Trends in Underrepresented Minority Participation in Health Professions Schools*
Kevin Grumbach, Janet Coffman, Emily Rosenoff, and Claudia Muñoz
University of California, San Francisco
Center for California Health Workforce Studies
African Americans, Latinos, and Native Americans are underrepresented in all the health professions in the United States. In the past decade, educational organizations in the health professions have embarked on initiatives to increase the number of underrepresented minorities (URMs) entering health professions schools. Among the most prominent of these has been the “3000 by 2000” project directed by the Association of American Medical Colleges. URM enrollment in U.S. medical schools increased in the early 1990s, coinciding with the 3000 by 2000 initiative. However, these trends have abruptly reversed in recent years. Many observers have attributed much of this recent decrease to legislative and judicial decisions (e.g., Proposition 209 in California and Hopwood v. Texas) that have restricted the use of special consideration of race and ethnicity in admissions decisions.
Much less is known about national trends in the past decade in URM enrollment in health professions schools other than allopathic medicine. In addition, prior published analyses of URM trends in allopathic medical schools have not fully scrutinized the interplay between application and admission trends that have resulted in the decline in URM matriculants. To better understand trends in URM student enrollment across professions and to clarify the factors contributing to observed patterns in URM enrollment, we analyzed data for the past decade for a variety of health professions.
We contacted associations representing health professions schools to obtain data about each profession for the years 1990–2000. Data were obtained from the following organizations: American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, Association of American Medical Colleges, American Dental Education Association, Association of Schools of Public Health, California Postsecondary Education Commission, and the College of Veterinary Medicine at North Carolina State University.
We requested unduplicated national counts of the number of applicants, acceptances, matriculants, and graduates for each year for each type of professional school. To evaluate the possible effects of the Proposition 209 and Hopwood v. Texas policies, we also requested information separately for California and Texas schools for each of these data elements. Many associations were unable to provide national or state data for some or all of the requested elements; in these instances, we relied on less optimal data such as number of total enrollees rather than number of new matriculants. Additionally, data were not always available for all the years requested. We did not examine retention rates in health professions schools because data on progression of students from matriculation through graduation were not available for most professions.
We defined URMs as African Americans, Latinos, and Native Americans. Some educational organizations use more restrictive definitions of URMs (e.g., include only certain subgroups of Latinos). However, we considered Latinos as a whole to be underrepresented and many organizations have data only for Latinos in the aggregate and not for specific subgroups.
URM trends in matriculants and enrollees over the past decade differ across the health professions (Figure 1). Nursing, public health, and pharmacy have seen a modest but steady rise in the proportion of matriculants and enrollees who are URMs. Other professions, such as allopathic and osteopathic medicine, experienced initial increases followed by decreases in the late 1990s. Dentistry, in contrast, is a profession with a steady decrease in the proportion of URM matriculants over the entire decade. All health professions fall well short of “population parity” measured against the proportion of URMs in the overall U.S. population; according to 2000 U.S. Census data, African Americans, Latinos, and American Indians constitute 25% of the U.S. population.i
The number of URMs matriculating is a function of three components: the number of URMs applying, the proportion of URM applicants accepted, and the proportion of the accepted students who matriculate. These dynamics differ for each profession in producing the patterns shown in Figure 1.
Data are most complete for medical schools accredited by the Licensing Council for Medical Education (often referred to as allopathic medical schools). The completeness of the data permits a thorough analysis of the dynamics of URM participation in allopathic medical schools. In addition, data from allopathic medical schools are available in detail for years prior to 1990 and we include 1980–1990 data as well as 1990–2000 data in these analyses.
Allopathic medicine experienced a rise and fall in the percent of matriculants who are URMs, reaching a high of 15.5% in 1994 before falling to 13.8% in 2000. Through much of the 1990s, allopathic medicine had a higher proportion of URM students than all health professions other than public health, although nursing has recently surpassed allopathic medicine in its proportion of students who are URMs.
Trends in URM applicants, acceptances, and matriculants track together for allopathic medical schools (Figure A-1). The numbers of both URM applicants and acceptances have dropped off in recent years since peaking in the 1996– 1997 period. Because virtually all of URMs (and non-URMs) accepted to
medical school matriculate, the large decrease in URM applicants in the late 1990s has contributed to the decrease in URM matriculants. There were 6,663 URM applicants in 1996, but only 5,511 by 2000 (a 17% decrease). The large decrease in URM applicants parallels the trend for non-URMs, which dropped from 40,304 to 31,581 (a 22% decrease) during the same time period (Figure A-2). Figure A-2 reveals a similar, although less dramatic, trend in the late 1980s for both URM and non-URM applicants, indicating that this cycling is not new to allopathic medicine. However, as Figure A-1 indicates, allopathic medical schools maintained a fairly constant number of URM matriculants in the late 1980s despite the decrease in the number of URM applicants. This contrasts with the case in the late 1990s when the decrease in URM applicants was associated with a commensurate decrease in URM acceptances and matriculants.
Acceptance rates are the key factor explaining the divergence in the applicant and acceptance/matriculant trends for URMs in the 1980s and 1990s. In the late 1980s, acceptance rates for both URM and non-URM applicants increased as the number of applicants fell, producing a fairly stable proportion of URMs in matriculating classes (Figure A-3).
A major shift in acceptance rates for URMs relative to non-URMs then occurred in the early 1990s. As the number of URM and non-URM applicants began to surge in the early 1990s, acceptance rates for non-URMs decreased
more than acceptance rates for URMs (Figure A-3). In 1989, 64% of non-URM applicants were accepted by at least one medical school, compared with only 37% in 1994. In contrast, the percent of URM applicants accepted to medical schools declined by a much smaller amount, from 54% in 1989 to 43% in 1994. By the early 1990s, URM applicants were more likely to get into medical school than non-URM applicants for the first time in more than a decade. These changes in acceptance rates largely account for the increasing proportion of URMs in medical school classes in the early 1990s.
This trend began to reverse in 1995. Unlike the case in the early 1980s, the fall in both URM and non-URM applicants in the late 1990s was accompanied by rising fortunes for non-URM—but not URM—applicants in terms of the likelihood of acceptance into medical school (Figure A-3). Acceptance rates for URM applicants stagnated in the late 1990s, while acceptance rates for non-URMs began to increase. By 1999, acceptance rates for URM applicants had once again fallen below those for non-URMS.
As Figure A-4 shows, the net result of these patterns of applicant numbers and acceptance rates is a growth in the proportion of URMs matriculating in allopathic medical schools in the early 1990s, followed by a decrease in the late 1990s. Although the decrease in the number of URM applicants in the late 1990s explains some of the decrease in URM matriculation, it is by no means the whole explanation. In fact, the number of non-URM applicants decreased by an even larger relative amount in the same period. However, unlike URMs, the
non-URM students applying to medical school in the late 1990s experienced a growing likelihood of acceptance. Clearly, a shift occurred in the late 1990s in the competitiveness of the URM applicant pool and/or in how admissions committees evaluated these applicants relative to non-URMs.
Restrictions on the ability of admissions committees to use race and ethnicity as special considerations in evaluating applicants were felt most heavily in California and Texas in the late 1990s. Were URM acceptance rates in these two states disproportionately affected in the late 1990s?
The trends shown in Figure A-5 suggest that URM acceptance rates did not “recover” in the late 1990s in California and Texas to the same extent that they did in the rest of the United States. While acceptance rates for URMs experienced a modest upturn in the late 1990s in the rest of the United States, URM acceptance rates remained relatively flat in California and Texas—although the differences in late 1990s trends are not terribly dramatic between these states and the rest of the nation.
Medical schools in California and Texas did, however, experience much more substantial decreases than the nation’s remaining schools in the proportion of URMs in entering classes in the late 1990s. In Texas, URMs dropped from 21.0% of matriculants to 15.6% in 2000 (Figure A-6). In California, the percent of matriculants who were URMs decreased from a high of 21.9% in 1992 to 15.6% in 2000. These numbers are especially disturbing because of the high proportion of minorities residing in California and Texas. To reach population parity, California would need 40% of matriculants to be URMs, and Texas
would need 43%.ii In the United States, excluding California and Texas, the percent of matriculants who were URMs decreased much less substantially, from 14.4% in 1996 to 13.4% in 2000. (See Figure A-6) Thus, most of the overall decline in URM matriculation in medical schools in the United States is accounted for by the decreases in California and Texas. In 1995, California and Texas were educating 18.0% of all URMs matriculating in allopathic medical schools in the United States. By 2000, the figure was 15.5% (See Figure A-7).
Osteopathic medical schools have one of the lowest proportion of URM matriculants among the health professions (See Figure 1). The trend in URM matriculants in osteopathic medical schools in the 1990s follows the same “rise and fall” pattern of allopathic schools, although the proportion of URMs entering osteopathic medical school classes is only about half that of allopathic schools throughout this decade.
One of the most striking health professional school trends in the 1990s was the surge in the total number of applicants to osteopathic medical schools. While the number of applicants to allopathic medical schools approximately doubled in the early 1990s, the number of overall applicants to osteopathic medical schools grew by nearly 350%. It is not known exactly how many osteopathic school applicants also apply to allopathic schools, although presumably many apply to both types of schools (Figure O-1). The number of applicants to osteopathic schools fell off in the late 1990s, but not to the same degree as allopathic applicants. The growth in the number of non-URM applicants outpaced that of URMs. Although the number of URM applicants to osteopathic medical schools doubled between 1990 and 1999, the number of non-URM applicants increased more dramatically, by 168% (Figure O-1).
Data on the number of students accepted by osteopathic schools were not available. We were able to obtain data on matriculants and could compute “matriculation rates” (that is, the percent of applicants to osteopathic schools who matriculated in an osteopathic school). However, the matriculation rate may have different implications than the acceptance rate, depending on the rate at which accepted applicants actually matriculate. Because almost all accepted students accepted to allopathic medicine programs matriculate, getting accepted into medical school is the key driver of matriculation. It is not clear whether this same pattern holds for osteopathic medical schools. If a more substantial number of accepted students opt not to matriculate in osteopathic medical schools (perhaps because they also applied to allopathic schools and matriculated in an allopathic school), then more caution needs to be exercised in interpreting trends in matriculation rates as indicative of policies affecting admissions decisions or of related factors influencing acceptance rates.
As a result of the increasing number of applicants to osteopathic programs, the matriculation rates fell steeply in the early 1990s. In 1990, the matriculation rate of non-URMs was significantly higher than that of URMs (62.6% compared to 44.9%). This gap between the two groups diminished in the early 1990s and even reversed for a short time. By 1995, the matriculation rate for URMs was 23.5%, compared to 22.1% for non-URMs (Figure O-2). However, as was the case for allopathic medicine, the greater matriculation rates for URMs were a short-lived phenomenon. In 1998 (the last year for which osteopathic data are available), 23.5% of URM and 29.2% of non-URM applicants matriculated at osteopathic medical schools.
The large growth in overall applicants is not the only unique aspect of osteopathic medical school trends. Unlike allopathic medical schools, which have had relatively stable first-year class size for the past decades, osteopathic schools
expanded in the 1990s. The overall number of matriculants to osteopathic medical schools increased by almost 50% between 1989 and 1998 (Figure O-3). Non-URM matriculants increased by 50%, from 1,682 to 2,525. URM matriculants increased by 36%, from 162 to 220.
The net result in terms of URMs as a percent of osteopathic matriculants follows many of the same dynamics as observed for allopathic schools. In 1989, URMs represented 8.8% of osteopathic matriculants. This peaked at 10.0% in
1995, and fell to 8.0% in 1998 (Figure O-4). While the numbers of applicants to both types of schools rose steeply in the early 1990s, matriculation rates decreased by a much greater amount for non-URMs than for URMs. As a result, the proportion of URMs matriculating in both types of medical schools increased in the early 1990s. However, as applicant numbers started to fall off later in the 1990s, acceptance (or matriculation) rates rebounded for non-URMs but not for URMs. In both types of medical schools, URM applicants did not experience the same “bounce” as non-URM applicants from the decreasing overall student demand for medical school slots in the late 1990s.
As was the case for osteopathic medicine, data for dentistry are limited to numbers of applicants and matriculants and do not include numbers of students accepted. Dentistry is the only profession among the ones studied that experienced a steady decrease throughout the 1990s in URMs as a proportion of matriculants.
Dental schools experienced a surge in the overall number of applicants in the 1990s, with only a slight fall off in the past few years (Figure D-1). Between 1989 and 1999, the number of non-URM applicants to dental schools increased by 90%, from 4,238 to 8,057. However, the number of URM applicants did not increase proportionally, rising only 26%, from 758 to 953 (Figure D-1).
Unlike the situation for allopathic and osteopathic medicine, dentistry started the 1990s with equivalent matriculation rates for both URM and non-URM applicants. About 7 in 10 applicants in both groups matriculated in 1990. The matriculation rates for URMs and non-URMs followed symmetrical trends throughout the 1990s, with both dropping steadily as a result of the surge in total
number of applicants (Figure D-2). The matriculation rate for URMs went from 69.3% to 42.4%, while the non-URM rate fell from 75.3% to 46.7% between 1989 and 1999. Because the number of non-URM applicants increased by a much larger degree than the number of URM applicants, equivalent matriculation rates among URMs and non-URMs led to fewer URM matriculants and more non-URM matriculants. The number of URM matriculants dropped by 23%—from 525 in 1989 to 404—in 1999. (Figure D-3.) The number of non-
URMs matriculating increased by 18%, from 3,190 to 3,761. URMs as a percent of dental school matriculants fell steadily through the 1990s, from 14.1% in 1989 to 9.7% in 1999 (Figure D-4).
As in the rest of the United States, California and Texas also saw the proportion of URMs matriculating decrease through the 1990s (Figure D-5). In the rest of the United States, (excluding Texas and California), URMs as a percent of total matriculants fell from 15.0% to 10.4% between 1989 and 1999. In
Texas, the proportion of URMs matriculating fell from 16.5% to 12.9% between 1989 and 1999. California’s exceptionally low proportion of URMs fell from 6.7% to 3.6%. California’s population consists of 40% URMs,iii meaning that the percent of URM dental students in California in 1999 was 10 times below population parity.
Trends in California and Texas may not differ very much from trends in the rest of the United States for dentistry because admissions decisions may not have been the key limiting factor for URM matriculation into dental schools in the 1990s. Unlike the case for allopathic and osteopathic medicine, dentistry began the 1990s with URM applicants already as likely as non-URM applicants to matriculate into dental school. Driving the decrease in URM dental matriculants in the 1990s was the tremendous increase in the popularity of dental careers among non-URM students. Although URM and non-URM applicants had similar (though diminishing) odds of successfully matriculating into dental schools, non-URM students swamped the applicant pool. In 1989, there were about 5.5 non-URM applicants for every 1 URM applicant to dental school. In 1999, there were about 8.5 non-URM applicants for every 1 URM applicant. Thus, for dentistry, the limiting factor for URM matriculation may be attracting sufficient numbers of URM applicants.
Limited data were available for pharmacy schools, but the available data do indicate that URM enrollment in pharmacy schools has had a modest but steady growth through the 1990s (Figure P-1). The number of URMs enrolled in pharmacy schools (both in B.S. and Pharm.D. programs) increased by 19%, from 3,306 in 1990 to 3,939 in 1999 (Figure P-1). URMs as a percent of total enroll
ment increased from 12.5% in 1990 to 13.8% in 1999 (Figure P-2). Data on unduplicated counts of applicants are not available to analyze applicant trends.
Of the health professions analyzed, nursing is the only field that does not require a graduate degree for initial licensure for practice. Nursing has a unique opportunity for URM diversification because of the many educational entry points into the profession. Pre-licensure education is available both at the associate and bachelor degree level. Of all the clinically oriented health professions studied, nursing has exhibited the most sustained increase in the proportion of URM students and now has the highest proportion of URM enrollees of any health profession, other than public health.
Because national annual data on diploma and associate degree nursing programs were not available for all the years studied, we limited our analysis to baccalaureate nursing programs. There has been a steady increase in URM enrollment in baccalaureate nursing programs between 1991 and 1999 (See Figure N-1). URM enrollment increased 48%, from 11,661 to 17,303. This contrasts with a large decrease in non-URM enrollment that began in the mid-1990s.
Because of this decrease in the late 1990s, non-URM enrollment increased a modest 5% between 1991 and 1999, from 89,800 to 93,883. The steady increase in URM enrollment and the minimal increase in non-URM enrollment resulted in a growing percent of URMs in baccalaureate nursing programs (Figure N-2), rising from 12.2% to 16.0%.
The recent affirmative action legislation (Proposition 209) does not appear to have affected nursing enrollment in California. Figure N-3 shows that the proportion of URMs enrolled in nursing programs in California (including both associate degree and baccalaureate degree programs) continued to increase even after the 1996 events. URMs as a proportion of enrollees steadily increased from 15.8% in 1991 to 22.2% in 1997. The steady gains in URM enrollment in California enrollment, despite Proposition 209, may be because most basic nursing education in California is done at the community college level rather than at University of California schools or California State University campuses. Seventy-two percent of first-year nursing enrollees in 1998 were enrolled at the associate degree level.iv At California community colleges, the admissions process differs from other institutions in that there is not an admissions committee selecting the most “qualified” or well-prepared applicants. Once applicants to a California community college meet minimum criteria, positions are allocated either by waiting lists or by a “lottery system.” This admissions process was not affected by Proposition 209.
Public health programs have the highest proportion of URM applicants and enrollees of the health professions. Figure PH-1 shows that through the 1990s, URMs represented 19%–21% of applicants to public health programs. The proportion of URMs in public health programs has been consistently higher than other health professions, and the percentage has been steadily increasing. (Figure PH-2.). URMs represented 15.3% of public health students in 1990 and 19.5% in 1999.
Veterinary medicine has been called “the health profession serving the most diverse patient population.” Veterinary medicine has the lowest proportion of URM applicants, accepted students, and enrollees of the health professions. Figure V-1 shows that in the last five years, approximately 6%–7% of veterinary applicants have been URMs. The application trends have held steady for the last five years. (Data were not available for the early 1990s.) Enrollment trends have also held fairly steady through the last five years, with URMs representing approximately 6% of veterinary students (See Figure V-2).
Veterinary medicine has one of the lowest overall acceptance rates of any health profession. In 1995, the acceptance rate for non-URMs was 35%, while the acceptance rate for URMs was 25% (See Figure V-3). Acceptance rates converged in the 1995–1997 period. However, as was the case for allopathic and osteopathic medicine, acceptance rates for non-URMs, but not for URMs, started to increase again in the late 1990s. This suggest that admissions decisions may have become less favorable towards URMs in recent years.
Disparities in the racial and ethnic composition of the student body of health professions schools continue to exist for all the health professions studied. However, URM matriculation and enrollment does not follow a single trend for all the health professions. While some professions have made improvements and are moving closer to racial and ethnic parity with the U.S. population, others seem to be losing ground. Some professions have been more successful than others in attracting URM applicants during cycles of rising and lowering popularity of the profession among students overall.
Although trends in the number of applicants is an important influence of trends in URM matriculation and enrollment in health professions schools, admissions decisions and other factors affecting the likelihood of an applicant being accepted remain a key determinant of matriculation and enrollment trends. In allopathic medicine, osteopathic medicine, dentistry, and veterinary medicine, there is an emerging gap in acceptance and matriculation rates for URM applicants compared with non-URMs, with URM rates falling behind.
There is circumstantial evidence that recent legislative and judicial decisions limiting the consideration of race and ethnicity in health professions schools’ admissions decisions may be contributing to diverging trends for URM and non-URM acceptance rates, at least for allopathic medicine. Unlike the case for schools in the rest of the nation, acceptance rates for URM applicants to California and Texas schools have not started to rise in response to a decreasing number of applicants. A decreasing proportion of URM medical students in the United States is enrolling in schools in California and Texas. For other health professions schools, trends in California and Texas are more consistent with trends in the rest of the nation. This may be because these schools and their admissions committees are under less public scrutiny than those in medicine or are less affected by recent changes in public policy. In addition, in professions such as dentistry, the small pool of URM applicants may be the overwhelming factor limiting URM admissions.
Trends in URM matriculation in public health, nursing, and pharmacy are encouraging. Although large disparities remain, the trends in these professions suggest that progress is possible. Continued progress will require ongoing commitment to racial and ethnic diversity in health professions schools. Moreover, all health professions schools stand to benefit from policies that promote greater educational achievement for URMs at all levels of the educational pipeline, from primary grades through college. Sustained growth in URM enrollment in health professions schools will require a more academically prepared pool of URM students who are interested in careers in the health professions.
Ongoing monitoring of trends in URM participation in health professions schools would benefit from more systematic and standardized reporting of data. Although some professions have excellent, comprehensive databases on undu-
plicated applicants, acceptances, and matriculants, data are very limited in many professions. For most of the professions, systematically collected data on attrition after matriculation are absent. Improved analysis of the dynamics of applicant numbers, acceptance rates, matriculation rates, and attrition rates would allow for more informed policymaking to tailor interventions to the unique dynamics of each profession.
The authors thank the following organizations and individuals for supplying the data for the analyses in this paper: David Bristol, College of Veterinary Medicine at North Carolina State University; Lois Colburn and Kuhua Zhang, Association of American Medical Colleges (AAMC); Karen Helsing, Association of Schools of Public Health (ASPH); Susan Meyer, American Association of Colleges of Pharmacy (AACP); Charles Ratliff and Leslie Taylor, California Postsecondary Education Commission (CPEC); Janis Stennett, American Association of Colleges of Nursing (AACN); Lorrie Van Akkeren, American Association of Colleges of Osteopathic Medicine (AACOM); and Richard Weaver, American Dental Education Association (ADEA).
U.S. Census Bureau, Census 2000 Brief, Overview of Race and Hispanic Origin 2000, issued March 2001 http://www.census.gov/population/www/cen2000/briefs.html. The U.S. Census separates race from “Hispanic or Latino” origin. For our purposes we combined Hispanic or Latino origin (12.5%) with Black or African American (12.3%) and American Indian or Alaska Native (.9%). Because of this, the statistic may be slightly inflated because of Blacks or African Americans and American Indians who are of Hispanic or Latino origin.
U.S. Census estimates for July 1999. http://www.census.gov/population/estimates/state/srh/srh99.txt. For this comparison we considered Blacks, American Indian/Alaska Natives and those of Hispanic origin to be URMs.
U.S. Census estimates for July 1999. http://www.census.gov/population/estimates/state/srh/srh99.txt. For this comparison we considered Blacks, American Indian/Alaska Natives and those of Hispanic origin to be URMs.
California Board of Registered Nursing. (2000). Annual School Report, 1998– 1999. Sacramento, CA.