Friday, April 20, 2018

Elderly -- Health Status

Social Justice, Health Disparities, and Culture in the Care of the Elderly

Excerpted from: Peggye Dilworth-Anderson, Geraldine Pierre, Tandrea S. Hilliard, Social Justice, Health Disparities, and Culture in the Care of the Elderly, 40 Journal of Law, Medicine & Ethics 26 (Spring, 2012)(44 footnotes omitted)


This paper addresses two interconnected concepts -- health disparities and social justice -- as they pertain to screening, diagnosis of disease, and health care access among minority elders in the American society. Health disparities are defined as differences in treatment provided to members of different racial or ethnic groups that are not justified by the underlying health conditions or treatment preferences of patients. Disparities currently exist in many aspects of American health care. For example, when compared to whites, the infant mortality rate is higher for African Americans; health insurance coverage is lower for Latinos and African Americans; and ethnic minorities experience poorer care and survival rates for HIV, even after controlling for other confounding factors including income, insurance, health status, and severity of disease. Among older Americans, health status varies by race, income, and gender. Older minority Americans have consistently been shown to have worse health than whites of the same age group across measures of disease, disability, and self-assessed health. When compared to whites, elderly Latinos have higher rates of diabetes and disabilities, and older African Americans have more chronic conditions.

According to Barry Levy and Victor Sidel (2005), social justice encompasses two distinct ideas based on the underlying themes of justice, fairness, and equity. The first is that individuals should not be denied of economic, socio-cultural, political, civil, or human rights based on the perception of their inferiority by those with more power or influence. This can be exhibited through forms of stigmatization or stereotyping particular groups. The second idea is that society -- as a collective -- must act to ensure the conditions under which people can be healthy, in the form of policies and actions that affect societal conditions. The idea of social justice can be applied directly to all areas of health care, particularly access, diagnosis, and provision.

In the context of health disparities, social justice refers to the minimization of social and economic conditions that adversely affect the health of individuals and communities. Several factors related to social injustice may lead to increased rates of disease, injury, disability, and death. These factors include poverty, inadequate education, lack of health insurance coverage, and limited availability of medical care. Advocates of social justice have long established the need to provide comprehensive health care services that would aid every individual, regardless of income, geographic location, and racial identification. This mission is even more urgent for America's elderly minority population, as reflected by the nation's primary policies in health care. The Healthy People Report of 2010 identifies eliminating health disparities and improving quality and years of life as the two central goals of the nation's health care agenda. These issues remain of critical importance in the Healthy People 2020 initiative. Research has revealed that inequity in the provision of medical needs is more common among older African Americans, older women, as well as those with incomes below the poverty line. The implications of this from a social justice perspective are numerous, as the injustices of health care are reflected through the inability of the most vulnerable minority elders to access quality and equitable care when they need it the most.

The interaction of health disparities, justice, and cultural interpretation of disease is presented as a complex problem that researchers and providers must unravel in order to reduce inequalities in health care, while being aware of cultural differences and promoting equality for all older Americans.

With this concern in mind, in this paper, we use a case study on Alzheimer's disease as an example of the profound disparities and social injustices faced by older minority Americans.

We discuss what we call the conundrum of health disparities -- the intricate and difficult problem of distinguishing between disparities in diagnosis and treatment based on need -- and the role that cultural perception and normalization of disease (in this instance Alzheimer's disease) plays in racial and ethnic minorities being less likely than whites to receive and utilize health care services.

The conundrum takes into account. . . the relationship between disparities, cultural beliefs and perceptions, and lack of social justice in differences in diagnoses, access to care, and screening.

My Aging Minority Rural Grandparents

My Aging Minority Rural Grandparents: Disparities in the Health and Health Care of the Rural Elderly Minority Population and the Need for Culturally Competent Health Care Providers

Camille M. Davidson

Camille M. Davidson,  My Aging Minority Rural Grandparents: Disparities in the Health and Health Care of the Rural Elderly Minority Population and the Need for Culturally Competent Health Care Providers, 21 American University Journal of Gender, Social Policy and the Law 57 (2012) (130 Footnotes)

Camille DavidsonThis is a story about my rural elderly grandparents and how the lack of culturally competent health care providers affects their health and health care. As I write this article, they are ages ninety-two and ninety-six, and they are aging in their rural Mississippi home. As rural elderly African Americans, they beat the odds in a country where African Americans are sicker and die younger than their Caucasian counterparts, and where the health of rural Americans lags behind the population in general.  My grandparents embody the intersection of three of health care's most disadvantaged population characteristics: age, race, and geographic location.

As a result of their age, race, and geographic location, the quality of care they receive is inadequate and their overall health status suffers. Taken separately, each of the three population subsets--the elderly population, the rural population, and the African American population--is a disparity population. So it is no surprise that, when combined, the health of the rural elderly African American lags behind the health of the majority of the population.

Although there are a number of reasons for the inadequate health and health care of such individuals, in this Article I focus on the non-financial barrier of the limited availability of culturally competent health care providers. Most conversations about disparities focus on lack of insurance and other financial barriers to health care. For my grandparents, and other similarly-situated individuals, eliminating disparities means more than removing financial barriers such as access to health insurance.

One of the major components of the Patient Protection and Affordable Care Act (ACA) is an increase in insurance benefits to all individuals.  By 2014, the ACA will require all individuals to have health insurance coverage.  Proponents of health insurance mandates accurately state that lack of health insurance coverage or underinsurance--coverage that does not meet all medical needs--is a major cause of health disparities. Simply *59 stated, when an individual does not have insurance and does not qualify for government assistance, he or she is not inclined to seek needed care. Since lack of insurance and underinsurance disproportionately affect minorities, rural populations, and often the elderly, such populations are less healthy than the general population.  Simply removing financial barriers will not eliminate disparities that exist among these populations, although a reduction of disparities requires affordable health insurance coverage. Data suggest that members of disparity populations with adequate insurance coverage still have a lower quality of health and health care than the general population.  Therefore, non-financial barriers must be addressed.

The patient-provider relationship is essential to quality health and health care.  My grandparents do not have an effective relationship with their health care providers because they do not trust them, which, in turn, is because their health care providers are not equipped to understand their unique cultural needs. In order to eliminate such distrust, medical professionals must be trained in cultural competency. They must be able to communicate with those patients who do not look like them and who do not share their cultural background and beliefs. When health care providers are not culturally competent, the end result is inadequate health care and health disparities for certain population subsets.

As members of the super-elderly community--those over eighty years old--my grandparents are part of the fastest growing segment of our population.  Like others their age, they live daily with chronic illnesses and they have a greater need for health care providers than the general population.  So, while I am fascinated that they have survived to be among *60 the super-elderly who live relatively independently, I am concerned about whether they will continue to thrive as they age.

In Part II of this Article, I define “cultural competency” and discuss the need for culturally competent health care providers. In Part III, I specifically address the provisions of the ACA that address cultural competency training for health care providers. Part IV is a call for action suggesting that lawyers and policymakers will need to come up with innovative programs to make sure culturally competent health care providers are available to serve disparity populations in general and specifically the rural elderly African American population.

II. Cultural Competency and the Rural Elderly African American Population

A.        My Grandparents: Super-elderly, Rural, and African AmericanMy grandparents' circumstances demonstrate the need for health care providers equipped to communicate with the rural elderly African American population. Their interactions with health care providers demonstrate the importance of cultural competency training and the impact such training has on the health and health care of individuals.

As I write this article, my grandparents age at their home in Shaw, Mississippi, a small, rural town of about 2100 people located in the Mississippi Delta.  Shaw, Mississippi is one of several small towns located in Bolivar County.  The town is approximately ninety-two percent African American, and the majority of the population lives near or below the poverty line.  The closest “city” is Cleveland, a small college town of about 12,000.  A drive to downtown Cleveland from my grandparents' home takes approximately twenty minutes along Highway 61.

My grandfather was (and still thinks he is) a farmer, and my grandmother is a retired homemaker. Together they raised six children and sent all of them to college. While they could move near any of those children, they have chosen to grow old in their rural Mississippi home. *61 They currently rely on the assistance of their children, and, most recently, a part-time in-home aide.

Like many other rural elderly African Americans, my grandparents are deeply religious, hardworking, and self-sufficient.  Their beliefs impact the health care that they choose to receive (or not receive) and affect their overall health. They may be inclined to rebuff suggestions by family members to see a physician because they do not instinctively trust their physicians. In their opinion, physicians do not listen to them, do not understand their frustrations and ailments, and do not respect them. Often, my grandparents are inclined to tough it out with respect to ailments or illnesses even though such an attitude may have long-term repercussions. Sometimes, when the ailment does not get better, my grandparents simply think it is “God's will.” Their beliefs and subsequent actions often mean that more serious medical problems may surface later. My grandparents' barriers are not financial. They have private insurance coverage and Medicare. Instead, non-financial barriers are what limit their quality of care.

As I write this article, my grandmother, a diabetic who has nursed a wound on her leg, must now make some decisions regarding surgery. A physician has made recommendations to her, but she does not readily trust the physician or those recommendations. The wound that afflicts my grandmother has been recurrent for almost two years. Although a home health nurse had, until recently, visited every two weeks, her healing has not progressed consistently.

The family encouraged my grandmother to visit her primary care physician. However, she does not connect with him and so does not freely share her health concerns with him. She would rather rely on her children to assist her than attempt to explain her issues to a health care provider, who she perceives as not caring about her.

Eventually, she visited her primary care physician and he referred her to a wound specialist. The specialist spoke “at” her rather than “to” her. He informed her that she needed surgery to remove a clot, and that the procedure would require an overnight hospital stay.

Somehow, in her ninety-plus years, my grandmother had never spent the night in a hospital, so she was understandably reluctant. But family members encouraged her and--dare I say--persuaded her to do what we thought was right for her health and well-being. The doctors told her that *62 she would not even have to stay overnight if the procedure was done early in the morning. At no point were any family members told this would be a two-part process.

On the day of the scheduled procedure, my grandmother arrived at the hospital before 9:00 AM. She had followed doctor's orders and had eaten nothing, so she was hungry. After spending all morning in the hospital, she was told that she would have to reschedule because something had come up. A staff person relayed the information. She did not see the physician that day. She asked for an apology but never received one.

Amazingly, my grandmother rescheduled the procedure, but again there was a breakdown in communication. After spending the day in the hospital, my grandmother (and the rest of the family) thought that she had received the necessary procedure. The physician told her everything went well. Only later, when hospital staff called to say that they needed to schedule the procedure, did she (and we) discover that the sedation was merely evaluative and she had not received the necessary treatment. The lack of communication is the primary reason why my grandmother does not readily accept the recommendations of her physician.

Although my grandfather does not hesitate to visit his primary care physician's office, he also does not trust the physician's diagnoses or recommendations, and does not always follow the recommendations. The end result for both my grandmother and grandfather is a lack of quality health care.

For years, experts studying the medical field have argued that the primary reason minorities do not seek early medical attention is because they are distrustful of the predominantly white system.  My grandparents are no exception. Their health suffers because they distrust their health care providers. Their distrust results from the inability of the health care provider to connect and communicate with his or her rural elderly African American patient.

At a recent symposium, I spoke about this need for culturally competent health care providers. One of the audience members asked me why I suggested that there was a problem when almost all medical schools teach cultural competency. The audience member was correct in that “[c]ulture is the rage in medical schools and hospitals across the country.”  There has been an “explosion of programs designed to teach what is called *63 ‘cultural competence.”’  I maintain that the teaching in the monolithic medical school environment is inadequate.  While medical students believe that their schools teach them cultural competency, disconnect continues to exist between the patient and the health care provider in the clinical setting. “Health care professionals, like many individuals, are reluctant to believe that they themselves engage in discriminatory behavior.”  So, while medical schools are paying attention to the issue, more effective cross-cultural competency training is necessary.

B. The Demise of the Patient-Provider Relationship and the Importance of Cultural Competence

My grandparents often claim that physicians are not what they used to be. They maintain that when they were younger and raising their children, physicians cared about their total person. What has contributed to the apparent demise of the patient-provider relationship? What is cultural competence and why is it important?

Although African Americans have historically distrusted health care providers, my grandparents' reactions to their health care providers most likely changed when the health care delivery model changed. The traditional Fee-for-Service model allowed “health care professionals to address the unique individuality of patients.”  In my grandparents' rural community, they took comfort in the therapeutic relationship afforded by the Fee-for-Service model of health care.  In contrast, the current model of health care delivery leaves little opportunity for such relationship-building. The disconnected delivery of health care under the managed care system has contributed to the demise of the patient-provider relationship. *64 Gone are the days of long conversations between physicians and their patients.

The managed care model requires physicians to see more patients in shorter periods of time.  Sadly, the days of the family physician that cared for all of a patient's needs--“someone who can coordinate and manage all their preventive, chronic and acute care”  longer exist. My grandparents may remember the physician of the 1960s who knew all of their ailments and concerns, as well as those of their children, but that physician is rare under today's managed care model. Today's managed care model manages “quality care [[through] efficient cost effective services.”  Unfortunately, this “fast paced, impersonal[,] economically focused health care system” adversely affects the health and health care of many elderly African Americans.

Without a personal connection, physicians often make judgments about diagnoses, treatments, and medications based on stereotypes associated with the groups to which the patient belongs.  Therefore, cultural competence becomes increasingly important under a managed care health care model. A culturally competent professional is one who understands and can interpret that major culture of his or her patients, including “health beliefs, cultural practices, and folk remedies.”

Cultural competence is the ability of the members of a professional system or environment to work effectively in cross-cultural situations. “The United States Department of Health and Human Services' Office of Minority Health (OMH) 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 *65 social groups.”’  Although urban, rural, African American, Latino, Asian, and elderly populations constitute various cultures in the United States, cultural competency training is often limited to ethnic- and race-based stereotypes.

Professor Lisa Ikemoto has written about cultural competence as follows:

The basic premise of cultural competency is that the near monoculture of the health care system interferes with the care of the growing number of patients who are not part of that culture. Cultural competence efforts aim at changing the institutional culture of health care and accompanying social services. The efforts include enabling health care and social service workers to provide effective access and care to patients with diverse values, beliefs, and practices. A primary and oft-stated goal of cultural competence is to contribute to the elimination of racial and ethnic gaps in health outcomes.

Cultural competence is especially important in the clinical setting. The physician-patient relationship is an integral part of effective medical care, and cultural competence affects how a health care provider communicates and delivers care to his or her patient. “Research suggests that the quality of communication between physician and patient strongly influences the quality of care that the patient receives, and that social and cultural stereotypes can interfere with communication.”  Additionally, these breakdowns are further evidenced by the abundance of communication-related patient complaints.

Ineffective communication contributes to the distrust between my grandparents and their health care providers. Trust is at the crux of the physician-patient relationship.  For a patient to trust his or her health care provider, the provider must understand the patient. When patient and provider are not part of the same culture, the health care provider must work to establish trust. Part of establishing trust is to understand the *66 culture of the patient. Therefore, cultural competency training is important.

All individuals have preconceived notions about people who do not look like them, and health care providers are no exception.  A health care provider's preconceived stereotypes affect how that provider treats his or her patients. “A physician's stereotypical or biased beliefs can interfere with his or her exercise of decision-making authority in making recommendations among different treatment alternatives.”  A physician's first impressions are, in many ways, as important as his or her scientific training because that perception determines the remainder of the physician-patient communication. “‘How a doctor thinks can first be discerned by how he speaks and how he listens.”’

C. Culturally Competent Medical Professionals Are Necessary to Eliminate Health and Health Care Disparities

Congress defined a disparity population as follows: “A population is a health disparity population if . . . there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population.”  My grandparents represent three distinct disparity populations as a result of their race, age, and geographic location. Individually and in combination, their representative populations experience health disparities. The elimination of such disparities comes from a culturally competent health care provider.

1. African American Disparities

The DNA makeup of the human race is consistent across ninety-nine percent of the population.  Despite the almost identical human makeup, health studies show that African Americans are sicker and have shorter lives than Caucasians.  African Americans have disproportionately higher *67 rates of disease, mortality, and survival than the majority population.

Research also strongly suggests that race is not a proxy for class. “A significant body of evidence suggests that minority race adversely affects the quantity and quality of health care provided to minority patients.”  Even when socioeconomic status is the same, disparities still exist between African Americans and their Caucasian counterparts. “[R] egardless of socioeconomic status,” African Americans have more difficulty accessing health care, attempt to access it less, and are more likely to express frustration when doing so.  There is even discrepancy in treatment and outcome among patients of racial or ethnic minorities who have the same health insurance as the majority.

Although several factors contribute to these outcomes, the patient-provider relationship is crucial. The Institute of Medicine (IOM) released a report titled “Unequal Treatment: Confronting Racial Disparities in Health Care in 2002.”  The report concluded that there is evidence suggesting that bias, prejudice, and stereotyping by health care providers may contribute to disparities in health care.  A study in the Archives of Internal Medicine determined African Americans to be less trusting of the medical system than Caucasians.  Almost two-thirds of African Americans are convinced that physicians are experimenting with new prescription drugs on people without approval.  The Health Care Financing Administration also conducted a study and concluded that *68 identical insurance does not result in equal health care.

In Unequal Treatment, the IOM committee offered several recommendations to conquer racial and ethnic disparities. The first recommendation was for “cross-cultural education of medical professionals.”  The culturally competent health care provider is a necessity because the current medical system interferes with the communication and relationship-development required by adequate health care.  One reason African Americans resist professional medical assistance is because of the lack of culturally competent care by medical professionals.

Cultural competence is necessary to overcome the history of mistrust between African Americans and their health care providers. African Americans are more skeptical than other social groups, due to a history of experimentation and medical developments based on entrenched racial stereotypes. The experimentation has included the Sickle Cell Screening Initiative, involuntary sterilization in the name of family planning, racism and stereotyping within the medical system, and experimentation.  Vernellia Randle reminds us of the Tuskegee Syphilis Experiment:

The most well[-]known post-slavery experiment is the Tuskegee Syphilis Experiment which the United States engineered from 1932 through 1972. The Tuskegee Experiment involved four hundred African American men in a government[[-]sponsored study to research the effects of untreated syphilis. While the men were not deliberately exposed to syphilis, as some rumors maintained, they were never told that they were not being treated or that effective treatment was available. Furthermore, even though the experiment was regularly reported over the course of the forty years, there was no outcry from the medical establishment. The effects of the Tuskegee Syphilis Experiment of maintaining and strengthening the distrust in the health care system cannot be underestimated. The *69 Tuskegee study served to reinforce the belief in the African American community that the distrust of the medical system was not merely an historical issue.

“Patients of color have expressed a continuing distrust in the health care system and in individual medical providers, and with good reason.”  In a recent study, focusing on “the effect of unconscious racial bias on clinical decision-making, researchers found a striking correlation between the presence of implicit negative stereotypes of African Americans and a decreased likelihood to provide appropriate medical treatment.”  Hence, “African American patients do not receive the same care as white patients when they seek medical treatment.”

“‘Implicit racial biases are prevalent in the United States, in general, and as such it should not be surprising that they are prevalent among physicians as well.”’  These unconscious racial biases lead to at least some of the variations in the quality of care.  have the opportunity to improve patient health, or to offer palliative care when disease prevails, and a relationship based on respect, communication, and trust improves the odds for success in both of these undertakings. Although the influence of managed care on medicine may make this ideal difficult to attain at times, surely all patients, whatever their race or background, deserve the physician's best efforts on their behalf. This best effort demands that physicians carefully examine their beliefs and practices and take affirmative steps to communicate effectively with their patients. Paternalistic or stereotypical assumptions about patients based on race or ethnicity have no place in modern medical care. Instead, all patients deserve the opportunity to participate in medical decision making with information about the full range of treatment options.

2. Rural Population Disparities

About one-fifth of the U.S. population lives in rural areas. *70 Approximately five percent of the total rural population lives in towns of 2,500 residents or less.  Most rural Americans are Caucasian.  Racial and ethnic minorities account for about seventeen percent of the rural population.  Most rural African Americans reside in the Southeast. “[G]eographically rural areas of America are a substantial and significant component of our society.”  Because so much of the United States is rural, and because of the number of citizens this land supports, rural counties have been described as “the backbone of America.”

Each rural community is unique in nature, which often makes studying the needs of the rural population difficult; however, generally speaking, there are many shared characteristics of small, rural towns, and those living in such towns have similar living experiences.  For example, most rural residents experience “close social or kinship relationships” and have a “preference for informal support systems in times of need.”  Even adjusted for age, rural residents have higher mortality, disability, and chronic disease rates than urban residents. “[C]ompared with urban Americans, rural residents have higher poverty rates, a larger percentage of elderly, tend to be in poorer health, have fewer doctors, hospitals, and other health care resources, and face more difficulty getting to health care services.”

Several factors contribute to the lack of access to quality health care for rural populations. “Financial, sociocultural, and structural features of the rural environment create barriers to health care.”  A common contributor *71 to health and health care disparities of rural populations is geographic isolation and professional isolation. “Rural hospitals are . . . aging, shrinking, and in short supply.”

Rural populations suffer because there are insufficient health care professionals to meet demand from patients.  Physicians who were not the product of a rural community are not inclined to work in those areas; therefore, recruiting and retaining health professionals in rural areas is difficult.  Newly-minted physicians shun rural practices “because of the perceived professional isolation, a lack of amenities, higher poverty rates and the many other challenges that come with providing care to rural patients.”  Additionally, rural doctors may face cultural or educational barriers to providing medical care, such as opposition to welfare programs or lack of particular skills training in clinic staff.

Unlike people who live in urban areas, rural individuals tend to base their health care decisions on cultural beliefs.  A health care professional must understand the unique cultural needs of the rural population in which he or she serves. For example, rural residents often base their idea of health on whether or not a person is able to work.  This self-reliance can “undermine healing if the patient and family avoid formal health care treatment and ‘tough it out[,]”’ particularly with a problem like substance abuse or domestic violence that is viewed as private.  However, if a health care professional is attuned to such a cultural attitude, he or she can adjust care accordingly, for instance, by maintaining secrecy to preserve family integrity. Therefore, rural populations need culturally competent health *72 care providers.

3. Elderly Population Disparities

America is growing old. Those over sixty-five are the most rapidly growing subset of the population, with the super-elderly (persons aged eighty-five years and older) comprising the largest increase.

“The population in the United States is rapidly aging, both in terms of actual numbers and percentages.”  Today, older Americans are living longer. According to the 2010 census, nearly two million of America's elderly are ninety years old or older.  The super-elderly are the fastest growing segment of the elderly population.

Since “[t]he rate of population growth among the elderly is greater than that of the total population,” their health and health care is important to society. “The elderly use physician, hospital, and long-term care services at higher rates and with greater frequency than younger age groups.”  The elderly need culturally competent health care providers because a person's living patterns determine his or her health status in old age. Health care providers must educate patients about the impact of their choices because everything from cigarette use to obesity impacts health. 

*73 Finally, medical educators must highlight the rural elderly because “[t] he elderly population differs from the general population in terms of its geographic distribution.”  Approximately one-fourth of the elderly live in non-metro areas and are more likely to stay in these areas than those who are younger.

4. Rural, African American, and Elderly Disparities

If each of the population subsets experience health and health care disparities, it is no surprise that individuals who embody all three subsets suffer health and health care disparities. The health of the minority elderly in the United States is one of the most important issues facing the nation's health care system today. “The number of minority group elderly is expected to increase more than 500% by the middle of the next century, from 4.3 million persons in 1990 to 22.5 million by the year 2050.”  As a result, “minority elderly will become ‘an even larger and more important component of the aging of America.”’  Rural ethnic minorities suffer because of race and geographic location. We often hear the terms “minority community” and “urban area” interchanged. However, not all African Americans live in urban inner-city areas and programs designed for urban areas may not address rural needs.

“[T]he combined effects of rural residence and minority race/ethnicity can result in greater disadvantage than these characteristics alone.”  These problems are compounded by the increasing isolation of the rural elderly, as the extended families that used to provide their care leave rural areas with no additional services stepping in to take their place.  To the extent that health professionals often prejudge the needs of the elderly, the African American elderly are frequently treated without being given the opportunity for input into their treatment plans[,] which sometimes results in inappropriate and inadequate care. This lack of opportunity to give input into their treatment plan, coupled with high costs of insurance, social cultural issues and what many view as an unresponsive health care system affects their ability to practice self-advocacy in health care decision-making.

The culturally competent professional can help relieve the “[f]ears of reprisal and discomfort” that result when elderly African Americans interact with physicians of the majority culture.  Cultural competency training equips providers with the ability to understand their patients. Therefore, the patient should begin to trust the physician and believe that such provider has an interest in his or her well-being.

Rural elderly African Americans must begin to trust the system. The thought of “not being heard” should not prevent them from sharing important information with their provider.  Although informal networks are important, they cannot replace annual physician visits. Therefore, cultural competency is especially important to treat this population.


Congress recognized that the federal government has some responsibility to educate health care professionals and several provisions of the ACA address the concerns raised in Part II.  The ACA attempts to increase the health care workforce in underserved areas and also addresses issues of diversity training for health care workers. Further, the new law also discusses the aging of America.

A. Increase Workforce

Several provisions of the ACA address the physician workforce. *75 Recognizing that numbers of primary care physicians are on the decline, the ACA not only creates new education and training programs but also expands existing programs.  Sections 5201 and 5301 encourage medical students to work as primary care physicians.  For example, the ACA amends the Public Health Service Act to require medical students who receive loan funds “to practice in primary care for 10 years . . . or until the loan is repaid, whichever comes first.”  The ACA also amends the Public Health Service Act to provide grants to entities for programs that train primary care professionals and other underserved communities, such as rural areas.

Most of the assistance provided through the ACA is through grants. For example, the ACA encourages primary residency training through teaching health center development grants.  The centers include several entities, including Rural Health Clinics.  The rural physician training grants established under the ACA encourage medical schools to recruit students who will likely practice in “underserved rural communities” by providing grants and training to such students.

B. Diversity Training

The ACA addresses the issue of cultural competency with workforce diversity training in several sections.  These sections deal primarily with racial and ethnic diversity of health care professionals.

The ACA enables the Secretary of Health and Human Services to facilitate cultural competency training for health professionals through provision of grants for “research, demonstration projects and model curricula.”  After collaborating with select entities to develop training, the Secretary must evaluate the curricula by collaborating with “health *76 professional societies, licensing and accreditation entities, health professions schools, and experts in minority health and cultural competency, prevention and public health and disability groups, [and] community-based organizations . . . .”  An internet clearinghouse will be used to disseminate any model curricula. 

Section 5402 supports diversity training for health professionals when it authorizes appropriations for educational assistance and increases the annual limit on the loan repayment amount to $30,000.  Diversity training will help ensure culturally competent health professionals. The section also authorizes appropriations for educational loan repayments for disadvantaged individuals who serve as medical school faculty, scholarships for disadvantaged students, reauthorization for loan repayments and fellowships regarding faculty positions, and reauthorization for education assistance in the health professions regarding individuals from a disadvantaged background.

C. Elderly Population

Provisions of the ACA also address the issue of geriatric services.  As the population ages, the workforce must be trained to care for the needs of the population. The ACA amends the Public Health Service Act to provide two new sections with respect to the geriatric workforce. First, grants are available to entities that “operate a Geriatric Education Center.”  Incentives are also available to certain health care professionals who are “entering the field of geriatrics, long-term care, and chronic care management.”


III. A Call for Action

A. The ACA Provides the Framework

The ACA provides a framework for recruiting physicians, especially primary care physicians, and training them in the area of cultural *77 competency. With the enactment of the ACA, our administration recognized many of the issues addressed in Part II. Our health care system is fractured. The system of managed care does not encourage relationship-building between physicians and health care providers in general, and especially between physicians and their rural elderly African American patients.

The provisions of the ACA discussed in Part III may assist with recruiting and training a workforce that is able to address the needs of the rural elderly African American population. However, questions certainly remain. To begin with, are the incentives outlined in the ACA enough of an incentive for a younger generation of physicians to move into primary practice in general, and specifically into a rural area? Pipeline programs must be put in place to recruit and train those who are likely to serve the rural elderly populations.

Data suggest that children who grow up in rural areas are more likely to practice in those areas.  Also, “[m]inority physicians are more likely to practice in some of the communities hardest hit by the health disparities.”  Unfortunately, these individuals are not attending medical school in large numbers. Medical schools are homogenous, with very little economic or ethnic diversity. As of 2008, 7.1-7.3% of entering medical students identified as African American, 7.4-7.5% as Hispanic, 20-21% as Asian, and 62-63% as Caucasian, non-Hispanic.  An increasing percentage-- 55%, up from 51%--of new medical students have come from the top quintile of family income, while the percentage of new medical students who come from families in the lowest quintile has remained below 5.5%.  This homogeneity has created a health care system that is unable to properly care for the increasing number of patients who are not part of the system's dominant culture.  It affects “(1) the manner in which patients understand and seek health care; (2) the attitudes of health care providers; (3) the way providers approach offering health *78 care services; and (4) the organizational system.”  Although health care providers may determine what health care their patients need, they do not always give the same care to all patients.

B. Diversity in Medical School Is Necessary

If we wait until students reach medical school to address issues of cultural competency and practicing in remote areas, we have waited too long. To attempt to teach cultural competency to a homogenous group of medical students may be a fruitless endeavor. When medical schools are homogeneous, both ethnically and economically, the training and incentives that the ACA offers may be useless.

Effective cultural competency training requires a diverse population of students. Effective training requires an audience with various racial, cultural, economic and religious backgrounds. The interaction with such diverse individuals is the smartest way to eliminate assumptions, biases, and stereotypes that may impede a physician's ability to make sound medical recommendations or diminish the patient's trust in the physician. “[T]he benefits of classroom diversity in medical schools extend far beyond the classroom. Ideally, the physician workforce will mirror the increasingly diverse society in which it practices.”  To accomplish this, we must develop “a pipeline of . . . youth interested in both health care careers and returning to or remaining in rural communities.”

IV.  Conclusion

I am cautiously optimistic. The ACA provides a framework for ensuring a culturally competent health care workforce. What happens next depends on how much the general population recognizes the seriousness of the problem. Many of the provisions of the ACA only give Congress authorization to appropriate funds. That means that the provisions must face the annual appropriations process if they are ever to take effect.

The ACA is a start, not a solution to the problem. We cannot rely solely on legislation to remove years of distrust between patients and health care providers. Because the solutions are long-term, in the interim work is to be done by lawyers and policymakers to ensure access to care for all individuals.

a1Assistant Professor, Charlotte School of Law. B.B.A. magna cum laude, Millsaps College; J.D., Georgetown University Law Center.

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