Health Care in a Context of Civil Rights (1981) / Chapter Skim
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HEALTH CARE OF MEMBERS OF RACIAL AND ETHNIC MINORITY GROUPS
HEALTH CARE OF MEMBERS OF RACIAL AND ETHNIC MINORITY GROUPS
Pages 20-71
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From page 20... ...
However, the disparities reviewed in this chapter, in the committee's view, suggest that the question of discrimination in health care deserves more attention than it has received. The focus of this review stems from questions regarding civil rights and health care.
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The following descriptions, several of which come from a recent hearing of the U.S. Civil Rights Commission, are typical of these incidents, the outcomes of which have included babies being born in hospital parking lots, serious medical complications, and the death of patients.
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The purpose of this chapter is neither to validate specific complaints nor to recommend how the legal and financial questions that arise in these situations should be resolved, but to provide a larger context within which certain social policy questions regarding equity or fairness in health care can be considered and to suggest some means by which disparities can better be understood.
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From page 23... ...
However, the absence of racial differences in health care, except where there are differences in need for care, would be strong evidence that no widespread patterns of discrimination exist. It is significant, therefore, that the committee found that racial and ethnic factors continue to be important in health care.
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Civil Rights Commission and others, it was clear that an era was at an end, at least with regard to medical institutions in the United States, most of which received federal funds and were covered by the Civil Rights Act. (The practice of medicine in the offices of physicians was not directly affected by Title VI because of a DHEW determination that the indirect method through which they received federal dollars from Part B of Medicare did not constitute federal involvement sufficient to bring them under the authority of the Civil Rights Act.)
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From page 25... ...
annual compendium of information, Health United States: 1979, notes that "in general, the health status of minorities has improved during recent years, and their use of health services has increased."11 In Health and the War on Poverty, Davis and Schoen observed that "poor people's access to medical care has increased remarkably [in the decade 1965-75]
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From page 26... ...
However, measures of health status can provide an indicator of progress that remains to be achieved and are also an essential prerequisite to intelligent interpretation of differences in the use of services. Measures of Mortality The most recent figures from the National Center for Health Statistics continue to show the existence of substantial racial/ethnic variations in mortality.
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From page 27... ...
and Japanese Americans (3.3) .18 There has been little change in either black or white rates since 1950, whereas the other three groups have all shown significant declines in mortality.19 Similar racial/ethnic differences are seen in life expectancy figures, which show white life expectancy to exceed black life expectancy by four to five years, whereas the life expectancy for Japanese and Chinese Americans appears to exceed white life expectancy.21 Available data for Hispanic populations, though somewhat dated and incomplete, suggests a mortality level that falls between rates for blacks and whites.22 Racial differences in infant mortality rates remain pronounced.
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From page 28... ...
Nor can such mortality data be used uncritically as an indicator of racial differences in medical care because mortality rates are affected by many other factors. However, some indications of possible differences in medical care for different populations may come from data on variations in both incidence and mortality rates for a disease.
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Considerable evidence exists that people's perceptions about their present health status are affected by many factors (including cultural factors and their own previous health
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Table 1, from the National Health Interview Survey conducted by the National Center for Health Statistics, presents data on racial, ethnic, and income differences in self-reported health status, limitation of activity, restricted-activity days, and bed days.4 The relationship between health status and income is apparent in Table 1. In addition, within the two income categories, most of these measures show the health status of whites to be better than the other two groups, although the differences are neither large nor internally consistent.
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SOURCE: Division of Health Interview Statistics, National Center for Health Statistics. Data from the Health Interview Survey.
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Ambulatory Care Visits to physicians provide a basic measure of the receipt of health care services and have been examined in national surveys conducted by the National Center for Health Statistics (NCHS) and the Center for Health Administration Studies (CHAS)
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2.95 4.56 3.25 4.36 Hispanic4 4.2 4.0 4.5 3.5 4.3 2.9 Percent of Persons with One or More Physician Visits in Past Year White3 76 77 76 77 77 73 655 675 786 645 756 Black 74 77 74 776 Hispanic4 69 71 69 €5 74 56 ,'-Data from National Center for Health Statistics (NCHS)
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From page 34... ...
more than follow-up visits. Among children, although differences in use of physician services have narrowed considerably as a result of a variety of federal programs, small racial differences still exist, as Dutton's review of the most recent information available through the Health Interview Survey conducted by the National Health Statistics shows.61 White children had more visits to physicians (4.3 per year)
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From page 35... ...
Although the causal factors underlying low birth weight are not well understood,68 prenatal care in pregnancy has played a major role in the overall downward trend in infant mortality in the United States in recent decades. By all measures, blacks on average receive less-adequate prenatal care than whites.
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From page 36... ...
were constructed that incorporate measures of both medical care and need for medical care.76 While both of these measures have limitations, they are amenable to use in population-based surveys, and since 1963 these measures have shown that wide income and racial differences exist in medical care.78 By contrast, the 1976 CHAS survey showed that earlier racial/ethnic differences had either disappeared or that, in terms of their self-reports of disability and symptoms, blacks were receiving more medical care than whites.7 At the same time, the credence given to these measures must be tempered both by the methodological problems mentioned earlier and by other uncertainties in their use and interpretation. (One such uncertainty, as Dutton notes, is seen in the fact that different analyses of the same data from the 1976 survey have shown that large income differences exist in the use-disability ratio (number of physician visits per 100 disability days)
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From page 37... ...
Thus, it is clear that more than poverty underlies the racial disparities in where people obtain their medical care. Racial differences in the source of care also are evident in a community study of the health care of rural and "urban fringe" blacks and whites in North Carolina, where "74 percent of the rural and 64 percent of the urban whites named a private physician as their usual source of care, against 22 and 18 percent of blacks in the respective areas."86 The researchers concluded that, because so few blacks and Medicaid patients were served by community physicians (and thus served by neighborhood health centers and county health departments)
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From page 39... ...
"Difficulty getting to the doctor" was second only to cost as a barrier to care cited by poor people and non-whites questioned in the 1974 Health Interview Survey, and surveys such as those conducted by the National Center for Health Statistics (NCHS) and the Center for Health Administration Studies (CHAS)
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1978 Health Interview Survey, unpublished data.
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SOURCE: National Center for Health Statistics. 1978 Health Interview Survey, unpublished data.
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More useful are the studies that have been conducted at the local level. The relative scarcity of private physicians in urban neighborhoods in which ethnic minorities predominate has been documented in a variety of studies.
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Data from a 1968-71 survey conducted in 10 cities shows that, even within the same general neighborhoods, large racial differences exist in where people obtain medical care, as is shown in Table 8.102 The data strongly suggest that the disproportionate use by blacks of hospitals and public clinics cannot be attributed simply to proximity, because the usual source of medical care for whites in the same neighborhoods consistently differs from that of blacks. These differences were very large in some cases; in southeast Philadelphia, for example, more than half of blacks, but fewer than 10 percent of whites, reported that a hospital or public clinic was their usual source of medical care.
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From page 44... ...
163-174. Discrimination by Physicians Many of the data presented thus far -- most notably the findings that blacks make less use of private physicians than do whites with similar incomes and insurance coverage and that black and white residents of the same general urban areas use different sources of care -- are consistent with the hypothesis that minority group use of health care is influenced by patterns of discrimination among physicians.
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From page 45... ...
Differences in physician acceptance of Medicare and Medicaid patients are most pronounced in areas where racial/ethnic minority groups are concentrated. Thus, in the non-metropolitan Northeast and West, only
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46 Table 9. GENERAL PRACTITIONERS' ACCEPTANCE OF MEDICARE AND MEDICAID PATIENTS, BY AREA AND REGION, 1975 Percent Percent Taking Percent Percent Taking Patients New Medicare Patients New Medicaid Region Medicare Patients Medicaid Patients Large SMSAs Northeast 25.9 79.9 12.4 56.2 North Central 25.6 78.3 12.9 52.1 South 27.3 78.3 10.9 42.8 West 29.3 84.5 17.0 49.9 Small SMSAs Northeast 30.3 84.8 19.8 73.0 North Central 26.3 80.3 12.9 53.7 South 26.0 67.5 15.8 46.0 West 21.8 83.3 17.9 61.6 Non-metropolitan Northeast 36.1 85.0 19.7 78.5 North Central 28.0 75.9 12.4 65.0 South 25.3 60.6 18.8 51.3 West 19.8 64.6 13.5 58.7 Totals Large SMSAs 26.9 79.8 12.9 49.7 Small SMSAs 26.1 76.3 16.2 55.2 Non-metropolitan 26.8 68.8 16.4 59.9 SOURCE: The Physician Capacity Utilization Surveys: Special Analyses, DHEW Publication No.
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From page 47... ...
(The non-metropolitan South; it should be noted, is not notably different from other non-metropolitan areas of the country regarding the difference in acceptance of new Medicare and Medicaid patients.) Quality of Ambulatory Care In discussing the results of a study they conducted in the rural South in the mid-1970s, Davis and Marshall make the following observations about what they learned about racial differences in the quality of medical care: Cursory, inadequate physical examinations are frequently given to minority patients.
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From page 48... ...
Relatively few physicians provide care to relatively large numbers of Medicaid patients; estimates from a national survey suggest that 5 percent of the physicians in the country may provide care to one-third of the Medicaid patients. Physicians who provide care to relatively large numbers of Medicaid patients include disproportionate numbers of general practitioners, and, because of the negative association between age and specialty training, they tend to be older than the average physician.116 Foreign medical graduates also provide a disproportionate amount of the care to Medicaid patients.117 Kavaler's study of 126 physicians participating in the Medicaid program in the black and Puerto Rican slums of New York City found that 35 percent had no access to hospital beds and 42 percent had only limited privileges at proprietary hospitals.
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From page 50... ...
Regarding a set of surgical procedures about which particular concern has been expressed over the years -- sterilization -- available data show earlier racial differences in incidence to have largely disappeared. Data from the Hospital Discharge Survey, for example, show that, in 1971, black women were undergoing tubal sterilization at a rate of 12 per 1,000 women aged 15-44, while the comparable rate for white women was 5.3; by 1975, the rate of tubal sterilization among blacks was still 12 per 1,000, while the rate for whites was 11.6 per 1,000.132 Similar trends are evident in survey data published by the National Center for Health Statistics.
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From page 51... ...
Patterns of Hospital Use The racial patterns in physician visits have parallels in patterns of hospitalization, although no national data exist that are comparable to the data reviewed above on racial * When this report was written, all available data from the NCHS interview survey were for women who had been married.
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From page 52... ...
traditionally "black" hospital. Writing in the late 1960s, DeVise described the racial trends in hospitalization as follows: The dual system of Negro indigent patient hospitals and white private patient hospitals has persisted even though extensive Medicare and Medicaid programs now reimburse private hospitals and physicians for the care of indigents; even though OEO and Children's Bureau now pay private hospitals to set up free neighborhood health centers and pediatric clinics; even though there has been a sevenfold increase in the number of Negro physicians admitted to practice in private white hospitals; even though the Negro ghetto has more than doubled in area, absorbing in the process six more white hospitals; even though the average distance from Negro homes to Cook County Hospital has increased from five to eight miles, while the average distance from Negro homes to white hospitals stayed under one mile.140 A vivid measure of the nature of the travel patterns involved in the use of Cook County Hospital comes from the calculation that the 500,000 patient miles per month that were traveled to Cook County Hospital would be reduced to 50,000 miles if patients used the hospital nearest their homes.141 The average distance traveled by all black patients to the various Chicago hospitals where they were admitted was six miles; the average trip for a white patient was three miles.142 Travel time was also used as an indicator of a racial dual track system in a study of hospital use in Cleveland.143 Seventy-four percent of the blacks surveyed, compared with 59 percent of whites, traveled beyond the hospital that was second nearest to their home.
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From page 53... ...
However, applicable research methodologies have been developed in studies of segregation in other areas, such as education and residence,146 and data that are potentially useful for describing racial patterns of where people obtain medical care exist from programs such as Medicare and Medicaid. In principle, studies could be done of the degree of segregation in hospital use in various cities, the extent of its variation from city to city, and whether it is increasing or decreasing in response to factors such as economic trends and civil rights enforcement activity.
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From page 54... ...
In a study of racial differences in the treatment of children in five mental health clinics, Jackson, Berkowitz, and Farley found that black children were less likely than white children to be accepted for treatment, less likely to receive individual treatment, and (at two clinics) to be seen for a lesser length of time.150 In his study of services provided to members of different ethnic groups in 17 centers in Seattle, Sue found significant differences in the types of personnel seen both at intake and during therapy.151 At intake and during therapy, blacks saw significantly fewer psychiatrists, psychololgists, social workers, and nurses, and more "other professionals," non-professionals, and "other personnel," than did whites.152 This was true even after demographic differences were controlled statistically.
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From page 55... ...
An example is Shaw's study using 1968 hospital discharge information from the Commission on Professional and Hospital Activities.153 He found differences between whites and blacks in the rates that various diagnostic and therapeutic techniques were documented in medical records, as is shown in Table 12. Furthermore, the data show that these racial differences were less likely to occur in small hospitals than in large hospitals, and were less likely to occur in the western section of the United States than in the remainder of the country.
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If they are great, differences might be identified within individual institutions. Data from the National Center for Health Statistics Hospital Discharge Survey might also prove amenable to such research.
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Despite evidence showing greater needs for dental treatment among blacks than among whites, national data from the Health Interview Survey show that whites use the services of dentists more than do "other races."157 As Table 14 shows, this can be partially explained by differences in income, particularly since public funding of dental care is very limited, but racial differences exist even within income categories. Although fewer data are available, there is also evidence of low levels of dental care among the Chicano population.158 The explanation of the striking racial discrepancies regarding need and use of service in the dental area is not clear.
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From page 60... ...
More studies are needed that empirically examine the factors that influence the medical care decisions of minority group members. In recent years, the National Center for Health Statistics and the National Center for Health Services Research have shown more concern with collecting data that will be statistically valid for members of minority groups.161 Such data are expensive to collect because of sampling problems, yet they are of great importance if equity questions in American health care are to be assessed.
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From page 61... ...
Cain, Bureau of Health Planning and Resource Development, DHEW, and to David Tatel, Director, Office for Civil Rights, DHEW, November 7, 1977; Sylvia Drew Ivie and Howard Newman, Joint memorandum from the Director, Office for Civil Rights, and the Administrator, Health Care Financing Administration on "Civil Rights Responsibilities," August 28, 1980; Dorothy T Lang, Letter to Rep.
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From page 62... ...
Cain, Bureau of Health Planning and Resource Development, DHEW, and to David Tatel, Director, Office for Civil Rights, DHEW, November 7, 1977.
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From page 63... ...
Gomez, "Older Mexican Americans: A Study in an Urban Barrio," Chapter 6: Health Status and Health Care Utilization, Unpublished manuscript; Chicano Health Institute of Students, Professors, and Alumni, The California Raza Health Plan: An Action Guide for the Promotion of Raza Health in California (Berkeley, CA, CHISPA: 1979)
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From page 64... ...
110; National Center for Health Statistics, Prevalence of Selected Chronic Respiratory Conditions, United States-1970, Vital and Health Statistics, Series 10, No. 84, (Washington, D.C.: Government Printing Office, 1973)
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From page 65... ...
Although groups that receive little or no prenatal care have higher infant mortality rates, questions of causation remain. Low birth weight is generally acknowledged to be the major risk factor for infant mortality, and the higher incidence of low birth weight infants among blacks is amply documented and is true regardless of age, marital status, and receipt of prenatal care (NCHS, Series 21, Number 37)
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From page 66... ...
69. National Center for Health Statistics, Prenatal Care; United States, 1969-1975, Vital and Health Statistics, Series 31, No.
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From page 67... ...
89. National Center for Health Statistics, "Advance Data, Health Interview Survey 1974," DHEW Publication No.
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Civil Rights Commission on the federal role in rural health care delivery, April 15, 1980, p.
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From page 69... ...
133. National Center for Health Statistics, National Survey of Family Growth (Unpublished data)
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Flaherty and Robert Meagher, "Measuring Racial Bias in Inpatient Treatment," American Journal of Psychiatry 137 (June 1980)
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From page 71... ...
Eva J Salber and Angel1 Beza, "The Health Interview Survey and Minority Health," Medical Care 18 (March 1980)
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