CHAPTER 10 - DISPARITIES
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- By the year 2050, persons of color are expected to represent nearly half of the U.S. population.a
- Minorities are far more likely to be uninsured than whites. In 2005, African-Americans were almost twice as likely as non-Hispanic whites to be uninsured (19.6 percent vs. 11.3 percent). Hispanics are almost three times as likely as non-Hispanic whites to lack health coverage (32.7 percent vs. 11.3).b
- Even when they have insurance equal to whites, minorities often receive a lower quality of care than do their white counterparts.c
- Among the types of quality disparities experienced by African-Americans, Asians, American Indians and Alaska Native, more are growing worse than are diminishing. For Hispanics, the opposite is true.d
- Some 23 percent of African-Americans report receiving poor quality medical care because of their race or ethnicity, compared to one percent of whites.e
- One in five Hispanic Americans (21 percent) say they received poor quality medical care because of their accent or how well they spoke English.f
- A Robert Wood Johnson Foundation survey found that more than three-quarters (78.4 percent) of non-federal acute care hospitals in the United States collect information on the race of their patients, and half collect information on patient ethnicity (50.4 percent) and language (50.2 percent).g
Many African-Americans, Hispanics and other racial and ethnic minorities face barriers when they need care – hurdles less commonly experienced by whites. Even when minority patients have health coverage, they are likely to receive lesser amounts and lower quality of care than whites.1
Compounding these problems, minorities are on the whole less healthy than whites, for a variety of reasons. This combination of disparities in health and health care has received substantial attention in recent years from policymakers:
- Eliminating health disparities is one of two overarching goals of Healthy People 2010, a report developed by multiple federal agencies, which lays out many health objectives for the country.2
- Unequal Treatment, a 2002 report by the respected Institute of Medicine (IOM), summarizes a huge array of studies on disparities.3
- The 2006 National Healthcare Disparities Report, the fourth such report produced by the federal Agency for Healthcare Research and Quality, concluded that African-Americans, Hispanics, American Indians and Alaska Natives receive lower quality care than whites on a number of measures.4
While a bipartisan consensus may be forming among policymakers about the need for national action on health disparities, awareness of the problem is much less evident among the public and health care providers. Only 25 percent of whites think getting quality health care is more of a problem for minorities than for whites. This is quite different from the 56 percent of Hispanics and 44 percent of African-Americans who think so.5 (See chart, “Hispanics, African-Americans Perceive Much More Discrimination in Care than Whites. ”)
Similarly, 25 percent of white physicians believe that the health care system treats people unfairly based on their race or ethnicity “very often” or “somewhat often.” In contrast, 77 percent of African-American physicians believe this is true, as well as 52 percent of Hispanic physicians and 33 percent of Asian physicians.6
Fortunately, gaps in access and quality are narrowing for some groups. An increasing percentage of blacks enrolled in Medicare managed care plans are getting nationally recommended care for certain conditions.7 Among the types of “core” quality disparities experienced by Hispanics, more are improving than are getting worse, compared to whites.8 Looking at "core" measures of access to care, more are improving than worsening for all minority groups except Hispanics.9
But the quality disparity trend is negative for African-Americans, Asians, American Indians and Alaska Natives; more measures are getting worse than better. And the portion of “core” quality disparities that are worsening compared to whites is substantial (40 percent for American Indians and Alaska Natives, 35 percent for Asians, 30 percent fo African-Americans and 25 percent for Hispanics).10
Any growth in disparities is troubling, especially considering that minorities will constitute almost half of the U.S. population by 2050, according to Census Bureau projections.11 (See chart, “Projected U.S. Population by Race & Hispanic Origin: Selected Years.”) In several states and communities, “minorities” already make up a majority of the population. This is true in Texas, New Mexico, California, Hawaii and the District of Columbia. 12
What causes disparities in health and health care? How important are they? What is being done to address them? What more, if anything, needs to be done?
What Causes Disparities?
Minority status or ethnicity alone doesn’t necessarily condemn a person to bad health or lack of access to quality health care. But factors associated with race and ethnicity – lower incomes or holding jobs that don’t provide health coverage, for example – do influence a person’s health and whether someone gets needed care.
Those with higher incomes enjoy better health,13 and minorities’ incomes lag consistently behind those of whites. In 2004, more than 24 percent of blacks and almost 22 percent of Hispanics had incomes below the federal poverty level, compared to 8.6 percent for non-Hispanic whites.14
A large number of physicians and members of the public think income makes a difference in how patients are handled. Almost half of physicians polled in one study (47 percent) believed that the health care system “very or somewhat often” treats people unfairly based on how much money they have. This view was held by 71 percent of the public polled.15 (See chart, “Beliefs About How Often the Health Care System Treats People Unfairly Based on… [Factors])
Lack of Health Coverage
Also, minorities are far more likely to be uninsured than whites. In 2005, African-Americans were almost twice as likely as non-Hispanic whites to be uninsured (19.6 percent vs. 11.3 percent). Hispanics are almost three times as likely as non-Hispanic whites to lack health coverage (32.7 percent vs. 11.3 percent).16 This is largely because African-Americans and Hispanics are much less likely than whites to have employer-sponsored coverage.17
Almost three out of four physicians surveyed (72 percent) say the health care system treats people unfairly “very or somewhat often” based on their health insurance status. 18
And not having coverage can be dangerous to your health, according to a wide array of studies conducted by, among others, the nonpartisan Institute of Medicine (IOM). People without health insurance often go without care or delay care. An estimated 18,000 adults die each year because they are uninsured and can't get appropriate health care, according to the IOM.19
Health Status Differences
Minorities tend to have more health problems and more serious health problems than whites. Among nonelderly adults, about 17 percent of Hispanic, and 16 percent of black Americans report they are in only “fair or poor” health, compared with about 10 percent of whites.20
One study estimates that every year in the U.S., 100,000 more blacks die than would be the case if white and black mortality rates were the same.21 African-American men, for example, are 50 percent more likely to have prostate cancer than white men, and are more than twice as likely as whites to die as a result of the cancer.22 Non-Hispanic black children age 3 to 10 have more asthma attacks than Hispanics or non-Hispanic whites, a trend that has been growing worse.23
Cervical cancer occurs five times more often among Vietnamese–American women than among non-Hispanic white women.24
Compared to the general U.S. population, American Indians are more than six times more likely to suffer from alcoholism, four times more likely to have tuberculosis and almost three times more likely to have diabetes.25
Access to Quality Health Care
Having access to health care is important both for preventing disease and treating it once it appears. As the federal Agency for Healthcare Research and Quality points out: “Poor access to health care comes at both a personal and societal cost: for example, if persons do not receive vaccinations they may become ill and spread disease to others, increasing the burden of disease for society overall, in addition to the burden borne individually.”26
Many minorities find that they have difficulty getting the health care they need. For instance:
- A look at 81 cardiac care studies found that 68 of them reported racial or ethnic differences in care for at least one minority group.27
- Minorities are less likely than whites to have a usual primary care provider or a provider for ongoing health care.28 Those without a usual source of care tend to have higher medical costs and poorer health outcomes.29
- Preventive services can also be lacking for minorities; in 2000, minority women received substantially less breast cancer and cervical cancer screenings than whites.30
- Blacks have higher rates of avoidable hospital admissions than other groups.31
A 2005 study found that hospitals are less likely to respect the preferences of black and Hispanic patients than whites for surgical and obstetrical services. For example, twice as many blacks and three times as many Hispanics reported such problems with obstetrical care as did whites (21 and 32 percent vs. 10 percent). No racial differences were noted for patients hospitalized for medical reasons.32
Racial and ethnic health and health care disparities may be caused by a number of other potential sources, beyond those noted above.
Too few minority providers. Minorities are underrepresented in health care professions. This is particularly important because minority providers are significantly more likely than their white peers to serve and understand minority and medically underserved communities. The Institute of Medicine reports that in 2000, Hispanics made up 12 percent of U.S. residents but only 3.5 percent of physicians, 3.4 percent of psychologists and 2 percent of nurses. One eighth of U.S. residents were black, but blacks made up only one twentieth of U.S. physicians and dentists.33 In total, underrepresented minorities made up 25 percent of the population, but 6.1 percent of physicians, 7.4 percent of nurses, 6.9 percent of psychologists and 6.8 percent of dentists.34
Provider stereotyping. Many health care providers have preconceived notions of some minorities that may affect the quality of care. In one study based on actual clinical encounters, physicians were found to rate blacks, for example, as less intelligent than whites, less educated, more likely to abuse drugs and alcohol, less likely to comply with medical advice, and more likely to lack social support.35
Communication difficulties. Many minority patients experience difficulties in communicating with their health care providers. Some minorities have difficulty with English and often cannot find providers who speak their language, with clinical consequences. A 2006 study, for instance, found that among parents of children enrolled in the California State Children’s Health Insurance Program, 15 percent said they had needed a medical interpreter in the previous six months. But less than half of this group (47 percent) said an interpreter was always available, despite a California state law requiring all SCHIP health plans to provide a trained medical interpreter to those needing one. The authors reported that the “use of interpreters reduced White-Hispanic disparities in reports of care by up to 28 percent.”36,37
Geography. Minority communities often have fewer sources of health care than white communities, or none at all. A 2005 study showed that 70 percent of black heart attack patients on Medicare were treated at just 20 percent of medical centers. At hospitals treating the most blacks, death rates for all heart attack patients were 19 percent higher than at facilities that treated only white heart attack patients. A coauthor of the study told USA Today: "African-Americans live in very different places than whites, and in general they get treated at lousy hospitals." 38
Other possible explanations for disparities generally include health practices among minority communities (such as a preference for home remedies or folk medicine), psychosocial stress and risk-increasing environmental exposures.39
Latest Findings on Disparities
2006 National Healthcare Disparities Report
The 2006 National Healthcare Disparities Report, mentioned earlier, examined numerous health care indicators – including ones that measure both access and treatment outcomes. The report found that the disparity picture looks somewhat better for Hispanics compared to whites when it comes to quality of care, but worse for other minorities. Looking at access to care, the situation is reversed, with access worsening for Hispanics and improving for other minorities. 40
It’s important to note that while the range of disparities measured in the report is still fairly limited, improvements were modest and in none of the areas measured were disparities eliminated. While the jury is still out, several points are clear:
- Disparities still exist.
- Some disparities are diminishing, while others are increasing.
- Opportunities for improvement remain.
- Information about disparities is improving.
New England Journal of Medicine Studies
Two 2005 reports in the New England Journal of Medicine indicate that little progress has been made in addressing racial/ethnic disparities in the care of patients needing treatment for serious conditions. A third 2005 study found some promising news in the preventive care arena. A fourth study, from March 2006, found that overall quality of care is actually slightly better for blacks and Hispanics than for whites among those with access to care.
In the first study, researchers analyzed data from 1994 to 2002 and concluded that racial differences between African-Americans and whites had persisted in three heart-related situations. White men were the most likely to get two helpful interventions, followed by white women, black men and black women. Black women were significantly more likely to die in a hospital after a heart attack (myocardial infarction) than white men. In-hospital death rates for white women and black men were similar to white men. The researchers said there is “no evidence that the differences have narrowed in recent years.” 41
The second study examined data for men and women enrolled in Medicare, and measured rates at which common surgical procedures – such as coronary artery bypass surgery and total hip replacement – were performed on different groups. The investigators found that between 1992 and 2001 the difference between the rates for whites and African-Americans increased significantly for five of the nine procedures, remained unchanged for three procedures, and improved significantly for only one procedure. In no region in the entire nation had the gap in surgery rates between blacks and whites been eliminated. The authors conclude that there had been no meaningful or consistent reductions in the gaps in care between black and white Medicare enrollees.42
But a third study found some modest progress in addressing disparities in primary care. Using data from enrollees in Medicare managed care plans, the study found a narrowing in racial disparities from 1997 to 2003 for seven preventive care measures, including mammography, glucose testing and cholesterol testing. However, the same study found that racial disparities for two other key areas –glucose control among diabetics and cholesterol levels in patients after a heart attack – actually widened.43
The fourth study, by the RAND Corporation, looked at the experiences of patients who had had at least one encounter with the health care system in the previous two years, indicating at least minimal access to care. Researchers measured whether patients got recommend care when seen for disease prevention services and for 30 acute and chronic conditions that constitute the leading causes of death and disability.
According to the study, overall quality scores were a few percentage points higher for blacks and Hispanics than for whites.44 The authors of the study note that these findings are “at odds with many other published studies.” One reason, they suspect, is the quality indicators they chose, which are broader than those used in studies of complicated, expensive procedures (as described above). “When we confined our analysis to indicators used in previous studies that demonstrated racial or ethnic disparities, we observed a trend toward better care for whites than for blacks.”45
Most important, according to lead researcher Steven Asch of RAND Health, is that all racial and ethnic groups received recommended care far too infrequently – an average of only 54.9 percent of the time. Said Asch, “We are all in the same boat, and it’s a leaky one.”46
Public Sector Proposals to Reduce Disparities
As noted above, national policymakers are coming to recognize the importance of eliminating racial and ethnic disparities in our health care system. The federal government has set as a goal, articulated in Healthy People 2010, the elimination of these disparities.
To make progress toward that goal, analysts offer a range of proposals including:
- Health coverage expansions. Since minorities disproportionately lack coverage, and having coverage is such an important link to quality care, initiatives to provide more people with insurance could have a substantial effect on disparities.47,48 (For a fuller description, see Chapter 1, “The Uninsured”.)
- Safety net improvements. Even without insurance, many minorities might gain better access to quality care if safety net facilities, such as community health centers, were more numerous, better equipped and more adequately staffed. Initiatives have been debated in Congress to make improvements along these lines. President Bush’s 2007 budget includes funding for more than 300 new or expanded community health centers, including 80 new sites in high-poverty counties.49
- Educating health professionals. Proposals have been put forth by several members of Congress to develop curriculum materials for health professional schools that focus on building cultural awareness among all professionals. In the same vein, there are proposals to increase support for programs that improve diversity among health professionals, including by aiding historically black colleges and universities.
- Better data. Policymakers of both political parties have offered plans to expand research into disparities from both a clinical and a health systems point of view. But more work is needed. A 2006 study supported by the Robert Wood Johnson Foundation shows that the majority of U.S. hospitals collect accurate information about their patients’ race, ethnicity and language preference, but few are using the data to improve the quality of health care that is delivered to patients.50
Some Private Sector Efforts
A number of efforts are underway, funded by private sector foundations, to develop practical solutions to racial and ethnic disparities that can be implemented in real-world clinical settings.
The Robert Wood Johnson Foundation launched three such initiatives in late 2005.51 “Expecting Success: Excellence in Cardiac Care” is a national program focusing on reducing disparities in cardiac care for African-American and Hispanic patients. Hospitals in Texas, Mississippi, North Carolina, Florida, New York, Illinois, Michigan and Washington, DC, involved with “Expecting Success” will be identifying quality gaps in their treatment of cardiac patients and will implement hospital-wide strategies aimed to reducing them.
A second program, “Finding Answers: Disparities Research for Change,” is providing $5 million in grants to encourage health plans, hospitals and community clinics to concentrate on racial and ethnic disparities as a priority in their quality improvement programs. Targeted patients are expected to include those being treated for cardiovascular disease, depression and diabetes.
“Leading Change: Disparities Solutions Initiative,” the third effort, will synthesize the results of other disparities projects funded by the Robert Wood Johnson Foundation and will use these results to help health care systems develop and implement successful programs of their own to reduce disparities. The foundation also supports “Speaking Together: National Language Services Network,” to help hospital staff better communicate with patients of limited English proficiency. (For information about all the above, go to www.rwjf.org/portfolios/npolist.jsp?iaid=133.)
A multifaceted project by The Commonwealth Fund titled the “Program on Quality of Care for Underserved Populations” identifies methods to improve care and reduce disparities for low-income and racial and ethnic minority patients, and works to get these methods into clinical practice, among other goals.
One Commonwealth grant to the Institute for Urban Family Health in New York City will help develop a set of best practices for diabetes care that should cut down on disparities.52 Another grant to the University of Florida is designed to improve communication with patients who have difficulties with English.53 Yet another Commonwealth-funded effort will help hospitals track and improve care delivered to minority patients with heart attacks, heart failure and pneumonia, using racial and ethnic data submitted by hospitals as part of a Medicare quality improvement effort.54 (For other groups working on disparities, see the box, “More Information on Reducing Disparities.”)
Given the growth in the minority population over the coming years, how well the health care system responds to their needs will go a long way toward signaling how well the system functions for all Americans.
- How do the number and distribution of minority physicians and other providers compare to the minority population in your community?
- How available are providers who speak languages other than English? What are providers doing to increase their staffs’ cultural sensitivity to the main minority groups in your community?
- What steps, if any, are medical or nursing schools in your area taking to increase the number of minority applicants and graduates?
- Talk to local groups to find out what kinds of special efforts they have underway, if any, to target minority populations who have a high incidence of certain diseases.
- Some health insurers and hospitals have begun to improve the data collected on minority health care experiences. Are efforts like that underway in your area? Are they making any difference in the care delivered to minorities? Do minority group members feel the data collection is necessary, or that it is an intrusion on their privacy?
- Visit a community health center or clinic located in a neighborhood with a large minority population. How long must patients wait to see a clinician? Are there personnel who speak the needed languages? Is funding for the facility at risk, stable or improving?
- How do minorities in your community feel about their interactions with health care providers? How do they think they are perceived by the health care system? What improvements would they like to see on the part of providers?
Experts and Websites
Aday, Lu Ann, Lorn Baine Professor in Public Health and Medicine, University of Texas, 713/500-9177
Akio Kawata, Paul, Executive Director, National Minority AIDS Council, 202/483-6622
Asch, Steven, RAND Corporation, 310/393-0411 x.6516
Bach, Peter, Memorial Sloan-Kettering Cancer Center, 646/735-8137
Barr, Michael, Vice President for Practice Advocacy and Improvement, American College of Physicians, 202/261-4500
Beal, Anne, Senior Program Officer, The Commonwealth Fund, 212/606-3854
Betancourt, Joseph, Director of the Disparities Solution Center, Massachusetts General Hospital, 617/724-9713
Bloche, Gregg, Professor of Law, Georgetown University and The Brookings Institution, 202/662-9123
Bronheim, Suzanne, Senior Policy Analyst, National Center for Cultural Competence, 202/687-8914
Carter-Pokras, Olivia, Professor, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, 410/706-0463
Christopher, Gail, Director, Health Policy Institute, Joint Center for Political and Economic Studies, 202/789-3500
Cole, Lorraine, President and Chief Executive Officer, Black Women's Health Imperative, 202/548-4000
Corrigan, Janet, President, National Quality Forum, 202/783-1300
Daus, Gem, Policy Director, Asian and Pacific Islander American Health Forum, 202/466-7772
Doty, Michelle, Associate Director of Research, The Commonwealth Fund, 212/606-3860
Escarce, Jose, Director, Data and Methods Core, Center for Population Health and Health Disparities, RAND Corporation, 310/393-0411 x7189
Falcon, Adolph, Vice President for Science and Policy, National Alliance for Hispanic Health, 202/387-5000
Griss, Bob, Executive Director, Inst. of Social Medicine & Community Health, 703/272-7707
Hasnain-Wynia, Romana, Vice President, Research, Health Research and Educational Trust, 312/422-2643
Hawkins, Dan, Vice President, National Association of Community Health Centers, 301/347-0400x3001
Hill, Martha, Dean, School of Nursing, John Hopkins University, 410/955-7544
Jha, Ashish, Assistant Professor of Health Policy and Management, School of Public Health, Harvard University, 617/432-5551
Krause, Jean, Executive Vice President and Chief Executive Officer, American College of Physicians Foundation, 877/208-4189
Ku, Leighton, Senior Fellow of Health Policy, Center on Budget and Policy Priorities, 202/408-1080
Lavizzo-Mourey, Risa, President & CEO, Robert Wood Johnson Foundation, 888/631-9989
Lillie-Blanton, Marsha, Vice-President in Health Policy, Kaiser Family Foundation, 202/347-5270
Madyun, Atiba, Division Director, National Black Caucus of State Legislators, 202/624-5457
Moore, Evelyn, President, National Black Child Development Institute, 202/833-2220
Nelson, Alan, Special Advisor to the CEO, American College of Physicians, 703/385-3360
Noyes, Jackie, Associate Executive Director, American Academy of Pediatrics, 202/347-8600
Perez, Lucy, National Health Director, NAACP Division of Health Advocacy, 410/580-5672
Puckrein, Gary, Executive Director, National Minority Health Month Foundation, 202/223-7560
Rowland, Diane, Executive Vice President, Kaiser Family Foundation, 202/347-5270
Rubenstein, Leonard, Executive Director, Physicians for Human Rights, 202/728-5335 x501
Scholle, Sarah, Assistant Vice President of Research and Analysis, National Committee for Quality Assurance, 202/955-3500
Siegel, Bruce, Research Professor, Department of Health Policy, George Washington University, 202/530-2399
Skinner, Jonathan, Professor of Economics, Dartmouth College, 603/646-2535
Somers, Stephen, President, Center for Health Care Strategies, 609/528-8400
Youdelman, Mara, Staff Attorney, National Health Law Program, 202/289-7661
Zambrana, Ruth, Professor and Graduate Director in Women's Studies, University of Maryland, 301/405-0451
Bach, Peter, Senior Advisor, Office of the Administrator, Centers for Medicare and Medicaid Services, 202/690-6726
Chesley, Francis, Director, Office of Extramural Research, Education, and Priority Population, Agency for Healthcare Research and Quality, 301/427-1449
Graham, Garth, Deputy Assistant Secretary, Office of Minority Health, Department of Health and Human Services, 240/453-2882
Haywood, Trent, Deputy Chief Medical Officer, Centers for Medicare and Medicaid Services, 410/786-1034
Robinson, William, Director, HRSA Office of Minority Health and Health Disparities, Department of Health and Human Services, 301/443-2964
Ruffin, John, Director, National Center on Minority Health and Health Disparities, National Institutes of Health, 301/402-1366
Tharpe, Don, President and CEO, Congressional Black Caucus Foundation, 202/263-2800
Thomas, Daniel, Senior Health Policy Consultant, National Black Caucus of State Legislators, 301/871-2624
Aguilu, Eduardo, Deputy Chief Executive Officer, Latin American Health Institute, 617/350-6900
Bocchino, Carmella, Senior Vice President, Medical Affairs, America's Health Insurance Plans, 202/778-3200
Gorham, Millicent, Executive Director, National Black Nurses Association, 301/589-3200
Grealy, Mary, President, Healthcare Leadership Council, 202/452-8700
Ignagni, Karen, President and CEO, America's Health Insurance Plans, 202/778-3200
Kahn, Charles, President, Federation of American Hospitals, 202/624-1500
Keehan, Sister Carol, President, Catholic Health Association, 202/296-3993
Rios, Elena, President, National Hispanic Medical Association, 202/628-5895
Schwartz, Roger, Legislative Counsel and Director of State Affairs, National Association of Community Health Centers, 202/296-0158
Suh, Dong, Policy and Planning Director, Asian Health Services, 510/986-6830 x262
Tuckson, Reed, Senior Vice President, UnitedHealth Group, 952-936-1253
Tyson, Bernard, Senior Vice President, Health Plan and Hospital Operations, Kaiser Permanente, 510/271-2659
Agency for Healthcare Research and Quality www.ahrq.gov/research/mentalix.htm
Alliance for Health Reform www.allhealth.org
Alliance of Community Health Plans www.achp.org
American Academy of Pediatrics www.aap.org
American College of Physicians www.acponline.org
American Medical Association www.ama-assn.org
America's Health Insurance Plans www.ahip.org
Asian and Pacific Islander American Health Forum www.apiahf.org
Asian Health Services www.ahschc.org
Black Women's Health Imperative www.blackwomenshealth.org
Catholic Health Association www.chausa.org
Center for Health Care Strategies www.chcs.org
Center on Budget and Policy Priorities www.cbpp.org
Centers for Medicare and Medicaid Services www.cms.hhs.gov
The Commonwealth Fund www.cmwf.org
Congressional Black Caucus Foundation www.cbcfinc.org
Cross Cultural Training White Memorial Medical Center www.whitememorial.com/content/residencies/family/index.asp
Dartmouth College Dept. of Economics www.dartmouth.edu/~economic
DHHS Office of Minority Health www.omhrc.gov
Families USA www.familiesusa.org
Federation of American Hospitals www.fah.org
George Washington University Department of Health Policy www.gwhealthpolicy.org
Georgetown University Law Center www.law.georgetown.edu/
Harvard School of Public Health www.hsph.harvard.edu/
Health Research and Educational Trust www.hret.org
Healthcare Leadership Council www.hlc.org
Institute of Medicine www.iom.edu
John Hopkins University School of Nursing www.son.jhmi.edu
Joint Center for Political and Economic Studies www.jointcenter.org
Kaiser Commission on Medicaid and the Uninsured www.kff.org/about/kcmu.cfm
Kaiser Family Foundation www.kff.org
Kaiser Foundation Health Plan Inc. www.kaiserpermanente.org
Latin American Health Institute www.lhi.org
Massachusetts General Hospital www.mgh.harvard.edu
NAACP Division of Health Advocacy www.naacp.org/rat/health/health_index.html
National Alliance for Hispanic Health www.hispanichealth.org
National Association of Community Health Centers www.nachc.com
National Association of Public Hospitals www.naph.org
National Black Caucus of State Legislators www.nbcsl.org
National Black Child Development Institute www.nbcdi.org
National Black Nurses Association www.nbna.org
National Center for Cultural Competence http://gucchd.georgetown.edu/nccc/
National Center on Minority Health and Health Disparities http://ncmhd.nih.gov/
National Committee for Quality Assurance www.ncqa.org
National Governors Association www.nga.org
National Health Law Program www.healthlaw.org
National Hispanic Medical Association www.nhmamd.org
National Immigration Law Center www.nilc.org
National Medical Association www.nmanet.org
National Minority AIDS Council www.nmac.org
National Minority Health Month Foundation www.nmhmf.org
National Quality Forum www.qualityforum.org
Physicians for Human Rights www.phrusa.org
RAND Corporation www.rand.org
Robert Wood Johnson Foundation www.rwjf.org
UnitedHealth Group www.unitedhealthgroup.com
Univ. of Texas School of Public Health www.sph.uth.tmc.edu
University of Maryland Dept. of Women's Studies www.womensstudies.umd.edu
University of Maryland School of Medicine Dept. of Epidemiology and Preventive Medicine http://medschool.umaryland.edu/Epidemiology/
Wellpoint Health Networks, Inc. www.wellpoint.com
a U.S. Census Bureau (2004). "Census Bureau Projects Tripling of Hispanic and Asian Populations in 50 Years; Non-Hispanic Whites May Drop to Half of Total Population." News Release, March 18. (www.census.gov/Press-Release/www/releases/archives/population/001720.html)
b U.S. Census Bureau (2006). “Table 8: People With or Without Health Insurance Coverage by Selected Characteristics: 2004 and 2005.” August 29. (www.census.gov/hhes/www/hlthins/hlthin05/hi05t8.pdf)
c Institute of Medicine (2002). “Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare.” March, p. 1. (www.iom.edu/Object.File/Master/4/175/Disparitieshcproviders8pgFINAL.pdf)
d Agency for Healthcare Research and Quality (2006). "Key Themes and Highlights From the National Healthcare Disparities Report." December, p. 6. (www.ahrq.gov/qual/nhdr06/nhdr06high.pdf)
e Robert Wood Johnson Foundation (2005). “Americans’ Views of Disparities in Health Care.” December 9, p. 1. (www.rwjf.org/files/research/Disparities_Survey_Report.pdf)
f Robert Wood Johnson Foundation (2005). “Americans’ Views of Disparities in Health Care.” December 9, p. 1. (www.rwjf.org/files/research/Disparities_Survey_Report.pdf)
g Robert Wood Johnson Foundation (2006). “New Study Indicates Majority of Hospitals Collect Patients’ Race, Ethnicity and Language Data; Yet Few Hospital Use the Data to Improve Quality of Care.” Feb. 9. News release. (www.rwjf.org/portfolios/features/newsreleasesdetail.jsp?id=10394&iaid=133)
1 Lillie-Blanton, Marsha and Catherine Hoffman (2005). “The Role Of Health Insurance Coverage In Reducing Racial/Ethnic Disparities In Health Care.” Health Affairs, Vol. 24, No.2, pp. 398-408. (www.healthaffairs.org)
2 Healthy People 2010. “Healthy People: What Are Its Goals?” (http://www.healthypeople.gov/About/goals.htm)
3 Institute of Medicine (2002). “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” (www.iom.edu/CMS/3740/4475.aspx)
4 Agency for Healthcare Research and Quality (2006). "Key Themes and Highlights From the National Healthcare Disparities Report." December, p. 3. (www.ahrq.gov/qual/nhdr06/nhdr06high.pdf)
5 Robert Wood Johnson Foundation (2005). “Americans’ Views of Disparities in Health Care.” December 9, p.1 and Table 1. (www.rwjf.org/files/research/Disparities_Survey_Report.pdf)
6 The Kaiser Family Foundation (2002). “National Survey of Physicians, Part I: Doctors on Disparities in Medical Care.” March, p. 2. (www.kff.org/minorityhealth/20020321a-index.cfm)
7 Trivedi, Amal N., et al. (2005). “Trends in the Quality of Care and Racial Disparities in Medicare Managed Care.” New England Journal of Medicine, Vol. 353, No. 7, pp. 692-700, Aug. 18. (http://content.nejm.org/cgi/content/abstract/353/7/692)
8 Agency for Healthcare Research and Quality (2006). "Key Themes and Highlights From the National Healthcare Disparities Report." December, p. 6. (www.ahrq.gov/qual/nhdr06/nhdr06high.pdf)
9 Agency for Healthcare Research and Quality (2006). "Key Themes and Highlights From the National Healthcare Disparities Report." December, p. 7. (www.ahrq.gov/qual/nhdr06/nhdr06high.pdf)
10 Agency for Healthcare Research and Quality (2006). "Key Themes and Highlights From the National Healthcare Disparities Report." December, p. 6. (www.ahrq.gov/qual/nhdr06/nhdr06high.pdf)
11 U.S. Census Bureau (2004). "Census Bureau Projects Tripling of Hispanic and Asian Populations in 50 Years; Non-Hispanic Whites May Drop to Half of Total Population." News Release, March 18. (www.census.gov/Press-Release/www/releases/archives/population/001720.html)
12 U.S. Census Bureau (2005). “Texas Becomes Nation’s Newest ‘Majority – Minority’ State, Census Bureau Announces.” News release. Aug. 11. (www.census.gov/Press-Release/www/releases/archives/population/005514.html)
13 National Center for Health Statistics (2003). “ Health, United States, 2003: with Chartbook on Trends in the Health of Americans.” P. 26. (http://www.cdc.gov/nchs/data/hus/hus03.pdf).
14 U.S. Census Bureau (2005). “Income Stable, Poverty Rate Increases, Percentage of Americans Without Health Insurance Unchanged.” News release. Aug. 30. (http://www.census.gov/Press-Release/www/releases/archives/income_wealth/005647.html) and “Income, Poverty, and Health Insurance Coverage in the United States:2004.” P. 9. http://www.census.gov/prod/2005pubs/p60-229.pdf
15 The Kaiser Family Foundation (2002). “National Survey of Physicians, Part I: Doctors on Disparities in Medical Care.” March, p. 2. (www.kff.org/minorityhealth/20020321a-index.cfm).
16 U.S. Census Bureau (2006). “Table 8: People With or Without Health Insurance Coverage by Selected Characteristics: 2004 and 2005.” August 29. (www.census.gov/hhes/www/hlthins/hlthin05/hi05t8.pdf)
17 U.S. Census Bureau (2006). “Table HI01. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics: 2005.” August 29. (http://pubdb3.census.gov/macro/032006/health/h01_000.htm) “Income Stable, Poverty Rate Increases, Percentage of Americans Without Health Insurance Unchanged.” News release. Aug. 30. (www.census.gov/Press-Release/www/releases/archives/income_wealth/005647.html)
18 The Kaiser Family Foundation (2002). “National Survey of Physicians, Part I: Doctors on Disparities in Medical Care.” March, p. 2. (www.kff.org/minorityhealth/20020321a-index.cfm).
19 Institute of Medicine (2002). “Care Without Coverage: Too Little, Too Late.” Washington DC; National Academies Press.” P. 162. (http://www.nap.edu/books/0309083435/html/index.html).
20 AHRQ/Agency for Healthcare Research and Quality (2000). “Improving Health Care for Minority and Other Vulnerable Populations.” Rockville, MD. February. (http://www.ahrq.gov/research/minorhlth.htm).
21 David R. Williams and Pamela Braboy Jackson (2005). “Social Sources of Racial Disparities in Health.” Health Affairs, March/April, p. 325. (www.healthaffairs.org)
22 Families USA (2006). “Improve Public Programs, Improve Minority Health.” January, p.2. (www.familiesusa.org/assets/pdfs/minority-health-tool-kit/Improve-Programs.pdf) (NOTE: Original citation at ACS, “Cancer Facts and Figures, 2003,” www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf)
23 Centers for Disease Control and Prevention. “Health, United States, 2005.” Executive Summary, p. 5 and Fig. 16. (www.cdc.gov/nchs/data/hus/hus05.pdf)
24 Fred Hutchinson Cancer Research Center. “Cervical Cancer: Overview of Hutchinson Center Research.” (www.fhcrc.org/research/diseases/cervical_cancer)
25 Families USA (2006). “Improve Public Programs, Improve Minority Health.” January, p.2. (www.familiesusa.org/assets/pdfs/minority-health-tool-kit/Improve-Programs.pdf)
26 Agency for Healthcare Research and Quality (2005). “2005 National Healthcare Disparities Report.” December, Chapter 3. (www.qualitytools.ahrq.gov/disparitiesreport/2005/browse/browse.aspx?id=9132)
27 Lillie-Blanton, Marsha et al. (2002). “Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence.” Kaiser Family Foundation and American College of Cardiology Foundation. October. (www.kff.org/uninsured/20021009c-index.cfm).
28 Agency for Healthcare Research and Quality (2005). “2005 National Healthcare Disparities Report.” December, Chapter 3. (www.qualitytools.ahrq.gov/disparitiesreport/2005/browse/browse.aspx?id=9139)
29 The Robert Graham Center (2004). “The Importance of Having Health Insurance and a Usual Source of Care.” September. (www.graham-center.org/x560.xml)
30 American Cancer Society (2005). “Cancer Prevention and Early Detection: Facts and Figures 2005.” P. 35 and p. 37. (www.cancer.org/downloads/STT/CPED2005v5PWSecured.pdf )
31 Agency for Healthcare Research and Quality (2005). “2005 National Healthcare Disparities Report.” “Healthcare Utilization.” December. (www.qualitytools.ahrq.gov/disparitiesreport/2005/browse/browse.aspx?id=9141)
32 The Commonwealth Fund (2005). “Is Hospital Service Associated with Racial and Ethnic Disparities in Experiences with Hospital Care?” (www.cmwf.org/publications/publications_show.htm?doc_id=366003) Summary of original article -- LeRoi S. Hicks et al. (2005). “Is hospital service associated with racial and ethnic disparities in experiences with hospital care?.” American Journal of Medicine, Vol. 118, n. 5, pp. 529-535, May. (www.amjmed.com/article/PIIS0002934305000987/abstract)
33 Smedley, Brian D. et al.(eds) (2004). “In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce.” Institute of Medicine. Figure 1-5, Total Physicians by race/ethnicity 2000, p. 35. (http://books.nap.edu/catalog/10885.html).
34 Institute of Medicine (2004). “In the Nation’s Compelling Interest: Ensuring Diversity in the Health Professions.” PowerPoint presentation. (www.iom.edu/CMS/3740/4888/18287/20133.aspx)
35 Van Ryn, M and J. Burke. (2000). “The Effect of Patient Race and Socio-Economic Status on Physician’s Perceptions of Patients.” Social Science and Medicine, 50:813-828 cited in Institute of Medicine (2002). “Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare.” March, p. 4-5. (www.iom.edu/Object.File/Master/4/175/Disparitieshcproviders8pgFINAL.pdf)
36 The Commonwealth Fund (2006). “The Impact of Interpreters on Parents’ Experiences with Ambulatory Care for Their Children.” (www.cmwf.org/publications/publications_show.htm?doc_id=360684) Summary of original article – Morales, Leo S. et al. (2006). “The Impact of Interpreters on Parents’ Experiences with Ambulatory Care for Their Children.” Medical Care Research and Review, Feb., Vol. 63, No.1, pp. 110-28.
37 Morales, Leo S. et al. (2006). “The Impact of Interpreters on Parents’ Experiences with Ambulatory Care for Their Children.” Medicare Care Research and Review, Vol. 63., No. 1, pp. 110-128. (Abstract at http://mcr.sagepub.com/cgi/content/abstract/63/1/110)
38 Szabo, Liz (2005). “Hospital inequalities widen the care gap.” USA Today, October 24. (www.usatoday.com/news/health/2005-10-24-health-care-gap_x.htm) Original article: Skinner, Jonathan et al. (2005). “Mortality After Acute Myocardial Infarction in Hospitals That Disproportionately Treat Black Patients.” Circulation, Vol. 112, pp. 2634 – 2641.
39 Centers for Disease Control and Prevention. “Health, United States, 2005.” Executive Summary, p. 5, (www.cdc.gov/nchs/data/hus/hus05.pdf)
40 Agency for Healthcare Research and Quality (2006). "Key Themes and Highlights From the National Healthcare Disparities Report." December, p. 6-7. (www.ahrq.gov/qual/nhdr06/nhdr06high.pdf)
41 Vaccarino, Viola et al. (2005). “Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002.” New England Journal of Medicine, Vol. 353, pp. 671-682.
42 Jha, Ashish K. et al. (2005), “Racial trends in the use of major procedures among the elderly.” New England Journal of Medicine, Vol. 353, pp. 683-691.
43 Trivedi, Amal N. et al. (2005). “Trends in the Quality of Care and Racial Disparities in Medicare Managed Care.” New England Journal of Medicine, Vol. 353, pp. 692-700.
44 Robert Wood Johnson Foundation (2006). “RAND Study Finds All Socio-Demographic Groups at Risk for Poor Quality Health Care.” News release. March 15. (www.rwjf.org/newsroom/newsreleasesdetail.jsp?id=10399) and Ashe, Steven M. et al. (2006). “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?” New England Journal of Medicine, Vol. 354, pp. 1147-1156 (March 16). (www.nejm.org)
45 Asch, Steven M. et al. (2006). “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?” New England Journal of Medicine, Vol. 354, p. 1154. (March 16). (www.nejm.org)
46 Comments by Steven Asch during a Families USA conference call on the study, March 29, 2006.
47 Lillie-Blanton, Marsha and Catherine Hoffman (2005). “The Role Of Health Insurance Coverage In Reducing Racial/Ethnic Disparities In Health Care.” Health Affairs, Vol. 24, No.2, pp. 398-408. (www.healthaffairs.org)
48 Ayanian, John Z. et al. (2000). “Unmet Health Needs of Uninsured Adults in the United States.” Journal of the American Medical Association, Vo. 284, No. 16, Oct. 25. (www.jama.ama-assn.org)
49 Office of Management and Budget (2006). “Health and Human Services (www.whitehouse.gov/omb/budget/fy2007/hhs.html)
50 Robert Wood Johnson Foundation (2006). “New Study Indicated Majority of Hospitals Collect Patients’ Race, Ethnicity and Language Data: Yet Few Hospitals Use the Data to Improve Quality of Care.” News release. Feb. 9. (www.rwjf.org/newsroom/newsreleasesdetail.jsp?id=10394)
51 Robert Wood Johnson Foundation (2005). “Three National Initiatives Aimed at Eliminating Racial & Ethnic Disparities in Health Care Treatment Unveiled Today.” News release. October 6. (http://solvingdisparities.org/home/article/11865?lpid=1484)
52 The Commonwealth Fund. “Using Electronic Health Records to Improve Quality and Reduce Disparities in Diabetes Care.” (www.cmwf.org/grants/grants_show.htm?doc_id=382358)
53 The Commonwealth Fund . “Impact of Cultural and Linguistic Standards on Patients’ Experience with Inpatient Hospital Care.” (www.cmwf.org/grants/grants_show.htm?doc_id=366701)
54 Hasnain-Wynia, Romana (2005). “Using Data from the CMS National Voluntary Hospital Reporting Initiative to Identify Disparities.” Presentation at a June 20, 2005 program sponsored by The Commonwealth Fund and the Alliance for Health Reform.