 Americans holds decidedly negative attitudes toward Chinese Americans, and an additional 43% hold "somewhat negative" attitudes. Many responses suggested that a significant segment of Americans fear Chinese Americans' influence and power; over one-third (34%)
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Not surprisingly, white and non-white Americans hold widely diverging views of the prevalence of racial discrimination. A 1995 poll, for example, found that nearly nine in ten African Americans (88%)
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The following sections illustrate that despite the more optimistic view of some that unfair treatment on the basis of race is rare, racial discrimination persists in a wide range of important aspects of American life. Racial Discrimination "Ifelt that because of my race that I wasn't serviced as well as a Caucasian person was.
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, in an analysis of the largest 30 U.S. cities, finds that residential segregation is most profound and consistent over time among African Americans, and is less prominent, but still significant among Hispanic and Asian-American families.
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, isolation indices for African Americans are 80 or more, indicating that in these cities, the average African American lives in a neighborhood that is more than 80% black. Further, other measures indicate that many African-American communities are characterized by "hypersegregation;" that is, African Americans tend to be concentrated in compact, densely packed, contiguous tracks in central cities.
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If 50% of residents are African American, 73% of whites report that they would not want to live in the neighborhood, 65% reported that they would feel uncomfortable, and 53% would try to leave. In actual practice, the presence of smaller percentages of African Americans in previously allwhite neighborhoods initiates a pattern of destabilization whereby whites tend to leave in large numbers.
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. While housing audits have largely focused on the possibility of discrimination against African Americans, a few studies suggest that Hispanics face similar discrimination, particularly among darker-skinned Hispanics or those who identify themselves as mixed European and Indian ancestry (Massey, 2001~.
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In other words, in nearly one-third of instances Hispanic applicants were denied an application, denied an interview, or did not receive an offer of employment while the matched white auditor received the opposite outcome. Criminal Justice Minority Youth in the juvenile justice System Minority youth are overrepresented in the juvenile justice system in the United States.
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of juvenile cases waived to criminal courts in 1996/7 involved African American youth (Office of Juvenile Justice and Delinquency Prevention, 1999~. Overrepresentation of minority youth in juvenile justice systems occurs in all 50 states and the District of Columbia.
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This section presents a discussion of the history of healthcare service delivery for racial and ethnic minority populations in the United States. The discussion is focused on the experience of African Americans only because historical documentation of healthcare for this group is more extensive than for other racial and ethnic minorities.
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This section will discuss how the legacy of segregated and inferior healthcare for African Americans continues to reverberate in today's healthcare settings. Important factors such as the makeup of the healthcare workforce, primary settings in which racial and ethnic minorities receive care, opportunities for training of minority healthcare providers, and other aspects of the structure and delivery for healthcare for many African Americans are shaped by these historical trends.
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From page 104... ...
This essentially resulted in the exclusion of minority physicians from practicing in these institutions. Marginalized groups, including African Americans, American Indians, Hispanic Americans, and others from racial or religious minority groups were isolated, excluded from training, and professionally segregated (Byrd and Clayton, this volume)
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Historical Determinants of the Contemporary Minority Health Professions Workforce During the post-Reconstruction period, several "Negro" medical schools and hospitals emerged. Eight medical schools for African Americans were established between 1865 and 1910 [Howard University Medical School, Washington, D.C.
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In this climate, the medical establishment was agitating for control and educational reform. More than 200 medical schools were founded in the United States between 1800 and 1900 (Stevens, Goodman, and Mick, 1978~.
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In 1948, for example, one-third of all medical schools were officially closed to blacks and many more failed to accept a single black student until two decades later (Raup and Williams, 1964~. By 1920, only two black medical schools remained, Howard University Medical School and Meharry Medical College (Smith, 1999~.
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Medical specialists were in very short supply in the black communities, and access to white hospitals even for those doctors who graduated from white medical schools was limited. For AfricanAmerican physicians, acquiring specialty training or hospital expertise was rare, because these doctors were denied opportunities to access specialty training (Byrd and Clayton, 2001~.
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Twenty-eight percent of African Americans and 30% of Hispanics report this difficulty, compared with 16% of whites and 21% of Asian-American adults (Lillie-Blanton et al., 2001~. In the 1980s, African Americans and Latinos were more likely than their white counterparts to receive care in hospital outpatient departments (particularly teaching and public hospitals)
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analyzed data from the 1996 Medical Expenditure Panel Survey (MEPS) , and found that African Americans and Latinos, regardless of insurance coverage, were almost twice as likely as whites to receive care from a hospital-based provider (Figures 2-10 and 211~.
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0.1 (0.1) African American 89.5 (2.3)
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The CHC model has proven effective not only in increasing access to care, but also in improving health outcomes for the often higher-risk populations they serve. The continuity of care has been found to be better in CHCs than in hospital outpatient departments or physician offices, and a study examining preventable hospitalizations among medically underserved communities found that in communities served by federally qualified health centers, rates of preventable hospitalizations
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In this section, data on the demographic profile of healthcare providers that work primarily in racial and ethnic minority communities is reviewed. Physicians Minority medical graduates, including African Americans, Asian Americans, Hispanics, and American Indians, represent 9% of the country's physicians.
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These minority graduates are more likely to work in states with large minority populations, such as California, New York, and Texas (AAMC, 2000~. Underrepresented racial and ethnic minorities (African Americans, Mexican Americans/Chicanos, mainland Puerto Ricans, and American Indians/Native Americans)
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on the Workforce in Minority Communities An important phenomenon began to emerge during the 1930s and 1940s that would have a profound effect on the healthcare provided to racial and ethnic minorities, as the numbers of international medical graduates (IMGs) securing residency training positions in U.S.
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The NACHM report was one of several that led to the rapid expansion of existing undergraduate medical education programs as well as the creation of new medical schools. Three decades later, the number of students graduating from United States medical schools doubled and the number of IMGs who entered residency training programs each year almost doubled between 1988 and 1994, from 3,600 to 6,700 (COGME, 1996~.
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have documented that physicians in urban areas who accept Medicaid patients are more likely to be foreign medical graduates and are less likely to be board certified than those who do not accept Medicaid. Ginzberg (1994)
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This cultural configuration has existed for nearly 50 years in many of the largest metropolitan teaching hospitals serving millions of racial and ethnic minorities. However, this racial/ethnic interface has been inadequately studied to determine the impact it has on minority patients' perceptions of their healthcare experience, utilization of services, trust, compliance, health status, and quality of care.
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medical colleges and other health professions organizations began a concerted effort to expand opportunities for careers in the health professions to ethnic minorities who, for a variety of historic, social, political, and economic reasons, had not previously enjoyed such opportunities. The Association of American Medical Colleges (AAMC)
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Racial and ethnic minorities are four times more likely to receive care from non-white physicians than white physicians (Moy and Bartman, 1995~. Further, racial and ethnic minority physicians are more likely to practice in minority and medically underserved communities.
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Unfortunately, despite public laws and sentiment to the contrary, vestiges of this history remain and negatively affect the current context of healthcare delivery. And despite the considerable economic, social, and political progress of racial and ethnic minorities, evidence of racism and discrimination remain in many sectors of American life.
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Organizations responsible for the education, training, and licensure of health and medical professionals should develop special initiatives to increase levels of awareness of healthcare disparities among current and future healthcare providers.
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