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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- tiesâhow 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
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 individualsâ own words, are offered as a means of understanding some of patientsâ and providersâ 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 âgive voiceâ 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: â¢ 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); â¢ Liaison panel discussions with consumer and professional groups, federal agency representatives, and minority health advocates held in the spring and summer, 2001; â¢ 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 populationsâincluding 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
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 whitesâa 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).
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.
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
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 agencyâs 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
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.
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
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 âvery wellâ (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 âvery wellâ (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.
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 âvery well.â 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 âvery well,â 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,
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 âHealthy Familiesâ 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 âThere are those that donât get promoted because of their race or whatever. The reason [may be because] theyâre not well liked by administration or it may be just that they [administrators] donât want that person in that setting because of their raceâthat is out there. Racism is alive and well, and those of us who think that itâs not are living in some kind of dream world.â (African-American nurse) âIâve 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, âI 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.
91 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES youâll never take them and youâll come back and tell me youâre still eating pigâs feet and everythingâ¦then why do I still need to write this prescription.â And Iâm like âI donât eat pigâs feet.ââ (African-American patient) âMy name is . . . [a common Hispanic surname] and when they see that name, I think there is some kind of prejudice [against] the name . . . weâre talking about on the phone, thereâs a lack of respect. Thereâs a lack of acknowledging the person and making one feel welcome. All of the courtesies that go with the profession that they are paid to do are kind of put aside. They think they can get away with a lot because âHereâs another dumb Mexican.ââ (Hispanic patient) âIf you speak English well, then an American doctor, they will treat you better. If you speak Chinese and your English is not that good, they would also kind of look down on you. They would [be] kind of prejudiced.â (Chi- nese patient) The first chapter reviewed evidence of disparities in the process, struc- ture, and outcomes of healthcare. This information alone presents an in- complete picture of the social, political, and economic contexts in which racial and ethnic disparities occur. In particular, to understand the ques- tion of whether discrimination occurs in healthcare, it is necessary to re- view what is known about racial attitudes and racial discrimination in other aspects of American life. This section reviews this evidence, with the goals of: â¢ illuminating trends in racial attitudes that may be assumed to carry over into healthcare settings; and â¢ understanding the persistence and pervasive quality of discrimi- nation that has characterized the American racial and ethnic minority experience. Indeed, towards this latter goal, it is useful to consider that the con- cept of âraceâ depends fundamentally on the existence of social hege- mony. As Michael Omi (2001) notes, â[t]he idea of race and its persistence as a social category is only given meaning in a social order structured by forms of inequalityâeconomic, political, and culturalâthat are orga- nized, to a significant degree, by raceâ (Omi, 2001, p. 254). Racial Attitudes and Relations âOften times, the system gets the concept of black people off the 6 oâclock news, and they treat us all the same way. Hereâs a guy coming in here with no insur- ance. Heâs low breed.â (African-American patient)
92 UNEQUAL TREATMENT Racial attitudes and relations in recent decades have been character- ized by both progress and strife. Sociologist Lawrence Bobo (2001) notes five trends regarding racial attitudes and race relations in this period that offer, at times, a conflicting picture of race in America. The first, more positive trend is that Americansâ attitudes toward the goals of integration and equality have improved steadily over the past three decades. Second, this trend has not resulted in increasing public support for policies or other significant efforts to improve educational, employment, housing, and other opportunities for U.S. racial and ethnic minorities. Third, white Americans continue to express support for negative stereotypes of minor- ity groups in surprisingly large numbers, even though few of these indi- viduals would identify themselves as bigoted or racist. Fourth, white and non-white Americans differ significantly in their perception of the preva- lence of racial discrimination in the United States. Finally, minoritiesâ attitudes regarding race relations suggest a deepening level of alienation from U.S. society. Regarding the first trend, Bobo notes that racial attitudes in America have improved significantly over the past 50 years. In the 1940s, for ex- ample, opinion surveys indicated that over two-thirds of white Ameri- cans endorsed the view that African-American and white children should attend separate schools, a view that was reflected in both formal policy and practice. Over half of respondents felt that public transportation should be segregated by race, and that whites should receive preference over minorities in access to jobs. By 1995, 96% of white Americans ex- pressed the view that black and white children should be allowed to at- tend the same schools. Similarly, by the 1970s, few whites endorsed the view that public transportation should be segregated, or that whites should receive preferential treatment in hiring. In 1965, slightly more than 60% of whites stated that they would not move if a black family moved next door; by 1995, well over 90% shared this belief. Bobo con- cludes that over time, âsupport for principles of racial equality and inte- gration has been sweeping and robust. So much so, that it is reasonable to describe it as a change in fundamental norms with regard to raceâ (Bobo, 2001, p. 273). Despite these positive overall trends, Americansâ attitudes cannot be characterized as wholly egalitarian with regard to racial minorities, par- ticularly when asked about policies and practices that might increase their direct contact with minority groups. For example, while the vast majority of Americans support school integration in principle, when asked whether they would send their own children to integrated schools, support de- clines as the degree of contact with minorities increases. When asked if they would object to sending their children to a school with a âfewâ black children, over 90% of whites report no objection. If black children consti-
93 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES tuted half of the school enrollment, support dips to approximately three- quarters of respondents. If the school is presented as âmostly black,â sup- port falls to below 50%. While these trends have remained fairly stable since the mid-1970s, white support for sending their children to âmostly blackâ schools has fallen to below 40% at various points, particularly in the early and mid-1980s. Similarly, the percentage of white respondents who report that they would move should their neighborhood become in- tegrated increases linearly with the proportion of blacks as residents (Bobo, 2001). In addition, a substantial proportion of white Americans continue to endorse negative stereotypes about minorities. The 1990 General Social Survey (GSS) revealed that whites viewed blacks more negatively relative to whites on a number of dimensions, including intelligence (54% rated blacks as less intelligent in relation to whites), industriousness (62% rated blacks as lazier than whites), propensity towards violence (56% rated blacks as more prone to violence), and preference for living on public assistance (78% rated blacks as preferring to live off of welfare as com- pared with whites). Whites also rated Hispanics more negatively in rela- tion to whites along the same dimensions, as 31% of whites gave Hispan- ics a low rating relative to whites in intelligence, 47% rated Hispanics as âlazierâ than whites, 54% rated Hispanics as more prone to violence, and 59% believed that Hispanics are more likely than whites to prefer to live off of welfare (Bobo, 2001). It should be noted, however, that these per- centages may be conservative due to tendencies among the general public to respond in a socially desirable, non-racist manner. Negative stereotyping of minorities is not limited to African Ameri- cans and Hispanics. A recent survey commissioned by the Committee of 100 to study Americansâ attitudes toward Asian Americans found that at least 1 in 4 Americans holds decidedly negative attitudes toward Chinese Americans, and an additional 43% hold âsomewhat negativeâ attitudes. Many responses suggested that a significant segment of Americans fear Chinese Americansâ influence and power; over one-third (34%) of respon- dents believe that Chinese Americans have âtoo much influence in the U.S. high technology sector,â while 23% believe that Chinese Americans have âtoo much power in the business world.â Nearly one in three (32%) respondents believe that Chinese Americans âalways like to be at the head of things,â and nearly 1 in 4 believes that Americans are losing jobs at the hands of Chinese Americans. Nearly 1 in 3 believe that Chinese Ameri- cans are more loyal to China than to the United States, and 46% of those surveyed believe that âChinese Americans passing on information to the Chinese government is a big problem.â Respondents who endorsed 5 or more of the 12 negative stereotypes posed about Chinese Americansâ 25% of the sampleâwere found to hold overwhelmingly negative atti-
94 UNEQUAL TREATMENT tudes toward Chinese Americans. These respondents, who tended to have lower levels of education, lower incomes, and were more likely from the South, believe in large majoritiesâranging from 68% to 73%âthat Chi- nese Americans âdonât care what happens to anyone but their own kind,â and are âtaking away too many jobs from Americansâ (Edsall, 2001). Not surprisingly, white and non-white Americans hold widely di- verging views of the prevalence of racial discrimination. A 1995 poll, for example, found that nearly nine in ten African Americans (88%) felt that police treat blacks unfairly, compared with 47% of whites (Schuman et al., 1997). In another poll, slightly over one in five whites (22%) but 57% of African Americans endorsed the view that blacks are discriminated against âa lotâ (ABC News/Lifetime Television, 1999). Bobo (2001) cites a survey that finds African Americans to be three times as likely as whites to feel that there is âa lotâ of discrimination against blacks in attaining âgood-payingâ jobs. Nearly 70% of African Americans endorsed this view, compared with slightly more than 20% of whites. Interestingly, 40% of Hispanics and slightly over 10% of Asian Americans supported this view. When asked whether Hispanics face âa lotâ of discrimination in getting good-paying jobs, Hispanics (60%) were three times as likely as whites (20%) and one and a half times as likely as African Americans to endorse this view. Bobo (2001) summarizes these data, stating, â[minori- ties] not only perceive more discrimination, they also see it as more âinsti- tutionalâ in character . . . [whereas] many whites tend to think of discrimi- nation as either mainly a historical legacy of the past or as the idiosyncratic behavior of the isolated bigotâ (Bobo, 2001, p. 281). Strikingly, white Americansâ perceptions of minorities appear to be based on inaccurate notions of racial progress. A national survey conducted by the Washington Post, The Henry J. Kaiser Family Foundation, and Harvard University revealed that âwhether out of hostility, indifference or simple lack of knowledge, large numbers of white Americans incorrectly believe that blacks are as well off as whites in terms of their jobs, incomes, schooling, and healthcareâ (Morin, 2001, p. 1). Over seven in ten (71%) white Americans surveyed expressed the view that African Americans en- joy the same or greater opportunities than whites; 65% of whites endorse this view with respect to Hispanics. In terms of income, 42% of whites surveyed believe that African Americans are better off or about the same as the âaverage white person,â and nearly half (49%) believe that African Americans have similar or higher levels of education. Half of surveyed whites endorsed the view that African Americans hold similar or better jobs than whites. More than six in ten (61%) whites believe that African Americans have equal or better access to healthcare as whites, and nearly half (48%) of these respondents believe than Hispanics have equal or better access to healthcare (Morin, 2001). All of these responses are inaccurate
95 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES with respect to major demographic data collected by the U.S. Bureau of the Census and other data sources, as outlined in this chapter. The following sections illustrate that despite the more optimistic view of some that unfair treatment on the basis of race is rare, racial discrimina- tion persists in a wide range of important aspects of American life. Racial Discrimination âI felt that because of my race that I wasnât serviced as well as a Caucasian person was. The attitude that you would get. Information wasnât given to me as it would have [been given to] a Caucasian. The attitude made me feel like I was less important. I could come to the desk and they would be real nonchalant and someone of Caucasian color would come behind me and theyâd be like âHi, how was your day?ââ (African-American participant) What Is Discrimination? Discrimination, the differential and negative treatment of individuals on the basis of their race, ethnicity, gender, or other group membership, has been the source of significant policy debate over the past several de- cades. Federal and state laws adapted since the landmark 1964 Civil Rights Act outlaw most forms of discrimination in public accommoda- tions, access to resources and services, and other areas. While this legisla- tion appears to have spurred significant change in some segments of American society, such as in the overt behavior of lenders and real estate agents, debate continues regarding whether and how discrimination per- sists today. Conservative legal scholars and social scientists argue that discrimination has largely been eliminated from the American landscape (Thernstrom and Thernstrom, 1997; DâSouza, 1996), while others argue that discrimination has simply taken on subtler forms that make it diffi- cult to define and identify. Complicating this assessment is the fact that while individual discrimination is often easier to identify, institutional dis- criminationâthe uneven access by group membership to resources, sta- tus, and power that stems from facially neutral policies and practices of organizations and institutionsâis harder to identify. Further, it is diffi- cult to distinguish the extent to which many racial and ethnic disparities are the result of discrimination or other social and economic forces. There is little doubt among researchers who study discrimination, however, that the United Statesâ history of racial discrimination has left a lasting residue, even in a society that overtly abhors discrimination. âDe- liberate discrimination by many institutions in American society in the past had left a legacy of [social and] economic inequality between whites and minorities that exists today . . . [but] legal evidence of discrimination
96 UNEQUAL TREATMENT in specific cases is not the same as statistical measures of the overall level at which discrimination existsâ (Turner and Skidmore, 1999, p. 5-6). Mortgage Lending African-American and Hispanic applicants for conventional home mortgages are rejected at rates greater than twice that of white applicants (U.S. Department of Housing and Urban Development, 1999). But are these disparities due to minoritiesâ generally lower credit ratings and lower incomeâimportant predictors of loan outcomes that are themselves by-products of past discrimination? After controlling for measures of creditworthiness, such as loan type, property and credit, data compiled by the Federal Reserve Bank of Boston revealed large differences in loan denial rates between minority and white applicants. Hispanic and African-American applicants faced an 80% greater likelihood of loan denial. The Urban Institute reanalyzed these data and replicated the finding that creditworthiness or technical factors could not explain the disparity. These researchers concluded that âthe Boston Fed Study results provide such strong evidence of differential de- nial rates (other things being equal) that they establish a presumption that discrimination exists, effectively shifting the âburden of proofâ to lendersâ (Turner and Skidmore, 1999, p. 12). A 1999 Urban Institute study of mortgage lending practices found that minorities face discrimination in several stages of the mortgage lend- ing process. Paired testers sought loans using similar credit histories, in- comes and financial histories, and presented the same mortgage needs. Overall, minorities received less information about loan products and were accorded less time with lending officers. Further, they were quoted higher lending rates than whites in most of the cities where tests were conducted. Potentially discriminatory practices began at early stages of the loan process, such as pre-application inquiries, and persisted through to the loan approval stage (Turner and Skidmore, 1999). Housing Discrimination Despite the presence of fair housing and anti-discrimination laws, American cities remain starkly segregated by race. Massey (2001), in an analysis of the largest 30 U.S. cities, finds that residential segregation is most profound and consistent over time among African Americans, and is less prominent, but still significant among Hispanic and Asian-Ameri- can families. Using the indices of dissimilarity (the relative number of minorities who would have to change geographic locations so that an even racial distribution could be achieved) and isolation (the percentage of mi-
97 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES norities residing in the geographic unit of the average minority indi- vidual), Massey found that, on average, African Americans live in com- munities that are overwhelmingly African American, with dissimilarity indices averaging 77.8 in northern cities and 66.5 in southern cities (indi- ces above 60 are considered high). In six metropolitan areas (Chicago, Cleveland, Detroit, Gary, New York, and Newark), isolation indices for African Americans are 80 or more, indicating that in these cities, the aver- age African American lives in a neighborhood that is more than 80% black. Further, other measures indicate that many African-American communi- ties are characterized by âhypersegregation;â that is, African Americans tend to be concentrated in compact, densely packed, contiguous tracks in central cities. Black residents in these areas are unlikely to ever come into contact with non-blacks in their neighborhoods or in adjoining neighbor- hoods, and would have âlittle direct experience with the culture, norms, and behaviors of the rest of American society, and have few social con- tacts with members of other racial groupsâ (Massey, 2001, p. 410). Patterns of segregation among Hispanic and Asian-American popu- lations, in contrast, are less stark than that of African Americans. The dramatic increase of both Asian and Hispanic immigrants to the United States has led to large concentrations of these populations in some ur- ban areas, but other segments of these populations have achieved re- markable levels of integration with whites. In several cities with large Hispanic populations, such as Brownsville and McAllen (Texas) and Mi- ami (Florida), Hispanic segregation is high, with isolation indices aver- aging 77.2. This suggests that more than 3 of 4 Hispanics lacks regular neighborhood contact with individuals from other racial and ethnic backgrounds. In cities that are not majority Hispanic, concentration of Hispanics is less likely, with dissimilarity indices averaging 49.6 (sug- gesting that about half of communities in these cities are segregated by race and ethnicity) and isolation indices averaging 45.1 (both are in the moderate range). Asian-American segregation indices are quite moder- ate, with dissimilarity indices averaging 40.6 and isolation indices aver- aging 20.6 (Massey, 2001). These patterns of segregation are not merely the product of socioeco- nomic differences, Massey notes. Segregation of African Americans, for example, occurs independently of social class. African-American families earning at least $50,000 annually are as likely to live in neighborhoods as segregated as those in which African-American families earning less than $2,500 per year reside. Further, the most affluent African Americans are even more segregated than lower-income Asian-American and Hispanic families; blacks earning more than $50,000 annually live in more segre- gated conditions than Asian-American or Hispanic families earning less than $2,500 annually (Massey, 2001).
98 UNEQUAL TREATMENT Importantly, segregation does not appear to result merely from the choices of African-American and other minority groups to live apart from white Americans. Polling data indicate that African Americans strongly en- dorse the idea of residential integration, and would prefer to live in racially mixed neighborhoods. Virtually all African Americans endorse the state- ment that âblack people should have a right to live wherever they can afford to,â and over 70% would vote for a community law to enforce this right (Bobo, Schuman, and Steeh, 1986). Nearly 90% of African Americans state that they would be willing to live in any racially mixed area (Farley et al., 1994). Similarly, most white Americans endorse the view that housing op- portunities should be open to all and that housing discrimination should be abolished. In practice, however, white Americansâ attitudes shift sig- nificantly with increasing residential segregation, as measured by polling data and patterns of movement after previously all-white neighborhoods become integrated. Farley et al. (1994) asked white residents in the De- troit metro area if they would feel uncomfortable in a neighborhood where 7% of the residents were black; 13% of respondents reported that they would be unwilling to enter such a neighborhood. When the percentage of black residents is presented as one-fifth of the total, one-third of whites reported that they would be unwilling to enter. If 30% of residents are African American, 59% of whites reported that they would be unwilling to move in, 44% reported that they would feel uncomfortable, and 29% reported that they would try to leave if they lived in such a neighborhood. If 50% of residents are African American, 73% of whites report that they would not want to live in the neighborhood, 65% reported that they would feel uncomfortable, and 53% would try to leave. In actual practice, the presence of smaller percentages of African Americans in previously all- white neighborhoods initiates a pattern of destabilization whereby whites tend to leave in large numbers. Summarizing studies of neighborhood racial transformation, Massey (2001) notes that the presence of one Afri- can-American family among every five white families tends to fuel a pro- cess of neighborhood turnover; in some cases, this turnover has acceler- ated when African Americans have numbered as few as three percent of a neighborhood (Massey, 2001). Despite the existence of federal laws barring discrimination in hous- ing, racial discrimination appears to be a key mechanism preventing neighborhood integration. Prior to passage of the 1968 Fair Housing Act, racial discrimination was institutionalized in the real estate industry and was widely practiced. Today, Massey (2001) states, minority home seek- ers, particularly African Americans, are more likely than not to face dis- crimination when attempting to purchase or rent a home. This discrimi- nation occurs largely in the form of subtle, covert barriers. Housing audit studies, for example, provide a powerful means of assessing the likeli-
99 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES hood of discriminatory practices. Auditors are trained to present compa- rable needs and desires in home purchases or rental properties, and are provided with similar socioeconomic traits. These studies, according to Massey, consistently indicate that housing discrimination has persisted in the years following passage of the Fair Housing Act. The U.S. Depart- ment of Housing and Urban Developmentâs (HUD) Housing Discrimina- tion Study, for example, was conducted in 20 audit sites around the United States and revealed that white auditors were, on average, provided with 45% more housing options in the rental market and 34% more options in the sales market than black auditors. In addition, whites were shown additional units 65% more often than blacks. Subtle âsteeringâ of minor- ity auditors away from predominantly white neighborhoods increased the likelihood of discrimination to 60%; in total, between 60% and 90% of the housing shown to white auditors were not shown to comparable black auditors (Yinger, 1995). For Hispanics, the likelihood of discriminatory treatment was equally high, as Hispanic auditors faced unfavorable treat- ment 43% of the time when seeking rental units, and 45% of the time when seeking to purchase a home (Fix, Galster, and Struyk, 1993). White auditors also received greater assistance in obtaining credit; in 46% of encounters, whites received more favorable credit assistance in sales transactions and were offered more favorable terms in 17% of rental transactions. In addition, greater credit assistance was provided to whites; of all instances in which agents discussed a fixed-rate mortgage, 89% were with white auditors, as were 91% of instances in which adjustable-rate loans were discussed (Yinger, 1995). These findings have been replicated in several other housing audit stud- ies conducted in different locations in the United States. Galster (1990) found that racial steering occurred in approximately 50% of transactions, and that âselective commentaryâ from agents was common (including positive com- ments provided to white auditors regarding predominantly white neighbor- hoods that are not provided to African-American auditors). While housing audits have largely focused on the possibility of discrimination against Afri- can Americans, a few studies suggest that Hispanics face similar discrimina- tion, particularly among darker-skinned Hispanics or those who identify themselves as mixed European and Indian ancestry (Massey, 2001). The con- sistency of these findings, coupled with data noting persistent racial segrega- tion in the vast majority of American communities, prompts Massey to con- clude, ârather than declining in significance, race remains the dominant organizing principle of U.S. urban housing marketsâ (2001, p. 420). The consequences of such segregation for individual health status are significant (Williams, 2001; Massey, 2001). Many community resources that affect health, including access to employment and educational op- portunities, are inequitably distributed; a close association exists between
100 UNEQUAL TREATMENT a groupâs spatial position in society and its socioeconomic opportunities. For example, some communities are characterized by better schools, safer streets, better public services, fewer environmentally based health haz- ards, and better access to quality healthcare. African Americans, regard- less of income, tend to be segregated in neighborhoods characterized by fewer of these resources and higher levels of health risks. âCompared with whites of similar socioeconomic status,â Massey (2001) notes, âblacks tend to live in systematically disadvantaged neighborhoods, even within suburbsâ (2001, p. 392). Employment Audit studies using matched pairs of minority and non-minority au- ditors have also revealed consistent patterns of discrimination in hiring. As in housing audit studies, these studies carefully match testers on such attributes as educational level and personality characteristics, and care- fully coach testers to ensure consistent responses to typical job interview questions. Fix, Galster, and Struyk (1993), for example, report findings from two studies of housing discrimination that assessed unfavorable treatment encountered by qualified job applicants responding to adver- tisements in major newspapers for entry-level positions. The first, con- ducted in San Diego and Chicago, assessed unfavorable treatment of His- panics compared with white applicants. Because this study was part of a larger project assessing the potential adverse impact of new immigration legislation that banned the hiring of undocumented aliens, Hispanic testers were selected who âlooked Hispanic and had definite accentsâ (Fix, Galster, and Struyk, 1993, p. 19). The second study, conducted in Chicago and Washington, D.C., assessed potential discriminatory treatment of African-American applicants relative to whites. Findings revealed that opportunity denial (defined as the denial of opportunity to obtain an ap- plication, obtain an interview, or receive an offer of employment) occurred 20% of the time in black-white audits and 31% of the time in Hispanic- Anglo audits, across all study sites. In other words, in nearly one-third of instances Hispanic applicants were denied an application, denied an in- terview, or did not receive an offer of employment while the matched white auditor received the opposite outcome. Criminal Justice Minority Youth in the Juvenile Justice System Minority youth are overrepresented in the juvenile justice system in the United States. While minorities (African Americans, Hispanics, Asian
101 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES Americans, and American Indians) constituted only about one-third of juveniles in the United States in 1997, they represent two-thirds of de- tained and committed youth in juvenile facilities. These disparities are most pronounced among African-American youth; while they comprise 15% of the juvenile population, they account for more than one in every four juvenile arrests and 45% of delinquent cases involving detention. Further, nearly half (46%) of juvenile cases waived to criminal courts in 1996/7 involved African American youth (Office of Juvenile Justice and Delinquency Prevention, 1999). Overrepresentation of minority youth in juvenile justice systems oc- curs in all 50 states and the District of Columbia. According to data col- lected by the U.S. Office of Juvenile Justice and Delinquency Prevention (OJJDP), minority youth face a higher probability than white youth of being arrested, referred to court intake, held in short-term detention, peti- tioned for formal processing, adjudicated delinquent, and confined in a secure juvenile facility. While these disparities may reflect a greater level of involvement in crimes (e.g., African-American youth are involved in 39% of violent crimes, as reported by victims), African-American youth disproportionately account for juvenile arrests for violent crime (44%) and confinement (45%), suggesting differential treatment by race (U.S. Office of Juvenile Justice and Delinquency Prevention, 1999). A growing number of well-controlled studies demonstrate that mi- nority youth are treated differently in the juvenile justice system than white youth, even considering the severity of crime and differences in rates of offenses. Minority youth, for example, are more likely than whites to be placed in public secure facilities, while white youth are more likely to be housed in private facilities or diverted from the juvenile justice sys- tem (U.S. Office of Juvenile Justice and Delinquency Prevention, 1999). These disparities are most pronounced at the beginning stages of process- ing within the juvenile justice system, but tend to accumulate as juveniles move through stages of the juvenile justice system. OJJDP researchers note that approximately two-thirds of studies of racial differences in pro- cessing demonstrate that race influences decision-making in the juvenile justice system, leading researchers to conclude that âthere is substantial evidence that minority youth are treated differently from majority youth within the juvenile justice systemâ (U.S. Office of Juvenile Justice and Delinquency Prevention, 1999, p. 3). What Is the Relationship Between Racial and Ethnic Disparities in Healthcare and Broader Racial Attitudes and Discrimination? The study committee considered studies of racial and ethnic discrimi- nation in sectors outside of healthcare as an important aspect of the evi-
102 UNEQUAL TREATMENT dence base to better understand the contexts in which care is delivered to racial and ethnic minority patients. These data are not meant to imply that inferences can be drawn from this literature regarding possible dis- crimination in healthcare settings. To the contrary, most social scientists agree that individuals with higher levels of education (such as healthcare professionals) generally hold more egalitarian attitudes than less educated individuals and abhor racial or ethnic prejudice and discrimination. In addition, as will be noted in later sections of this report, healthcare profes- sionals are sworn to beneficence, and the vast majority are drawn to their disciplines out of feelings of compassion and a strong desire to heal. Data on the persistence of racial and ethnic discrimination in other sectors of American life are important, however, because they are likely to affect the clinical encounter and process of healthcare delivery in at least three ways: â¢ experiences of discrimination, whether real or perceived, are expe- riences that minority patients are likely to bring to the clinical encounter, and are thereby likely to shape their expectations, attitudes and behaviors toward providers and health systems; â¢ minority patients encountering health systems are likely to interact with many individuals in addition to healthcare providers, such as ad- ministrative and clerical staff, who may be expected to mirror social atti- tudes and trends regarding race and ethnicity; and â¢ healthcare providers, like all other individuals, are likely influ- enced in their racial and ethnic attitudes by broader social trends. THE CONTEXT OF HEALTHCARE DELIVERY FOR RACIAL AND ETHNIC MINORITY PATIENTSâAN HISTORICAL OVERVIEW âWhat would you recommend (to the IOM) to better understand what minori- ties experience in getting healthcare?â (Focus Group Moderator) âUnderstand what the past healthcare history has been to Native Americans. Maybe just having an understanding of how Native American healthcare has been across the U.S., not just here in the Southwest, but everywhere. I think that would make [healthcare providers] effective because they would know whatâs happened in the past and not repeat the same mistakes.â (American Indian healthcare consumer) This section presents a discussion of the history of healthcare service delivery for racial and ethnic minority populations in the United States. The discussion is focused on the experience of African Americans only because historical documentation of healthcare for this group is more ex- tensive than for other racial and ethnic minorities. It is not meant to ex- emplify other groupsâ healthcare experiences and histories (for a discus-
103 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES sion of aspects of the history of U.S. healthcare for American Indians and Alaska Natives, see Joe, this volume). An historical account of the healthcare experience of African Americans is illustrative, however, of how the historic context shapes the contemporary structure of and access to care for racial and ethnic minorities. This section will discuss how the legacy of segregated and inferior healthcare for African Americans con- tinues to reverberate in todayâs healthcare settings. Important factors such as the makeup of the healthcare workforce, primary settings in which racial and ethnic minorities receive care, opportunities for training of mi- nority healthcare providers, and other aspects of the structure and deliv- ery for healthcare for many African Americans are shaped by these his- torical trends. A BRIEF HISTORY OF LEGALLY SEGREGATED HEALTHCARE FACILITIES AND CONTEMPORARY DE FACTO SEGREGATION From the earliest periods in Americaâs history, sharp divisions across racial and ethnic lines were customary in virtually all sectors of society, including healthcare. The origins of racially segregated healthcare sys- tems can be traced back to slavery. While these systems were loosely organized, plantation health services were the earliest and one of the only systems comparable to todayâs managed-care plans (Smith, 1999). Planta- tion owners, as employers, had a significant financial interest in preserv- ing the health of their employees (Byrd and Clayton, this volume). Slaves received care in hospitals-of-sorts on plantations. In some states, white physicians organized hospitals for slaves, or contracted with plantation owners to provide care to their slaves (Smith, 1999). The early and mid 1800s also saw the emergence in America of scien- tific theories about race. Polygenism, and movements such as anthro- pometry, phrenology, and craniometry (theories that human races were distinct and hierarchical biological species) were at the forefront of scien- tific inquiry. Black soldiers during the Civil War were often used as sub- jects in studies comparing races to demonstrate black inferiority (Byrd and Clayton, this volume). After emancipation, the plantation system of medical care ended and the Freedmenâs Bureau was established by the federal government to pro- vide assistance to former slaves. The medical department of the Bureau established nearly 100 hospitals for freed slaves, However, by 1868 only one (Howard University Medical Center) remained (Smith, 1999). After this point, African Americans received healthcare in segregated facilities in northern hospitals created by local governments. In the south, where most African Americans resided, local municipalities and states began to provide payments to hospitals to subsidize care for the underserved,
104 UNEQUAL TREATMENT which included segregated care for the poor (Smith, 1999). American In- dians, who experienced displacement and high mortality, had little con- tact with health systems until the second half of the 19th century. This healthcare, administered by the government, was also poor, inadequately funded, and not sensitive to culture (Byrd and Clayton, this volume). As the country approached the 20th century, two major social trans- formations converged to sharpen the racial divisions in healthcare ser- vices (Smith, 1999). First, with the development of surgical and other medical advances, both public and voluntary hospitals became important practice sites. Middle- and upper middle-class citizens began paying for services at these facilities, shifting power away from hospital boards to medical staff, who decided who received what kind of care. Second, the passage of Jim Crow laws solidified racial divides by legally separating facilities that provided care to black and white communities. In the scien- tific community, theories such as Darwinism, eugenics, and later, psycho- metric testing were developed to explain and predict the inferiority of certain groups, such as immigrants, African Americans, the poor, and the mentally retarded (Byrd and Clayton, this volume). As hospital facilities became more important to the practice of medi- cine, organizations such as the American College of Surgeons sought to standardize hospital practices, which enabled medical staffs at hospitals to become more organized and exercise control over practices in their fa- cilities (Smith, 1999). This essentially resulted in the exclusion of minority physicians from practicing in these institutions. Marginalized groups, including African Americans, American Indians, Hispanic Americans, and others from racial or religious minority groups were isolated, ex- cluded from training, and professionally segregated (Byrd and Clayton, this volume). The response by minority physicians was to create their own facilities. American Indians and Alaska Natives, by treaty agree- ments, in large part received their healthcare through the Federal govern- ment. However, the diversity and dispersion within the Native American community made it difficult to provide consistent and reliable care (Byrd and Clayton, this volume). In a parallel movement, issues of payment for medical care became prominent as these services became increasingly important in peoplesâ lives. Questions about whether care should be based on need or ability to pay became influenced, in part, by race (Byrd and Clayton, this volume). The passage of civil rights legislation in 1964 and Medicare and Med- icaid legislation in 1965 stimulated profound changes in the structure of healthcare. With mandated integration, one of the most significant changes was the closing of black hospitals (Smith, 1999). Between 1961 and 1988, 70 black hospitals either closed or merged with white facilities. This transformation was taking place while white hospitals were experi-
105 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES encing growth and financial prosperity. While on the surface these clos- ings may have seemed like a mere shifting of service sites, they had quite profound and devastating effects in minority communities. These clos- ings meant a loss of geographic convenience and accessibility to care, a sense of safety with known institutions, and a loss of a major source of employment in the community (Smith, 1999). In addition to the loss of these facilities, a similar fate was befalling many public facilities that had provided access to many minority patients. Another major, and more recent, shift in healthcare structure began in the late 1980s with the rise of managed care. This movement was initiated as both private and public payers were overwhelmed by rising costs and were searching for alternative ways to control their expenditures. By 1996, two-thirds of African Americans and Latinos with private insurance were enrolled in managed care plans. The transformation of Medicare pro- grams to managed care formats led to further downsizing of large urban hospitals (Smith, 1999). Historical Determinants of the Contemporary Minority Health Professions Workforce During the post-Reconstruction period, several âNegroâ medical schools and hospitals emerged. Eight medical schools for African Ameri- cans were established between 1865 and 1910 [Howard University Medi- cal School, Washington, D.C. (1868); Meharry Medical College, Nashville, Tennessee (1876); Leonard (Shaw) Medical School, Raleigh, North Caro- lina (1882-1915); Louisville National Medical College, Louisville, Ken- tucky (1887-1911); Flint Medical College, New Orleans, Louisiana (1889- 1911); Knoxville Medical College, Knoxville, Tennessee (1895-1910); the Medical Department of the University of West Tennessee (1900-1923); and Chattanooga National Medical College, Chattanooga, Tennessee (ca. 1902)] (Cobb, 1981). At least nine northern medical schools had admitted blacks by 1860. As a result, by 1895 there were approximately 385 black doctors, 7% of whom had been trained in white medical schools. Num- bers of African Americans graduating from white institutions gradually increased, and in 1905, 14.5% of the countryâs 1,465 black physicians were from white medical schools (Duke University Medical Center, 1999). Training black health professionals was essential to African-Ameri- can communities during the prolonged post-Reconstruction period of crushing poverty, poor health status and inadequate or absent healthcare (Byrd and Clayton, this volume). Abraham Flexnerâs 1910 report on the status of minority health and minority health professionals reinforced this need. Flexner severely criticized medical education in the United States, noting that many U.S. medical schools had poor facilities, inadequate fac-
106 UNEQUAL TREATMENT ulty with little scientific basis for instruction, and functioned principally as âdiploma mills.â These proprietary schools offered after-hours educa- tion and training, and contributed to the tension regarding the social and professional place for inexpensive medical education and primary care (Martensen, 1995). These tensions have not been completely resolved to- day. In this climate, the medical establishment was agitating for control and educational reform. More than 200 medical schools were founded in the United States between 1800 and 1900 (Stevens, Goodman, and Mick, 1978). At the end of the 20th century, the United States had the highest physician-to-population ratio in the world (Smith, 1999). Flexner believed strongly in the German scientific tradition he had experienced at the new Johns Hopkins University and suggested in the report that only univer- sity-based medical schools were appropriate for the responsibility and challenge of training physicians. Regarding the education of Negro phy- sicians, he reports: âThe medical care of the Negro race will never be wholly left to Negro physicians. Nevertheless, if the Negro can be brought to feel a sharp responsibility for the physical integrity of his people the outlook for their mental and moral improvement will be distinctly brightened. The prac- tice of the Negro doctor will be limited to his own race, which in turn will be cared for better by good Negro physicians than poor white ones. But the physical well-being of the Negro is not only of moment to the Negro himself. Ten million of them live in close contact with sixty million whites. Not only does the Negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the ignorant and unfortunate white contaminates him. Self-protection not less than humanity offers weighty counsel in this matter; self-interest seconds philanthropy. The Negro must be educated not only for his sake, but for ours. He is, as far as human eye can see, a permanent fact in the nation. He has his rights and due and value as an individual; but he has, besides, the tremendous importance that belongs to a potential source of infection and contagion. The pioneer work in educating the race to know and practice fundamen- tal hygiene principles must be done largely by the Negro doctor and Negro nurse. It is important they both be sensibly and effectively trained at the level at which their services are now important. The Negro is perhaps more easily âtaken inâ than the white; and as his means of extri- cating himself from a blunder are limited, it is all the more cruel to abuse his ignorance through any sort of pretense. A well-taught Negro sanitar- ian will be immensely useful; an essentially untrained Negro wearing an M.D. degree is dangerous.â (Flexner, 1910, as quoted in Smith, 1999, p. 15). .
107 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES The Flexner report had an enormous impact on medical education and the entire healthcare delivery system. The American Medical Asso- ciation and major philanthropic organizations closed ranks behind the report. The AMAâs Council on Medical Education pushed states to re- strict eligibility for state licensure to physicians graduating from approved medical schools (Smith, 1999). Within a few years the number of medical schools was reduced from approximately 155 to 70 (Smith, 1999). The curriculum was lengthened, entrance requirements were raised, and the scientific content of the curricula was increased (Byrd and Clayton 2001). These reforms were costly and many institutions were unable to survive the changes demanded by reformers. These changes, however, forever altered the class background of those trained to become physicians. Many poorer, part-time, and night students found economic barriers to medical education insurmountable, and the proportion of students from working- class and poor families remained steady at approximately 15% for most of the 20th century (Ziem, 1977). Medical education therefore was largely limited to a predominantly upper-class, white, and male population (Ziem, 1977). This increase in training costs had profound effects on the availability of doctors, particularly in the African-American community. In fact, the physician-to-population ratio among black Americans in 1974, twenty years after the Brown v. Board of Education Supreme Court decision that outlawed segregation in schools was worse than in the 1940s (Blackwell, 1977). Further hampering black progress, integration of the nationâs medi- cal schools was not seriously addressed until a decade after the 1954 Brown v. Board of Education decision. In 1948, for example, one-third of all medi- cal schools were officially closed to blacks and many more failed to accept a single black student until two decades later (Raup and Williams, 1964). By 1920, only two black medical schools remained, Howard Univer- sity Medical School and Meharry Medical College (Smith, 1999). The clo- sure of the other black medical schools dramatically reduced the commu- nity resource that produced many of their primary care physicians. These closures ensured that the segregation of healthcare in hospitals, in the health professions, and the professional societies would become en- trenched in U.S. society. While the black population made up about 10% of the total population in the mid-1950s, for example, black physicians made up only about 2.2% of all physicians (Reitzes, 1958). The nationâs overall physician-to-population ratio was 1 to 770. For the nonwhite population, however, the physician-to-population ratio was 1 to 4,567, and the black physician-to-population ratio was 1 to 3,736 (Reitzes, 1958). This disparity was not surprising, given that the burden of training black healthcare professions increasingly fell to only a few institutions. In 1956,
108 UNEQUAL TREATMENT 74% of all black medical students attended Howard or Meharry (Ziem, 1977). It was not until 1969 that all of the nationâs medical schools en- rolled more black students than did Howard or Meharry alone (Ziem, 1977). During the late 19th and early 20th century, black physicians and com- munity leaders had built their own hospitals in several cities around the country. Many of these hospitals served as major training centers for black health professionals. Medical specialists were in very short supply in the black communities, and access to white hospitalsâeven for those doctors who graduated from white medical schoolsâwas limited. For African- American physicians, acquiring specialty training or hospital expertise was rare, because these doctors were denied opportunities to access spe- cialty training (Byrd and Clayton, 2001). Failure to acquire the requisite credentials automatically excluded blacks from academic medicine and prestigious hospital staff appointments. To compound these problems, organized medicine and local specialty societies failed to open doors for minorities to gain equal footing in the profession. The American Medical Associationâs (AMA) refusal to require its affiliates to desegregate until the mid-1960s made it virtually impos- sible for most black physicians to gain privileges at white hospitals be- cause local society membership was a prerequisite (Byrd and Clayton, 2001). Smith (1999) described a fear among black medical leaders that the American College of Surgeons standardization efforts could eventually eliminate black hospitals and black medical professionals. In response, the black medical leadership formed its own organization, the National Medical Association (NMA), which was founded in 1895. Blacks were, in effect, excluded from AMA affiliates and the existing medical establish- ment, unable to fully open the doors to training opportunities until the Civil Rights Era. THE SETTINGS IN WHICH RACIAL AND ETHNIC MINORITIES RECEIVE HEALTHCARE âSo youâre talking about [the] hospital. I think [large] hospitals, their equip- ment, [they have] more equipment, Iâm talking about [a] large hospital, a hospi- tal versus clinics. I like to go to a place where they have more, a lot of equipment, and complete their services so I donât have to go to different places. I can go to . . . a central place where theyâll be able to take care of everything. And then language again, thatâs important. A Chinese interpreter [is necessary].â (Asian- American patient) The legacy of racial segregation of healthcare is, in many respects, mirrored in stark racial and ethnic differences in the contexts in which
109 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES care is received. Rates of health insurance vary greatly among racial and ethnic groups, as do primary sites where care is received, and who deliv- ers this care. Most of these racial and ethnic differences are due to socio- economic factors. For example, as will be discussed in Chapter 3, patients with Medicaid have difficulty accessing private sector office-based care (Lillie-Blanton et al., 2001) and are more often relegated to public hospi- tals and clinics. New studies indicate, however, that even when income and education are controlled, minorities are more likely to receive care in the lowest quality facilities with the least likelihood of appropriate follow-up. Minorities have more difficulty than the majority population in locat- ing a âusual sourceâ of medical care (see Figure 2-9). African-American and Latino patients report greater difficulty than whites obtaining medi- cal care at a consistent location. In 1996, for example, almost a third of Latino patients reported having a regular healthcare provider. Similarly, more minority patients report having little or no choice in where to go for medical care. Twenty-eight percent of African Americans and 30% of His- panics report this difficulty, compared with 16% of whites and 21% of Asian-American adults (Lillie-Blanton et al., 2001). In the 1980s, African Americans and Latinos were more likely than their white counterparts to receive care in hospital outpatient departments (particularly teaching and public hospitals), community-based clinics, and emergency rooms as usual sources of care (Lillie-Blanton et al., 2001; Smith, 1999; Gaskin, 1999). Persons with public or no insurance were also more likely to receive care in these settings (Cornelius et al., 1991, as cited 40 30 28 30 23 21 Percent 20 20 17 20 16 14 10 0 1977 1987 1996 African American Hispanic White FIGURE 2-9 No usual source of medical care. SOURCE: 1996 Medical Expendi- ture Panel Survey, as cited in Lillie-Blanton et al., 2001.
110 UNEQUAL TREATMENT in Lillie-Blanton et al., 2001). In a study to assess whether ethnicity is associated with site of care beyond insurance coverage, Lillie-Blanton, Martinez, and Salganicoff (2001) analyzed data from the 1996 Medical Expenditure Panel Survey (MEPS), and found that African Americans and Latinos, regardless of insurance coverage, were almost twice as likely as whites to receive care from a hospital-based provider (Figures 2-10 and 2- 11). Those who were uninsured were also more likely to rely on hospitals for care. Many people from racial and ethnic backgrounds are disproportion- ately served by safety net urban hospitals, defined as those facilities whose Medicaid utilization rate exceeds one standard deviation above the mean Medicaid utilization rate for urban hospitals in the state. Ethnic minori- ties comprise 43% of patients seen at these hospitals, but make up only 19% of patients seen at other urban hospitals (Collins et al., 1999). Ap- proximately half of African-American (47%) and Hispanic (53%) adults under age 65 report relying on safety net emergency rooms, outpatient departments, or clinics for their healthcare, compared with 30% of whites. Childrenâs healthcare service use reveals similar patterns. White chil- dren see physicians at twice the rate of minority children (Collins et al., 1999). However, African-American and Latino children are over-repre- sented in emergency rooms and hospital outpatient departments (Table 2-1; Lillie-Blanton et al., 2001). Even across type of insurance, African- ethnicity insurance 20 16 14 15 11 Percent 10 10 5 4 5 0 Whites African Hispanics Private Any Uninsured Americans Medicaid FIGURE 2-10 Site of care: Hospital outpatient departments and emergency rooms. SOURCE: Medical Expenditure Survey, 1997, as cited in Lillie-Blanton et al., 2001.
111 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES ethnicity insurance 20 16 16 15 15 15 Percent 10 7 6 5 0 Whites African Hispanics Private Any Uninsured Americans Medicaid FIGURE 2-11 Site of care: Other non-hospital facilities. SOURCE: Medical Ex- penditure Survey, 1997, as cited in Lillie-Blanton et al., 2001. TABLE 2-1 Site of Usual Source of Care by Insurance and Race/ Ethnicity, Children 0â17, 1996 Hospital Clinic or Office-based Outpatient Dept. ER % (SE) % (SE) % (SE) Private Health Insurance White 93.6 (0.8) 6.3 (0.8) 0.1 (0.1) African American 89.5 (2.3) 10.1 (2.2) 0.4 (0.4) Latino 85.9 (2.4) 13.7 (2.4) 0.4 (0.3) Medicaid White 90.1 (2.3) 9.9 (2.3) 0.0 (0.0) African American 74.6 (3.8) 22.8 (3.7) 2.7 (1.8) Latino 80.3 (3.2) 18.8 (3.1) 0.9 (0.6) Uninsured White 90.8 (2.3) 8.3 (2.1) 0.9 (0.6) African American 73.7 (6.1) 24.1 (6.2) 2.2 (1.9) Latino 81.6 (3.2) 17.2 (3.1) 1.2 (0.8) SOURCE: Medical Expenditure Panel Survey, 1996, as cited in Lillie-Blanton et al., 2001.
112 UNEQUAL TREATMENT American and Latino children are more likely to receive care in these set- tings than their white counterparts. Racial and ethnic minority patients are also more likely to report ex- periencing difficulty in accessing specialists. Eight percent of whites, 16% of blacks, 22% of Hispanics, and 26% of Asian Americans report this diffi- culty (Collins et al., 1999). Within the Asian-American community, Chi- nese Americans indicated the most difficulty (21%). Among Medicare beneficiaries age 65 and older diagnosed with diabetes, black patients were less likely to have had an office visit with a cardiologist or eye spe- cialist (Collins et al., 1999). Impact of Community Health Centers on Healthcare in Minority and Medically Underserved Areas During the 1960s, several new federal efforts were developed to in- crease healthcare services in poor communities. To this end, services such as the National Health Service Corps and the Community and Mi- grant Health Centers Program were initiated to help strengthen the workforce in medically underserved communities (Heinrich, 2000). By 1996, 625 community health centers (CHCs) provided services at over 3,900 sites (COGME, 1998). Today, these facilities serve underserved rural areas, migrant and seasonal farm worker communities, and urban communities. These federally funded CHCs include four programs: community health centers, migrant health centers, healthcare for the homeless, and healthcare for residents of public housing (COGME, 1998). CHC services are provided by primary care and other physician specialists, nurse practitioners, physician assistants, certified nurse mid- wives, dentists, and psychiatrists. The vast majority (approximately two-thirds) of patients served by CHCs are non-white (COGME, 1998). In some communities, CHCs are the predominant source of care. In others, local governments have created and funded primary care clinics using the federal CHC model, helping to fill the void left by a lack of office-based providers. By the mid-1990s, rates of Hispanic visits to community health centers were 700% higher than for whites. For black, non-Hispanic individuals, visits to CHCs were 550% higher than white, non-Hispanic visits (Table 2-2). The CHC model has proven effective not only in increasing access to care, but also in improving health outcomes for the often higher-risk populations they serve. The continuity of care has been found to be better in CHCs than in hospital outpatient departments or physician of- fices, and a study examining preventable hospitalizations among medi- cally underserved communities found that in communities served by federally qualified health centers, rates of preventable hospitalizations
TABLE 2-2 Number of Primary Care Visits Made to Primary Care Delivery Sites in the United States in 1994 Community Hospital Overall Health Centers Physicianâs Offices Outpatient Departments Per 100 Per 100 Per 100 Per 100 In Persons In Persons In Persons In Persons Thousands Per Year Thousands Per Year Thousands Per Year Thousands Per Year Race/Ethnicity Hispanic 28,087 (8.6) 109.1 3608 (31.7) 14.0 21,205 (7.3) 82.4 3275 (15.3) 12.7 Black, non-Hispanic 27,425 (804) 91.0 3356 (29.5) 11.1 19,930 (6.8) 66.1 4140 (19.4) 13.7 Asian/Pacific Islander 11,910 (3.7) 141.0 539 (4.7) 6.4 10,903 (3.7) 129.1 468 (202) 5.5 White, non-Hispanic 257,622 (79.2) 134.9 3891 (34.1) 2.0 240,265 (82.2) 125.8 13,466 (63.1) 7.0 Health Insurance Payer Medicare 49,117 (15.1) N/A 1375 (10.6) N/A 44,899 (15.4) N/A 2843 (13.3) N/A Medicaid 38,120 (11.7) N/A 5151 (39.7) N/A 26,367 (9.1) N/A 6602 (30.9) N/A Private 190, 681 (58.7) N/A 2754 (21.2) N/A 180,226 (62.0) N/A 7701 (36.1) N/A Uninsured 33,376 (10.3) N/A 3339 (25.7) N/A 27, 458 (9.4) N/A 2579 (12.1) N/A Other payment 13,758 (4.2) N/A 350 (2.7) N/A 11, 758 (4.1) N/A 1623 (7.6) N/A SOURCE: Forrest & Whelan, 2000. Visit counts were multiplied by sampling weights, which account for the multistage sample design and nonresponse of in-scope practitioners, to obtain national estimates. Rates were based on the U.S. Bureau of the Census estimates of the U.S. civilian noninstitutionalized population as of July 1, 1994. N/A indicates that visit rates were not calculated by health insurance payer because denominators were not available. HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES 113
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 Medicareâs 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 countryâs physicians. Of these 9%, one-third (33.3%) is African American, 40.1% are
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).
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.
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
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
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 programsâ¦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.
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 âinternationally mobile scientistsâ 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 âwhen 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.â 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 patientsâ 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 âI heard an Anglo doctor complaining that his daughter is having trouble get- ting into medical school. Then another doctor jumps in, another Anglo, âOh donât worry about it. I know the admissions coordinator. Iâll get her in. Iâll give him a call and sheâll be in.â When does a Hispanic or black student have those advantages, the connections? I certainly didnât have any connections, and I still donât have any connections. I couldnât get my son into medical school if I tried.â (Hispanic physician)
121 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES âWhen I was in medical school I had a racist comment by one of the white stu- dents. He said the only reason why youâre here, it wasnât said to me but I overheard it, the only reason why black students are here is because theyâre black and this that and the other. What was really interesting was that OK, sure Iâm black, but I donât take the black test, I donât take the black boards, we take the same exams.â (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 Courtâs Bakke decision in 1976, but other efforts, such as AAMCâs âProject 3000 by 2000,â 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 1994âa collective decrease of 9.1% in minority stu- dent matriculation at these institutionsâwhile 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
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 Texasâ public medical schools dropped 54% (Carlisle and Gardner, 1998b). And among Californiaâs 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 administratorsâ 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 nationâs 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 physiciansâ 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: â¢ 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.
123 HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES â¢ The quality of healthcare depends as much on physiciansâ 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). â¢ 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 âstakeholders.â These efforts include, but are not limited to: the public education efforts of U.S. DHHS, which recently launched its âClosing the Health Gapâ 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.
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 providersâ 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.