Health Action in Depth

July 2003

Racial and Ethnic Disparities in Health Care

The news is discouraging: Men, women, or children of color often receive less frequent care, less aggressive care, or substandard care compared to the medical treatment received by whites. In too many instances, they simply do not receive needed medical treatment at all.

Racial and ethnic disparities in health care have received increasing  attention in the last few years. This problem has even been studied by the vaunted Institute of Medicine (IOM), which published a book titled "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" earlier this year. This kind of documentation is important-it proves that the disparities are real, pervasive, and harmful to the health of patients of color. It also raises the profile of the issue, encouraging policymakers to redress this brand of injustice.

But how extensive are these disparities? How far does research on the issue go toward solving the problem of racial and ethnic disparities in health care? And how are nonprofit organizations, the federal government, and health care foundations working to eliminate these disparities?

The Disparities
It is important to paint a picture of the depth and breadth of the racial and ethnic inequities in health care faced by people of color every day. These inequities are measured in terms of health status, the kinds of medical treatment delivered, and health coverage. Below we have listed just a few such disparities:

Health Status:

• Health problems that disproportionately affect people of color include asthma, certain cancers, diabetes, high blood pressure (hypertension), and obesity.
• African Americans experience the highest death rates from cancer, heart disease, HIV/AIDS, and stroke of any racial group.
• Hispanics are twice as likely as whites to die from diabetes. And Hispanics who speak primarily Spanish are in poorer health and are less likely to have a regular doctor compared with Hispanics who speak primarily English, whites, and African Americans.
• Native Americans disproportionately die from cirrhosis and liver disease and diabetes.
• Some Asian American groups suffer from rates of cervical, liver, and stomach cancers that are well above national averages.

Medical Treatment Delivered:

• In general, people of color tend to receive poorer quality health care than whites even when access-related factors, such as health insurance status and income, are equal.
• Health care disparities show up in relation to a variety of kinds of medical treatment- cancer diagnostic testing, cardiac care, care for HIV/AIDS, maternal and child health care, rehabilitative and nursing home services, and many surgical procedures.
• People of color have less access to mental health services, are less likely to receive needed mental health services, and those in treatment often receive poorer quality mental health care.

Health Coverage:

• People of color are less likely than whites to have health coverage. And even when they are insured, they may face additional barriers to care due to other socioeconomic factors, such as high out-of-pocket costs and transportation difficulties.
• Men of color overall are less likely to have health insurance, less likely to use health care services, and less likely to have access to mental health, substance abuse, and oral health services.
• Women of color are also less likely to have health coverage. While approximately 12 percent of white women are uninsured, that number rises to 19 percent for Asian American/Pacific Islanders, 20 percent for African Americans, 27 percent for American Indian/Alaskan Natives, and 35 percent for Latinas.

It's important to note that characterizations based on broad racial and ethnic categories can sometimes mask significant variations in health care experience, particularly within Asian American and Latino communities. For example, Korean Americans have statistically higher rates of stomach cancer than other Asian Americans. Such differences may exist between Latino groups as well, so it is important to be aware of these distinctions.

Racial and ethnic differences are often associated with cultural and language difficulties that can aggravate health disparities. Cultural differences can lead to barriers between patients of color and their health care providers, leading to difficulties in treatment. And numerous studies have noted a lack of translation services in many health care settings. Obviously, language barriers can prevent proper explanations of diagnosis and treatment. 

The IOM notes that "racial and ethnic disparities in health status largely reflect differences in social, socioeconomic, and behavioral risk factors and environmental living conditions." But, while health care in and of itself is insufficient to redress racial and ethnic disparities in health status, it is unacceptable for any group to receive inferior quality health care. And, as the IOM observes, "...the extent to which minorities are well or poorly served provides an important indicator of the state of healthcare in the nation."

What's Being Done to Eliminate Disparities?
Now that there is more recognition of the problem of racial and ethnic disparities in health care, it's beginning to get long overdue attention on several fronts. Nonprofit and other private organizations are taking a range of actions to educate their constituencies and to pressure government agencies to take a more active role in the issue. (For a list of some of these organizations, see our Web site under Communities of Color.) Federal agencies have set goals for the elimination of such inequalities. In addition, several large health care foundations have launched projects to shed light on the problem and to attract more people of color to the health professions.  

In January 2000, the Department of Health and Human Services (HHS) released Healthy People 2010, the nation's health goals for this decade. A major project promoted by Dr. David Satcher, then U.S. Surgeon General, Healthy People 2010 adopted as one of its major themes the elimination of racial and ethnic disparities in health status. HHS's Initiative to Eliminate Racial and Ethnic Disparities in Health focuses on six areas: cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS, immunizations, and infant mortality.

In addition, three prominent health care foundations have launched efforts to combat this problem:

1. The Kaiser Family Foundation (www.kff.org) has created an extensive section on their Web site devoted to the issue of minority health; Kaiser also supports the development of better solutions to the problems contributing to the poorer health access and outcomes of many people of color.
2. Two of the W. K. Kellogg Foundation's (www.wkkf.org) health policy goals are expanding the health work force so that it is more reflective of the racial and ethnic makeup of the groups served and increasing access to health care, especially for vulnerable groups.
3. The Robert Wood Johnson Foundation (www.rwjf.org) has created a Minority Medical Faculty Development Program, which is aimed at attracting people of color to several areas of medical and health services research.

Where Are We Now?
While health disparities between people of color and whites have improved in some areas, they have actually widened substantially in other areas. But there are some rays of hope. For example:

• A study published in the Journal of the American Medical Association (JAMA) in May 2003 found that providing African Americans suffering from heart failure with equal access and treatment resulted in survival rates equal to those of whites. One newspaper commented that the study "appears to affirm what health care advocates have argued for years: Access to equal care will close the 'health gap' between blacks and whites." This study focused on Medicare patients, who were presumed to have access to the same levels of care.
• A study published in the June 2003 issue of the journal Cancer also included patients with Medicare coverage and found that death rates for African American and white women with breast cancer were equal for those in Medicare, presumably because such coverage afforded them equal access to treatment. (Overall, African American women die of breast cancer at higher rates than white women with comparable degrees of illness.)

Have we conquered these disparities? Not by a long shot. But progress is being made.  As the two studies mentioned above show, equalizing access to medical treatment can go a long ways toward eliminating health disparities. Unfortunately, we are living in a time of often deep Medicaid cuts, which drastically affect access to health care services and health outcomes for low-income beneficiaries and people with disabilities within communities of color. Fortunately, as noted in our article on page 3, we have staved off the worst Medicaid changes, at least for now, and state Medicaid programs are getting some additional financial help from the federal government.

More attention is also being paid to the issue of the uninsured generally, raising hopes that something will be done to address the problems uninsured people face. Congress has set aside $50 billion to expand health coverage for the uninsured, although it is unclear if a bipartisan agreement can be reached on a specific way to use these funds. At the same time, some states are stepping up to the plate and looking for ways to expand coverage (Maine is a prime example of such action). And last month, leaders of the Congressional Black Caucus called for universal access to health coverage to address health disparities between African Americans and whites. There is reason to hope that increasing recognition of this problem will lead to improved access and treatment.