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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. The historical evolution of healthcare for persons of color, the current financial and or- ganizational structures of health systems, the settings in which care is de- livered, and the nature of the workforce providing care may, both inde- pendently and jointly, influence the quality of care that minorities receive. This chapter describes some of these environmental factors and the influ- ences they may have on healthcare for racial and ethnic minorities. The first two sections of this chapter describe aspects of the social and economic contexts in which racial and ethnic minority groups live in the United States. These sections review: a) the health, health insurance, and linguistic status of these groups, and b) racial attitudes and patterns of segregation and discrimination in various sectors of American life. The third section reviews the history of segregated healthcare and contempo- rary settings in which racial and ethnic minorities receive healthcare, in- cluding the influence and importance of community health centers. The last section focuses on the healthcare workforce in minority communi- ties—how this workforce originated, where individuals practice, who they serve, and the influence of international medical graduates on healthcare in minority communities. The chapter concludes with a discussion of medical education, how affirmative action has served to increase the pres- ence of underrepresented minorities in the health professions workforce, and how recent legal challenges to affirmative action have affected and may have a future impact on the healthcare workforce. 80

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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. Where possible, data on subpopulations of racial and ethnic groups (e.g., Cuban American, Puerto Rican, Mexican American, and other subgroups of the Hispanic popula- tion) are presented. This information is supplemented, where appropri- ate, by qualitative data regarding the experiences of racial and ethnic mi- nority patients and healthcare professionals. These data, presented in individuals’ own words, are offered as a means of understanding some of patients’ and providers’ experiences and perceptions of how race or ethnicity may affect both care processes and the systems and settings in which care takes place. As such, these data are not intended to substitute for empirical findings. Rather, they serve to “give voice” to the experi- ences of key actors in healthcare disparities, and illuminate how health- care disparities are perceived by patients and their providers. Qualitative data were gathered via three mechanisms: • Roundtable discussions with minority healthcare consumers, pro- fessionals and advocates at one of two large national conferences (the Asian American and Pacific Islander Health Forum conference and the Indian Health Service Research Conference, both held in April, 2001); • Liaison panel discussions with consumer and professional groups, federal agency representatives, and minority health advocates held in the spring and summer, 2001; • Focus group sessions conducted during this same time period; and interviews with American Indian and Alaska Native tribal leaders and a cadre of healthcare providers serving American Indian and Alaska Na- tive communities (Joe, this volume). For more information on these data collection activities and a sum- mary of focus group and liaison panel findings, please see Appendixes A and D. 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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82 UNEQUAL TREATMENT Americans. As depicted in Figure 2-1, African Americans have the high- est rates of morbidity and mortality of any U.S. racial and ethnic group. The mortality rate for African Americans is approximately 1.6 times higher than that for whites—a ratio that is identical to the black/white mortality ratio in 1950 (Williams and Rucker, 2000). American Indians and Alaska Natives also experience higher mortality rates than whites, accompanied by low life expectancy. And while other racial and ethnic minorities ex- perience 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 Sta- tistics, 2000]), and an elevated burden of disease among some groups for specific causes of mortality. As depicted in Figure 2-2, some causes of mortality, such as diabetes, disproportionately affect African-American, Hispanic, and American Indian/Alaska Native populations. In addition, some subpopulations of racial and ethnic groups experience an elevated incidence and mortality due to specific diseases. Alaska Natives experi- ence the highest rates of colon and rectal cancers of any racial or ethnic group in the United States (Institute of Medicine, 1999b). Korean Ameri- cans have the highest rates of stomach cancer (48.9 per 100,000 popula- tion) among U.S. males, followed by Japanese Americans (30.5 per 100,000 population; Institute of Medicine, 1999b). Similarly, Vietnamese-Ameri- can women experience the highest incidence of cervical cancer in the United States, at rates nearly six times higher than that of white women (Institute of Medicine, 1999b). 690.9 700 Death per 100,000 Residence 600 500 452.2 458.1 Population 400 342.8 300 264.6 200 100 0 White Black American Asian or Hispanic Indian or Pacific Islander Alaska Native FIGURE 2-1 Age-adjusted death rates for all causes of death by race and Hispanic origin: United States, 1950-1998. SOURCE: Health, United States, 2000 (2001).

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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). 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). The problem is particularly acute among the working poor and individu- als who have no employment-based insurance, and among whom minori- 40 35 32.8 35 Uninsured Rate (percent) 30 22.8 25 22 20 17.5 12.7 15 10 5 0 Hispanic American Non-Hispanic Asian American Non-Hispanic General Indian and African and South White Population Alaska Native American Pacific Islander Under Age 65 FIGURE 2-3 Probability of being uninsured for population under age 65, by race and ethnicity. SOURCE: Hoffman and Pohl, 2000.

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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. NOTE: Numbers may not add to 100 percent due to respondents reporting more than one source of coverage and due to rounding. SOURCE: Fronstin, 2000. ties, particularly Hispanic Americans, are over-represented. Lack of in- surance poses the most significant barrier to care. Insurance status, per- haps more than any other demographic or economic factor, determines the timeliness and quality of healthcare, if it is received at all (Institute of Medicine, 2001b). African Americans African Americans are less likely to possess private or employment- based 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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85 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES 2-4). In addition, African Americans are almost twice as likely as non- Hispanic whites to be uninsured. High rates of uninsurance among this population occur despite the fact that over 8 in 10 African Americans are in working families, as a disproportionate percentage of African Ameri- cans work in jobs that provide no heath insurance (The Henry J. Kaiser Family Foundation, 2000a). As illustrated in Figure 2-3, the probability of being without health insurance coverage for African Americans is 22.8 percent, compared with 17.5 percent in the general population. American Indians and Alaska Natives The U.S. government is obligated through treaty and federal statutes to provide healthcare to members of federally recognized American In- dian tribes. This trust, however, has not been fully met, for several rea- sons. The federal Indian Health Service (IHS) provides healthcare ser- vices primarily on Indian reservations, which are home to only a minority of American Indians (as few as 30%), as the majority of the population currently lives in urban or other non-reservation areas (Brown et al., 2000). To obtain IHS care, Indians must travel to their home reservation. Not surprisingly, a large majority (80%) of American Indians and Alaska Na- tives report no access to IHS facilities (The Henry J. Kaiser Family Foun- dation, 2000a). Although the federal government contracts with a num- ber of urban Indian health organizations to provide services, such federal support is often limited. In general, the agency’s resources (slightly over $2 billion was appropriated to the agency in fiscal year 1998) are far below needs. In fiscal year 1997, for example, the agency reported $1,430 in per capita expenditures, a figure that is 1.4 to 2.8 times below the per capita spending of other federal health programs and agencies such as Medicaid ($3,369) and the Veterans Administration ($5,458) (National Indian Health Board, 2001). Figure 2-3 indicates that nearly one-third of American Indians and Alaska Natives (32.8%) 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 re- ceive Medicaid insurance and a similar proportion are uninsured or re- port only IHS coverage (The Henry J. Kaiser Family Foundation, 2000). Asian Americans and Pacific Islanders Some of the ethnic subgroups among Asian Americans and Pacific Islanders (API) have disproportionately high rates of uninsurance (Brown et al., 2000; Hoffman and Pohl, 2000). Rates vary considerably, although

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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%). Nearly one-fourth of API populations are uninsured (see Figure 2-3). Generally, rates of public insurance are lower for Asian Americans and Pacific Islanders, ex- cept for some Southeast-Asian subpopulations (Brown et al., 2000). Within API subgroups, Korean Americans are least likely to have health insurance. Less than half have job-based insurance (49%), while over one-third (34%) are uninsured and 14% receive Medicaid or other publicly funded insurance. Similarly, South East-Asian (e.g., Vietnamese, Cambodian, Laotian) and South-Asian (e.g. Indian, Pakistani, Bangla- deshi) populations are disproportionately uninsured (27% and 22%, re- spectively). Less than half (49%) of South East-Asians have job-based in- surance, while nearly seven in ten South-Asians (69%) have job-based insurance. Two in ten Chinese-American and Filipino-American families are uninsured (The Henry J. Kaiser Family Foundation, 2000b). These data are depicted in Figure 2-5. Other Public Job-Based Medicaid/Other Public Uninsured 100 90 Health Insurance Coverage (percent) 80 70 60 50 40 30 20 10 0 Chinese Filipino Korean South East Japanese South White Asian Asian FIGURE 2-5 Health insurance coverage by Asian-American and Pacific-Islander subgroups vs. whites (Ages 0-64), 1997. SOURCE: The Henry J. Kaiser Family Foundation, 2000b.

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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. The probability of being uninsured among Hispanic Americans is 35 percent, compared with 17.5 percent for the general population (Hoffman and Pohl, 2000). This disparity, depicted in Figures 2-3 and 2-4, largely results from the lack of job-based insurance provided to Hispanic Americans, who disproportionately work in blue- collar and service-oriented jobs. The vast majority (87%) of uninsured Hispanics are in working families, yet only 43% of Hispanics receive health insurance through work. Further, nearly one-third of Hispanics (30%) work for an employer who does not offer health insurance to work- ers (The Henry J. Kaiser Family Foundation, 2000b). The high rate of uninsurance among Hispanics is also a reflection of a lower-than-average rate of participation in publicly funded health plans. In families with incomes less than the federal poverty level, 45 percent of all Hispanics are uninsured, compared with 32 percent of non-Hispanic whites (Fronstin, 2000). Differing eligibility standards may play a significant role in the lower rates of coverage for Hispanics under some publicly funded insur- ance plans, as many state and federal guidelines do not permit coverage for extended family members or families where married spouses live in the same household. Hispanic subgroups vary in rates and sources of insurance coverage. Cuban Americans experience the highest rates of job-based or other pri- vate insurance (65%), and along with Puerto Ricans, are least likely to be uninsured (21%). Less than half of Puerto Rican, Central and South American-descendent, and Mexican Americans have job-based or other private insurance (45%, 46% and 44%, respectively), and over one-third of Puerto Rican Americans (34%) are insured by Medicaid or other publicly funded programs. More than 4 in 10 Central and South American descen- dent-Americans are uninsured (42%), as are 38% of Mexican Americans. These data are displayed in Figure 2-6. Linguistic Barriers Many racial and ethnic minority Americans experience language barri- ers. These barriers range from low or no English proficiency to limited proficiency in speaking, reading or comprehending English. In healthcare settings, these linguistic barriers can present significant challenges to both patients and providers, despite federal regulations that encourage and sup- port the use of interpreters (Office of Civil Rights, U.S. Department of Health and Human Services, 2000). According to the 1990 U.S. Census, 14 million people living in the United States have no or limited English-language skills

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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), 1997. SOURCE: The Henry J. Kaiser Family Foundation, 2000b. (data from the 2000 Census are not available as of this writing). These popu- lations can be found throughout the United States, although they are dis- proportionately represented in large urban centers and in five states (more than 10% of the population in California, New York, Texas, New Mexico, and Hawaii have limited English-language skills [Woloshin et al., 1995]). Nearly 8 million individuals (7,741,259) live in linguistically isolated house- holds, e.g., households in which no person over age 14 speaks English “very well” (U.S. Bureau of the Census, 1993). The percentage of individuals living in linguistically isolated households for each racial and ethnic group is depicted in Figure 2-7. Hispanic or Latino More than 1 in 4 (25.3%) Hispanic individuals in the United States live in a linguistically isolated household. These include 4,560,000 indi- viduals in over 1.5 million households. In addition, nearly 8 million His- panic Americans (7,716,000) do not speak English “very well” (U.S. Bu- reau of the Census, 1993). Given recent population shifts (e.g., an increase in foreign-born Hispanic immigrants), it is likely that these figures grossly underestimate the number of Hispanic Americans with limited or low English proficiency.

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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. SOURCE: U.S. Bureau of the Census, 1993. American Indian and Alaska Native More than one in 20 American Indians or Alaska Natives lives in a household in which no adolescent or adult speaks English “very well.” According to the 1990 U.S. Census, 281,990 persons aged five years or older speak one of the American Indian languages at home; half of these (142,886) speak Navajo. Nearly 170,000 American Indians or Alaska Na- tives do not speak English “very well,” and over 32,000 American Indian or Alaska Native households are linguistically isolated (U.S. Bureau of the Census, 1993). Asian Americans and Pacific Islanders Large segments of Asian-American and Pacific Islander communities face linguistic isolation. According to 1990 U.S. Census estimates, more than 1.5 million Asian or Pacific Islander Americans live in linguistically isolated households. Over half of Laotian, Cambodian, and Hmong fami- lies are linguistically isolated, while between 26%-42% of Thai, Chinese,

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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 linguisti- cally isolated. Healthcare Providers Many healthcare providers are acutely aware of the impact of lan- guage barriers and other cultural differences and how these factors affect their healthcare practice. In a recent survey of physicians who participate in the “Healthy Families” programs, L.A. Care (the local health authority of Los Angeles County) found that 71% of providers believe that language and culture are important in the delivery of care to patients. Slightly over half (51%) believe that their patients did not adhere to medical treatments as a result of cultural or linguistic barriers. Yet, over half of these provid- ers (56%) report not having had any form of cultural competency training (Cho and Solis, 2001). RACIAL ATTITUDES AND DISCRIMINATION IN THE UNITED STATES “There are those that don’t get promoted because of their race or whatever. The reason [may be because] they’re not well liked by administration or it may be just that they [administrators] don’t want that person in that setting because of their race—that is out there. Racism is alive and well, and those of us who think that it’s not are living in some kind of dream world.” (African-American nurse) “I’ve had both positive and negative experiences. I know the negative one was based on race. It was [with] a previous primary care physician when I discov- ered I had diabetes. He said, ‘I need to write this prescription for these pills, but 59.8 54.7 51.5 42.1 35.1 34.8 26.6 14.8 11.2 7.2 8.1 1 n n n an e i se an e n an g a ia oa ia es es ia on Th ne di re di ai an ot an m m m In bo Ko aw hi La m na Sa H p C an am ua Ja H et i As G Vi C FIGURE 2-8 Percentage of Asian Americans that are linguistically isolated, by subgroup. SOURCE: U.S. Bureau of the Census, 1990 General Population Characteristics.

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114 UNEQUAL TREATMENT were lower than in communities not serviced by these centers (Epstein, 2001). Patients in underserved areas served by these centers had 5.8 fewer preventable hospitalizations per 1,000 population over three years than those in underserved areas not served by a federally qualified health center. While CHCs were developed on the premise that they would service all patients regardless of their ability to pay, limited federal subsidies have forced many clinics to reduce the amount of uncompensated care they provide. Between 1981 and 1991, federal funding increased at half the rate of increase in the urban consumer price index for medical care (Rosenbaum and Dievler, 1992, as cited in COGME, 1998). Changes in the cost of medical technology, shift of services from inpatient to outpatient settings, and Medicare’s Prospective Payment System have placed a strain on many hospitals. While most have remained operational, approxi- mately 5% of non-federal community hospitals closed between 1985 and 1988, a rate two to three times higher than in the preceding four years (GAO, 1990). Concerned about loss of their Medicaid patient base, many CHCs have begun participating in managed care arrangements. By 1996, almost half (45%) of CHCs participated in such arrangements (Shi et al., 2000). This shift has generated fears among some that these centers will be less able to serve patients who need care the most, with declines in Medicaid reimbursement and increased difficulty providing non-reim- bursable services under managed care (GAO, 1995; Shi et al., 2000). In fact, recent studies suggest that CHCs provide care to a smaller propor- tion of uninsured patients, while they are serving increasing proportions of Medicaid patients under managed care (Shi et al., 2001). THE HEALTHCARE PROFESSIONS WORKFORCE IN MINORITY AND MEDICALLY UNDERSERVED COMMUNITIES Demographics of Healthcare Providers The historical antecedents of physician and other healthcare provider training, as discussed above, significantly shape the current landscape of health professions education and the healthcare workforce. In this sec- tion, 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. Of these 9%, one-third (33.3%) is African American, 40.1% are

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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 In- dian (AAMC, 2000). 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 (Afri- can Americans, Mexican Americans/Chicanos, mainland Puerto Ricans, and American Indians/Native Americans) represent a smaller subset of this population, as less than 6% of the U.S. physician workforce is composed of individuals from these backgrounds. Significantly, well over 1 in 4 Ameri- cans is African American, Hispanic, or American Indian/Alaska Native (U.S. Bureau of the Census, 2000). Minority physicians are more likely than their non-minority peers to work in hospital-based practices. Whereas only 1 in 5 (21.4%) of all physi- cians nationally work in hospital-based practices, nearly one-third (32.1%) of African American physicians, over half (50.3%) of Asian American phy- sicians, over 1 in 3 (35%) of Hispanic physicians, and nearly 2 in 5 (39.3%) of American Indian/Alaska Native physicians work in such settings. Non-minority physicians are more likely to work in office-based prac- tices, as 3 in 5 (60.5%) work in such settings, compared with 55.7% of African Americans, 40.8% of Asian Americans, 54.8% of Hispanics, and 53.1% of American Indian/Alaska Natives. Minority physicians are far more likely than non-minorities to be residents or fellows, owing to the generally younger age of minority physicians (AAMC, 2000). In terms of specialty practice, minorities are more likely to be found in family prac- tice (11.5% of African American, 12.7% of Hispanic, and 24.7% of Ameri- can Indian/Alaska Native physicians are family practitioners, compared with 9.9% of all physicians), obstetrics-gynecology (12.1% of African American, 8.3% of Hispanic, and 7.3% of American Indian/Alaska Native physicians are found in OB/GYN, compared with 6% of all physicians), and pediatrics (10.1% of African American and 11.1% of Hispanic physi- cians are pediatricians, compared with 8.7% of all physicians), but are poorly represented in other specialties, such as cardiology, surgery, and psychiatry (AAMC, 2000). Among physicians participating in managed care arrangements, Asian-American physicians are more likely to be in solo practice (56%), while African-American physicians are more likely to practice in staff- model HMOs (19%), white physicians are more likely to be in group prac- tice (45%), and Latino physicians were more likely to be in a hospital- or clinic-based practice (25%). Latino physicians are least likely to have man- aged care patients compared with physicians of other racial or ethnic groups, even after controlling for their lower rate of board certification. Twenty-six percent of Latino physicians had no managed care patients compared with 10% for African-American physicians, 13% for white phy- sicians, and 14% for Asian physicians (Mackenzie et al., 1999).

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116 UNEQUAL TREATMENT Nurses In 2000, 12.3 percent of registered nurses were racial and ethnic mi- norities. 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. A larger percentage (86.4%) of minority nurses were employed in nursing, as compared with 81% of white, non-Hispanic nurses. Minority nurses were also more likely to work full-time (U.S. Health Resources and Services Administration, 2001). Geographically, there are distinct patterns of practice between the minority and non-minority nursing workforce (Table 2-3). Recent esti- mates revealed that black nurses were more likely to practice in the south and middle Atlantic regions of the country. Hispanic nurses were repre- sented in higher proportions in the west and east south-central areas. Asian/Pacific Islander nurses were more likely to be found practicing in the Pacific and mid-Atlantic states. The west south-central and Mountain areas of the United States were the sites with the highest percentages of American Indian and Alaskan Native nurses. The most common employ- ment setting for minority as well as non-minority nurses was in hospitals (U.S. Health Resources and Services Administration, 2001). Impact of International Medical Graduates (IMGs) 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. hospitals, especially those serving underserved urban and rural communities, be- gan to increase sharply. Between 1933 and 1940, the composition of the 5,056 immigrant physicians admitted to the United States was predomi- nantly European (Stevens, Goodman, and Mick, 1978). By the 1960s, how- ever, immigration policies had changed such that visas were easily attain- able and institutions were beckoning Third World IMGs to the United States for training because of a perceived short supply of physicians (Stevens, Goodman, and Mick, 1978). This movement was occurring as courts ended federally sponsored hospital segregation and as Medicare and Medicaid legislation was passed by Congress. Concurrently, the Civil Rights era laid the groundwork for significant changes in access to healthcare facilities and services for racial and ethnic minorities as well as for the poor and elderly.

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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) 89.7 96.5 86.8 87.4 92.1 85.6 93.9 96.6 92.4 83.5 Black (non-Hispanic) 4.4 1.3 5.6 7.3 6.3 5.0 2.8 1.4 1.1 3.1 Asian/Pacific Islander 3.4 0.8 5.4 2.7 0.5 3.8 2.0 0.5 1.7 8.3 American Indian/Alaska Native 0.5 0.1 0.2 0.2 0.3 1.3 0.3 0.6 1.4 0.7 2.5 3.5 Hispanic 1.6 0.4 1.2 1.4 0.5 3.7 0.7 0.5 Other 0.7 0.8 1.0 1.0 0.2 0.5 0.4 0.4 0.8 1.0 SOURCE: National Sample Survey of Registered Nurses, March 2000. HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES 117

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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). The geo- graphic maldistribution of physicians that had been systematically dis- cussed for over 30 years as a problem became a public agenda item. By and large, health professionals had chosen to locate and practice in afflu- ent urban and suburban communities, while large numbers of minorities and the poor had limited access to care. 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). The number of first-year resi- dency positions filled increased to 140% of the yearly U.S. medical school graduates. The physician-to-population ratio (excluding resident physi- cians) increased by 65%, from 115 to 190 physicians per 100,000 (COGME, 1996). Most of this increase was in the medical specialties, increasing the specialist physician-to-population ratio 121% from 56 to 123 specialists per 100,000 population (COGME, 1996). Healthcare expenditures also rose dramatically during this period. Federal spending for all health services just before Medicare and Medic- aid was enacted in 1965 was $4 billion, rising to $15.7 billion in 1970, $33.8 billion in 1975, and $65.7 billion in 1980. During the same period of time, state and local spending increased from the pre-Medicare/Medicaid level of $4.8 billion to $31.3 billion. The poor greatly increased their use of healthcare services. By 1976, poor children averaged 65% more physician office visits, poor adults averaged 27% to 33% more visits, and the elderly poor averaged 18% more visits than in 1964. In fact, the poor in each age group increased their use of health facilities more than the non-poor (U.S. Department of Health and Human Services, 1980), contributing to the in- creased demand for healthcare professionals. Today, IMGs are a significant part of the U.S. health workforce. The number of residency positions filled by IMGs in 1998-99 was 25,415, or more than one-fourth (26%) of all residents on duty in U.S. hospitals in 1998-99 (COGME, 1999). Many work in minority and medically under- served communities, where few other physicians choose to practice. Verghese (1994) and White (1993) concluded that individual IMGs have established themselves as critical providers of healthcare services in se- lected rural underserved areas. Most, however, locate in large cities, and practice in urban underserved areas. They are disproportionately distrib- uted in teaching hospitals with high percentages of Medicaid low-pay or no-pay patients. Sixteen percent of all teaching hospitals had an entire

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119 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES resident staff consisting of greater than 40% IMGs (MedPAC, 1999). A detailed survey of the healthcare providers working in nine of the poorest neighborhoods in New York City revealed that greater than 70% of the physicians were graduates of foreign medical schools (Bellochs and Carter, 1990). The data also revealed that only 24% of the practicing phy- sicians were board certified, while the citywide average was 64%. Many other investigators (Fosset et al., 1990; Mitchell, 1991; Mitchell and Cromwell, 1980; Perloff et al., 1986a) 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) summarized his study of healthcare for the poor in four of the nations largest cities: A long-term trend of abandonment and avoidance by physicians had drained the low-income neighborhoods in all four metropolitan areas of private practitioners; physician-population ratios were as low as 1: 10,000 to 1: 15,000, in contrast to affluent neighborhoods with ratios of 1: 300 or even higher. Moreover, the majority of practitioners serving the poor con- sisted of foreign medical graduates, many with indifferent professional competence and language problems that impeded effective communica- tion. Deterred by the low reimbursement rates paid by state Medicaid programs…the majority of U.S. trained physicians refused to accept Med- icaid patients or limited the numbers they were willing to treat, leaving the field to group practices with questionable standards (Medicaid mills) that thrived on volume throughput (Ginzberg, 1994, p. 1465). While from varied geographic locations around the globe, the largest share of IMGs working in the United States today are from South Asian nations. Table 2-4 illustrates the country of origin for the top 10 countries with the highest number of medical graduates in the United States. TABLE 2-4 Top 10 Countries with Highest Proportion of Medical Graduates in the United States Country Percentage of the U.S. IMG Population India 19.5% Pakistan 11.9% Philippines 8.8% Ex-USSR 3.1% Egypt 2.6% Dominican Republic 2.5% Syria 2.5% United Kingdom 2.4% Germany 2.3% Australia 2.1% SOURCE: The Educational Commission for Foreign Medical Graduates, 1992.

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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). As these authors note, two-thirds of IMGs are unpre- pared for the experience, having relied upon friends or family for advice. Many do not have the luxury of selecting a hospital in which to practice; rather, they accept the job that is offered. Often IMGs enter the United States thinking of themselves as “internationally mobile scientists” with knowledge and skills that are transferable anywhere in the world, only to be jolted by the reality of being treated as an alien or outsider inside the hospital (Stevens, Goodman, and Mick, 1978). In one survey (Stevens, Goodman, and Mick, 1978), 13% of IMGs felt that they were inadequately informed about the location of the American hospitals, including the fact that many large hospitals are in high-poverty areas of major cities. For others, complex malpractice claims and standards may pose problems, as well as large caseloads, documentation requirements, long hours, a fast pace, and language difficulties. The 12th CoGME Report (1999) observed that “when physician and patient differ with respect to race, ethnicity, language, religion and val- ues, ensuring fair, equitable, and culturally sensitive care is more chal- lenging.” The opportunity for miscommunication and cultural gaffes be- tween IMGs and minority patients abound and could be manifest in the way healthcare services are provided or received by the communities served. 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 in- adequately 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. THE PARTICIPATION OF RACIAL AND ETHNIC MINORITIES IN HEALTH PROFESSIONS EDUCATION “I heard an Anglo doctor complaining that his daughter is having trouble get- ting into medical school. Then another doctor jumps in, another Anglo, “Oh don’t worry about it. I know the admissions coordinator. I’ll get her in. I’ll give him a call and she’ll be in.” When does a Hispanic or black student have those advantages, the connections? I certainly didn’t have any connections, and I still don’t have any connections. I couldn’t get my son into medical school if I tried.” (Hispanic physician)

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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. What was really interesting was that OK, sure I’m black, but I don’t take the black test, I don’t take the black boards, we take the same exams.” (African American physician) In the late 1960s, many U.S. medical colleges and other health profes- sions 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 en- joyed such opportunities. The Association of American Medical Colleges (AAMC) and other groups actively encouraged member institutions to improve outreach programs and matriculation efforts targeted to minor- ity students, in the hope that their rates of participation in health profes- sions would achieve parity with the proportion of racial and ethnic mi- norities in the U.S. population (Nickens and Ready, 1999). This goal was established not only because its attainment would help to rectify inequi- ties in educational opportunities, but also because of a growing apprecia- tion that minority healthcare professionals are more likely to work in mi- nority and medically underserved communities, thereby addressing a growing public health need. By 1974, 10% of all medical school matriculants were underrepre- sented minorities (AAMC, 2000). This proportion decreased significantly in the wake of the U.S. Supreme Court’s Bakke decision in 1976, but other efforts, such as AAMC’s “Project 3000 by 2000,” initiated in 1990, resulted in significant increases that exceeded 1974 levels. Between 1990 and 1994, the number of underrepresented minority (URM) students increased 36.3% to 2014 students, or 12.4% of the total number of medical school matriculants. Since that time, however, the number and proportion of new URM medical school enrollees has declined significantly. Enroll- ment of African-American students in medical schools, for example, de- clined 8.7% between 1994 and 1996 (Carlisle and Gardner, 1998). The greatest declines have occurred in public medical schools, which prior to 1996 enrolled a greater proportion of URM students than private institu- tions. Over 60% of public institutions experienced declines in URM stu- dent enrollment since 1994—a collective decrease of 9.1% in minority stu- dent matriculation at these institutions—while only 44% of private medical schools experienced such declines (Carlisle and Gardner, 1998). While the reasons for these declines are complex, some evidence in- dicates that the declines have immediately followed significant policy shifts regarding affirmative action and higher education admissions pro- cedures. Several legislative and judicial challenges to affirmative action

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122 UNEQUAL TREATMENT policies in 1995, 1996, and 1997 (notably, the Fifth District Court of Ap- peals finding in Hopwood v. Texas, the California Regents decision to ban race or gender-based preferences in admissions, and passage of the Cali- fornia Civil Rights Initiative [Proposition 209] and Initiative 200 in Wash- ington state) have forced many higher education institutions to abandon the use of race and gender as factors in admissions decisions. Subse- quently, public medical schools in California, Louisiana, Mississippi, and Texas (the latter three states are subject to the Hopwood ruling) accounted for 44% of the decrease in URM matriculation in medical schools nation- wide (Carlisle and Gardner, 1998a). In 1997, African-American student enrollment in Texas’ public medical schools dropped 54% (Carlisle and Gardner, 1998b). And among California’s public and private medical schools, URM enrollment declined 32% in 1998 from its peak in the mid- 1990s (Grumbach et al., 2001). Because of the large minority populations in these states, much of the nationwide decline in URM enrollment re- flects the trends noted above, while more modest minority enrollment declines in states unaffected by legislative or judicial rulings may reflect administrators’ greater caution or perceived pressure to scale back affir- mative admissions policies. This decline in the numbers of underrepresented minority students in health professions education programs raises significant concerns regard- ing the ability of the healthcare workforce to address the nation’s future health service needs. 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 com- munities. A study of physicians’ practices in California found that on average, over half (52%) of patients in the practices of African-American physicians were African American, compared with nine percent among non African-American physicians. Among Hispanic physicians, average caseloads approached 55% Hispanic patients, compared with 20% among non-Hispanic physicians (Komaromy, Grumbach, Drake, et al., 1996). Yet African-American and Hispanic physicians constitute less than 6% of the physician workforce. The racial/ethnic diversity of health professionals also has broader implications for health service costs and improvements in the quality of care. For example: • Healthcare professionals from racial and ethnic minority groups have generally been more successful in recruiting minority patients to participate in clinical research. Such efforts are critical to link scientific advancements with quality service delivery in underserved communities.

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123 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES • The quality of healthcare depends as much on physicians’ scien- tific 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). • Racial and ethnic minorities disproportionately receive medical care in hospital emergency settings. Such care is more costly than routine medical care and preventive health services. Healthcare professionals from minority and underserved communities may be better poised to tai- lor preventive health and primary care programs and services to minority populations, thereby reducing associated costs. SUMMARY Racial and ethnic disparities in healthcare emerge from an historic context in which healthcare has been differentially allocated on the basis of social class, race, and ethnicity. 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 consid- erable economic, social, and political progress of racial and ethnic minori- ties, evidence of racism and discrimination remain in many sectors of American life. This persistent pattern of inequality suggests that inter- ventions to eliminate disparities must be comprehensive and sustained, and that raising public and healthcare provider awareness of the problem is an important first step. Toward this end, a number of public and pri- vate organizations have developed educational campaigns targeted to- ward healthcare consumers, their providers, policymakers, and other “stakeholders.” These efforts include, but are not limited to: the public education efforts of U.S. DHHS, which recently launched its “Closing the Health Gap” campaign to heighten awareness of health disparities; Di- versity Rx, which provides a clearinghouse of information on language, culture, and improving healthcare services for minorities; and The Henry J. Kaiser Family Foundation, which has developed a number of publica- tions targeted to the general public regarding healthcare disparities. Finding 2-1: Racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimina- tion in many sectors of American life.

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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. Media campaigns and other educational efforts to in- crease awareness of disparities should be targeted to broad audiences, including healthcare consumers, payors, providers, and health sys- tems administrators. Recommendation 2-2: Increase healthcare providers’ awareness of disparities. Organizations responsible for the education, training, and licensure of health and medical professionals should develop special initia- tives to increase levels of awareness of healthcare disparities among current and future healthcare providers.