Download Reducing Disparities in Life Expectancy

REDUCING DISPARITIES IN LIFE
EXPECTANCY: WHAT FACTORS MATTER?
A background paper prepared for the workshop on Reducing Disparities in
Life Expectancy held by the Roundtable on the Promotion of Health Equity
and the Elimination of Health Disparities of the Institute of Medicine,
February 2011.
Lesley M Russell, PhD
TABLE OF CONTENTS
TABLE OF CONTENTS ................................................................................................ 2
PREFACE....................................................................................................................... 4
EXECUTIVE SUMMARY ............................................................................................. 5
INTRODUCTION .......................................................................................................... 7
MEASURING DISPARITIES IN MORTALITY AND LIFE EXPECTANCY ............... 8
1. Life expectancy ................................................................................................... 8
2. Infant mortality.................................................................................................. 11
3. Maternal mortality ............................................................................................. 14
FACTORS THAT UNDERPIN HEALTH DISPARITIES ............................................ 17
1. Socioeconomic status ........................................................................................ 17
1.1
The Hispanic paradox ................................................................................ 18
1.2
Education................................................................................................... 19
1.3
Employment .............................................................................................. 22
1.4
Income....................................................................................................... 24
2. The built environment........................................................................................ 26
2.1
Housing ..................................................................................................... 29
2.2
Water......................................................................................................... 31
2.3
Air quality ................................................................................................. 32
2.4
Transport ................................................................................................... 32
2.5
Environmental racism ................................................................................ 34
2.6
Global warming ......................................................................................... 35
3. Access to health care ......................................................................................... 37
3.1
Health insurance coverage ......................................................................... 37
3.2
Medically underserved populations ............................................................ 42
3.3
Concordance between provider and patient ................................................ 47
3.4
Literacy and language ................................................................................ 50
3.5
System biases............................................................................................. 51
3.6
Indian Health Service................................................................................. 52
4. Healthy food systems......................................................................................... 53
5. Genetics ............................................................................................................ 54
6. Culture and acculturation................................................................................... 55
6.1
Immigration status ..................................................................................... 56
7. Discrimination, racism and stress....................................................................... 59
7.1
Residential segregation .............................................................................. 59
APPENDIX 1: HOW DISPARITIES DATA ARE COLLECTED.............................. 62
1. OMB requirements for the collection of racial and ethnic data ........................... 62
2. ACA requirements for the collection of data on racial and ethnic disparities ...... 63
3. Issues around collecting the data........................................................................ 64
APPENDIX 2: THE CONSEQUENCES OF RACIAL AND ETHNIC HEALTH
DISPARITIES 66
1. Health status (self assessed) ............................................................................... 66
2
2.
Risk factors ....................................................................................................... 66
2.1
Obesity ...................................................................................................... 67
2.2
Physical activity......................................................................................... 67
2.3
Diet and nutrition....................................................................................... 68
2.4
Diabetes..................................................................................................... 68
2.5
Hypertension.............................................................................................. 69
2.6
Smoking .................................................................................................... 69
2.7
Alcohol abuse ............................................................................................ 71
2.8
Substance abuse ......................................................................................... 72
2.9
Access to prenatal care............................................................................... 74
2.10 Access to family planning services............................................................. 76
3. Disease rates...................................................................................................... 77
3.1
Cancer ....................................................................................................... 77
3.2
HIV/AIDS ................................................................................................. 80
3.3
Cardiovascular diseases ............................................................................. 82
3.4
Asthma ...................................................................................................... 83
3.5
Mental illness............................................................................................. 84
3.6
Injury......................................................................................................... 86
4. Chronic illnesses and comorbidities ................................................................... 89
5. Preventable deaths ............................................................................................. 91
APPENDIX 3: THE ECONOMIC COSTS OF HEALTH DISPARITIES .................. 93
1. Lost income and labor productivity.................................................................... 93
2. Health care costs................................................................................................ 93
REFERENCES ............................................................................................................. 96
3
PREFACE
This paper has been prepared for the workshop on Reducing Disparities in Life
Expectancy held by the Roundtable on the Promotion of Health Equity and the
Elimination of Health Disparities of the Institute of Medicine. Its purpose is to provide
the Roundtable forum with the background data and information that will help them
assess the issues and needs, develop advice and guidance on priorities and policies, and
encourage the effective measurement and evaluation of progress in closing the gap on
health disparities.
The focus of this paper is on racial and ethnic health disparities. To this end every effort
has been made to include the most recent data that are available for all the major racial
and ethnic population groups. Although it can be informative to break these data down
further – for example, by sex, education, income, rurality, or disease status – and where
possible this has been done, this report does not look at those disparities which are based
on disability, gender identification and sexuality, or geography.
The author takes full responsibility for any errors or oversights.
4
EXECUTIVE SUMMARY
The draft National Prevention Strategy establishes a vision of improving life expectancy
and quality of life for all Americans, and sets the goal of reducing and eventually
eliminating, health disparities.
The World Health Organization defines health as “a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity”. 1 Individuals
may subjectively define health in many ways - as the absence of disease, as psychosocial
well-being, or as the ability to function physically and in social relationships.2
Physiological and behavioral risk factors for illness can be exacerbated by physical risk
conditions (such as poverty and pollution) and psychosocial risk factors (such as low selfesteem and isolation) and modified by protective factors (such as strong social networks,
meaningful paid employment, good nutrition, and access to effective health services).
Together these factors affect the mortality, morbidity, disability, functional
independence, well-being and quality of life of individuals, communities and
populations.3
Despite huge spending on health care, the United States consistently receives a poor
grade in international comparisons of these risk factors and health outcomes. The
existence and persistence of substantial disparities in mortality and morbidity between
and among racial and ethnic groups in the U.S. population have been well-documented.
Moreover, relatively little progress has been made towards the goal of eliminating these
disparities, and in some cases the gaps have grown.
This report attempts to collate the currently available data to document racial and ethnic
health disparities, looking first at the impact on life expectancy and mortality, and then at
what is known about how socioeconomic, environmental, cultural and genetic factors,
and access to health care affect these measures. Additional information is provided about
racial and ethnic disparities in the prevalence of a number of chronic illnesses and injury,
the risk factors that lead to these conditions, and how these vary by race and ethnicity.
Where possible, trends over time have been outlined and relevant international
comparisons have been provided.
The task has been frustrated by a lack of up-to-date data across all racial and ethnic
groups and a lack of consistency in how individual agencies report these data over time.
In many cases the data presented are more than a decade old, but more recent data could
not be found. The recently released report from the Centers for Disease Control and
Prevention4 has partially remedied this problem, although curiously this report does not
look at racial and ethnic differences in life expectancy.
A clear recommendation to emerge from this paper is that improvements must be made in
data collection and analysis and the ability to track agreed upon measures and outcomes
over time. In particular, future efforts to address disparities must acknowledge the
5
significant heterogeneity within each of the federally defined racial and ethnic groups,
and balance requirements for sufficient granularity to highlight local issues with the need
for sufficiently robust statistical significance to drive population-based policies and
programs.
The evidence is clear that while tackling the inequalities in the health care system is an
imperative, this alone is insufficient to reduce the disparities in life expectancy and
quality of life. Therefore, a second recommendation is that it is also essential to tackle
the current social, economic, and environmental inequalities that underpin so many
documented health disparities. This will require a concerted effort across research
disciplines, professional bodies, community services and organizations, and agencies at
all levels of government. The new health care reform law, the Affordable Care Act
(ACA), takes this approach and creates a National Prevention, Health Promotion, and
Public Health Council, composed of senior officials across the government, which will
design a focused strategy across Departments to promote the nation’s health. On June 10,
2010, the President signed an Executive Order creating the National Prevention Council.5
The final over-arching recommendation to emerge is that the data should be used to
highlight the priorities for action. They show not only show where disparities are severe
but also highlight where they do not exist (for example, Hispanics have better life
expectancy and infant mortality rates than many other racial and ethnic groups, despite
socioeconomic and health insurance statistics that are lower than average) and how they
emerge (for example, breast cancer incidence rates are higher among Asian women living
in the United States than among those living in Asian countries, and for this population
group, elevated breast cancer risks are linked to immigration to and longer residence in
the United States).
Health disparities generate a significant human and economic cost that is borne directly
by the individuals involved and indirectly by all Americans. As minorities become an
increasing percentage of the American population, their health status will increasingly
define the nation’s health. The costs of failing to tackle health disparities will result in
higher health care and social welfare spending, a less productive workforce, and an
increasingly divided society. Addressing these health disparities is also an issue of social
justice that can be regarded as a moral imperative.
6
INTRODUCTION
Racial and ethnic minorities experience disparities across a significant number of health
status measures and health outcomes. These racial and ethnic differences are driven by
factors such as income, education, and work status, as well as poor housing,
neighborhood segregation, and other environmental factors within communities.
Significant disparities in health status and outcomes result from failures within the health
care system. Problems accessing services and a lower quality of care for minority
populations clearly affect the health of these populations. The Institute of Medicine
(IOM) report, Unequal treatment: Confronting racial and ethnic disparities in health
care6, defines a disparity as a difference in treatment provided to members of different
racial or ethnic groups that is not justified by the underlying health conditions or
treatment preferences of patients.
Racial and ethnic minorities make up more than half of America’s uninsured and they
suffer higher rates of chronic illness than the general population. They are more likely to
experience risk factors that predispose them to chronic illnesses such as obesity, and are
much less likely to receive preventive screenings, regular care, and to fill needed
prescriptions that could prevent or ameliorate their conditions. Because being uninsured
often means postponing needed heath care services, people of color are diagnosed at
more advanced disease stages, and once diagnosed, they receive poorer care. Inevitably,
they are sicker and die sooner.
The 2003 IOM report highlights that even when access-related factors such as insurance
status and income are controlled for, racial and ethnic minorities tend to receive lower
quality health care than non-minorities. The sources of these disparities are complex,
rooted in historic inequalities, perpetuated through stereotyping and biases in the health
care system, health care professionals and patients, and aggravated by barriers of
language, geography and cultural familiarity.
The 2009 National Healthcare Disparities Report7 found that while some disparities in
health care quality and access have been eliminated over time, many others have
persisted unchanged, and the recent Health Disparities and Inequalities Report – United
States, 20118 similarly found that socioeconomic disparities continue. The magnitude
and pattern of disparities are different within subpopulations, and some disparities exist
across multiple population groups.
The needed reforms in the health care system, with its current focus on clinical care, will
not have a long-term and sustainable impact on key measures of health status such as life
expectancy and infant mortality unless and until there are also broader improvements in
population health. This will require tackling the underlying social, economic and
environmental factors. The following sections outline current knowledge and data about
the way in which these factors impact on the health of minority populations in the United
States.
7
MEASURING DISPARITIES IN MORTALITY AND LIFE
EXPECTANCY
1. Life expectancy
Although life expectancy is not the only indicator of health disparities, it is certainly the
most definitive and provides a measure of health outcomes that are determined not only
by access to health care but also by factors such as socioeconomic status (SES), health
behaviors, and the environment.
When health in the United States is compared to that in other countries, the picture is
disappointing. The World Health Organization (WHO), in its annual World Health
Statistics 2010, compares the United States to the nations of the world on a large variety
of health measures, and these highlight that the United States lags behind many
developed countries9 (see Figures 1 and 2).
Healthy life expectancy is a measure that indicates the number of years that a newborn
can expect to live a healthy and productive life. Japan leads in this measure with a
healthy life expectancy of 76 years on average for both genders. There are 30 other
countries that exceed the United States in healthy life expectancy, including Australia,
Italy, Spain, France, Germany, Greece and the United Kingdom. The difference between
Japan and the United States for females is 6 years; the difference for males is 5 years.
In very large part the low standings of the United States on these international tables are a
reflection of the racial and ethnic disparities in health. African Americans live, on
average, five years less than other Americans; in particular, the life expectancy at birth
for black males is some six years less than that for white males and nearly nine years less
than Hispanic males (see Figure 3).
One of the underlying causes for these differences is poor infant mortality rates in the
United States (see next section). But the differences in life expectancy continue
throughout Americans’ lives.
The life expectancy in the United States of a 65 year old woman is 19.8 years lower than
that in 22 other Organisation for Economic Co-operation and Development (OECD)
countries, including France (22.3 years), Spain (22.2 years), Canada (21.3 years) and
United Kingdom (20.2 years). For 65 year old men, the difference in life expectancy in
the United States compared to other nations is less pronounced: 17.1 years in the United
States, 17.6 in the United Kingdom, 17.8 years in Spain, 18.0 years in France and 18.1
years in Canada.10
8
Figure 1:
Life expectancy at birth for males and females, 2008
Data from World Health Organization. World Health Statistics, 2010. Accessed at
http://www.who.int/whosis/whostat/EN_WHS10_Part2.pdf
Differences in healthy life expectancy are affected by the effectiveness of treating
disease, especially those that are amenable to care, including bacterial infections,
treatable cancers, diabetes, heart disease, stroke, and complications from common
surgical procedures. In 2002, the United States ranked last among the 19 countries of the
OECD with an age-adjusted amenable mortality rate before age 75 of 109.7 deaths per
100,000 population, having slipped from 15th ranking in 1997. This U.S. rate was 50
percent higher than the rate in France, Japan, Spain, Italy, Canada, and Australia, despite
the fact that the United States spends more than any other country on health care.11
9
Figure 2:
Healthy life expectancy for males and females, 2007
Data from World Health Organization. World Health Statistics, 2010. Accessed at
http://www.who.int/whosis/whostat/EN_WHS10_Part2.pdf
The homicide rate also influences these data. The United States ranks 29th among the 31
OECD countries, with a homicide rate that is double that of most other countries. The
United States has 5.2 deaths per 100,000 population, compared to homicide rates under 2
deaths per 100,000 population in France, Germany, Canada, Spain and the United
Kingdom. The homicide rate disproportionately affects young black adults, with young
black adult homicide rates seven times that of young white adults.12
10
Figure 3:
Life expectancy at birth, by race and sex, 2006
Data from Centers for Disease Control and Prevention (2010). United States life tables by Hispanic origin.
National Center for Health Statistics. Vital Health Stat 2(152). Accessed at
http://www.cdc.gov/nchs/data/series/sr_02/sr02_152.pdf
2. Infant mortality
Infant mortality is one of the most important indicators of the health of a nation, as it is
associated with a variety of factors such as maternal health, quality and access to medical
care, socioeconomic conditions, and public health practices. The U.S. infant mortality
rate is higher than those in most other developed countries (see Figure 4), and the gap
between the U.S. infant mortality rate and the rates for the countries with the lowest
infant mortality appears to be widening.13
11
Figure 4:
Neonatal, infant and childhood mortality rates, 2008
Data from World Health Organization. World Health Statistics 2010. Accessed at
http://www.who.int/whosis/whostat/EN_WHS10_Part2.pdf
Infant mortality rates for babies of all birth weights are twice as high for African
American babies as the national average. In 2005, the most recent year for which
complete data are available, Asians/Pacific Islanders had the lowest rates of infant
mortality (4.9 per 1000 live births, followed by Hispanics (5.6), Whites (5.7) American
Indian/Native Alaskan (8.1) and African Americans (12.3). These figures were
essentially unchanged over the period 2000-2005, but show improvement over the figures
for 1995 (see Figure 5).
The Agency for Healthcare Research and Quality (AHRQ) initially collected data
separately for Asians and Native Hawaiians and Other Pacific Islanders, and it is
unfortunate that these two groups have now been combined as it is clear from 2000 and
2001 data that their infant mortality rates are very different (see Figure 6).
12
Figure 5: Infant mortality rates per 1000 live births, by race and ethnicity, 19952005
Data from AHRQ National Disparities reports 2003-2009 and National Vital Statistics Report 2006.
Accessed at http://www.ahrq.gov/qual/measurix.htm and http://www.cdc.gov/nchs/products/nvsr.htm
It is interesting to looking at the infant mortality rates in comparable countries that have
Indigenous populations. In Australia, the national infant mortality rate in 2006-08 was
4.4/1000 live births, and the Aboriginal and Torres Strait Islander rate was 10 (the rate
varied from 13.6 in the Northern Territory to 6.4 in South Australia).14 In New Zealand,
in 2006-07 the Maori infant mortality rate was 7.1 and the non-Maori rate was 4.6. 15 And
in Canada, in 2007 the overall national rate was 5.1 and the rate for Inuit living in
Nunavut province was 15.0.16
13
Figure 6.
Infant mortality rates, by race and ethnicity, 2000-2005
Data compiled from AHRQ National Disparities reports 2003-2009. Accessed at
http://www.ahrq.gov/qual/measurix.htm
3. Maternal mortality
Maternal death continues to be the international standard by which a nation’s
commitment to women’s status and their health can be evaluated. It is the primary
measure of whether women can expect to survive complications that arise during
pregnancy and the post-partum period.
The U.S. maternal mortality rate has declined dramatically since 1950, when the rate was
83.3 deaths per 100,000 live births; however, the maternal mortality rate in 2006 (13.3
per 100,000 live births) was 62 percent higher than the rate reported in 1990 (8.2 per
100,000).
According to the National Center for Health Statistics, this increase may largely be due to
changes in how pregnancy status is recorded on death certificates.17 However, it is clear
from 2004 data that the rate has increased, perhaps due in a part to a disturbing upward
trend in Hispanic maternal mortality (see Figure 7).
Figure 7: Maternal deaths by race and ethnicity, 2004 and 2006
14
Data from Health Resources and Services Administration. Women’s health USA 2009. Accessed at
http://mchb.hrsa.gov/whusa09/hstat/mh/pages/237mm.html and Centers for Disease Control and
Prevention (2008). Safe motherhood. Promoting health for women before, during and after pregnancy.
Accessed at http://www.cdc.gov/nccdphp/publications/aag/pdf/drh.pdf
The Maternal Mortality Estimation Inter-agency Group composed of the WHO, the
United Nations Children’s Fund, the United Nations Population Fund, and the World
Bank, together with independent technical experts, recently released a new set of global
United Nations inter-agency maternal mortality estimates that presents even bleaker
figures for the United States, with maternal mortality rates rising to 24/100, 000 live
births in 2008. This represents an increase in maternal mortality rates of 96 percent over
those in 1990.18 The WHO data show that the maternal mortality rate in the United
States in 2008 was higher than many comparable countries, and the same as that in Chile,
Saudi Arabia, and Turkey19 (see Figure 8).
Figure 8:
International comparison of maternal mortality rates, 2008
15
Data from World Health Organization (2010). Trends in maternal mortality: 1990-2008. Estimates
developed by WHO, UNICEF, UNFPA, and The World Bank. Accessed at
http://www.childinfo.org/files/Trends_in_Maternal_Mortality_1990_to_2008.pdf
16
FACTORS THAT UNDERPIN HEALTH DISPARITIES
1. Socioeconomic status
Socioeconomic status (SES) is a complex concept consisting of two aspects, both of
which may exert influences on health directly or through associated behaviors. One
aspect includes resources, such as education, income, and wealth; the other includes
status or rank, a function of relative positions in a hierarchy, such as social class. 20
There are two alternative explanations for the association of SES and health. The first
is that SES influences health status (social causation); the other is that health status
contributes to SES (social drift or selection). The data are more compelling for social
causation than for social drift, although the latter is more likely for diseases with early
onset that have more profound effects on life trajectories, such as schizophrenia.21 There
is a link between health problems and reductions in income and wealth at older ages. 22
It has been proposed that there are three pathways through which SES impacts health: its
association with healthcare, environmental exposure, and healthy behavior and lifestyle.
Together, these pathways are estimated to account for up to 80 percent of premature
mortality. 23 Lower SES may lead to higher prevalence rates for health risk factors such as
obesity and smoking, and for many common chronic conditions via complex pathways
linking behavioral and psychological, social, biological, and genetic factors.24
There is solid evidence that racial and ethnic differences in morbidity and mortality are
tied to SES, 25 but the role of SES factors as a cause of racial and ethnic health
differences is complex. This is highlighted by the “Hispanic paradox,” or the better than
expected health experienced by the socioeconomically disadvantaged Hispanic
population.26 The Hispanic paradox is discussed in more detail at the end of this section.
The influence of SES on health is assumed to begin early in life, perhaps even in the
prenatal period, and accumulate throughout the life course. People of higher SES are
more likely to have grown up in childhood homes with better nutrition, fewer health risk
behaviors, safer neighborhoods, and more economic resources. As adults, higher SES
persons are more likely to have better, more secure employment and housing. They
smoke less, eat better, and exercise more than persons with fewer resources. They also
have a greater ability to access and afford health services and may receive better
treatment from health care providers.27
Higher SES brings a greater financial ability to cope with economic problems and an
increased resilience and ability to cope with stress, while lower SES is linked to more
disruptive life events such as family breakup and unemployment as well as fewer
financial resources to cope with such events.28
17
Both health and SES have many dimensions and can be conceptualized and measured in
multiple ways. Research shows that conclusions regarding the role of socioeconomic
factors in racial and ethnic health disparities can vary, depending on the socioeconomic
measure selected, and that often correlations between measures of income and measures
of education are not strong.
More specifically, for women, it has been shown that the correlations between education
and income measures are weaker for African Americans, Asian/Pacific Islanders, and
especially for Latinas, compared to those observed for whites, European/Middle
Easterners and American Indians/Alaskan Natives. 29
Moreover, SES measures are not equivalent across racial groups. That is, there are racial
differences in income returns for a given level of education, the quality of education, the
level of wealth associated with a given level of income, the purchasing power of income,
the stability of employment and the health risks associated with working in particular
occupations.30
1.1
The Hispanic paradox
There is widespread evidence of a Hispanic paradox in the United States, in which most
Hispanic groups are characterized by low SES, but better than expected health and
mortality outcomes, as reflected in life expectancy and infant mortality rates (see Figures
3, 5 and 6). A closer look at the data reveals variations by age, gender, Hispanic
subgroup, acculturation, country of birth, and cause of death.
There has been much debate about the causes of this paradox. It has been postulated that
it is due to migration effects: Hispanics who migrate to the United States are more likely
to be healthy (a selection effect), and the immigrants who return to their home countries
are the least healthy (often called a “salmon bias” or return migration effect). Although
there is some evidence that Mexican-born people with poor health opt to return to Mexico
at higher rates than healthier Mexican immigrants, this effect is too small to explain the
Hispanic paradox, and other research has refuted these proposals.31
Other researchers argue that the effect is due to cultural factors such as stronger kinship
and social support mechanisms in the Hispanic community. These cultural factors may
act as a buffer against the effects of disease. 32 Additional factors that may play a role
include the use of alternative and herbal medicines, good nutrition, and community
support for pregnant women and the elderly.
The evidence of an epidemiological paradox in mortality is much stronger for some
groups of Hispanics than for others, with a sizable mortality advantage for Hispanics of
Mexican, Central American, or South American origin in analyses that controlled for age,
sex, and socioeconomic status, but not for Puerto Ricans or Cubans.33 Certainly the
widespread differences that exist among Hispanics in terms of race, language, nativity,
and time in the United States, SES and health status argue that examination of this
paradox should approach Hispanics as a diverse group rather than a monolithic entity.34
18
Current trends such as an increase in overweight and obesity among Hispanic youth raise
the possibility of a marked deterioration in the health of the Hispanic population of the
United States over the next several decades.35
1.2
Education
There is a large and persistent association between education and a wide variety of health
measures. The health differences between the more educated and the less educated are
significant, as exemplified by the fact that the U.S. death rate for people with less than 12
years of education is 2.5 times higher than that for those with 13 or more years of
education. 36
A working paper issued by the National Bureau of Economic Research (NBER) in 2006,
explored and attempted to quantify the relationship between education and health. 37
The education gradient is found for both health behaviors and health status. The better
educated are less likely to smoke, have excessive intakes of alcohol, or be overweight and
are more likely to have health insurance coverage and access to care. The better educated
also report lower morbidity from cardiac conditions, stroke, emphysema, diabetes, and
asthma. They are substantially less likely to report that they are in poor health, and less
likely to report anxiety or depression.38
The magnitude of the relationship between education and health varies across these
conditions, but is generally large. An additional four years of education was found to
lower five-year mortality by 1.8 percentage points; it also reduces the risk of heart
disease by 2.16 percentage points, and the risk of diabetes by 1.3 percentage points.39
Although some of the education effect is related to income, occupational choice, and
status, the NBER paper posits increasing levels of education lead to different thinking
and decision-making patterns that influence health and wellbeing.
As Figure 9 highlights, there are substantial differences in educational attainment among
racial and ethnic minority groups in the United States. American Indians/Alaska Natives
and Hispanics have the lowest levels of education. Almost 38 percent of Hispanics have
not graduated from high school, and less than one-third have any college education. In
contrast, 69 percent of Asian/Pacific Islander Americans have some college education,
and 52 percent have a bachelor degree or higher.
19
Figure 9: Percentage of adults aged 25+ according to highest level of educational
attainment, 2008
60
percentage of population
50
40
less than HS completion
HS completion
30
some college
associate degree
at least bachelor degree
20
10
pa
ni
c
N
is
H
ac
i fic
Is
la
nd
AI
/A
er
k
Bl
ac
te
hi
W
ia
n/
P
As
Al
lA
m
er
ica
ns
0
Data from National Center for Education Statistics. Accessed at
http://nces.ed.gov/pubs2010/2010015/tables/table_27a.asp
The relationship between educational level and the prevalence of a number of key
diseases is presented in Table 1. This highlights the “protective effect” that education has
on disease prevalence, in some cases delaying the average age of onset for more than 10
years.
20
TABLE 1: Age at which persons of different educational levels experience
equivalent prevalence incidence of specified diseases
Disease
Heart problems
Heart attack
Hypertension
Stroke
Diabetes
Chronic lung disease
8
Years of Education
12
16
51
51
51
51
51
51
54
58
55
56
57
60
~57
~64
~58
~61
~64
~70
Based on logistic models of prevalence from the Health and Retirement survey. Data from National
Research Council. (2004). Critical perspectives on racial and ethnic differences in health in late life. N.B.
Anderson, R.A. Bulatao & B. Cohen, Editors. Panel on Race, Ethnicity, and Health in Later Life, Division
of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.
Accessed at http://www.nap.edu/openbook.php?record_id=11086&page=315
There is also a strong correlation between infant mortality and maternal educational level
(see Table 2). These data also highlight two conundrums. The first is the low infant
mortality rates for Asian/Pacific Islanders and Hispanics, even for those mothers with
less education. The second is that infant mortality rates for college-educated black
women are higher than those for women of all other racial and ethnic groups, even those
with less than a high school education.
Table 2:
Infant mortality rates (infant deaths / 1000 live births) for mothers
aged 20+ by race/ethnicity and education 2001-2003
Race / ethnicity
Less than HS
White, Non Hispanic
African American
American Indian / Alaska Native
Asian / Pacific Islander
Hispanic
9.2
15.1
10.7
5.0
5.2
Educational level
High school
College or more
6.5
13.4
9.2
5.6
5.3
4.2
11.5
7.0
3.9
4.6
Data from KaiserEDU (2007). Race, ethnicity and health care. Accessed at
http://www.kaiseredu.org/Issue-Modules/Race-Ethnicity-and-Health-Care-The-Basics/Key-Data.aspx
21
1.3
Employment
Employment is a key contributor to health status as it contributes to both SES and selfesteem. It also provides income to facilitate access to factors important to health such as
housing and transportation. It also is a key factor in the ability to afford health care and
health insurance coverage.
The majority of Americans still get health insurance coverage through their employment.
However, a large body of literature documents the disproportionate lack of access to
employer-sponsored health insurance among racial and ethnic minorities.
Compared with white Americans, a disproportionate share of Hispanics and African
Americans have nonstandard employment, and Hispanics are more likely to have
employment in small firms. These work arrangements increase the risk of being
uninsured since they are less likely to come with an offer of health insurance compared to
regular large firm employment.40
During the current economic recession, there has been a continuing decline in the
percentage of workers with employment-based coverage, and the benefits that are being
offered have also changed, with increases in deductibles, co-payments for office visits,
and prescription drug copayments. In general, workers least likely to have employmentbased coverage at the beginning of the recession are more likely than other workers to
have lost that coverage. Hispanic workers are more likely to lose coverage than Whites
or African Americans.41
Employment correlates positively with health, although it’s not clear if it is a cause or a
consequence. Full-time employment predicts slower declines in perceived health and in
physical functioning for both men and women; healthy people get and keep jobs more
than unhealthy people do. 42 Workers who are in poor health have a 40 percent increase
in the odds of being laid off or fired.43
Recent research has also highlighted the impact of unemployment on health. The risk of
heart attack or stroke in people between 51 and 61 years old who have lost their jobs is
more than double that of the employed.44 People who lose their job face increased odds of
developing a new health problem such as diabetes, high blood pressure or heart disease,
and even when re-employed, those workers had an increased risk of new stress-related
health conditions.45
22
Table 3:
Employment status for populations 25 + years, by race/ethnicity and
education level
% employed
Race/
Ethnicity
Employment/
unemployment
Total US
Employment –
population population ratio
Unemployment
rate
White
Employment –
population ratio
Unemployment
rate
African
Employment –
American population ratio
Unemployment
rate
Asian
Employment –
population ratio
Unemployment
rate
Hispanic
Employment –
population ratio
Unemployment
rate
Final education level
Less
than
HS
39.7
HS
Some
graduate college
Associate
degree
Average
for
Bachelor population
group
degree
56.1
62.7
70.7
73.9
61.7
14.6
9.7
8.6
6.8
4.6
7.9
41.3
56.2
62.6
71.1
73.7
62.0
13.9
9.0
7.9
6.2
4.2
7.3
30.1
55.6
63.2
68.8
74.9
58.1
21.3
14.0
12.1
10.3
7.3
12.3
40.8
56.2
63.3
69.6
74.0
65.3
8.4
7.5
8.9
7.5
5.6
6.6
53.6
65.5
70.6
73.8
77.0
63.8
13.7
10.4
9.6
8.5
5.7
10.5
Data from Bureau of Labor Statistics (2009). Labor Force Characteristics by Race and Ethnicity, 2009.
Accessed at http://www.bls.gov/cps/cpsrace2009.pdf
Data from the Bureau of Labor Statistics highlight that in 2009 all major race and
ethnicity groups in the United States experienced major employment difficulties. For the
second year in a row, employment fell more sharply for African Americans and
Hispanics than for Whites and Asians.46 The employment issues faced by African
Americans and Hispanics are due to a variety of factors, including a tendency to be
employed in occupations with high levels of unemployment, lower levels of education,
greater concentration in areas where job opportunities are limited, and the likelihood of
discrimination in the workplace.47
23
1.4
Income
Hispanics and African Americans have considerably lower earnings than Asians and
Whites. In 2009, the median weekly earnings of full-time workers were $541 for
Hispanics, $601 for Blacks, $757 for Whites and $880 for Asians. For all races and
ethnicities women earned less than men. These earnings disparities hold across all major
occupational groups, both white collar and blue collar.48
As Figure 10 shows, the median family income (measured in 1999 and 2009 dollars
respectively) has barely changed over the past decade, and the net impact of this is that
families today have less money than they had at the turn of the century. This is reflected
in the continuing increase in the number of Americans living in poverty. In 2009, the
Federal Poverty Level (FPL) for a family of four was $21,756.
Racial and ethnic minorities, women, children, and families headed by single women are
particularly vulnerable to poverty and deep poverty. Although African Americans
represent 13.3 percent of the general population, they represent 24.2 percent of the poor
population. Hispanics, who make up 15.9 percent of the population, represent 28.3
percent of the poor population. 49 In 2009, 9.4 percent of Whites lived in poverty with
over 4 percent in deep (persistent) poverty; 25.3 percent of Hispanics lived in poverty
with 10.4 percent in deep poverty; and 25.8 percent of African Americans lived in
poverty with 11.9 percent in deep poverty. 50
Children represent a disproportionate share of the poor in the United States; they are 25
percent of the total population, but 35 percent of the poor population. Hispanic and black
children are more likely to live in poor families than are white and Asian children. In
2009, 17 percent of white children and 14 percent of Asian children were poor, compared
with 33 percent of Hispanic children and 35 percent of black children. 51
24
Figure 10: Median family income in U.S dollars
70,000
60,000
US dollars
50,000
40,000
1999
2009
30,000
20,000
10,000
0
Total U.S.
population
White, non
Hispanic
Black
AI/AN
Asian
Hispanic
Data from US Census Bureau, 2000 and 2010. Accessed at
http://www.census.gov/main/www/cen2000.html and http://2010.census.gov/2010census/
Somewhat different data on poverty has been generated by the Kaiser Family Foundation,
using data from 2005 for the non-elderly population (see Table 4).
Although poverty exists in both urban and rural areas, and a larger proportion of the poor
population resides in urban areas, non metropolitan residents are more disadvantaged.
This is particularly true when assessing persistent poverty.52 Indian reservations have a
poverty rate of 26 percent, the highest poverty rate of any ethnic grouping in America. 53
25
Table 4:
Poverty status of the non-elderly population by race and ethnicity, 2005
Percentage of the population
Race/ethnicity
Poor
( 100% FPL)
12
Near Poor
(100-199% FPL)
14
Non Poor
(200%+ FPL)
74
African American
33
21
46
Asian
17
16
68
American Indian /
Alaska Native
2+ races
34
23
43
21
20
59
Hispanic
29
29
42
White, non Hispanic
Data from KaiserEDU (2007). Race, ethnicity and health care. Accessed at
http://www.kaiseredu.org/Issue-Modules/Race-Ethnicity-and-Health-Care-The-Basics/Key-Data.aspx
2. The built environment
The built environment encompasses all buildings, spaces, and products that are created or
modified by people. It includes homes, schools, workplaces, parks and recreation areas,
greenways, business areas, and transportation systems. It extends overhead in the form of
electric transmission lines, underground in the form of waste disposal sites and subway
trains, and across the country in the form of highways. It includes land-use planning and
policies that impact communities in urban, rural, and suburban areas.54
Poor housing can contribute to a number of adverse health outcomes and there is a
growing awareness that health is linked not only to the physical structure of a housing
unit, but also to the neighborhood and community in which the house is located.55
Deteriorating and crime-ridden neighborhoods contribute to experiences of stress and
barriers to accessing services. Neighborhood quality and quality of associated services
vary considerably, depending on the racial and ethnic composition of the neighborhood.
Certain African American and Hispanic households tend to report more problems in their
neighborhoods, including crime, litter, housing deterioration, and poor public services.56
26
The environment in which people live affects physical health, social and emotional
functioning, and the cognitive development of children. The availability of neighborhood
amenities, such as playgrounds, community centers, and libraries provide both adults and
children with opportunities to be active and engaged in the broader community.
In 2007, 46.7 percent of children lived in neighborhoods that had four neighborhood
amenities (defined as sidewalks, parks or playgrounds, recreation or community centers,
and a library), while 28.6 percent of children lived in neighborhoods with at least one
indicator of poor conditions, such as vandalism, litter on the street, or dilapidated
housing.57
The percentage of children living in neighborhoods with amenities and poor conditions
varied significantly by poverty status. Among children with household incomes of 100
percent or less of the FPL, 39.5 percent lived in neighborhoods with four neighborhood
amenities, compared to 46.7 percent of children with household incomes of 200-400
percent of FPL and 54.2 percent of children with incomes of more than 400 percent of
FPL.
African American children were most likely to live in neighborhoods with one or more
poor conditions (37.0 percent), and Hispanic children were second most likely (33.5
percent). White children were least likely to live in neighborhoods with one or more poor
conditions (24.4 percent) (see Figure 11).
27
Figure 11: Children under age 18 with one or more poor neighborhood conditions,
by race/ethnicity, 2007
40
35
Percentage of children
30
25
20
15
10
5
0
Total U.S.
Population
White, non
Hispanic
Black
Other, non
Hispanic
Hispanic
Data from Health Resources and Services Administration. Child health USA 2008-09. Accessed at
http://mchb.hrsa.gov/chusa08/popchar/pages/107nc.html
In order to assess the potential contribution of the various components of the environment
to health, the relationships between social disadvantage, environmental exposures and
illnesses, and the ways in which the environment impacts on health disparities, it is
necessary to have a set of measurement tools. The paucity of tools for measuring
environmental health has been a concern since the early 1990s.58
In a paper published in 2006, researchers from the Environmental Protection Agency
(EPA) and the University of Michigan developed a conceptual framework for monitoring
environmental health disparities.59 They grouped the measures into four categories:
social processes (such as residential segregation); environmental contaminants/exposures
(such as exposure to particulate matter); body burdens of environmental contaminants
(such as blood mercury concentrations); and health outcomes (such as asthma morbidity
and mortality).
28
2.1
Housing
People spend more than 50 percent of every day inside their homes.60 So it’s not
surprising that the housing environment is one of the major influences on health and wellbeing.
In 1938 the Committee in the Hygiene of Housing, established by the American Public
Health Association, created the Basic Principles of Healthful Housing61 which provided
guidance regarding the fundamental needs of humans as they relate to housing. These
include physiological and psychological needs, so the definition of good housing is not
just about adequate shelter from the elements, good sanitation, and being vermin free, but
also about privacy and protection from undue noise.
Many housing deficiencies affect health and safety. For example, lead-based paint and
dust may contribute to lead poisoning in children; water leakage and mold may contribute
to asthma attacks; improper use and storage of pesticides may result in unintentional
poisoning; and lack of working smoke, ionization, and carbon monoxide alarms may
result in serious injury and death.
While lead poisoning crosses all socioeconomic, geographic, and racial boundaries, the
burden of this disease falls disproportionately on low-income families and families of
color living in older, poorly maintained housing. For example, African-American
children are at twice the risk of white children for lead poisoning. 62
In 2005, 6 percent of all U.S. residents and 14 percent of low-income renters lived in
homes with severe or moderate physical problems, such as water leaks that can cause
mold growth and trigger allergic reactions and asthma attacks.63 Low-income minority
renters in non-metropolitan areas have a higher incidence of housing quality problems
compared to other renters or homeowners.64 Minority parents are substantially less likely
than are White parents to have safety measures in their homes such as stair gates, safety
latches on cabinets, or lower hot-water thermostat settings.65
A study done in 1999 by the Urban Institute, using 1997 data from the National Survey of
American Families, showed that 13 percent of all non-elderly persons lived in families
that reported housing hardship (being unable to pay rent, mortgage, or utility bills).66
Rates of housing hardship for African Americans, Hispanics, and Native Americans were
twice as high as those for Asians and Whites. Asians, however, were significantly less
likely than Whites to report housing hardship. There are also pronounced disparities
within racial and ethnic groups. For example, rates of housing insecurity for low-income
Asian families were more than five times higher than those for higher-income Asian
families.
29
Table 5: Non-elderly in families that were unable to pay rent, mortgage or utility
bills in past year
All
Americans
Lowincome
Higherincome
All
incomes
White,
nonHispanic
African
American
Asian and
Pacific
Islander
25.4
24.2
29.8
20.7
American
Indian/
Native
Alaskan
40.5
7.4
6.5
13.2
3.5
5.3
11.6
13.4
11.1
21.4
8.5
24.4
19.4
Hispanic
25.4
Data from Urban Institute’s calculations from the 1997 National Survey of America’s Families. Accessed
at http://www.urban.org/publications/309308.html
Although these data have apparently not been updated since 1997, there is no reason to
believe that the situation has improved in the past decade, as wages have remained
constant, housing prices have risen – and then collapsed, and the demand for public
housing and emergency shelters for the homeless has risen sharply. The 2009 American
Community Survey shows that 42.5 percent of renter households have housing costs that
consume 35 percent or more of their incomes. 67
Public housing can help provide for the needs of those who otherwise struggle to keep a
roof over their heads. Located in more than 3,500 communities across the country,
public housing is a vital national resource that assists 2.3 million vulnerable Americans.
Nearly two-thirds of all public housing households include an elderly person or an
individual with a disability.68 Poor and minority populations are overrepresented in public
housing, mostly located in central cities.69
Nearly two million children live in public housing communities, and over two-thirds of
them are African American or Hispanic. A study conducted in 2005 in Los Angeles and
supported in part by AHRQ found that Black and Latino children living in such
communities are 2 to 4 times more likely than children in the general population to suffer
from chronic physical and mental problems.70 Nearly one-third of Black and Latino
households had children with one chronic medical condition, and another third had
children with two or more chronic conditions. The top five chronic conditions reported by
parents for one or more children in their households were asthma (32 percent), eye/vision
problems (24 percent), Attention Deficit Hyperactivity Disorder (ADHD) (17 percent),
dental problems (16 percent), and depression (8 percent).
The researchers called for studies to determine whether children in public housing suffer
from excessive health problems because of the criteria and eligibility for public housing,
or whether the public housing environment is responsible for unhealthy children.
30
The New Zealand Housing, Crowding and Health Study has shown that household
crowding in low-income families leads to increased rates of infectious diseases and
illnesses such as asthma caused by passive smoking in children.71
2.2
Water
According to the EPA, there are approximately 160,000 public or community drinking
water systems in the United States. The current estimate is that 42 million Americans
(mostly in rural America) get their water from private wells or other small, unregulated
water systems. The presence of adequate water, sewer, and plumbing facilities is central
to the prevention, reduction, and possible elimination of water-related diseases.
Water-related diseases can be organized into four categories:
• waterborne diseases, including those caused by both fecal-oral organisms and
those caused by toxic substances;
• water-based diseases;
• water-related vector diseases; and
• water-scarce diseases.72
We tend to think of Third World countries when these issues are raised, but diseases such
as cholera, shigella, leprosy, and dengue fever are not unknown in the United States.
Every year about 18,000 cases of shigella infections are reported and this bacterial group
accounts for more than 10 percent of food-borne illnesses in the United States.73 West
Nile virus, which is spread by a mosquito vector, is now widespread in the United States,
and in 2009 caused 32 deaths.74
An estimated 4 million to 33 million cases of gastrointestinal illness associated with
public drinking water systems occur annually. 75 The presence of chemical contaminants
in water can lead to other adverse health effects; for example, pesticides can cause
reproductive problems; polychlorinated biphenyls and lead can cause neurological
disorders; and nitrates can cause methemoglobinemia or “blue baby syndrome”. 76 Old
lead water pipes also contribute to increased blood lead levels. The issues of lead
poisoning are discussed in the section on housing, above.
Water contamination has many sources, including naturally occurring chemicals and
minerals (e.g., arsenic, radon, uranium), local land-use practices (e.g., fertilizers, nitrates,
pesticides, concentrated animal feeding operations), manufacturing processes, sewer
overflow, and malfunctioning wastewater treatment systems.
There is evidence that drinking water in Indian communities is a significant human health
concern. Over 900,000 people living in Indian country are served by water systems that
fail to meet federal standards.77 In 2008, 55 percent of public water systems in Indian
country either violated a health-based standard for drinking water quality or had a
significant monitoring and reporting violation, compared to 27 percent of all systems in
the United States.78
31
A sensitive issue is that of water fluoridation, which the Centers for Disease Control and
Prevention (CDC) recognizes as one of ten great public health achievements of the 20th
century.79 Community water fluoridation still prevents tooth decay, although people now
also get fluoride from other sources such as toothpaste, rinses, and topical applications at
the dental office. Water fluoridated at the recommended optimum level is safe and
reduces tooth decay up to 60 percent in children under 6 years and up to 40 percent in
older children and adults. At present, 69 percent of individuals on public water systems more than 184 million people - are receiving the benefits of community water
fluoridation. 80
There are profound disparities in the oral health of Americans, with poor children, the
elderly, and members of racial and ethnic minority groups particularly vulnerable.81 The
California Children's Dental Health Initiative found minority children the most
vulnerable: nearly half of Asian and African American students and nearly three-fourths
of Latino students have untreated dental decay. 82
2.3
Air quality
Air pollution, an important public health problem, is associated with damage to the
respiratory and cardiovascular systems, cancer and premature death. Disadvantaged
populations and racial and ethnic minorities are more likely to live in heavily polluted
neighborhoods and to work in high-risk occupations with lower air quality.
More than 72 percent of African Americans live in counties that violate federal air
pollution standards, compared to 58 percent of white. The proportion of Asian and
Pacific Islander and Hispanics who live in counties where the particulate levels are high
are about double those for any other racial and ethnic group.83 More than 61 percent of
African American children, 69 percent of Hispanic children, and 68 percent of Asian
American children live in areas that exceed the 0.080 parts per million ozone standard.
Only 51 percent of white children live in such areas.84
These disparities in living and working conditions play a critical role in the incidence and
burden of asthma in these populations. For example: although African Americans
represent only 12.7 percent of the U.S. population, they account for 26 percent of all
asthma deaths,85 and African Americans and Hispanics are almost 3 times as likely as
Whites to die of asthma.
2.4
Transport
Land use and travel patterns are closely linked, and the ready availability of roads over
safe bicycle or pedestrian routes has obvious consequences: although 25 percent of all
trips in the United States are shorter than one mile, 75 percent of these are by car.86
These facts have consequences for both pollution and obesity.
The pollutants that originate from cars and trucks, especially nitrogen oxides,
32
hydrocarbons, ozone, and particulate matter, account for a substantial part of the air
pollution burden of American cities. People with asthma are particularly susceptible.
Higher ozone levels are associated with higher incidence and severity of respiratory
symptoms, decreased lung function, more emergency room visits and hospitalizations,
more use of medications and more absenteeism from school and work. Particulate matter
is associated with many of the same respiratory effects as well as elevated mortality. 87
As outlined above, minority populations are more likely to live in areas where air
pollution levels are high.
In the United States, the association between obesity and use of car transit was
demonstrated in a study of Atlanta adults.88 This study found that measures of the built
environment and travel patterns are important predictors of obesity across gender and
ethnicity. Each additional hour spent in a car per day was associated with a 6 percent
increase in the likelihood of obesity. Conversely, each additional kilometer walked per
day was associated with a 4.8 percent reduction in the likelihood of obesity.
A large study of young adults showed that the vast majority of this age group, of all
racial/ethnic backgrounds, but particularly African Americans and Hispanics, do not use
active transportation means (such as walking or cycling) to get to school and/or work.
Active transportation is more common among those who are not overweight and more
active young adults of higher socioeconomic status, particularly full-time students89 (see
Table 6).
On the other hand, lack of transportation can also be a problem, particularly for families
with small children, the chronically ill and the elderly. It is a recognized barrier to health
care and one which is exacerbated if the patient needs a variety of health care services.
Some consumers are constrained in their ability to access affordable and nutritious food
because they live far from a supermarket or large grocery store and do not have ready
access to transport. Some 11.5 million low-income people live more than one mile from
a supermarket.90
33
Table 6: Prevalence of different modes of transportation to work and school for
adolescents, by race/ethnicity (%)
Car transit
f/t work
p/t work
f/t school
Public transit
f/t work
p/t work
f/t school
Active transit
f/t work
p/t work
f/t school
Total
White
African
American
Hispanic
Asian
91.7
86.9
70.7
93.5
89.0
70.1
86.7
73.5
72.4
88.7
88.4
77.4
85.2
85.1
65.3
4.9
7.0
9.2
2.9
4.6
8.0
11.1
21.1
9.6
8.0
6.3
10.5
10.8
9.3
22.1
6.1
13.1
33.0
6.3
13.1
35.8
6.2
13.0
25.9
4.8
11.5
20.0
7.9
16.1
32.5
Data from National Longitudinal Study of Adolescent Health. Accessed at
http://www.nature.com/oby/journal/v13/n5/full/oby2005100a.html
Motor vehicle accidents are a particular health problem for American Indians and Alaska
Natives. Motor vehicle crashes are the leading cause of unintentional injury for
American Indians and Alaska Natives aged 1 to 44 years. Adult motor vehicle-related
death rates for this population group are more than twice that of Whites and almost twice
that of African Americans. Among infants less than one year of age, American Indians
and Alaska Natives have consistently higher total injury death rates than other racial and
ethnic populations, and among American Indians and Alaska Natives aged 19 years and
younger, motor vehicle crashes are the leading cause of injury-related death.91
Some of the causes of these high rates relate to the low overall rate of seat belt use on
reservations (55.4 percent, but as low as 8.8 percent on some reservations), low child
safety seat use rates, and a high prevalence of alcohol-impaired driving. 92
2.5
Environmental racism
Environmental racism can be defined as the intentional siting of hazardous waste sites,
landfills, incinerators, and polluting industries in communities inhabited primarily by
minorities and the poor. The landmark study, Toxic Wastes and Race in the United
States, described the extent of environmental racism and the consequences for those who
are victims of polluted environments.93 The study revealed that the greatest number of
commercial hazardous facilities were located in communities with the highest
composition of racial and ethnic minorities. In the early 1990s, over 15 million AfricanAmerican, over 8 million Hispanics, and about 50 percent of Asian/Pacific Islanders and
34
Native Americans were living in communities with one or more abandoned or
uncontrolled toxic waste sites. 94
In 1992, the EPA released a report entitled Environmental Equity.95 This report
concluded that minority and low-income populations experience higher than average
exposures to selected air pollutants, hazardous waste facilities, contaminated fish, and
agricultural pesticides in the workplace. While this exposure does not always result in an
immediate or acute health effect, high exposures, and the possibility of chronic effects are
nevertheless a clear cause for health concerns.
The report also found that environmental and health data are not routinely collected and
analyzed by income and race. Nor are data routinely collected on health risks posed by
multiple industrial facilities, cumulative and synergistic effects, or multiple and different
pathways of exposure. The report alluded to the difficulties of assessing the impact of
environmental hazards in low income and minority communities.
A 2007 study that examined possible factors leading to "environmental racism" found
that although the average African American or Hispanic resident of a major U.S. city
lives in a more polluted part of town than the average white person, the levels of
inequality vary widely between cities and defy simple explanation.96 The study looked at
61 of the largest U.S. metropolitan areas and concluded that the role poverty and
residential segregation play in environmental racial inequality is highly contingent on
local conditions.
Although there was a flurry of reports on “environmental racism” in the early 1990s, the
focus seems to have turned away from this issue, and there is little current reporting of
environmental data by race and ethnicity. Yet there continues to be evidence that
environmental pollution may be a key factor in explaining certain health care disparities.
For example, large numbers of toxic chemicals have been found in the umbilical cord
blood of babies from racial and ethnic minority groups – evidence that children are
exposed to a host of dangerous substances while still in the mother’s womb.97
2.6
Global warming
The CDC considers climate change a serious public health concern, and lists the
following as possible health issues:
•
•
•
•
•
•
•
•
•
Direct effects of heat,
Health effects related to extreme weather events,
Air pollution-related health effects,
Allergic diseases,
Water- and food-borne infectious diseases,
Vector-borne and zoonotic diseases,
Food and water scarcity, at least for some populations,
Mental health problems, and
Long-term impacts on chronic diseases and other health effects.98
35
As with other environmental hazards, members of certain ethnic and racial minority
groups will likely be disproportionately affected.
Climate change is expected to result in an increase in the frequency and intensity of
extreme weather events, such as heat waves, droughts, and floods. The higher
temperatures resulting from climate change will also increase chemical interactions
between nitrogen oxide, volatile organic gases, and sunlight, leading to increased
concentrations of ambient ozone in urban areas.99
Lower SES groups and racial and ethnic minorities are affected by heat-related illnesses
at greater rates due to factors such as lack of access to air conditioning, lack of
transportation, occupations that require outdoor work, and the heat-island effect in urban
neighborhoods. These same groups are also more likely to live in areas with dangerous
levels of air pollution.
Studies have shown that some plants, such as ragweed and poison ivy, grow faster and
produce more allergens under conditions of high carbon dioxide and warm weather. As a
result, allergic diseases and symptoms could worsen with climate change. 100
Altered weather patterns resulting from climate change are likely to affect the distribution
and incidence of food- and water-borne diseases. For example, outbreaks of Vibrio
bacteria infections following the consumption of seafood and shellfish have been
associated with increases in temperatures. Heavy rainfall has been implicated as a
contributing factor in the overloading and contamination of drinking water treatment
systems, leading to illness from organisms such as Cryptosporidium and Giardia.101
Vector-borne and zoonotic diseases, such as plague, Lyme disease, West Nile virus,
malaria, hanta virus pulmonary syndrome, and dengue fever have been shown to have
distinct seasonal patterns, suggesting that they are weather sensitive, and climate change
could aid in the establishment of exotic vector-borne diseases imported into the United
States.102
Climate change is predicted to alter agricultural production, both directly and
indirectly.103 This may lead to scarcity of some foods, increases in food prices, and a
threat to the access to food for those Americans who already experience food insecurity.
Given the complexity of factors that influence human health, assessing the health impacts
related to climate change poses a difficult challenge. The challenge is complicated
because climate change is expected to bring a few benefits to health, including fewer
deaths due to exposure to cold. The health effects of climate change on a given
community will depend not only on the particular exposures it faces, but also on the
underlying health status, age distribution, health care access, and the SES of its residents.
The quality of medical care and public health systems in the United States may lessen
climate impacts on human health within the country. 104
36
3. Access to health care
Addressing racial and ethnic disparities in access to health care is a necessary but not
sufficient requirement for closing the gap on health disparities. Tackling health care
disparities will require a focus on both access and quality, together with provisions to
ensure culturally competent care. The implementation of the provisions and policies of
the Affordable Care Act (ACA) provides a unique opportunity to address these issues.105
3.1
Health insurance coverage
The IOM found that insurance status, more than any other demographic or economic
factor, determines the timeliness and quality of health care, if it is received at all. 106
The U.S. Census Bureau releases annual reports on Income, Poverty, and Health
Insurance Coverage in the United States, making it possible to track how health coverage
for the larger racial and ethnic minority groups has varied over time. However, this is not
so easy for smaller groups such as American Indians, Alaskan Natives, Native
Hawaiians, and Other Pacific Islanders.
Data from other sources are available to fill in some of these gaps, and have been used in
this section of this report, but comparisons should be made cautiously, as it is not always
clear how each racial grouping is defined.
As Table 7 and Figure 12 show, there was little change in the percentage of the different
racial and ethnic groups with health coverage over the seven years to 2009, although
there were significant changes in where people received that coverage.
37
Table 7:
Percentage of population with health insurance coverage, 2009
(% difference from 2002 shown in parentheses)
With coverage
Medicaid
Medicare
15.7
14.3
(+35.0)
(+6.7)
Total
83.3
(-2.4)
Private
63.9
(-9.1)
White
88.0
(-2.2)
72.8
(-8.8)
10.7
(+38.9)
17.1
(+8.2)
4.6
(+21.0)
12.0
(+18.8)
African
American
79.0
(-1.7)
48.7
(-10.8)
27.1
(+17.3)
11.9
(+13.3)
4.1
(+17.1)
21.0
(+6.6)
Asian
82.8
(+0.4)
66.7
(-3.9)
13.9
(+33.6)
9.3
(+9.4)
2.6
(+13.0)
17.2
(-3.4)
Hispanic
67.6
(+0.3)
39.8
(-17.6)
26.5
(+47.0)
6.7
(+17.5)
2.0
(+11.0)
32.4
(-0.1)
All
Americans
Military
4.1
(+17.0)
No
coverage
16.7
(+13.6)
Data compiled from U.S. Census Bureau Annual Reports on Income, Poverty, and Health Insurance
Coverage in the United States, for the years 2002 to 2009. Accessed at
http://www.census.gov/hhes/www/hlthins/hlthins.html
Eighty-eight percent of white Americans had health coverage in 2009, compared to 82.8
percent of Asians, 79.0 percent of African Americans, and 67.6 percent of Hispanics. In
the time frame considered, all racial and ethnic groups lost private coverage, with the
largest losses among Hispanics, African Americans, and Whites. It can be assumed that
many Whites and some African Americans who lost their private health insurance were
then without any coverage because they did not qualify for Medicaid. In contrast, the
number of Asians without health insurance coverage actually decreased slightly and there
was effectively no change in the number of Hispanics without coverage.
More than a quarter of all African Americans (27.1 percent) and Hispanics (26.5 percent)
were covered by Medicaid, compared to only 10.7 percent of Whites and 13.9 percent of
Asians. The important role that Medicaid plays in helping to provide access to health
care, especially in difficult economic times, is highlighted by the substantial increases
over the period 2002 to 2009 in the percentages of all racial and ethnic groups covered by
this program.
The percentages of the various population groups eligible for Medicare and their increase
over time presumably reflect both the median age and the aging of each population.
The increase in the percentages of all populations receiving military health benefits is
likely a consequence of the military expansion in response to the current conflicts in Iraq
and Afghanistan.
38
Figure 12:
Health insurance coverage by racial and ethnic group, 2009
100
90
80
% of population
70
All Americans
60
White, not Hispanic
50
Black, not Hispanic
Asian
40
Hispanic
30
20
10
0
With
coverage
Private
Medicaid
Medicare
Military
No
coverage
Data compiled from US Census Bureau Annual Reports on Income, Poverty, and Health Insurance
Coverage in the United States, 2009. Accessed at http://www.census.gov/prod/2010pubs/p60-238.pdf
Data from the National Health Interview Survey, January-March 2010,107 show how the
number of people without health insurance coverage is continuing to rise. The survey
found that the percentage of people in each racial and ethnic group without insurance at
some time during the 12 months preceding the interview was 34.1 percent for Hispanics,
24.6 percent for non-Hispanic African Americans, 17.9 percent for Asians, and 14.9
percent for non-Hispanic Whites. This is an increase of several percentage points from
2008 for all groups except Asians, who experienced little change.
Some older data, from 2003108, show that uninsured white Americans were more likely to
be adults, to have incomes above 400 percent of FPL, and to live in households without
children, than either African Americans or Hispanics without health insurance. One
quarter of uninsured African Americans were children and half of those without
insurance had incomes less than 50 percent of FPL. They were almost as likely to be
parents with children as adults without children. A similar proportion (24.2 percent) of
Hispanic children were uninsured, however 58.4 percent of Hispanics without health
insurance coverage were parents with children. For both African Americans and
Hispanics there was a correlation between poverty level and a lower likelihood of having
health insurance coverage.
Finding data to highlight the trends in health insurance coverage over time for American
Indians/Alaskan Natives and Pacific Islander groups is more difficult. Three-year
39
average data for 2001-2003 and 2005-07 from the U.S. Census Bureau Annual Reports
on Income, Poverty, and Health Insurance for groups without insurance are shown in
Table 8.
These data highlight the high proportion of Hispanics and American Indians/Alaskan
Natives who are without health insurance coverage – almost one-third of the population
groups. Disturbingly, for American Indians/Alaska Natives this percentage is increasing.
These data do not allow for a clear understanding of any differences in health insurance
coverage between Asian, Native Hawaiian, and Other Pacific Islander groups, but it
appears that Asians are more likely to have health insurance than Native Hawaiians and
Other Pacific Islanders.
Table 8:
Percentage of racial and ethnic groups without health insurance
coverage, three-year average 2001-2003 and 2005-7.
Racial/ethnic group
All
White, alone or in combination
White alone
White alone, not Hispanic
African American, alone or in combination
African American alone
American Indian/Alaskan Native, alone or in combination
American Indian/Alaskan Native alone
Asian, alone or in combination
Asian alone
Asian, Native Hawaiian and Other Pacific Islander, alone or in
combination
Asian and/or Native Hawaiian and Other Pacific Islander
Hispanic (any race)
20012003
data
15.1
14.2
14.1
10.6
19.4
19.6
23.8
27.5
18.3
18.5
18.3
20052007
data
15.4
14.5
10.6
19.6
32.1
18.6
32.8
20.5
32.8
16.5
-
Data from U.S. Census Bureau. Accessed at http://www.census.gov/prod/2004pubs/p60-226.pdf and
http://www.census.gov/prod/2008pubs/p60-235.pdf
Children’s health coverage
Data from the Children’s Defense Fund show that in 2009 there were more than 8 million
uninsured children in America.109 Nationally, about 10.3 percent of American children
are uninsured, but the percentage of uninsured children in each state varies widely.
Uninsured children are more likely to be White or Hispanic (see Table 9), to be teenagers
(aged 13-18 years), and to live in households where the annual income is less than 133
percent of the FPL.110
40
Table 9:
Uninsured children by racial and ethnic group
Race/Ethnicity
White
Hispanic
African American
Asian/Pacific Islander
American Indian
Other (multi-racial)
The uninsured (5)
Number of children
38.5
38.1
15.7
4.7
1.1
1.9
3.1 million
3.1 million
1.3 million
380,000
91,000
152,000
Data from Children’s Defense Fund (2009). Who are the uninsured children, 2008. Profile of America’s
uninsured children. Accessed at http://www.childrensdefense.org/child-research-datapublications/data/data-uninsured-children-by-state.pdf
Some slightly different data are provided in a recently published article, 111 which found
that an estimated 7.3 million children were uninsured on an average day in 2008,
4.7 million (65 percent) of whom were eligible for Medicaid or the Children’s Health
Insurance Program (CHIP) but not enrolled.
The estimated national Medicaid/CHIP participation rate is 81.8 percent for children, but
participation rates currently vary greatly across states, from lows of 55.4 percent in
Nevada and 66.2 percent in Utah, to highs of 95.4 percent and 95.2 percent in the District
of Columbia and Massachusetts, respectively. Together just three states - California,
Texas, and Florida - contain 38.6 percent of all Medicaid/CHIP-eligible uninsured
children in the nation. 112
Kenney et al. also found substantial variation in participation rates across different
subgroups of children eligible for Medicaid/CHIP coverage. African American children
and those in the "other/multiple race" category had the highest participation rates among
eligible children, at around 87 percent; Hispanic and Asian/Pacific Islander children had
participation rates of 78.8 percent and 79.4 percent, respectively. American
Indian/Alaska Native children had the lowest participation rates at 68.0 percent.113
Participation rates were higher among children with family incomes below 133 percent
FPL (84.2 percent) and among those who were in households that received help through
the Supplemental Nutrition Assistance Program (formerly known as food stamps)
(93.5 percent), compared to higher-income children and children not living in households
receiving food stamps.
Despite their relatively high participation rate, the poorest children made up a sizable
majority (63.4 percent) of all children who were eligible but uninsured. Children whose
parents are not citizens or do not speak English also had lower participation rates.
The Children’s Health Insurance Reauthorization Act became law in February 2009,
providing coverage for an estimated 4 million additional children by expanding eligibility
41
and introducing improvements to state enrollment and retention processes. In April
2010, the federal government awarded $50 million in outreach grants, including
$40 million to organizations in forty-two states and an additional $10 million for targeting
American Indian children. These efforts can be expected to raise participation rates and
change the composition of the population of children enrolled in public coverage.
However, state budget shortfalls will undoubtedly reduce state-level efforts to promote
greater enrollment and retention among eligible children even as the ongoing recession
means that more children are becoming eligible. Ultimately, policy changes to be
implemented in 2014 under the ACA will introduce major changes to CHIP coverage for
children.
3.2
Medically underserved populations
Having health insurance coverage is only the first step to accessing quality care. Patients
need to be able to gain entry into the health system, access sites where patients can
receive needed services, and find providers who can meet the medical and cultural needs
of individual patients.
Many racial and ethnic minorities and individuals of lower SES have reduced access to
care, especially routine care, because they live in areas that are medically underserved.
They may also constitute a medically underserved population because the otherwise
adequate numbers of health care providers in their geographic area do not serve their
population group (for example, doctors may not accept Medicaid patients).
The current Medically Underserved Population (MUP) criteria date back to 1975, when
they were issued to implement legislation enacted in 1973 and 1974 establishing grants to
support health maintenance organizations and community health centers serving
medically underserved populations. The criteria include: percent of the population with
incomes below the poverty level; primary care physician-to-population ratio; infant
mortality rate; and percent of the population aged 65 or over. In addition, high-need
populations living in more affluent and healthy communities can be designated as a MUP
if they face significant economic, sociological, and/or cultural and linguistic barriers to
primary care access.114
Section 5602 of the ACA requires the Health Resources and Services Administration
(HRSA) to establish a comprehensive methodology and criteria for designation of
medically underserved populations and Primary Care Health Professions Shortage Areas
(HPSAs). This effort is underway.115
As the data in Tables 10, 11, and 12 show, Americans in racial and ethnic minority
groups have reduced access to health care, a situation that is aggravated if they are poor
or uninisured. The data also highlight the effectiveness of public health insurance
programs such as Medicaid, CHIP, and Medicare in helping to provide access to a usual
place of medical care, especially for children. Community health centers and clinics such
as those provided by the Indian Health Service (IHS) also directly benefit minorities.
42
Emergency rooms and hospital outpatient services are used disproportionately by those
with no other access to primary care services.
It is disturbing to see that over 18 percent of adults who are Hispanic or American
Indian/Alaskan Native and 12 percent of Asian Americans have gone two or more years
without a medical visit, particularly as a significant proportion (more than 20 percent) of
these minorities who report fair to poor health also report that their health has
deteriorated over the past year.116
The very high number of visits to health care providers for Medicare/Medicaid
beneficiaries aged 65 and over reflects the increased incidence of multiple chronic
conditions in this population. It also highlights the possibility that better access to
preventive services and treatment earlier could help limit Medicare expenditures later.117
For children of racial and ethnic minorities, there is a direct correlation between having a
usual place of care and whether a child has seen a doctor it the past year. Thirteen
percent of uninsured children had not had contact with a doctor or other health
professional in more than 2 years (including those who never had a contact), compared
with 2 percent of children with private insurance coverage.
Dental health has a substantial impact on health status, with substantial links between
poor oral health and heart disease, stroke, the risk of having a low birth weight, preterm
baby and difficulties with controlling diabetes.118 High levels of unmet dental needs in
all populations are of concern, but this is particularly the case for the elderly and children.
In 2009, 4.6 million (7 percent) of children aged 2-17 years had unmet dental needs
because their families could not afford dental care. White children were more likely to
have had a dental contact in the past 6 months (65 percent) than African American
children (55 percent) or Hispanic children (54 percent). Thirty-five percent of uninsured
children had had no dental contact for more than 2 years (including those who had never
had contact with a dentist) compared with 14 percent children with Medicaid and 12
percent of children with private health insurance.
43
Table 10:
Access to a usual place of health care for the adult population, by race, ethnicity, income, and health coverage
Adult population (aged 18+) by race,
ethnicity, income and health coverage
Without a usual
place of care (%)
Where those with a usual place of care go (%)
Doctor’s office or
Clinic or health
Emergency rooms/
HMO
center
hospital outpatient
Total US population
White
White, not Hispanic
Black
American Indian/Alaskan Native
Asian
Native Hawaiian/Other Pacific Islander
Two or more races
Hispanic
16.2
15.9
14.3
16.6
23.1
18.2
15.7
20.8
28.4
76.2
77.6
78.3
70.3
38.7
77.4
52.7
60.1
60.2
20.0
19.3
18.2
21.9
52.6
19.1
17.8
31.9
34.1
2.9
2.2
2.6
7.0
8.7
2.3
*
6.2
5.2
Poor (below FPL)
Near Poor (100-200% FPL)
Not Poor (200%+ FPL)
27.5
23.1
12.5
57.2
65.7
81.2
33.6
28.0
16.3
7.5
5.2
1.7
Aged under 65
Private health insurance
Medicaid
Other
Uninsured
9.9
10.1
7.7
52.2
82.9
57.5
55.9
47.6
15.4
35.7
33.5
39.2
1.2
6.2
8.4
10.2
Aged 65 and over
Medicare/Medicaid
2.9
73.3
22.6
3.8
Data compiled from Summary health statistics for U.S. adults: National Health Interview Survey, 2009. Accessed at
http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf
* Relative statistical error greater than 50%
44
Table 11:
Frequency of access to health care for the adult population by race, ethnicity, income, and health coverage
Adult population (aged 18+)
by race, ethnicity, income
and health coverage
Number of outpatient visits to doctor or other health professional in past
12 months
(% of population)
More than 2
years since
health visit
(% of
population)
More than 2
years since
dental visit
(% of
population)
0
1
2-3
4-9
10+
Total US population
White
White, not Hispanic
Black
American Indian/Alaskan Native
Asian
Native Hawaiian/Other Pacific
Islander
Two or more races
Hispanic
19.0
18.1
15.5
20.3
29.9
25.6
27.3
16.6
16.3
15.8
16.6
17.6
21.3
25.7
26.2
26.3
27.4
26.1
27.6
24.5
23.1
24.2
24.7
25.9
23.3
14.9
19.8
14.7
14.1
14.5
15.4
13.7
10.1
8.8
9.2
9.3
8.9
7.1
9.1
18.3
12.2
8.9
25.1
24.3
22.3
29.7
36.1
22.0
21.9
24.8
32.6
14.0
19.1
21.2
20.2
27.2
16.1
12.7
8.4
10.6
18.5
30.0
35.0
Poor (below FPL)
Near Poor (100-200% FPL)
Not Poor (200%+ FPL)
27.7
24.2
16.0
15.0
15.6
17.1
19.0
22.7
28.5
21.7
22.0
25.1
16.6
15.5
13.3
15.2
12.7
7.3
41.6
39.3
18.0
Aged under 65
Private health insurance
Medicaid
Other
Uninsured
15.1
13.6
10.6
47.1
19.0
12.3
10.9
18.3
30.4
20.5
24.2
16.8
23.7
26.7
27.4
11.0
11.9
27.0
27.0
6.7
6.2
4.8
4.5
28.1
14.8
29.1
33.4
47.1
Aged 65 and over
Medicare/Medicaid
8.7
6.9
13.1
37.3
34.0
3.7
52.1
Data compiled from Summary health statistics for U.S. adults: National Health Interview Survey, 2009. Accessed at
http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf
45
Table 12:
Access to health care by children, by race, ethnicity and health coverage
Child population
(under 18) by race,
ethnicity, income and
health coverage
Without a
usual place
of care (%)
Where those with a usual place of care go (%)
Clinic
Doctor’s
office
Emergency
room
Hospital
outpatient
Time since last medical
contact (% of population)
1-2 years
2+ years
Unmet
dental need
(% of
popln)
Total US population
Aged 0-4
Aged 5-11
Aged 11-17
4.8
3.6
4.3
6.4
23.5
24.4
23.2
23.1
74.5
73.5
75.2
74.6
0.7
0.7
0.6
0.8
1.0
1.1
0.8
1.2
5.6
2.0
6.1
8.1
3.0
1.3
3.1
4.3
7.1
4.4
6.2
9.5
White
White, not Hispanic
Black
American Indian/Alaskan
Native
Asian
Native Hawaiian/Other
Pacific Islander
Two or more races
Hispanic
5.0
3.8
4.2
8.7
22.6
16.5
28.2
48.0
75.8
82.4
68.5
47.8
0.5
0.2
1.3
*
0.8
0.6
1.7
*
5.8
5.2
5.2
5.8
3.0
2.1
2.8
*
7.2
5.9
6.9
7.6
5.4
4.3
17.4
25.5
79.8
66.4
*
*
*
*
6.9
*
4.1
*
5.1
*
3.1
8.3
22.7
40.2
75.9
56.9
*
1.3
*
1.2
4.6
7.1
*
5.5
6.9
10.8
Poor (below FPL)
Near Poor (100-200%
FPL)
Not Poor (200%+ FPL)
7.8
5.6
39.8
30.3
56.7
67.3
1.5
0.8
1.6
1.3
6.1
7.4
5.3
3.5
10.1
10.9
3.3
15.2
83.6
0.2
0.7
4.6
1.8
4.5
Private health insurance
Medicaid/other public
Other
Uninsured
2.3
4.0
4.5
24.2
13.3
36.8
37.8
37.4
85.8
60.9
56.3
54.5
0.1
0.7
*
4.9
0.5
1.4
3.4
2.2
4.6
4.9
6.0
14.8
1.7
2.8
*
12.7
4.3
6.9
3.2
27.1
Data compiled from Summary health statistics for U.S. children: National Health Interview Survey, 2009. Accessed at
http://www.cdc.gov/nchs/data/series/sr_10/sr10_247.pdf
* Relative statistical error greater than 50%
46
The concept of medical underservice is used in reference to adequate access to primary
care services, but the problems are magnified when consideration is given to the ability of
racial and ethnic minorities to access to specialty health care and mental health services.
Although direct evidence that racial and ethnic minorities have reduced access to
specialist health care services is scarce, there is considerable indirect evidence to support
this (for example, increased mortality rates from cancer and suicide, lower levels of
participation in clinical studies, and decreased likelihood of registration for
transplants).119 These issues are discussed elsewhere in this paper.
There is also evidence to suggest that the time doctors spend with patients of different
racial and ethnic groups varies by medical specialty. For example, an analysis conducted
in 2000 showed that African Americans, who constituted approximately 12 percent of the
U.S. population in that year, used a disproportionately higher percentage of total patient
care hours of emergency medicine physicians (38 percent), obstetricians/gynecologists
(17 percent), and pediatricians (16 percent). But they received proportionately fewer
hours from "other" surgical specialties (8 percent) and general surgeons (9 percent).120
Disparities also abound in utilization of mental health treatment services.121 Compared to
white Americans, racial and ethnic minorities have less access to, and availability of,
mental health services.
These problems may be due in large part to the documented inability of primary care
doctors, especially those who care for racial and ethnic minorities, to provide timely and
affordable referrals to high-quality subspecialists, diagnostic imaging, ancillary services,
and to non-emergency hospital admissions122.
3.3
Concordance between provider and patient
The latest census figures highlight the fact that the United States is becoming
increasingly racially and ethnically diverse.123 Furthermore, higher birth rates among
racial and ethnic minority groups, relative to non-Hispanic Whites, and immigration
patterns suggest that this trend will continue, with growth in the Hispanic population as
the major contributor.
Although minorities now comprise more than 35 percent of the U.S. population (a percentage
which is growing), they are underrepresented in the health care professions, even as the
number of African American and Hispanic medical school graduates in the United States
has grown substantially over the past two or three decades (about doubling for
Hispanics). However there is one exception to this trend as the number of Asian
graduates has outpaced all the other minority groups, growing about eightfold over the
same period124 (see Figure 13).
47
Figure 13:
Ethnicity
U.S. Population, Medical School Graduates, and Doctors, by Race and
80
70
Percentage
60
50
Population
40
Medical Graduates
Practicing doctors
30
20
10
0
White
Asian
African
American
Hispanic
Native
American*
* includes American Indian, Alaskan Native, Native Hawaiian, and Other Pacific Islanders
Data from T Michael, J Dill & Edward S Salsberg (2008). The complexities of physician supply and
demand: projections through 2025. Association of American Medical Colleges. Accessed at
http://www.tht.org/education/resources/AAMC.pdf
Note that while the population and medical school numbers are for 2004, the data on doctors are from
2006.
In 2004, the Sullivan Commission on Diversity in the Healthcare Workforce examined
disparities and diversity in the health care system and noted that “the lack of minority
health professionals is compounding the nation’s persistent racial and ethnic
health disparities.”125
Increasing the number of under-represented groups in the health professions can help
address health care disparities by both improving access to care and by responding more
effectively to minority population needs. Studies have consistently shown that minority
physicians working in primary care are more likely to care for patients of their own race
or ethnic group, practice in areas that are underserved or have health care manpower
shortages, provide care for poor patients, patients with Medicaid insurance, or no health
48
insurance, and provide care for patients who report poor health status and use more acute
medical services such as emergency rooms and hospital care. 126
There is also evidence that race concordance - defined as shared racial or ethnic identities
between clinicians and patients – is related to patient reports of satisfaction, participatory
decision making, timeliness of treatment, and trust in the health system. 127
Several studies show that racial and ethnic concordance between health care professional
and patient is substantially and positively related to patient satisfaction, although it is not
essential for patient satisfaction.128 Quite simply, patients feel most comfortable with
doctors similar to themselves. However there are clearly a number of interrelated factors
in play, including simply the issue of patient choice.129
These issues are highlighted in the study done by Cooper and others in 2003,130 which
found that race-concordant visits were longer and had higher ratings of patient
satisfaction than race-discordant visits. Patients in race-concordant visits also rated their
doctors as more participatory, regardless of the communication that occurred during the
visit. The authors concluded that, because the association between race concordance and
higher patient ratings of care is independent of patient-centered communication, other
factors such as patient and physician attitudes may mediate the relationship.
Interestingly, the evidence suggests that the provider biases or patient expectations that
contribute to disparities in care for adults are attenuated in the relationships involving care for
children.131 One indication for this difference between adults and children may lie in the
disquieting levels of medical distrust among all patient populations, but especially among
African Americans.132 These findings of mistrust among African Americans are
consistent across all educational and income levels and may relate to issues such as the
Tuskegee experiment.133
On the other side of the doctor – patient relationship, research suggests that health care
providers’ diagnostic and treatment decisions, as well as their feelings about patients, are
influenced by patients’ race or ethnicity. 134 Doctor and patient attitudes may play off and
influence each other to the detriment of the patient's medical outcome.135 Lack of
concordance may mean that providers miss symptoms or ascribe them wrongly, fail to
recognize mental health problems, understand what complementary and alternative
treatments patients might be using, and are unable or unwilling to address concerns about
sensitive issues such as sexuality and end-of-life care.
For the foreseeable future, the majority of health care encounters will not be racially or
ethnically concordant, and so it is essential that all health care providers receive
appropriate training to ensure that they provide culturally competent care. Provisions are
included in the ACA to boost the delivery of such training.
49
3.4
Literacy and language
The issues around literacy and language are related to those discussed in the section on
cultural concordance above. However, literacy and language problems can give rise to
health care disparities even when there is provider-patient concordance.
Health literacy is defined in Healthy People 2020 as: "The degree to which individuals
have the capacity to obtain, process, and understand basic health information and services
needed to make appropriate health decisions". 136 About one third of the adult population
in the United States has limited health literacy, and that proportion is higher in racial and
ethnic minorities.137
Health literacy includes the ability to understand instructions that come with prescription
medicines, appointment slips, medical education brochures, doctor's directions and
consent forms, and the ability to negotiate complex health care systems. Health literacy is
not simply the ability to read; it requires a complex group of reading, listening, analytical,
and decision-making skills, and the ability to apply these skills to health situations. 138
In the absence of health literacy, patients may make medication errors, fail to properly
comply with treatment regimes, and be unable to give informed consent. For example, it
is postulated that the higher rates of poor health literacy in racial and ethnic minorities
may represent an important variable contributing to higher rates of diabetes
complications in minority groups.139
More than 46 million people in the United States do not speak English as their primary
language, more than 21 million speak English less than "very well", 140 and the proportion
of the population that speaks a language other than English at home is increasing.141
Language barriers have a major impact on both the quality and the costs of health care.
Patients with limited English-language proficiency encounter significant disparities in
access to health care and are at increased risk of experiencing medical errors.142
At least 66 million patient- provider encounters occur across language barriers each
year.143 Without interpreter services, these patients have a more difficult time obtaining
medical services, receive lower-quality health care, and have a greater chance of
experiencing negative health outcomes. As many as one in five Spanish-speaking
Americans report not seeking medical care because of language barriers. 144
All federal programs and those receiving assistance from the federal government must
take reasonable steps to ensure that persons who have limited English proficiency have
meaningful access to the programs, services, and information that those entities provide.
The standards on culturally and linguistically appropriate services (CLAS) in health care
are issued by the Office of Minority Health in the Department of Health and Human
Services (DHHS).145 They are designed to contribute to the elimination of health
disparities by addressing the linguistic and cultural needs of patients in an appropriate
manner. Clearly the language needs (and therefore the services such as translators that
50
are required) will vary from region to region, and in some cases from provider to
provider.
To provide these services it is necessary to know the spoken English language
proficiency and preferred language for the patient’s health-related encounters. The IOM
proposes that this can best be assessed by asking two questions: one assessing whether a
person rates his or her ability to speak English as less than “very well”, and a second one
to determine the language preferred for encounters. The IOM also recommends that
where possible and applicable, health care providers should also collect information on
the language spoken by the patient at home and the language in which the patient prefers
to receive written materials. 146
A 2007 report that looked at cultural and linguistic services in hospitals found that much
needs to be done to address cultural and linguistic barriers, particularly in the areas of
language access services, informed consent and related patient education processes, and
the collection and use of patient demographic data.147
It will also be important that there are methodologies developed for evaluating the
effectiveness of efforts to address language and cultural needs in improving both the
outcomes and the quality of care. These methodologies should also consider the costs
involved in providing language services and the cost-savings that such services can
achieve.
Given the higher rates of poor literacy in racial and ethnic minorities, and the particular
language barriers faced by those whose first language is not English, these population
groups will benefit disproportionately from efforts to improve health literacy.
3.5
System biases
This report has previously considered how individual biases on the part of either or both
the health care provider and the patient may influence health care. However there may
also be system biases - the ways in which health care systems are organized and financed,
and the availability of services – that can exert different effects on patient care,
particularly for racial and ethnic minorities. These go well beyond the barriers posed by
language and literacy discussed above.
The IOM report Unequal Treatment has proposed that changes in the financing and
delivery of health care services such as managed care systems may pose greater barriers
to care for racial and ethnic minorities than for non-minorities.148 The report cites a study
showing that minorities were less likely to access services after mandatory enrollment in
a managed care plan (an HMO) compared to white Americans mandatorily enrolled in
the same Medicaid plan and to other minorities enrolled in Medicaid non-managed care
plans as an example of this phenomenon.
51
Documented discriminatory practices in health care have included physician refusal to
participate in Medicaid, imposing qualifications unrelated to skills (such as membership
in a local medical society) as a means of barring minority doctors and doctors who treat
minority patients from membership on hospital staffs, and failing to make information
about programs and language services accessible. Location or relocation of services also
has been challenged as discriminatory.149
Several practices in managed care can have a disparate effect on minorities.150 For
example, managed care organizations can discriminate against minorities in their
selection of providers. A doctor or other type of provider that serves mainly poor
minorities may not be included in a managed care network because the provider’s
patients might be considered too costly for the network. Selective marketing, where
health insurers target well-to-do suburban areas for enrollment while ignoring inner-city
areas, or bypass certain zip codes when they do their marketing, can also occur.
The fragmentation of health care services and the subsequent lack of continuity of care
also put minorities at a disadvantage and are seen as a major contributor to disparities in
care.151 Although health care systems are complex and can often be difficult to navigate
for all members of society, deficits related to fragmented care are most likely to affect
patients who are disadvantaged because of race, ethnicity, language, immigrant status,
income, education, or lack of insurance coverage. These patients too often fall through
the cracks in the system. In high technology, multi-step health care procedures such as
heart surgery, cancer treatment, and organ transplants, small disparities at each step in the
process can yield a moderate to large disparity in the overall pattern of care.152
3.6
Indian Health Service
The Indian Health Service (IHS) delivers services to 1.9 million American Indians and
Alaska Natives through direct health care services and tribally operated health care
services. The purchase of health care from private providers is also an integral
component of the health system for services unavailable in IHS and tribal facilities or, in
some cases, in lieu of IHS or tribal health care programs.
The majority of IHS service providers are on or near reservations, but the IHS also serves
about 600,000 people living in urban areas.153 IHS facilities often represent the only
source of health care for American Indian and Alaska Native individuals, particularly for
those who live in the most remote and poverty stricken areas of the United States.
On an annual basis the IHS delivers almost 11 million outpatient services, 3.5 million
dental services, and over 54,000 inpatient services. The annual per capita spending is
$2,690, compared to the per capita spending for the total U.S. population of $6,826.154
The average cost of a health insurance plan is about 40 percent more than the IHS
funding level for each person served.155 This funding gap limits essential services and
contributes to health care disparities.
52
After adjusting for inflation and population growth, the amount of funding the IHS
receives has been steadily declining since the early 1990s. The National Indian health
Service Board estimates that the IHS needs $21.2 billion annually to meet the health care
needs of all its eligible members (the FY2010 budget was $4.4 billion).156
4. Healthy food systems
Food systems generate and exacerbate key health disparities in the United States.157
Strong evidence ties racial/ethnic and socioeconomic disparities to diet quality or diet
healthfulness and to obesity and diet-related disease. The limited resources for food in
low-income neighborhoods causes increased food expenditures and a lower-quality diet
higher in fat and calories, leading to obesity and overweight, diabetes and other related
health problems.158
The type of food stores in the neighborhood is important. Supermarkets are likely to sell
the widest variety of healthy foods at the cheapest prices, while convenience stores and
bodegas usually charge more, and tend not to sell fresh food. Studies have confirmed that
minority and low-income individuals who live near supermarkets have healthier diets.
For example, the likelihood that African-Americans’ diets will meet guidelines for fruit
and vegetable consumption increase by 32 percent with every additional supermarket
located in the census tract where they live. 159
A national study found that low-income neighborhoods have only three-fourths as many
chain supermarkets as middle-income areas; African American neighborhoods have only
half and Hispanic only one-third as many of the larger chain supermarkets as
predominantly white areas. Often, people must travel significant distances to have access
to large food stores. A Chicago study found that residents of poor neighborhoods must
travel more than two miles to access the same number of supermarkets as are available
within a half-mile to residents of non-poor areas,160 and rural residents of Mississippi
must travel more than 30 miles to reach a large store.161
Beyond the ability to access foods that are high in essential nutrients, there are
differences in the ability to access calories altogether. An estimated 11.1 percent of
Americans have “low food security” and 4.1 percent have “very low food security”, with
African Americans and Latinos estimated to have double the national rates.162In the
United States, food insecurity has been found to be highly correlated with obesity. 163
Marketing can affect perceptions, knowledge, and behaviors not only by promoting
particular items, brands, and categories of food but also by promoting social
identification and positive associations with brands. In 2008, $7.82 billion was spent on
food and beverage marketing and $5.62 billion on restaurant marketing, representing 15
percent and 28 percent increases respectively since 2004. In Food for Thought:
Television Food Advertising to Children in the United States, the Kaiser Family
Foundation reported that children and adolescents see up to 6,100 televised food
advertisements a year. Approximately one-third of the advertisements are for candy and
53
snacks, a quarter are for cereal, and a tenth are for fast food. Only 5 percent are for
healthy foods/beverages such as dairy products and fruit juice and none are for fruits and
vegetables.164
Studies have found that more food commercials are aired during “African American”
shows than others, and that the distribution of items advertised is more heavily skewed
toward unhealthy items. Additional research shows that low-income children watch more
television and have greater media exposure - and thus more exposure to food
commercials - than their higher-income peers. 165
Few interventions and policies are specifically developed to reduce differential food
marketing by race/ethnicity. Possible approaches include zoning changes, counteradvertising, marketing guidelines, “shaming” the advertisers publicly, and media literacy
education.
5. Genetics
Scientists in the medical and public health research community are deeply divided about
the associations between genes and race in determining the susceptibility, prevalence, and
outcomes of human disease.166
A significant part of the budget of the National Institutes of Health (NIH) can be
classified as supporting health disparities research either directly or indirectly. In 2010
direct funding for health disparities research was $209 million; the indirect figure is not
available, but in 2003 indirect funding was almost $3 billion.167 Some of this work
includes initiatives to identify genetic contributions to health disparities. For example, the
2003 vision statement by the National Human Genome Research Institute (then under the
auspices of Dr Francis Collins, who is now the NIH Director) for the future of genomics
named as a “grand challenge” the need to develop “genome-based tools” to address
disparities in health status.168 The statement acknowledged that social and economic
factors contribute significantly to disparities, but nevertheless asserted the need for
extensive research to better understand the contribution of genetics.
A paper published in 2004 by a group of bioethicists recognized that while genetic
research may well succeed in elucidating genetic factors that contribute to diseases
associated with health disparities, the reporting of such studies all too often tends to
downplay the fact that non-genetic factors are substantial contributors or that the onset or
severity of the disease results from a complex interaction of genetic and environmental
factors. The authors make the point that an over-focus on genetics in the effort to
alleviate health disparities could have the paradoxical result of actually exacerbating
disparities. 169
Genomics does have the potential to help eliminate health care disparities through the
development of targeted therapies, although realistically these are more likely to be based
54
on individual genetic make-up. Again, this expensive proposition comes with the
possibility that health care disparities will be increased.
There are reports of therapy failure in some racial and ethnic groups, and the Food and
Drug Administration (FDA) has approved race-specific pharmacotherapy to treat heart
failure and glaucoma in African Americans. For example, it has been suggested that the
antihypertensive effect of medicines such as ACE inhibitors and beta-blockers may be
less in Black patients than in other racial groups.170 However, most of the published
literature on this topic is limited by its retrospective nature.171
Firm conclusions regarding the influence of race on effectiveness of certain medications
cannot be made until prospective trials, with planned analysis of the effect of race, have
been performed. These types of findings boost the case for ensuring that racial and ethnic
minorities are better represented in clinical studies.
6. Culture and acculturation
The concept of culture as distinct from race and ethnicity has been proposed as an
explanation for differences in health behavior and health outcomes. 172 The definition and
conceptualization of culture varies across disciplines. The Office of Minority Health at
DHHS defines culture as “integrated patterns of human behavior that include the
language, thoughts, communications, actions, customs, beliefs, values, and institutions of
racial, ethnic, religious, or social groups.”173
Acculturation is a concept related to culture that is typically used to explain ethnic
disparities in health outcomes based on the assumption that culturally based knowledge,
attitudes, and beliefs cause people to behave in certain ways and make specific health
choices. Acculturation measures assume that there is a “mainstream” culture and an
“ethnic culture”; however, most studies on acculturation rarely define or describe what
constitutes these “mainstream” or “ethnic” cultures. A systematic review of acculturation
studies focused on Hispanic health found that only a handful (8 percent) included any
definition of culture, and in most instances the definition of culture was nebulous and
imprecise. 174
Culture, as defined above, is important to everyone, regardless of race or ethnicity.
However its importance is heightened for minority patients who receive their health care
in systems designed, operated, and staffed by majority groups. Culture is important
because it bears upon what both patients and health care professionals bring to the
clinical setting. It can account for variations in how patients communicate their
symptoms and which ones they report, whether people even seek help in the first place,
what types of help they seek, and what coping styles and social supports they have.175
Culture is a concept that also applies to health care professionals. Health professionals in
the United States and the institutions in which they train and practice are rooted in
55
Western medicine, which emphasizes the primacy of the human body in disease and the
acquisition of knowledge through scientific and empirical methods. This viewpoint may
differ substantially from that of the patient.176
Recently, there has been a considerable focus on efforts to improve cultural competency
in the health care workforce, as exemplified by the provisions included in the ACA to
fund increased efforts in this area. However, to date there has been little in the way of
rigorous research to evaluate the impact of cultural competency initiatives and techniques
on outcomes, including racial and ethnic disparities, with the exception of those to
address language barriers.177
Implicit in much research on acculturation is the assumption is that increased
acculturation brings immigrants’ values and behaviors in line with a standardized set of
values, primarily those associated with "white American culture." But there are now a
number of major minority groups in the United States, and some Hispanics, for example,
may interact more with other groups of color than with white Americans.
Acculturation may be seen as a risk factor for health. High levels of acculturation among
Latinos are associated with increased rates of cancer, infant mortality, and other
indicators of poor physical and mental health. In general, rates of risky health behaviors
(e.g., smoking, alcohol use, high body mass index) also increase with acculturation. The
results are not all negative, however, as there is also some evidence that it is associated
with several healthy behaviors, such as greater exercise and leisure-time physical
activity. 178
6.1
Immigration status
It is well documented that immigrants arriving in the United States are in better health
than their American counterparts, but that this health advantage erodes over time.
Similar patterns have been observed for immigrants to other developed countries.179
Health selection - the propensity of immigrants to be much healthier than a representative
person in the sending country, combined with the U.S. screening process for those
wishing to immigrate - is a quantitatively important phenomenon in establishing this
health advantage. However, great diversity exists among immigrants in the extent of
health selection and the nature of health selection of immigrants appears to be
fundamentally different among older immigrants.180
Research has shown that grouping together foreign-born Blacks, Hispanics, and Asians
misses important health differentials within these groups.181 Differences in
migration circumstances, human and social capital, context of reception, and lifestyle
characteristics help explain the variations.
Several examples illustrate this point.
56
•
A study looking at 15 Asian/Pacific Islander subpopulations found that these were
quite heterogeneous in terms of social and demographic characteristics, as well as
disability status.182 Japanese, Chinese, Filipino, and Asian Indian adults had
relatively higher SES and lower risk of disabilities. There were also differences
within subpopulations. For example, Vietnamese adults had better health than
Laotians, Hmong, and Cambodians. Relevant factors in for health status in these
populations include education, ability to speak English, refugee status, previous
traumas, and cultural health beliefs. 183
•
Compared to U.S.-born Blacks, black immigrants from Africa have superior
health, and black immigrants from minority white (Africa, South America) and
racially mixed (West Indies) regions have better health. But black immigrants
from majority white (European) regions have a similar health status to U.S.-born
Blacks. 184 Some studies suggest that those immigrants from cultures in which
Blacks are the majority have higher self-esteem, are more prepared to resist
efforts to discriminate against them, and their accents allow them to be perceived
by others as different from U.S.-born Blacks. However, this increased resilience
against racism erodes over time.185
•
Among Hispanics, Cubans are most likely to report that they are in good or
excellent health (82.9 percent, compared to 87.4 percent of Whites who report
good-excellent health), followed by those from Central and South America (80.5
percent), and Mexicans (78.3 percent). Puerto Ricans report health outcomes that
parallel those of African Americans (75 percent). The high numbers of illegal and
undocumented immigrants in this population has a direct effect on both health
status and the ability of individuals to access health care.186
The finding that age-adjusted mortality is lower for Hispanics than for non-Hispanic
Whites, despite the fact that Hispanics have lower socioeconomic status, is at the core of
what is called the Hispanic paradox, discussed earlier in this paper.
As previously noted, a key issue for immigrant populations is the ability to access health
care. The foreign-born population is more than twice as likely as natives to be uninsured.
In 2010, 14.1 percent of the native-born population did not have health insurance, but
34.5 percent of the foreign-born population was uninsured. Most of this gap, however,
can be explained by differences among two subgroups of the foreign-born population –
naturalized citizens and noncitizens, who include undocumented as well as resident
aliens.
Although 46.0 percent of noncitizens were uninsured in 2010, the percentage of
naturalized citizens who were uninsured was 19.0 percent, only slightly more than the
percentage of natives without health insurance.187 The figures are considerably worse for
Hispanics, with 59.3 percent of those who are not citizens being without health coverage
(see Tables 13 and 14).
57
Table 13: Health Insurance Coverage Status by Nativity and Citizenship for all
people, 2009 (%)
Population
group
Not
covered
Total
population
Nativeborn
Foreignborn
Naturalized
16.7
Non-citizen
Private
Group
Direct
coverage
purchase
55.8
8.9
Medicaid
Government
Medicare
Military
15.7
14.3
4.1
14.1
57.8
9.3
15.9
14.6
4.4
34.5
41.4
6.5
14.1
11.9
1.8
19.0
52.8
8.8
12.4
20.1
3.2
46.0
33.0
4.8
15.4
5.8
0.8
Data from U.S. Census Bureau, Current Population Survey, 2010. Annual social and economic
supplement. Accessed at http://www.census.gov/hhes/www/cpstables/032010/health/h09_000.htm
Table 14: Health Insurance Coverage Status by Nativity and Citizenship for
Hispanics, 2009 (%)
Population
group
Not
covered
Total
population
Nativeborn
Foreignborn
Naturalized
32.4
Non-citizen
Private
Group
Direct
coverage
purchase
36.5
3.3
Medicaid
Government
Medicare
Military
26.5
6.7
2.0
21.8
40.9
3.4
33.0
5.9
2.8
50.3
28.9
3.2
15.3
8.0
0.7
29.1
44.1
5.2
14.9
17.5
1.7
59.3
22.4
2.3
15.5
4.0
0.3
Data from U.S. Census Bureau, Current Population Survey, 2010. Annual social and economic
supplement. Accessed at http://www.census.gov/hhes/www/cpstables/032010/health/h09_000.htm
58
7. Discrimination, racism and stress
The stress induced by personal experiences of racial bias is viewed as one mechanism by
which racism in the larger society can affect health. Mental health is the most frequently
studied outcome of the effects of discrimination on health. Further research is needed to
assess the extent to which discrimination and the negative emotional states created by
discrimination might lead to health behaviors, such as impaired sleep patterns, decreased
physical activity, increased tobacco and substance use, and overeating, all of which may
ultimately be risk factors for chronic illnesses.188
The current evidence in support of the impact of discrimination and racism on physical
health is variable. A 13-year longitudinal study by the National Panel Survey of Black
Americans that focused on perceived and experienced racism and the effects on mental
and physical health found that the impact varied over the time frame of the study. 189
The CARDIA study of young black and white adults found that stress induced by racial
discrimination has as much or more of an impact on blood pressure as smoking, lack of
exercise, and a high-fat, high-sodium diet.190 The blood pressure of black adults who
reported that they typically accepted unfair treatment and had experienced racial
discrimination was about 7 mm Hg higher than for those who reported that they
challenged unfair treatment and racial discrimination.
A study of African American women found that, among smokers and drinkers, past year
racism was positively correlated with the number of cigarettes and drinks consumed.
Lifetime racism was negatively related to perceived health, and positively related to
lifetime history of physical disease.191
Nearly one in three African Americans has high blood pressure, compared with one in
four whites. High blood pressure also begins at an earlier age for African Americans and
is usually more severe.192 Could these differences be explained by stresses due to
discrimination?
In a study of the effect of racial and ethnic discrimination on health, David Williams and
his colleagues suggested that, in studying how individuals confront and adapt to
discrimination, it is also important to focus on the potential positive, as well as negative,
consequences.193 They posit that some stressful life experiences can change people’s
perspectives in ways that can improve and enhance their coping capacity and make them
better able to deal with future stressful experiences.
7.1
Residential segregation
Despite increased racial and ethnic diversity, American neighborhoods continue to be
segregated, and indeed some of the progress made toward integration since 1980 has
come to a halt this decade, according to a recent report that analyzed 2005-2009 data
from the U.S. Census Bureau’s American Community Survey. 194
59
The report found that African Americans are still the most segregated minority,
especially in major cities, and in some cities (New York, Milwaukee, Newark, Detroit
and Chicago) the levels of segregation for the black population are the same as those 30
years ago. An “Index of Dissimilarity” which measures how evenly two racial groups are
spread across neighborhoods, was used to analyze segregation. The lowest possible value
is zero, which indicates that the percentage of each group in every neighborhood is the
same as their overall percentage in the metropolitan areas. The highest value of 100
indicates that the two groups live in completely different neighborhoods. By this criteria,
Black-White segregation averaged 65.2 in 2000 and 62.7 in 2009. In 2009, the average
white person in metropolitan America lived in a neighborhood that wais 77 percent
White. Still, this represents growing diversity compared to 1980, when the average was
88 percent White. 195
Hispanic-White segregation was 51.6 in 2000 and 50 in 2009, and Asian-White
segregation has grown from 42.1 to 45.9 over this same timeframe. Immigration was a
major factor in the Asian and Hispanic numbers. Segregation of Asians from Whites has
begun to increase and is now almost as high as segregation of Hispanics.
Williams and others have argued that racial residential segregation is the cornerstone on
which Black-White disparities in health status have been built in the United States
because it shapes socioeconomic conditions for African Americans not only at the
individual and household levels, but also at the neighborhood and community levels.
They see residential segregation as not just a key determinant of racial differences in
socioeconomic mobility, but also as leading to social and physical risks in the residential
environments that adversely affect health.
For example, residential segregation affects the quality of education and educational and
employment opportunities. 196 Research using data from Census 2000 showed that the
average black household with an income over $60,000 lived in a neighborhood with a
higher poverty rate than did the average white household earning less than $20,000. And
while the average white elementary student attended a school where about 35 percent of
classmates were eligible for the reduced-price lunch program – an indicator of poverty –
the average African American or Hispanic student attended a school where 65 percent of
classmates were eligible.197 In other words, separate – in both neighborhoods and schools
– still means unequal.
It has been estimated that the elimination of residential segregation would lead to the
disappearance of black-white differences in earnings, high school graduation rates, and
idleness and reduce racial differences in single motherhood by two-thirds.198
In contrast, the consequences of the segregation of Hispanic, Asian and Pacific Islander
metropolitan populations are unknown, as is the impact of immigrants on segregation.
60
7.2
Indian reservations
The prevalence of high poverty rates on American Indian reservations suggests the need
to explore the extent to which reservation life reflects the problems associated with inner
city poverty and segregation.
About 40 percent of American Indians live on reservations, where typically tribal and
federal governments are the largest employers. The scarcity of jobs and lack of economic
opportunity mean that, depending on the reservation, 40-80 percent of adults on
reservations are unemployed. Many households earn only social security, disability, or
veteran’s income. The overall percentage of American Indians living below the FPL in
2008 was 28.2 percent, but poverty rates on some reservations were as high as 63 percent.
There is a housing crisis on reservations with many families living in substandard and
over-crowded housing that lack utilities as important as running water, telephones, and
electricity.199
However, these very real and problematic issues are off-set by some key advantages.
These include the fact that reservations provide a cultural base with the ability to share a
traditional way of life and speak the native language, a strong sense of family and
community, and ready access to social services and assistance programs.
In the same way that the legacy of slavery and discrimination has permeated African
American life, so too the lives of today's Indian elders are likely to have been influenced
by the history of oppression and repression experienced since North America was
colonized by Europeans. The disenfranchisement, the tradition of extermination, the
broken treaties, the forced marches of the 18th and 19th centuries, and the Indian
boarding schools are part of the context of the world and family experiences for many
American Indians.
61
APPENDIX 1: HOW DISPARITIES DATA ARE
COLLECTED
1. OMB requirements for the collection of racial and ethnic data
In 1997, the Office of Management and Budget (OMB) released the revised standards for
the collection of race and ethnicity known as Statistical Directive 15 and required federal
agencies to comply with these by January, 2003. These new standards included selfidentification as the preferred data collection method and the ability to report multiple
races for an individual. These standards were further revised in 2003.200
Development of these data standards stemmed in large measure from the enforcement of
civil rights laws. Data were needed to monitor equal access in housing, education,
employment, and other areas, for populations that historically had experienced
discrimination and differential treatment because of their race or ethnicity. The categories
thus represent a social-political construct designed for collecting data on the race and
ethnicity of broad population groups in the United States.
The minimum race categories for the 1997 OMB standards for collecting data on race and
ethnicity are: American Indian or Alaska Native; Asian; Black or African American;
Native Hawaiian or Other Pacific Islander; White. The minimum ethnicity categories
are: Hispanic or Latino; not Hispanic or Latino. The OMB standards allow for additional
race categories to be collected, although they must be additive (i.e., non-overlapping
subcategories) within the minimum set of race categories. Finally, the respondent
instructions specify “Mark (X) one or more races” to indicate what this person considers
himself/herself to be, which allows for multiple-race responses.
The 2003 revision of the standards for vital certificates recommends the following race
and ethnicity categories, which are in principle the same as those used for the 2000 and
2010 decennial censuses.
1. Hispanic Origin
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino (with space to write in group)
2. Race
White
Black or African American
American Indian or Alaska Native (with space to write in principal tribe)
Asian Indian
Chinese
62
Filipino
Japanese
Korean
Vietnamese
Other Asian (with space to write in race)
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (write in race)
Other (write in race)
The current format allows for multiple-race reporting for an individual, but not multiple
ethnicities.
There is an issue of comparability between data based on the 1997 race and ethnicity
categories and the more detailed 2003 categories. The National Center for Health
Statistics, with the help of the Census Bureau, has made efforts to estimate the resulting
respondent differences and mitigate the comparability issues.201
Other data collection requirements
For birth certificates, currently the race of the newborn is not collected and, for
reporting purposes, it is based on the race of the mother, which she is to self-report.
For death certificates, it is usually the responsibility of the funeral director to elicit
race and ethnicity of the decedent from a family member or responsible party.
2. ACA requirements for the collection of data on racial and
ethnic disparities
The ACA (Affordable Care Act) recognizes that greater efforts are needed to quantify
racial and ethnic disparities in health care, to investigate their causes and impacts, and to
implement and evaluate interventions to address them. There is a significant number of
provisions in the ACA that require the collection and analysis of data on racial and ethnic
health care disparities. These data will be critical for guiding both government policy
and the programs and practices of individual health care institutions and providers.
Section 4302 (Understanding health disparities; data collection and analysis) of the ACA
amends the Public Health Service Act to expand the current requirements for the
collection and analysis of health disparities data. By 2013, all federally-funded health
programs and population surveys will be required to collect and report data on race,
ethnicity, primary language and other indicators of disparity identified as appropriate by
the Secretary of DHHS. This provision also strengthens data collecting and reporting
63
mechanisms in Medicaid and CHIP, bringing them up to the same standards as for
Medicare.
The Secretary is required to ensure that these data are analyzed to detect and monitor
trends in health disparities and to disseminate this information to the relevant Federal
agencies and to the public. The OMB categories of race and ethnicity will be the
minimum standard, and the use of over-sampling is authorized to produce statistically
reliable estimates.
3. Issues around collecting the data
Improvements in data collection and reporting have the potential to raise public
awareness about racial and ethnic health care disparities and drive new evidence-based
initiatives that are effectively targeted. However, there are some barriers that, unless
addressed, will hinder implementation efforts and limit the usefulness of the data
collected.
To ensure that these new requirements are maximally effective, their implementation will
need to address a number of issues:
•
Design of questions that will allow patients to self-identify their race and ethnicity
accurately and without resistance.
•
Provision of a standard approach for rolling up these individual responses into the
OMB categories for analytical and reporting purposes.
•
Collection of information about spoken English language proficiency, the
preferred language for health-related encounters information, the language spoken
by the patient at home, and the language in which the patient prefers to receive
written materials.
•
Standardization of the way data on racial and ethnic disparities are collected
across the various agencies of DHHS and the development and promulgation of
best practices in this regard.
•
Requirements and incentives to ensure that all health insurance plans and
providers, regardless of whether they receive federal funding, collect, use and
share data on racial and ethnic disparities to agreed standards and methodologies.
•
The use of education and awareness materials to inform patients, providers and
health plans about the need for data collection on racial and ethnic disparities.
•
Training programs and resources, including health IT, to facilitate the collection
of these data to the agreed standards.
64
•
More research to improve the science of evaluating interventions to reduce
disparities, and the dissemination and uptake of best practices in this area.
•
Strong national leadership and coordination of efforts.202
There have been many recent reports and reviews in this area. It will be important to
utilize the knowledge base that these provide.
65
APPENDIX 2: THE CONSEQUENCES OF RACIAL AND
ETHNIC HEALTH DISPARITIES
1. Health status (self assessed)
While self-reported health is subjective, there is evidence that it is a strong prognostic
indicator for subsequent mortality for both genders and all racial/ethnic groups. A study
that used pooled 1986–1994 data from the National Health Interview Survey (NHIS)
found strong associations between self-reported health status and both socioeconomic
status and subsequent mortality. A self-report of fair or poor health was associated with
at least a twofold increased risk of mortality for all racial and ethnic groups. Even after
adjustment for socioeconomic status and measures of comorbidity, a significant relation
was found between self-reported health status and subsequent mortality. 203
Minorities in the United States generally rate their health as poorer than Whites. In the
2005 NHIS, nearly 20 percent of Blacks rated their health as fair or poor, compared to
17.8 percent of Hispanics, 16 percent of American Indians/Alaska Native, and 11 percent
of Whites.204 The currently available data from the 2010 NHIS are not broke down this
way and are not as detailed. It shows 54.4 percent of African Americans reporting
excellent or very good health, compared to 58.8 percent of Hispanics and 70.2 percent of
Whites.205
Almost half of African American adults report having a chronic illness or disability. The
disparity in chronic illness between Blacks and Whites persists across income levels and
after adjusting for age.206 Access to quality primary care is associated with reduced racial
and ethnic disparities in self-rated general and mental health status. This relationship is
particularly pronounced for the racial and ethnic minorities living at or below poverty
level.207
The importance of equitable access to health care services in reducing racial and ethnic
disparities is further highlighted by Canadian research. Unlike the United States, health
care access in Canada is not strongly determined by SES, which may explain why the
socioeconomic perspective fails to explain racial/ethnic variance in self-reported health
status that country.208
2. Risk factors
Disparities are widespread across a number of risk factors for disease and disability,
including obesity, smoking, diabetes, and hypertension. 209
66
2.1
Obesity
Obesity is debilitating and is often a catalyst to chronic illness. More than one-in-four
Americans (over 60 million people) are classified as obese (i.e. having a body mass index
of 30.0 or higher).210
Adult obesity rates for African Americans and Hispanics are higher than those for Whites
in nearly every state of the nation. Adult obesity rates for African Americans are greater
than or equal to 30 percent in 43 states and the District of Columbia. In nine states, the
rates exceed 40 percent. Adult obesity rates for Hispanics are greater than or equal to 30
percent in 19 states.211
Higher rates of obesity translate into higher rates of obesity-related diseases, such as type
2 diabetes and heart disease, so it is no surprise that African Americans and Hispanics
have higher rates of diabetes, hypertension and heart disease than other groups.212
The growing incidence of childhood obesity is a particular problem, as too often
overweight children grow into overweight adults, with all the accompanying health
problems. Obesity rates are higher for African American and Hispanic children and
adolescents than for their white peers. African Americans girls and Hispanic boys are at
greatest risk for being obese. Obesity rates for American Indian children are comparable
to those for African American children, and Samoan children also appear to be at high
risk. Asian American children are less likely to be obese. Although poor children are
more likely to be obese, this link varies across racial and ethnic groups.213
Increasing obesity rates present an international challenge, with the United States in the
unenviable position of usually ranking highest on the obesity tables.
2.2
Physical activity
A number of studies have demonstrated racial and ethnic disparities in leisure-time
physical activity, such that African Americans, Hispanics, Asians and Pacific Islanders
tended to be less physically active compared to Whites. 214
Not surprisingly, the ability of racial and ethnic minorities to engage in moderate and
vigorous physical activity is linked to the environment and to access to facilities, and
minorities generally have less supportive home and neighborhood environments for
activity and fewer convenient facilities. 215
Physical activity can also be occupationally related. Among employed individuals,
African Americans and Hispanics had significantly more individuals reporting no leisuretime physical activity compared with Whites. Hispanics had the greatest proportion of
individuals reporting no leisure-time physical activity, but significantly more Hispanics
had physically active occupations. Among employed Hispanics, Cubans and Dominicans
were most likely to report no leisure-time physical activity, and Mexicans had the
greatest percentage of workers with a physically active occupation.216
67
Although physically active occupations may be one of the factors that keep Hispanics in
better-than-average health, there is a down side: Hispanics workers have high rates of
fatal occupational injuries. Factors that potentially increase health and safety risks for
these workers include employment in high risk jobs, language and communication
barriers at work, inexperience, lack of information about health and safety and legal
rights on the job, and limited job options that may make individuals hesitant to speak
up.217
2.3
Diet and nutrition
Dietary and nutritional factors underlie many conditions (e.g., infant mortality,
cardiovascular diseases, diabetes, and certain cancers) that contribute to health disparities
between minorities and whites. Evidence is mixed regarding dietary differences by race
and ethnicity. Some research suggests that fruit and vegetable consumption is
comparable for African Americans and Hispanic middle-aged and older adults compared
to Whites. Other studies have found that African Americans consume less fruits and
vegetables than Whites.218
As previously discussed, the ability to purchase fresh produce is more limited for racial
and ethnic minorities.
2.4
Diabetes
Diabetes is a major risk factor for heart and kidney diseases and other conditions causing
severe disability. American Indians and Alaska Natives are at the greatest risk for
diabetes; nearly 18 percent of this population suffers from diabetes, and the prevalence is
2.8 times the overall rate. Nearly 15 percent of African Americans and 14 percent of
Hispanics have been diagnosed with diabetes compared with 8 percent of Whites219.
African Americans are from 1.4 to 2.2 times more likely to have diabetes than Whites.
For Hispanics, the highest rates for type 2 diabetes are among Puerto Ricans and the
lowest rates are among Cubans. Major groups within the Asian and Pacific Islander
communities (Japanese Americans, Chinese Americans, Filipino Americans, and Korean
Americans) all have higher prevalence for diabetes than Whites.220
Minorities also have higher rates of complications from diabetes. For example, the rate
of diabetic end-stage renal disease is 2.6 times higher among African Americans than
among Whites, and rates of blindness due to diabetes are twice as high for minorities as
for Whites. Diabetes-related mortality rates for African Americans, Hispanic Americans,
and American Indians are higher than those for white people. Asians and Pacific
Islanders have the lowest diabetes-related mortality of any racial/ethnic group in
America.221
Many people with diabetes remain undiagnosed, and those who have reduced access to
health care are more likely to have their diabetes unrecognized and untreated.222 If
current trends continue, one in every two minority children born today will develop type
2 diabetes at some point in their lives.223
68
Although type 2 diabetes disproportionately affects indigenous populations in the United
States, U.S. territories, and around the world (indigenous people suffer from diabetes at
2-5 times the rate of non-indigenous people), there is no evidence that the high rate of
diabetes among indigenous people is due to their genetic heritage. Recent research has
shown that while there is a genetic component to diabetes that affects people throughout
society, genes are no more important for indigenous people than for anyone else. It is
social disadvantage and aspects of the social environment such as poor diet, reduced
physical activity, stress, low birth weight, and other factors linked to poverty that are
responsible for the high rates of diabetes among these populations.224
2.5
Hypertension
African Americans have the highest prevalence of hypertension, and consequently
disproportionately higher rates of fatal stroke, death from heart disease, congestive heart
failure, and hypertension-related end-stage kidney disease than Whites. Thus, it is not
surprising that hypertension accounts for most of the difference in mortality between
African Americans and Whites.225 Hispanics have a similar prevalence rate of
hypertension to Whites, but they are 20 percent less likely to be aware of having
hypertension and 31 percent less likely to be treated for this condition.
Hypertension is a major cause of disparities in mortality between black and white
Americans because of the differences in prevalence and in hypertension control.226
Although systems-level barriers (e.g., lack of access, medication costs, high copayments) adversely affect blood pressure control, most cases of uncontrolled
hypertension in African Americans occur in patients with access to care. It has been
postulated that factors such as poor adherence to prescribed medications, poor knowledge
about hypertension, patients’ health beliefs, and their reluctance to engage in lifestyle
modifications may be important.227
It has been estimated that racial disparities in hypertension control contribute to nearly
8000 preventable deaths from heart disease and stroke annually among black adults in the
United States.228
2.6
Smoking
Tobacco use is the most common cause of preventable death in the United States and
contributes to increased morbidity and mortality from a variety of diseases, including
cancer, heart disease, and stroke. The risk of cancer associated with tobacco use is
especially pronounced. Asian American groups tend to have the lowest lung cancer and
heart disease rates across ethnic groups. On the other hand, African Americans seem to
be at greater risk for the negative effects of cigarettes.
Black men and women are more likely to get lung cancer and die from it than white men
and women. One explanation for this difference in lung cancer risk is the higher rate of
69
menthol cigarettes used by African Americans as compared to Whites (75 percent vs. 25
percent). Menthol cigarettes may increase nicotine and toxin absorption as smokers often
take in more smoke and hold it in longer due to the numbing effect of menthol.229
In 2009, the prevalence of current use of a tobacco product among persons aged 12 or
older was 11.9 percent for Asians, 23.2 percent for Hispanics, 26.5 percent for African
Americans, 29.6 percent for Whites, 36.6 percent for persons who reported two or more
races, and 41.8 percent for American Indians or Alaska Natives. These data, collected as
part of the annual National Survey on Drug Use and Health (NSDUH), include use of all
tobacco products. Figure 14 shows how smoking rates have declined for all population
groups except people reporting two or more races and American Indians/Alaska Natives
since 2005.
Current cigarette smoking among youths aged 12 to 17 in 2009 was more prevalent
among whites (10.6 percent) than Hispanic (7.5 percent), African American (5.1 percent),
and Asian (3.0 percent youths). The smoking prevalence rate for American Indian or
Alaska Native youths aged 12 to 17 declined dramatically from 18.9 percent in 2008 to
11.6 percent in 2009.230
Figure 14:
Current tobacco use rates, by race and ethnicity, 2009
Data from Substance Abuse and Mental Health Services Administration (2010). Results from the 2009
National Survey on Drug Use and Health: Summary of National Findings. Accessed at
http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm
70
In 2004, the CDC analyzed data collected during 1999-2001 from the NSDUH to look at
the prevalence of cigarette use231 among 14 minority populations. 232 Current cigarette
smoking was assessed by asking respondents, "During the past 30 days, have you smoked
part or all of a cigarette?" Persons who answered "yes" were classified as current smokers
(see Table 15). This appears to be the most recent analysis of this type. Its value is that it
shows the different rate of smoking among the various subpopulation groups.
Table 15: Percentage of youths and adults reporting cigarette use during the
previous month, by race and ethnicity, 1999-2001
Smoking rate
Youth aged 12-17 yr Adults aged 18+ yrs
Population group
Non Hispanic
White
African American
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Asian
Chinese
Filipino
Japanese
Asian Indian
Korean
Vietnamese
Hispanic
Mexican
Puerto Rican
Central/South American
Cuban
Total
16.0
7.0
27.9
11.0
8.1
5.8
7.4
5.2
8.7
10.6
6.8
10.8
11.0
10.8
9.6
12.4
13.8
27.4
25.7
40.4
16.2
12.3
14.8
19.0
12.6
27.2
26.5
23.1
22.8
30.4
21.3
19.2
26.5
Data from Centers for Disease Control and Prevention (2004). Prevalence of cigarette use among 14
racial/ethnic populations – United States, 1999-2001. MMWR 53(03):49-52. Accessed at
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5303a2.htm
2.7
Alcohol abuse
Data from the 2009 NSDUH shows that among persons aged 12 or older, Whites were
more likely than racial and ethnic minorities to report current use of alcohol
(56.7 percent). The rates were 47.6 percent for persons reporting two or more races,
42.8 percent for African Americans, 41.7 percent for Hispanics, 37.6 percent for Asians,
and 37.1 percent for American Indians/Alaska Natives. Alcohol use increased from 2000
to 2009 for all groups, most significantly for Asians and African Americans. 233
Among youths aged 12 to 17 in 2009, Asians had the lower rates of current alcohol use
(6.5 percent), while 10.6 percent of African American youths, 11.9 percent of American
71
Indian or Alaska Native youths, 15.2 percent of Hispanic youths, 16.1 percent of white
youths, and 16.7 percent of youths reporting two or more races were current drinkers.
The rate of binge alcohol use was lowest among Asians (11.1 percent). Rates for other
racial/ethnic groups were 19.8 percent for African Americans, 22.2 percent for American
Indians or Alaska Natives, 24.1 percent for persons reporting two or more races,
24.8 percent for Whites, and 25.0 percent for Hispanics.
Figure 15: Current, binge, and heavy alcohol use among persons aged 12 and
older, by race and ethnicity, 2009
Data from Substance Abuse and Mental Health Services Administration (2010). Results from the 2009
National Survey on Drug Use and Health: Summary of National Findings. Accessed at
http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm
2.8
Substance abuse
Data from the NSDUH show that in 2009, illicit drug use among persons aged 12 or older
varied by race/ethnicity, with the lowest rate occurring among Asians (3.7 percent).
Rates were 18.3 percent for American Indians/Alaska Natives, 14.3 percent for persons
reporting two or more races, 9.6 percent for African Americans, 8.8 percent for Whites,
and 7.9 percent for Hispanics234 (see Figure 16).
72
Figure 16:
2009
Illicit drug use among persons aged 12 or older, by race and ethnicity,
Data from Substance Abuse and Mental Health Services Administration (2010). Results from the 2009
National Survey on Drug Use and Health: Summary of National Findings. Accessed at
http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm
The rates of illicit drug use were higher for all population groups than the rates in 2000,
with the exception of people reporting two or more races (see Figure 17).
Asians as a group have the lowest rate of current illicit drug use, but the combined 1999
and 2000 NSDUH data show that there are variations among the various specific Asian
subgroups. For persons aged 12 and older, the rates for illicit drug use ranged from 1.0
percent of Chinese and 2.1 percent of Asian Indians to 6.9 percent of Koreans, 5.0
percent of Japanese, and 4.3 percent of Vietnamese. For the Hispanic population groups,
rates were 10.1 percent for Puerto Ricans, 5.5 percent for Mexicans, 4.1 percent for
Central or South Americans, and 3.7 percent for Cubans. 235
73
Figure 17: Current illicit drug use, by race and ethnicity, 2000 and 2009
Data from Substance Abuse and Mental Health Services Administration (2010). Results from the 2009
National Survey on Drug Use and Health: Summary of National Findings. Accessed at
http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm
The rates of illicit drug use are linked to cigarette and alcohol use. In 2009, the rate of
current illicit drug use was approximately 9 times higher among youths aged 12 to 17
who smoked cigarettes in the past month (52.8 percent) than it was among youths who
did not smoke cigarettes in the past month (5.9 percent). Among youths aged 12 to 17
who were heavy drinkers (i.e. consumed five or more drinks on the same occasion on
each of 5 or more days in the past 30 days), 69.9 percent also were current illicit drug
users, which was dramatically higher than the rate among those who were not current
alcohol users (5.2 percent).236
2.9
Access to prenatal care
The low levels of access to prenatal care for African American and American
Indian/Alaska Native women is a contributing factor to both infant and maternal
mortality rates (see Figure 18). The high rates for of care for the Asian/Pacific Islander
population group mask the fact that Asian women have the highest rates of care of all
groups ( it was 86 percent in 2001) and Native Hawaiian/Other Pacific Islander women
have quite low rates of care (77 percent in 2001).
74
This is not just a matter of affordable access to care, although that clearly has a role. Even
among women who are provided equal financial access to health care services,
unexplained racial and ethnic disparities persist in the initiation and use of both routine
and specialized prenatal care services. One study of pregnant Medicaid beneficiaries in
several states found that African Americans, Hispanics, and Asian/Pacific Islander
women were less likely to receive services such as prescriptions for multiple vitamins
and iron supplements, complete blood cell counts, analysis of blood type and RH status,
ultrasound, and maternal serum alphafetoprotein than white women. On the other hand,
they were more likely to receive screening tests for diseases related to high-risk behaviors
such as Hepatitis B, drug screening, and HIV tests.237
A large scale prospective study that investigated the effects of early prenatal care on birth
outcomes found all minority races experienced higher rates of intrauterine growth
restriction, gestational hypertension, preeclampsia, preterm labor, preterm premature
rupture of the membranes, gestational diabetes mellitus, placental abruption, placenta
previa, preterm birth, very-preterm birth (less than 32 weeks of gestation), cesarean
delivery, and vaginal bleeding compared with white women. African American women
sustained significantly more fetal loss at every interval throughout the pregnancy and the
neonatal period. After controlling for the fact that African American women were more
likely to have risk factors such as obesity, hypertension, drug use, and smoking, and for
site of enrollment, race remained the most significant predictor of perinatal mortality. 238
The high rate of hypertensive disorders in black women may be a factor here. In the
study reported above, black women had four times the rate of antihypertensive
medication use before pregnancy compared with white women. Preeclampsia accounts
for about 18 percent of maternal deaths in the United States, compared with 15 percent
globally. 239 The increasing incidence of preeclampsia may be due to increasing rates of
obesity, diabetes and high blood pressure. Another possible factor is the high rate of
uterine fibroids in African American women. The lifetime incidence for fibroids is 80
percent for African American women, compared with 60 percent for white women.240
75
Figure 18: Percentage of pregnant women who get prenatal care in the first
semester, by race and ethnicity, 2008
Data from AHRQ National Disparities reports 2003-2009. Accessed at
http://www.ahrq.gov/qual/measurix.htm
2.10 Access to family planning services
African American women are three times as likely as white women to experience an
unintended pregnancy; Hispanic women are twice as likely. In 2002, 15 percent of
African American women at risk of unintended pregnancy (i.e. those who are sexually
active, fertile and not wanting to be pregnant) were not practicing contraception,
compared with 12 percent of Latinas and 9 percent of white women. 241
Research suggests that Hispanic, white, and black women have equal access to family
planning services.242 This could be due to Title X programs and Medicaid expansions
implemented to improve access to family planning services for socioeconomically
disadvantaged women. However, there are differences in the types of services women
received. Specifically, Hispanic women are more likely to receive counseling about tubal
sterilization, and both Hispanic and black women were more likely than white women to
report receipt of counseling for a birth control method in general.
It is clear that for minority women there are issues other than access and affordability at
play in how they use family planning services, specifically patient preferences and
behaviors and provider-related factors. There is some research to suggest that that black
76
women are more likely to report perceived race-based discrimination when obtaining
family planning services.243
Abortion rates
Abortion rates have been declining in the United States for a quarter of a century, from a
high of 29.3 per 1,000 women aged 15–44 years in 1981, to an historic low of 19.4 in
2005. Since then, the long-term decline in the rate has stalled and in 2008 the rate rose to
19.6. In 2008 about one-third of all abortions (36 percent) were obtained by white
women, 30 percent by African American women, and 25 percent by Latinas. The
abortion rates among women in minority communities have followed the overall
downward trend over the three decades of legal abortion. 244
Although this is not reflected in the 2008 data cited above, a study using 2005
Guttmacher data found that African American women consistently have had the highest
abortion rates, followed by Hispanic women. This held true even when controlling for
income except for women below the poverty line, where Hispanic women had slightly
higher rates than black women.245 The Guttmacher Institute has postulated that the
plateau in abortion rates may reflect the current economic pressures facing American
families, 246 and it is possible that these pressures may also be the explanation for the
increasing proportion of abortions in white women observed in 2008.
3. Disease rates
Racial and ethnic minorities have high rates of debilitating disease such as cancer,
diabetes, and HIV/AIDS. One of the most glaring health disparities is apparent in the
African American community, where 48 percent of adults suffer from a chronic illness
compared to 39 percent of the general population. 247
3.1
Cancer
African Americans are more likely to develop and die from cancer than any other racial
or ethnic group. Among American men, for all cancers combined, the rate of new cancer
cases is highest among African American men, followed by White, Hispanic,
Asian/Pacific Islander, and American Indian/Alaska Native men. Death rates are highest
among African American men, followed by White, Hispanic, American Indian/Alaska
Native, and Asian/Pacific Islander men.248
Among American women, for all cancers combined, the rate of new cancer cases is
highest among white women, followed by African American, Hispanic, Asian/Pacific
Islander, and American Indian/Alaska Native women. Death rates are highest among
African American, followed by White, American Indian/Alaska Native, Hispanic, and
Asian/Pacific Islander women.249
77
African Americans experience higher incidence and mortality rates from many cancers
that are amenable to early diagnosis and treatment. For example, they are more likely
than Whites to suffer from colorectal, prostate, and cervical cancers, and they are also
more likely to die from these cancers. 250 Although white women have the highest
incidence of breast cancer, black women have the highest mortality rate from this cancer
among all races and ethnicities. Although black women are just as likely as white
women to get a mammogram, they are less likely to get timely access to quality care if
they then receive an abnormal diagnosis.251
Hispanics have a higher incidence rate of infection-related cancers, including stomach,
liver, and cervical cancers. Hispanic women are less likely to be screened for cervical
cancer than both white and black women. 252
Figure 19: Cancer deaths from all cancers, by race and ethnicity (rate per 100,000
people)
Data from AHRQ National Disparities reports 2003-2009. Accessed at
http://www.ahrq.gov/qual/measurix.htm
78
Screening rates are low for all groups, but particularly for Asians (see Table 15). It is
disconcerting to note that the percentage of women who have had a pap smear in the past
three years has declined since 2000 for all groups except those reporting two or more
races. The rate of screening for colon cancer (as measured by the percentage of people
aged 50 and over that had a FOBT test in the past 2 years) has also dropped by around 50
percent from rates in 2000 for all population groups. This may be due to a greater use of
colonoscopies and other screening mechanisms.
Table 15: Access to cancer screening by race and ethnicity (percentage of eligible
population)
Total
population
Pap smear past
3 years
(2005)
Mammogram
past 2 years
(2005)
FOBT past 2
years
(2003)
White
African
American
Asian
AI/AN
Two +
races
Hispanic
77.9
78.2
80.0
63.9
71.2
83.9
74.4
66.6
67.3
64.5
54.0
67.1
63.6
58.9
17.1
17.4
15.7
12.9
-
12.1
17.5
Data from AHRQ National Disparities reports 2003-2009. Accessed at
http://www.ahrq.gov/qual/measurix.htm
Some support for this contention – or, alternatively, support for the fact that different
surveys collect data differently - is found in the CDC data on colon cancer screening253
(see Table 16). These data, from the Behavioral Risk Factor Surveillance System, asks
about people aged 50 and over who have had an FOBT within the past year or a
colonoscopy within the past 10 years, and shows much higher screening rates that are
arguably more in line with reality.
79
Table 16: Access to colon cancer screening by race and ethnicity, 2002-2008
(percentage of population aged 50 and over)
White
2002
2004
2006
2008
55.3
58.2
62.5
66.2
African
American
51.8
55.3
58.9
62.9
Asian/PI
AI/AN
Other
Hispanic
50.9
39.6
57.0
62.9
54.1
45.2
50.5
57.8
50.4
56.0
58.0
57.9
43.8
46.0
47.1
51.5
Data from Centers for Disease Control and Prevention (2011). Health disparities and inequalities report –
United States, 2011. Morbidity and Mortality Weekly Report Suppl Vol 60. Accessed at
http://www.cdc.gov/mmwr/pdf/other/su6001.pdf
3.2
HIV/AIDS
Minority communities, especially African-American and Hispanics, have been
disproportionately affected by the HIV/AIDS epidemic, with the bulk of the disease
burden borne by the African Americans. From 2005-2008, more than half of the
diagnoses of HIV infection in the United States were in racial and ethnic minorities, with
African Americans accounting for a disproportionate share.
From 2005-2008, African Americans accounted for 49 percent of the total estimated
number of diagnoses of HIV infection in the 37 states and five U.S. dependent areas with
confidential HIV infection reporting in place since at least January 2005. During this time
period, African Americans accounted for 64 percent of the women diagnosed with HIV
infection, 66 percent of HIV infections attributed to heterosexual contact, and 66 percent
of the children diagnosed with HIV.254
In this same three-year time frame, Hispanics accounted for 20 percent of HIV infections
diagnosed, 17 percent of the women diagnosed, 18 percent of all infections attributed to
heterosexual contact, and 17 percent of children diagnosed with HIV.255
80
Figure 20: New cases of HIV/AIDS, by race and ethnicity, 2002-2007
Data from AHRQ National Disparities reports 2003-2009. Accessed at
http://www.ahrq.gov/qual/measurix.htm
HIV/AIDS in children
Racial and ethnic differences in the burden of HIV/AIDS among children have been
apparent since the earliest days of the epidemic. During 1981-86, more than 75 percent
of children with AIDS were African American or Hispanic.
During 2004–2007, the average annual overall rate of diagnoses of perinatal HIV
infection was 2.7 per 100,000 infants aged younger than 12 months. The highest rates
were among African American children (12.3 per 100,000), followed by Hispanic
children (2.0), children of other or multiple races (1.6), and white children (0.5). From
2004 to 2007, the annual rate of diagnoses of perinatal HIV infection for black children
decreased from 14.8 to 10.2 per 100,000), and the rate for Hispanic children decreased
from 2.9 to 1.7 per 100,000. The rates for white children and for children of other or
multiple races did not change significantly. 256
81
3.3
Cardiovascular diseases
Cardiovascular diseases (CVD) are the leading cause of death in the United States, and
disproportionate rates are seen in racial and ethnic minority populations. This is not
surprising given the racial and ethnic differences in cardiovascular disease risk factors
such as smoking, obesity, hypertension and diabetes. Systematically assessing and
quantifying modifiable cardiovascular disease risk factors is therefore crucial in minority
populations.257
The prevalence of CVD is highest in American Indians/Native Alaskans (8.8 percent).
The prevalence among African Americans is only slightly higher than that for Whites, but
overall, African American women have a higher prevalence than white women for four
related conditions - heart failure, coronary heart disease, hypertension, and stroke – and
African American men have a higher prevalence than white men for three of the four
conditions - heart failure, hypertension, and stroke. 258 The prevalence is lower in
Hispanics (5.8 percent) and lowest in Asians/Pacific Islanders (3.9 percent) (see Table
17).
Table 17:
Age-adjusted percentage of coronary heart disease among person aged
18 years and older, by race and ethnicity, 2007.
White
African
American
AI/AN
(2006 data)
Asian/PI
Hispanic
6.5
6.7
8.8
3.9
5.8
Data from DHHS Office of Minority Health, Heart disease data / statistics. Accessed at
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=127
Deaths from CVD do not mirror the prevalence rates. African Americans have
dramatically higher deaths rates than Whites, and American Indians/Alaska Natives and
Hispanics both have lower rates. Asians/Pacific Islanders have the lowest death rates,
especially for women (see Table 18). The bundling of Asians and Pacific Islanders hides
a wide range of death rates. Data from Hawaiian residents show that these range from
180.3 for Japanese and 180.9 for Whites to 313.1 for Native Hawaiians and 366.3 for
Filipinos.259
82
Table 18: Age-adjusted heart disease death rates per 100,000 population, by race
and ethnicity, 2007
White
Men
239.8
African
American
318.8
Women
153.0
208.2
AI/AN
(2006 data)
170.2
Asian/PI
(2006 data)
136.3
Hispanic
113.2
87.3
118.8
165.0
Data from DHHS Office of Minority Health, Heart disease data / statistics. Accessed at
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=127
It is likely that the high African American deaths rates are a reflection of the difficulties
that they face in getting affordable access to health care and the quality of the care they
receive. The reason for the low CVD deaths rates in the American Indian/Alaska Native
population is not clear.
Repeated studies have shown that racial and ethnic minorities are more likely to receive
poor cardiac care than Whites. For example, in spite of their higher mortality and
morbidity for cardiovascular disease, African Americans and Hispanics are less likely to
undergo treatment for their conditions and are especially less likely to receive hightechnology cardiac procedures, such as cardiac catheterization and coronary
revascularization. 260
3.4
Asthma
Asthma affects over 6.8 million children and adolescents in the United States. There is
profound variability in the prevalence and morbidity of asthma among racial and ethnic
groups.
Asthma prevalence is highest among African Americans, followed closely by American
Indians/Alaska Natives. Over 9 percent of these minority groups suffer from asthma,
compared to 7.6 percent of white Americans, and deaths from asthma, an outcome that
should be wholly preventable through effective management of the disease, are also
higher.261
Disparities also appear to exist in how asthma is treated in minority populations. Even
insured African Americans with asthma are more likely than insured Whites to be
hospitalized for asthma-related health conditions and are less likely to be treated by an
asthma specialist.262
Despite the availability of effective treatment, minority children continue to experience
disproportionate morbidity from asthma. African-American children are about three
83
times more likely to be hospitalized for asthma than their white peers, and about five
times more likely to seek care at an emergency room. Data from 2003-04 showed that
significantly fewer African American and Hispanic children reported using inhaled
corticosteroids, which have been shown improve long-term outcomes of patients with
asthma.263
3.5
Mental illness
The prevalence of mental illness differs between white Americans and racial and ethnic
minority populations. The prevalence of any psychiatric disorder in the past 12 months is
15 percent for African Americans, 9 percent for Asian Americans, 16 percent for
Hispanics, and 21 percent for Whites. American Indians/Alaska Natives have the highest
rates of frequent mental distress, with nearly 18 percent of the population reporting 14 or
more mentally unhealthy days, and this group also has high rates of substance use
disorders and completed suicide.264
Although African Americans and Hispanics have a lower risk of lifetime prevalence of
mental disorders than white Americans, they have a higher risk of persistence (longer
course of illness) and disability from mental illness. Among American Indian tribes, the
lifetime prevalence of any psychiatric disorder is higher (50-54 percent for men, 41-46
percent for women) than among the overall U.S. population (44 percent for men, 38
percent for women).265
Racial and ethnic minorities who meet criteria for a mental disorder diagnosis may be
undiagnosed or misdiagnosed, and disparities exist in both access to and quality of mental
health care for racial and ethnic minority groups. Examples of these disparities include the
underutilization of psychiatric services by persons from ethnic minority groups, problems
in getting people from these groups to seek treatment, and the inappropriate prescribing
of antipsychotic medications for African Americans and Hispanics. African Americans
and Hispanics are less likely than Whites to receive guideline-based care for depression
and anxiety.266
Many minorities face barriers in accessing mental health care, particularly with cost of
care and fragmented services. Limited English proficiency and limited health literacy
also pose barriers for immigrant populations. In a 2007 study, only 8 percent of Hispanics
who did not speak English and who reported a need for mental health services, received
services. Likewise, of the non-English speaking Asian/Pacific Islander population who
reported a need for mental health services, only 11 percent received services.267
Only 20 percent of American Indians report that they access care through the IHS. A
study of Southwest and Northern Plains tribal members living on or near reservations
found that they are less likely than the overall population to seek help for mental illness
from specialists, other medical providers, or traditional or spiritual healers.268
84
Suicide rates are highest in White and American Indian/Alaska Native populations (see
Figure 21). There has been no significant change in these rates over the period 20012005.
85
Figure 21:
Suicide deaths, by race and ethnicity, 2005
Data from AHRQ National Disparities reports 2003-2009. Accessed at
http://www.ahrq.gov/qual/measurix.htm
3.6
Injury
Racial and ethnic minorities, including African Americans, Hispanics and American
Indians, suffer disproportionately high rates of unintentional injuries. The increased death
and suffering caused by unintentional injuries in these populations reflect in part the
inequities that these population groups suffer with regards to SES, type of employment,
and hazardous exposures. Each of these determinants has been shown to play a major role
in the increased incidence of injury. Some of these issues and their impacts on health are
discussed in previous sections describing SES and the built environment.
Research has shown that race/ethnicity is a significant predictor of the number of
workdays missed in injured respondents. Among men, both Hispanic and African
Americans missed significantly more days than Whites, and African American women
missed significantly more days than white women. The implications of this finding are
not entirely clear, as a combination of demographic, work-related, biomedical, economic,
and psychosocial factors is believed to influence how long injured workers are absent
from work.269
86
Children
Accidental injury continues to be the greatest danger to children, causing more than half
of all childhood deaths. The leading causes of death among children ages one to 14 years
are motor vehicle crashes, drowning, and fires/burns. 270
Among children ages 14 years and under, black and Native American/Alaska Native
children experience the highest rates of unintentional death and injury. Native American
children are nearly twice as likely to die from an unintentional injury as white children.
The unintentional injury death rate for black children is one and a half times that of white
children. Children from lower income families and those living in rural areas are at
increased risk. 271
Areas of disparity in unintentional injury in infants, children and youth include:
•
•
•
•
Motor-Vehicle--Traffic Injury. American Indian/Alaska Native infants and children
are disproportionately affected by motor vehicle and traffic accidents. This finding
might be attributed, in part, to the rural residence of many of this population group, as
motor vehicle death rates are higher in rural areas than non-rural areas. Other risk
factors for this population groups include lack of passenger restraint use and alcohol
consumption.272
Drowning. Between 2000 and 2007, the fatal unintentional drowning rate for African
Americans across all ages was 1.2 times that of Whites. For American Indians and
Alaskan Natives, this rate was 1.7 times that of Whites. Factors such as the physical
environment (e.g., access to swimming pools) and a combination of social and
cultural issues (e.g., valuing swimming skills and choosing recreational water-related
activities) may contribute to the racial differences in drowning rates.273
Fire and Burn Injury. Fires and burns are a major cause of injury death among black
children. Racial disparities in such rates are linked to economic factors, poor housing,
and substandard electrical and heating systems. Minorities also are less likely to
engage in safety practices (e.g., using fireplace guards, turning down water heater
settings, and using smoke alarms).274
Suffocation/Choking. Unintentional suffocation/choking is a larger problem for
Blacks and American Indians/Alaska Natives aged 0-9 years than for Whites,
Hispanics, and Asians/Pacific Islanders. High suffocation rates among black infants
might result from greater use of the stomach sleeping position and bed-sharing
compared with Whites.275
87
Figure 22: Unintentional injury death rates for children aged 0-14 years, by race
and ethnicity, 2000-2004
Data from Safekids USA. Children at high risk. Accessed at
http://www.safekids.org/assets/docs/ourwork/research/high-risk.pdf
With regard to intentional injury disparities, homicide rates are highest among black
children. The majority of homicides of children aged less than 10 years are perpetrated
by family members, particularly parents or guardians, and represent the most severe form
of child maltreatment. Head trauma and brain damage due to violent shaking are the most
common causes of fatalities attributed to child abuse.276
The high homicide rates among black teenagers have been discussed previously.
Homicide among children aged 10-19 years is more likely to involve a weapon. Risk
factors include poor behavioral control, a history of early aggressive behavior, substance
abuse, exposure to family violence, poor parental monitoring and supervision, low
academic performance, and involvement in gang activity. 277
Young adults
The three leading causes of death for Americans in their twenties are tied to risky
behavior and are largely preventable: accidents (unintentional injuries), homicide, and
suicide. Together, these three causes accounted for 69 percent of the 42,000 deaths in this
age group in 2007.278 There are considerable variations among racial and ethnic groups
and between sexes (see Table 19). The death rate is more than two and a half times
higher for men than women among Whites and about three times higher for young men
88
among Hispanics and African Americans. These disparities are clearly linked to why
these young people die – gun violence, motor vehicle accidents, risky behavior and
substance and alcohol abuse.
Table 19:
Leading causes of death for young adults aged 20-29, by race and
ethnicity, 2007 (deaths/100,000 population)
Cause of death
Injuries
Homicide
Suicide
White
Male
Female
70.8
22.3
6.4
2.6
24.6
5.0
African American
Male
Female
49.0
14.8
102.2
11.3
14.5
2.4
Hispanic
Male
Female
55.7
13.0
28.0
4.0
12.8
2.9
Data from Mary Mederios Kent (2010). Young U.S. adults vulnerable to injury and violence. Population
Reference Bureau. Accessed at http://www.prb.org/Articles/2010/usyoungadultinjury.aspx?p=1
Rehabilitation
There is evidence that minority patients who have suffered traumatic brain and spinal
cord injuries are less likely to be placed in rehabilitation than white patients, suggesting
the existence of inequalities in access to these services. For example, one study found
that even after accounting for injury severity insurance status, African American and
Hispanic patients with traumatic brain injury (TBI) are 15 percent less likely to be placed
in rehabilitation.279 A second study of TBI patients found that at discharge and one year
post-injury, minorities had poorer functional outcomes compared with Whites on all
measures. 280 There are racial disparities in successful employment after spinal cord
injury, particularly between Whites and Hispanics. 281
4. Chronic illnesses and comorbidities
Many studies have demonstrated that uninsured American adults receive less appropriate
care and fewer needed health services than their insured peers.282 Chronically ill,
uninsured patients are four to six times more likely than sick patients with insurance to
have problems accessing care.283 A 2008 survey by the Commonwealth Fund found that
chronically ill adults in the United States are far more likely to skip care because of costs.
More than half (54 percent) of American chronically ill patients did not get recommended
care, fill prescriptions, or see a doctor when sick because of costs.284
A 2001 study looked at the effects of being uninsured on ethnic minorities' management
of chronic illness and found that, compared with insured respondents, uninsured
respondents were much less effective at managing their illnesses.285 The uninsured had
poorly controlled illnesses, frequent health crises, difficulty procuring medication, used
medication incorrectly, demonstrated poor understanding of their illness, and displayed
89
little knowledge of self-care measures or risk awareness. They rarely had a regular
physician or attended a specific health clinic. Lack of money was the primary reason
given for not seeking health care, and respondents often reported feeling extremely ill
before they sought care. Those who had identified and used a free clinic were much less
likely to delay seeking care.
Together, these facts mean that racial and ethnic minorities with chronic illnesses are at
increased risk of disabling and expensive consequences. For example, individuals whose
diabetes is not properly controlled are more susceptible to blindness, nerve damage, limb
amputation or dialysis for the rest of their lives.
Patients with chronic medical illness are known to have a high prevalence of comorbid
depression, which is associated with increased somatic symptoms, morbidity, mortality,
health care utilization, and health care costs. Elders with multiple comorbidities may be
particularly vulnerable to the debilitating impact of depression. 286 The barriers that racial
and ethnic minorities face in accessing mental health services thus contribute further to
the health care disparities faced by chronically ill patients.
Table 20:
Percentage of non-elderly adults with chronic conditions who lack
health insurance coverage
Adults with:
Any chronic condition
- White
- African American
- Hispanic
Percentage uninsured
17%
13%
19%
35%
Data from The Urban Institute (2005). Uninsured Americans with chronic health conditions: key findings
from the National Health Interview Survey. Prepared for the Robert Wood Johnson Foundation by The
Urban Institute and the University of Maryland, Baltimore County. Accessed at
http://www.urban.org/uploadedpdf/411161_uninsured_americans.pdf
90
Table 21:
Percent of adults with chronic illness who lack a usual source of
health care, by insurance status
Adults with
Any chronic condition
- White
- African American
- Hispanic
Percent without a usual source of care
All adults
Uninsured
Insured
11%
38%
5%
9%
36%
5%
11%
33%
5%
20%
46%
6%
Data from The Urban Institute (2005). Uninsured Americans with chronic health conditions: Key findings
from the National Health Interview Survey. Prepared for the Robert Wood Johnson Foundation by The
Urban Institute and the University of Maryland, Baltimore County. Accessed at
http://www.urban.org/uploadedpdf/411161_uninsured_americans.pdf
5. Preventable deaths
The excess rates of chronic illness in minority populations, much of which is preventable,
impose cost burdens on public programs as well as on individuals and purchasers of
private health insurance.
About 84,000 deaths occur in the United States each year due to the health care gap that
separates minorities from non-minorities.287 This is ethically unacceptable, and generates
huge social and economic costs on the individuals and communities involved and on the
public at large.
It has been estimated that in 2009, racial and ethnic disparities cost the health care system
$23.9 billion due to conditions such as diabetes, hypertension, stroke and renal disease –
all of which are amenable to reductions in prevalence through disease prevention and
management. Medicare alone spent an extra $15.6 billion, while private insurers incurred
$5.1 billion in additional costs due to the elevated rates of chronic illness among African
Americans and Hispanics. Over the next decade the total cost of these disparities is
estimated to be approximately $337 billion, including $220 billion for Medicare.288
Receiving medical treatment in a timely fashion is important for reducing mortality and
long-term disability from many conditions, including stroke, heart attack, and bacterial
infections. Minority patients often experience longer wait times for health care, both in
the out-patient and acute care settings.289
Each year in the United States, medical errors cause an estimated 44,000 to 98,000 deaths
and cost an estimated $29 billion in lost income, disability, and increased healthcare
costs.290 Errors and avoidable complications from surgery affect people of color more
91
than Whites. For example, Asians and Hispanics are more likely to die from
complications during hospitalization than Whites, and African Americans are much more
likely to suffer post-operative pulmonary embolism or deep vein thrombosis than
Whites.291
92
APPENDIX 3: THE ECONOMIC COSTS OF HEALTH
DISPARITIES
Health disparities generate a significant human and economic cost that is borne directly
by the individuals involved and indirectly by all Americans. The reduction or elimination
of racial and ethnic disparities in health is not just a moral imperative but an economic
issue.
1. Lost income and labor productivity
The increased burden of disease borne by racial and ethnic minorities adversely impacts
their workforce participation, leading to an increased number of workdays lost due to
illness and lower household earnings.292 Given that chronic illnesses tend to occur at
younger ages in minorities, the number of work years may be shortened or spent in lower
paying jobs. Many of these jobs do not offer paid sick leave or health insurance
coverage, so a vicious cycle is established where poor health means lost income and
missed work and the inability to access affordable health care which increasingly limits
the ability to recover and return to work.
Because health disparities persist across all income levels, this is not just an issue for the
less skilled and those with lower incomes. At every income level, racial and ethnic
minorities have fewer opportunities for prosperity and success because of health
disparities. 293
2. Health care costs
The excess rates of chronic disease borne by minority Americans impose cost burdens on
public programs as well as individuals and other purchasers of private health insurance.
A recent paper from the Urban Institute294 estimated that in 2009, disparities among
African Americans, Hispanics, and Whites as a consequence of elevated rates of selected
chronic illnesses (diabetes, hypertension, stroke and renal disease) and general poor
health cost the health care system $23.9 billion dollars. Most of this expenditure ($15.6
billion) was for Medicare, although private insurers spent $5.1 billion. Out-of-pocket
costs were over $2 billion. Even without taking into any account projected growth in per
capita health care spending, these annual costs will more than double to $50 billion by
2050 as the number of elderly Hispanics and African Americans increases.
Over the 10-year period from 2009 through 2018, it is estimated that the total cost of
these disparities is approximately $337 billion, including $220 billion for Medicare.
In reality these costs are much larger, as this analysis considered only selected chronic
diseases among two minority groups, and they did not include nursing home costs.
93
A study commissioned by the Joint Center for Political and Economic Studies provides
some insight into the full extent of the financial burden that racial and ethnic disparities
are putting on the health care system and society at large.295 The study found that
between 2003 and 2006, 30.6 percent of direct medical care expenditures for African
Americans, Asians, and Hispanics were excess costs due to health disparities. When the
indirect costs of these disparities such as lost productivity, lost wages, absenteeism,
family leave, and premature death inequities were included, the total cost was $1.24
trillion. Eliminating health disparities for minorities would have reduced direct medical
care expenditures by $229.4 billion over the three years studied.
Offsetting these costs to the health care system are the costs of the interventions to
address health care disparities, so it is essential to consider the “business case” for
these.296
These new costs may be attributable to adding health care personnel, better educating
patients or providers, and providing additional services. Any new cost can pose a
substantial barrier to a health care provider’s willingness to introduce and sustain new
interventions. This practical reality holds true even though the intervention may be
expected to add value, by reducing disparities in the care provided, by raising the quality
of services for minority patients, by reducing the downstream need for services, or by
improving the future health of disadvantaged patients.
Table 22: Economic burden of health disparities, 2003-2006
Potential reduction in the indirect costs associated with illness
and premature death if minority health inequalities were
eliminated.
Potential reduction in direct medical care expenditures if
minority health disparities were eliminated.
Percent excess direct medical care expenditures for African
Americans, Asians, and Hispanics that were due to health
inequalities.
$1 trillion
$229.4 billion
30.6%
Data from Thomas LaVeist, Darrell Gaskin & Patrick Richard (2009). The economic burden of health
inequalities in the United States. Joint Center for Political and Economic Studies. Accessed at
http://www.jointcenter.org/hpi/sites/all/files/Burden_Of_Health_FINAL_0.pdf
94
About the author
Lesley Russell is a Visiting Fellow at the Center for American Progress, a Visiting
Professor in the Department of Health Policy at George Washington University, and a
Senior Fellow at the Center for Australian and New Zealand Studies at Georgetown
University. She also has affiliations with the Menzies Centre for Health Policy and the
United States Studies Centre at the University of Sydney.
Dr Russell has substantial experience in working in health policy in the United States and
Australia, both in and out of government. She is actively involved in health policy
research, analysis and commentary across a wide range of issues and a number of
collaborations. A particular focus has been on health care reforms in Australia and the
United States, mental health, Indigenous health, health disparities, and the impact of cost
on patients’ compliance with their treatment and medication regimes
She has a PhD in Biochemistry from the John Curtin School of Medical Research at the
Australian National University, a BA from the Australian National University and a
BSc(Hons) from the University of Tasmania.
95
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