II. Present Racial and Ethnic Disparities in Health Care Documented
A. Populations Adversely Affected by Disparities
Socioeconomic factors other than race and ethnicity also contribute to health care disparities. Lower levels of income and education, substandard housing, poor nutrition, physical inactivity, and inadequate access to health insurance and health care all have an impact on health status and healthcare. Even when controlling for these other factors, however, racial and ethnic disparities remain. Thus, an independent focus on addressing racial and ethnic disparities is warranted. Understanding the racial and ethnic composition of the population is important to understanding which populations are vulnerable or at risk of being disadvantaged in the health care context.
The 2000 United States census shows that nonwhites comprise nearly 30 percent of the United States population. The nonwhite population includes Blacks or African Americans, Native Americans or Alaska Natives, Asian Americans, Hispanic Americans, Native Hawaiians, and other Pacific Islanders. By 2050, these groups are expected to comprise nearly 50 percent of the nation's population. In Massachusetts, racial and ethnic minority residents constitute 20 percent of the population, while in Boston, nearly half of the city's residents are from racial and ethnic minority groups.
Research has indicated that difficulty speaking English, like race, is a barrier to receiving care. Discrimination on the basis of primary language is considered discrimination on basis of national origin prohibited by Title VI of Civil Rights Act of 1964. In 2004, nearly 50 million Americans, or 20 percent, spoke a language other than English at home. A recent study found that even U.S. born African Americans--native speakers of English--were more likely to report discrimination than whites because of how they spoke the language.
Studies have recognized that collecting data is essential to the process of identifying and addressing racial and ethnic disparities in health care. The dynamic nature of the United States population and the evolving ways in which people identify themselves pose challenges, however, to data collection efforts. The data collection challenge, “lies in having a set of race and ethnicity categories that are sufficiently flexible to account for the changing population while ensuring the ability to compare data for different racial and ethnic groups over time” in reliable and usable categories that can be analyzed. In Massachusetts, thirty-one categories are being captured to give patients ways in which to describe themselves.
Research has demonstrated that aggregation of ethnic and national groups into large classifications, such as Hispanic or Asian Americans, masks the diversity and important differences experienced by sub-groups within these populations. For example, a recent study notes that Cuban Americans share socioeconomic characteristics more closely with non-Hispanic whites than with other Hispanic Americans of Puerto Rican or Mexican ancestry. Similarly, U.S. born African Americans suffer greater health problems than African Americans born outside the United States. In addition, Japanese Americans report fewer health problems than non-Hispanic whites, and Vietnamese Americans report more health problems than other Asian Americans. Moreover, age upon arrival in the United States, proficiency in English, and acculturation levels can cause variations even within sub-groups.
B. Illustrations of the Existence of Disparities
Disparities in health care treatment and outcomes occur in a broader legal and societal context. The status of health care services in New Orleans, Louisiana, before and after Hurricane Katrina provides an illustrative example. After Hurricane Katrina devastated New Orleans in 2005, the Kaiser Family Foundation published research examining the pre-Katrina healthcare delivery system for low-income people in New Orleans and how the hurricane affected that system. The assessment concluded that the healthcare delivery system for the poor in Louisiana was in crisis before Hurricane Katrina wrought its devastating impact. The demographics of the New Orleans area immediately prior to Katrina are instructive. At the time, 23 percent of New Orleans citizens were living in poverty as compared with 17 percent of the U.S. population. In addition to high rates of poverty, New Orleans also had one of the highest rates of uninsurance with 21 percent of the nonelderly population having no insurance as compared with 16 percent nationally, and approximately10 percent in Massachusetts.
Louisiana also reported some of the poorest health statistics in the country with high rates of infant mortality, heart disease, diabetes, AIDS cases, and lower than average childhood immunization rates. Most importantly, there were large disparities in the health status of minorities as compared to the white population. One-third of Louisiana residents and two-thirds of New Orleans residents were African American as compared with 12 percent nationally, and were more likely to experience heart disease, diabetes, and asthma than their white counterparts. In addition, Louisiana had high rates of infant mortality, chronic diseases such as diabetes, and AIDS cases. The Medical Center of Louisiana at New Orleans (MCLNO) and related facilities operated by Louisiana State University delivered a large portion of the health care services to low-income, uninsured, and minority populations. Charity Hospital was the hub of the system of 10 hospitals and 350 clinics serving a largely poor, predominantly minority population through inpatient care, networks of outpatient clinics, and one of the busiest emergency departments in the country. This institution accounted for 83% of uncompensated inpatient care and 88% of uncompensated outpatient care in New Orleans. The positive aspect of this arrangement was that it provided a focused approach to providing services to the population served. Such an arrangement also creates, however, a separate system of care for the low-income uninsured.
Before Katrina hit, the number of uninsured was increasing and the volume of services provided by MCLNO was decreasing due to shrinking resources. . ..With 50 percent of its total costs uncompensated, the hospital struggled to secure sufficient revenues simply to sustain operations. The hospital lacked the capital to make much-needed infrastructure improvements. Prior to Katrina, the deterioration of the facility was so severe that the hospital had been threatened with losing its accreditation. Officials had already been exploring options to replace the hospital with a smaller inpatient facility and primary care clinics located throughout the city. . ..
After the hurricane, MCLNO was closed along with most other hospitals in the city.
Most hospitals that have reopened are operating at very limited capacity and with significant financing and staffing challenges. MCLO operated a temporary trauma center and a medical clinic in the Convention Center and then moved to a former department store. A great deal of care has been shifted from New Orleans hospitals to hospitals in other cities such as Baton Rouge. These shifts in patient care may have the effect of reducing the volumes of care provided to low-income populations at these New Orleans institutions. These reductions could jeopardize the ability of these institutions to qualify for special federal payments for serving low-income, uninsured populations, making the financial position of these institutions even more precarious or unsustainable. Roughly forty percent of the total workforce has been furloughed.
What Katrina exposed to the nation was a highly segregated system of health care--a “two-tier” health system segregated by race and income. Katrina caused new levels of dislocation and deprival, rendering New Orleans uninhabitable for weeks, perhaps longer, and causing human suffering incredible by modern standards. But this natural catastrophe also revealed how fragile the social infrastructure was for certain populations in the first place. As David Barton Smith has written, on the fortieth anniversary of the Medicare program which eliminated formal segregation--the system is now still segregated or resegregated. The job of ensuring equality in health care is not finished.
C. Factors Affecting Disparities
Research continues to document racial and ethnic disparities in health care. The studies, while usually focusing on an isolated factor or treatment of a particular condition, recognize that a complex interplay of causes and circumstances may result in such disparities. For example, in Strengthening Medicare's Role in Reducing Racial and Ethnic Health Disparities, a study panel of the National Academy of Social Insurance identified four broad sets of factors contributing to disparities in quality of care: barriers to access to care, cultural and linguistic barriers, beneficiary attitudes and behaviors, and provider attitudes and behaviors. The NASI study panel report noted that access to care, a critical determinant of quality of care, depends on a number of factors, including insurance and the ability of a person to pay cost-sharing amounts such as co-payments and deductibles. To the extent that reforms such as the new Massachusetts health care statute address access to insurance and reduce the deterrent effect of cost sharing, such reforms are thought to have the potential to reduce disparities.
1. Barriers to Access to Care
Access depends on the availability of providers in a community, resources, such as equipment, information and referral networks, available to such providers, office hours, transportation resources, and the absence of other barriers such as lack of paid sick leave. As the NASI Report notes, members of racial and ethnic minority groups tend to obtain care from different individual and institutional providers than do whites. Though most minorities receive services from providers who are white, non-white providers tend to serve more non-white patients. Studies have found that providers who care for minorities are more likely to practice in public, or teaching, hospitals and in low-income areas. Many of these physicians experience difficulties in referring patients to specialists or to higher quality facilities and providers. Having a primary care provider also improves a person's access to care, and racial and ethnic minorities are less likely than whites to have a primary care provider.
2. Linguistic and Cultural Barriers
Linguistic and cultural differences also contribute to differences in quality of care. Beyond the lack of interpretive services and availability of printed materials in other languages for patients with limited English proficiency (LEP), providers from a different ethnic or cultural background than a patient are less able to take into account the patient's point of view or understand barriers to compliance. Some minority groups are skeptical about the heath care system and this mistrust can lead to avoiding the system or refusing procedures and treatments.
3. Patient Attitudes and Behaviors
Members of racial and ethnic minority groups are more likely to be uninsured before becoming eligible for Medicare. This lack of insurance correlates with a deficit in established connections to the health care system. Without these connections, the uninsured do not have experience in finding and using health care services. A lack of health services may contribute to poorer health status which, in turn, may require more extensive medical interventions to achieve parity in health outcomes anticipated from the interventions. Racial and ethnic minorities are more likely to perceive disrespect or unfair treatment due to race or ethnicity.
4. Provider Attitudes and Behaviors
Numerous studies have documented that the race and sex of a patient may influence physicians' recommendations for treatment. Causes range from conscious discrimination to unconscious beliefs or stereotypes about the ability to benefit from, comply with, or afford treatment.
