Health care services(1) in the U.S. have been improving for decades. Yet, in many instances, racial and ethnic minorities(2) continue to receive fewer health care services, lower quality services(3) and services later in the progression of illness.(1) Some disparities in health care services can be explained by differences in income, insurance status and medical need. However, there is increasing evidence that racial and ethnic disparities in care persist even after accounting for these factors.(1)

Disparities in health care services not only raise questions about the quality of health care as a whole, they also raise important ethical questions. Disparities in health care play a role in the differences in health status among racial and ethnic groups. Differences in health status may limit economic development in minority communities and, ultimately, across the nation, as the health of one portion of the population is linked to the health of the whole country.(1) These concerns will become more pressing as the percentage of the population belonging to a racial or ethnic minority increases.

The W I D E Scope of the Problem

There are significant differences across racial and ethnic groups in the amount, quality and timing of health care services received. Some examples are shown in Table 1.

Table 1. Examples of Racial and Ethnic Disparities in Health Care.

Cancer Screening: In 1998, 49 percent of Asian women received Pap tests (a screening test for cervical cancer), as compared to the national average of 64 percent.(4)

Diabetes Management: African American diabetics are 30 percent less likely than their white counterparts to have an eye care visit, which is an important part of diabetes management.(5)

Heart Disease Care: African Americans are much less likely to receive critical cardiac care, including diagnostic procedures, revascularization procedures and thrombolytic therapy.(6)

HIV Infection/AIDS Treatment: In 1998, 20 percent of African Americans did not receive the standard care for human immunodeficiency virus (HIV) infection, as opposed to 12 percent of whites.(7)

Immunizations: Sixty-nine percent of older whites received influenza vaccinations, compared with only 50 percent and 48 percent of older African Americans and Hispanics, respectively.(8)

Prenatal Care: In 1996, only 67 percent of Native American women received prenatal care in their first trimester of pregnancy, while 84 percent of white women and 81 percent of Asian women received such care.(9)

The severity of this problem varies by region, institution and population.(10) Though differences in care are documented most often between African Americans and whites,(11) examples can be found among all racial and ethnic groups in many critical areas of health are services. In addition, African Americans,(12) Asians(13) and Hispanics(14) are more likely to report lower satisfaction with those services they do receive.

Disparities are experienced by patients who are insured through private companies, patients who are beneficiaries of public funding and patients who have to pay out of pocket. Even within public programs, where the population is insured and has equal access to services, disparities persist. For example, African Americans under Medicare receive lower levels of care, including fewer office visits, mammograms, and colonoscopies than whites.(15) Within Medicare managed care, African Americans are less likely to receive beta-blockers after a myocardial infarction or have eye examinations if diabetic.(16)

Despite the overwhelming evidence of unequal treatment and available services, most people believe that African Americans and whites generally receive equal quality health care.(17) Similarly, physicians believe that disparities in health care very rarely, if ever, are the result of race or ethnicity.(11)

Reasons for Disparities in Health Care

Socioeconomic Differences: Income

Persons who are poor are more likely to receive fewer and lower quality health care services.(10) Because persons who are in a racial or ethnic minority group are more likely to be poor, they are more likely to receive fewer or lower quality services. Differences in care among minority and white populations are significantly reduced and even disappear in some cases when one accounts for income.(18)

Barriers to Access

Racial and ethnic minorities have lower rates of health insurance. For example, nearly one half of Hispanics under 65 report a time when they were uninsured in the past year, as opposed to one fifth of whites.(14)

Racial and ethnic groups also tend to live in areas with fewer health care providers(19) and limited transportation. Many minorities live in rural areas where there are fewer hospitals and health care centers. Even in urban areas, it may require taking multiple buses, for example, to get to a hospital, or the nearby facilities may be insufficiently staffed or supplied. Minorities generally face more "personal factors" in accessing health care, such as challenges in getting time off work to visit a doctor.(8) The result is that individuals forgo medical evaluation, preventive care and even treatment. People also may seek less cost-effective but more accessible alternatives to regular care, including emergency rooms even for routine needs.(8)

Medical Need

Patients in different racial and ethnic groups may receive different services and treatment because they have different medical needs. For example, African Americans have higher rates of dialysis because they have higher rates of end-stage renal disease than whites, which stem from higher rates of diabetes and hypertension.(20)

Higher rates of disease may come from lower rates of preventive care. Differences in medical need do not explain differences in preventive care because all groups have equal need for preventive services. Preventive care includes services like basic physical examinations and immunizations.

Differences in Health Care Delivery

Even after accounting for differences in income, barriers to access and medical need, racial and ethnic disparities in health care services persist.(1) Such disparities are especially well documented in cardiac care(6) but are seen among most illnesses. While precise reasons for these disparities are not well understood, it is believed that multiple, interacting factors in health care delivery are responsible, including the following:(1)

Language and Cultural Barriers

Very often patients who do not speak English have limited or no access to translation services, making it difficult to communicate with providers. Even if they speak English, cultural barriers may make the health care system especially difficult to navigate.(21)

Provider-Patient Interactions

Tight time and financial constraints may limit care providers' abilities to listen to patients effectively, and prompt them to rely more heavily on information they can observe about patients (including race and ethnicity) and on stereotypes.(1) Even individuals who believe they do not use stereotypes may do so without realizing it.(1) If patients mistrust the system, they may withhold information and prompt care providers to fall back on stereotypes.(1) This negative cycle may be more likely to occur under managed care or other financial structures where cost-containment pressures are particularly high.(19)

Patient Preferences and Biological Influences

Although it is unlikely that patient preferences play a large role in explaining racial and ethnic differences in health care, some researchers have noted that patients within some groups may prefer, refuse or overuse certain treatments.(1) In a few cases, researchers have postulated that differences in biological reactions to drugs may account for some of the difference but studies show the effect is minimal.(1)

Implications

Racial and ethnic disparities in health care services are a critical problem for the United States. They raise moral and ethical concerns, as well as concerns about health and economic impacts on minority communities and the nation as a whole. The issue of disparities in health care is likely to take on greater urgency as the percentage of minority Americans grows. By the year 2050, nearly half of the U.S. population will belong to a racial or ethnic minority.(22)

Impact on Health

Disparities in health care play a role in exacerbating or creating differences in health status among racial and ethnic groups. In some cases, it is has been shown that differences in health care create differences in health outcomes. One study reported that African Americans with coronary disease received poorer quality care and had lower survival rates than whites.(23) Another study showed that African Americans were less likely to receive surgical treatment for early-stage lung cancer and more likely to die sooner.(24)

The link between health care services and health status is, however, not always clear-cut. Although Hispanic women, for example, receive fewer prenatal care services than whites, some Hispanic groups experience lower infant mortality rates.(1),(25)

There is limited data that capture the relationships between health care and health status among racial and ethnic groups, so it is difficult to know which health care differences contribute most to differences in health status. In addition, other factors, such as income, education and culture, play a large role in differences in health status.(10) These factors affect health status by shaping people's daily lives (including their family structure,(26) work environment(27) or behaviors, such as smoking(13)) as well as by influencing their access to health care services.

The link between racial/ethnic disparities in health care and racial/ethnic disparities in health status is made more complicated by the relationship between health status and race or ethnicity. In many instances, minorities have poorer health status than whites.(1) For example, the African American death rate between 2000 and 2002 was 1.10 percent, whereas the white death rate was .84 percent. But minorities do not always fare worse. In the same time period, Hispanics and Asians faced death rates of .64 percent and .49 percent respectively (see Figure 2).(28)

Death rates from individual diseases show similar patterns. For example, African Americans and Hispanics are more likely than whites to die from diabetes but Asians are less likely to die from diabetes.(29) More information is needed to explain the reasons for these differences in health status and the role that differences in health care may play.

The health of the country as a whole is related to the health of individual populations, including racial and ethnic groups.(30) At a biological level, infectious disease can spread from underserved groups to the broader public. Alternatively, resources required to care for a particularly unhealthy portion of the population may limit resources available for the health care infrastructure that supports the entire population.(1) Poor quality of care for one part of the population may also raise questions about the overall quality of care in the U.S.

Impact on Economic Well-Being

Insofar as disparities in health care cause poor health, they may limit professional and economic advancement within minority communities.(1) In turn, this limits the potential of U.S. economic development as a whole. Racial and ethnic disparities also threaten the financial stability of the health care industry and federal government by raising costs for individuals, providers, private insurance and public programs, like Medicare and Medicaid.(1)

Inadequate care today frequently costs more in the future because missed or incorrect diagnoses or ineffective treatment for chronic illness can lead to otherwise unnecessary care. This problem is cyclical because disparities in health care can undermine the public's faith in medical and public health institutions. People then become reluctant to seek care until a problem reaches a critical stage, and costs are higher.(1)

Strategies to Address Disparities

The most promising current strategies to address disparities in heath care include enhancing services, improving access and increasing the number of minorities in health professions. Most of these efforts are in their early stages, and it has not been possible to evaluate their effectiveness fully.(33)

Enhancing Services

Some health care institutions and providers have developed programs that try to equalize care across populations by addressing specific needs of various racial and ethnic groups. The use of community workers, for example, helps providers reach people who might not otherwise seek care.(27) Language-translation services help patients who have difficulty with English. "Cultural competence" education teaches care providers how to better address patients' cultural beliefs and behaviors.(33)

Another strategy for enhancing and equalizing services is to require providers to base decisions on established clinical guidelines. In this way, patients will receive treatments based on medical need, not on race or ethnicity differences.(34)

Improving Access

Creating new programs in minority neighborhoods and increasing transportation to existing services elsewhere are important means of improving access. Increasing the availability of insurance coverage helps increase access as well.(35) To reduce barriers within health plans, experts recommend policies to strengthen the stability of patient-provider relationships over time, so patients can continue to visit care providers they are comfortable with.(1)

More Minorities in Health Professions

Experts believe that having a greater percentage of racial and ethnic minorities in the ranks of health care professionals will help reduce culture and language barriers within the system, and help ensure more providers are available in ethnic and minority communities.(27)

Because the mechanisms that cause disparities in health care have not yet been clearly delineated, there may be additional strategies that would work well. For these reasons, it is important to improve racial and ethnic-specific health services data collection and survey research.

While many health plans do not collect standardized racial and ethnic data, a growing number do.(34) Aetna U.S. Healthcare has implemented a program, "The Minority Health Initiatives," which includes voluntary collection of data on race/ethnicity and language preference. Few health organizations are likely to adopt similar practices unless there is a more compelling business reason to collect data (such as purchasers' consideration of racial and ethnic disparities) or a legislative mandate.

Both supporters and opponents of improved and expanded racial and ethnic-specific data recognize there are ethical, legal and practical challenges and concerns -- especially protecting patient confidentiality and privacy and preventing health plans and others from using the information discriminatorily.

As of 2004, no federal statutes prohibit the collection of racial, ethnic or primary language data. Although an increasing number of policies emphasize the need for such data collection, these policies are not uniform(35) and states can create laws that prohibit health plans from collecting this information.(36)

Given the complexity of the issues at hand, researchers and governmental agencies call for new survey research to understand the causal mechanisms at work.(1),(8) In addition, existing surveys such as MEPS,(37) NHANES,(38) and NHIS(39) could be expanded to include related questions to support these efforts.(8)

Federal Efforts to Date

The federal government plays a significant role in the health care of minority Americans. For example, it finances 45 percent of African Americans with insurance through Medicare, Medicaid and military health care, including the Department of Veterans Affairs and the Department of Defense's TRICARE program.(8) It also provides health care services, particularly preventive care, to minority groups through public health programs.

There have been an increasing number of efforts within federal agencies to document, understand and address racial and ethnic disparities. Important examples include the "Health-care Research and Quality Act of 1999" in which Congress requested that the Agency for Healthcare Research and Quality (AHRQ) produce two complementary annual reports.

The first of these, the National Healthcare Quality Report, addressed quality of care issues generally, noting that equality across populations is a necessary component and the second, the National Healthcare Disparities Report, focuses on health care disparities explicitly.(40) The first set of these reports was released in late December 2003.(41)

Federal organizations have also developed guidelines or quality measures for health care programs. Two examples: a cultural competence measurement profile for health care delivery settings and a disparities quality report card, both produced by the Health Resources and Services Administration (HRSA).(42)

In addition, as part of the regulations surrounding implementation of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000, health plans that participate in Medicare+Choice will be required to participate in a special project on either disparities in health care or cultural and linguistically appropriate services.(43)

What the Physician Can Do

Being informed with the facts about racial and ethnic disparities is an important first step. Physicians can then begin to look for instances where they see the potential for disparate care in the settings around them. For example, they can help patients connect with translation services and ensure that written instructions are provided in multiple languages. In addition, physicians can seek out cultural competence training for themselves and for staff. At the practice or hospital policy level, they can support efforts to train outreach workers and promote standardized data collection.

Summary

Racial and ethnic disparities in health care services in the United States are well documented. Not only does their existence raise critical ethical issues about fairness and equality but the disparities undermine the physical health of the nation and economies of our minority communities. In addition to federal and local legislative efforts, new programs and research will be needed to delineate and then hopefully address these concerns. This is especially critical given the U.S. demographic trends -- by the third quarter of this century, racial and ethnic minorities will be the majority.

Web Sites

http://www.cdc.gov/mmwr

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5419a2.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5419a2.htm

Acknowledgements

Ms. SteelFisher wishes to acknowledge the following people for their contribution to this conference:

Anne C. Beale, M.D., M.P.H., The Commonwealth Fund
Robert J. Blendon, Sc.D., Harvard University
Sheila P. Burke, M.P.A., R.N., Smithsonian Institution
Rachel Garfield, M.H.S., Program in Health Policy at Harvard University
Janet Kline, independent consultant
Thomas G. McGuire, Ph.D., Harvard University
Joseph P. Newhouse, Ph.D., Harvard University
Debra J. Perez, M.A., M.P.A., Program in Health Policy at Harvard University
Cathy Schoen, M.S., The Commonwealth Fund
Stephen C. Schoenbaum, M.D., The Commonwealth Fund
Brian D. Smedley, Ph.D., Institute of Medicine
Mara K. Youdelman, J.D., L.L.M., National Health Law Program
Julie Boatright Wilson, Ph.D., Harvard University
And the generous support of The Commonwealth Fund.