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2
The Healthcare Environment and
Its Relation to Disparities
Many aspects of the healthcare environment influence the quality of
care received by U.S. racial and ethnic minority groups. The historical
evolution of healthcare for persons of color, the current financial and or-
ganizational structures of health systems, the settings in which care is de-
livered, and the nature of the workforce providing care may, both inde-
pendently and jointly, influence the quality of care that minorities receive.
This chapter describes some of these environmental factors and the influ-
ences they may have on healthcare for racial and ethnic minorities.
The first two sections of this chapter describe aspects of the social and
economic contexts in which racial and ethnic minority groups live in the
United States. These sections review: a) the health, health insurance, and
linguistic status of these groups, and b) racial attitudes and patterns of
segregation and discrimination in various sectors of American life. The
third section reviews the history of segregated healthcare and contempo-
rary settings in which racial and ethnic minorities receive healthcare, in-
cluding the influence and importance of community health centers. The
last section focuses on the healthcare workforce in minority communi-
ties—how this workforce originated, where individuals practice, who they
serve, and the influence of international medical graduates on healthcare
in minority communities. The chapter concludes with a discussion of
medical education, how affirmative action has served to increase the pres-
ence of underrepresented minorities in the health professions workforce,
and how recent legal challenges to affirmative action have affected and
may have a future impact on the healthcare workforce.
80
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81
HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
Much of the data presented in this chapter are drawn from available
literature and large national data sources, such as the U.S. Census and the
National Center for Vital and Health Statistics. Where possible, data on
subpopulations of racial and ethnic groups (e.g., Cuban American, Puerto
Rican, Mexican American, and other subgroups of the Hispanic popula-
tion) are presented. This information is supplemented, where appropri-
ate, by qualitative data regarding the experiences of racial and ethnic mi-
nority patients and healthcare professionals. These data, presented in
individuals’ own words, are offered as a means of understanding some of
patients’ and providers’ experiences and perceptions of how race or
ethnicity may affect both care processes and the systems and settings in
which care takes place. As such, these data are not intended to substitute
for empirical findings. Rather, they serve to “give voice” to the experi-
ences of key actors in healthcare disparities, and illuminate how health-
care disparities are perceived by patients and their providers. Qualitative
data were gathered via three mechanisms:
• Roundtable discussions with minority healthcare consumers, pro-
fessionals and advocates at one of two large national conferences (the
Asian American and Pacific Islander Health Forum conference and the
Indian Health Service Research Conference, both held in April, 2001);
• Liaison panel discussions with consumer and professional groups,
federal agency representatives, and minority health advocates held in the
spring and summer, 2001;
• Focus group sessions conducted during this same time period; and
interviews with American Indian and Alaska Native tribal leaders and a
cadre of healthcare providers serving American Indian and Alaska Na-
tive communities (Joe, this volume).
For more information on these data collection activities and a sum-
mary of focus group and liaison panel findings, please see Appendixes A
and D.
THE HEALTH, HEALTH INSURANCE, AND LANGUAGE STATUS
OF RACIAL AND ETHNIC MINORITY POPULATIONS
This section provides an overview of factors that influence healthcare
and healthcare needs of minority populations—including their health and
insurance status, and linguistic barriers to care.
Health Status
Some racial and ethnic minorities experience higher rates of chronic
and disabling illnesses, infectious diseases, and mortality than white
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82 UNEQUAL TREATMENT
Americans. As depicted in Figure 2-1, African Americans have the high-
est rates of morbidity and mortality of any U.S. racial and ethnic group.
The mortality rate for African Americans is approximately 1.6 times higher
than that for whites—a ratio that is identical to the black/white mortality
ratio in 1950 (Williams and Rucker, 2000). American Indians and Alaska
Natives also experience higher mortality rates than whites, accompanied
by low life expectancy. And while other racial and ethnic minorities ex-
perience lower overall mortality rates than whites, these data mask both
inter-group variation (e.g., among Hispanics, Puerto Ricans experience
higher infant mortality rates than whites [National Center for Health Sta-
tistics, 2000]), and an elevated burden of disease among some groups for
specific causes of mortality. As depicted in Figure 2-2, some causes of
mortality, such as diabetes, disproportionately affect African-American,
Hispanic, and American Indian/Alaska Native populations. In addition,
some subpopulations of racial and ethnic groups experience an elevated
incidence and mortality due to specific diseases. Alaska Natives experi-
ence the highest rates of colon and rectal cancers of any racial or ethnic
group in the United States (Institute of Medicine, 1999b). Korean Ameri-
cans have the highest rates of stomach cancer (48.9 per 100,000 popula-
tion) among U.S. males, followed by Japanese Americans (30.5 per 100,000
population; Institute of Medicine, 1999b). Similarly, Vietnamese-Ameri-
can women experience the highest incidence of cervical cancer in the
United States, at rates nearly six times higher than that of white women
(Institute of Medicine, 1999b).
690.9
700
Death per 100,000 Residence
600
500 452.2 458.1
Population
400
342.8
300 264.6
200
100
0
White Black American Asian or Hispanic
Indian or Pacific Islander
Alaska Native
FIGURE 2-1 Age-adjusted death rates for all causes of death by race and Hispanic
origin: United States, 1950-1998. SOURCE: Health, United States, 2000 (2001).
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83
HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
White
Black
American Indian or
Alaska Native
200 Asian or Pacific Islander
Hispanic
150
100
50
0
Diabetes Mellitus
Diseases Cerebrovascular Malignant
Diseases Neoplasms
of Heart
FIGURE 2-2 Age-adjusted death rates for selected causes of death by race and
Hispanic origin: United States, 1950-1998. SOURCE: Health, United States 2000
(2001).
Insurance Status
Racial and ethnic minority Americans are significantly less likely than
white Americans to possess health insurance (see Figures 2-3 and 2-4).
The problem is particularly acute among the working poor and individu-
als who have no employment-based insurance, and among whom minori-
40
35
32.8
35
Uninsured Rate (percent)
30
22.8
25 22
20 17.5
12.7
15
10
5
0
Hispanic American Non-Hispanic Asian American Non-Hispanic General
Indian and African and South White Population
Alaska Native American Pacific Islander Under Age 65
FIGURE 2-3 Probability of being uninsured for population under age 65, by race
and ethnicity. SOURCE: Hoffman and Pohl, 2000.
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84 UNEQUAL TREATMENT
employment-
based coverage
individually
purchased
public insurance
no insurance
100
90
Rates of Coverage (percent)
80 44
53.1
59.1
70 65.8
72.8
60
4.2
50
4.2
20
40 6
25.7 6.6
15
30
7.5 14.2
20 10.8 35
24
22.8
10 17.5
12.7
0
Non-Hispanic Non-Hispanic Hispanic Other General
White African- Population
American Under Age 65
FIGURE 2-4 Sources of health insurance for population under age 65, by race and
ethnicity, 1999. NOTE: Numbers may not add to 100 percent due to respondents
reporting more than one source of coverage and due to rounding. SOURCE:
Fronstin, 2000.
ties, particularly Hispanic Americans, are over-represented. Lack of in-
surance poses the most significant barrier to care. Insurance status, per-
haps more than any other demographic or economic factor, determines
the timeliness and quality of healthcare, if it is received at all (Institute of
Medicine, 2001b).
African Americans
African Americans are less likely to possess private or employment-
based health insurance relative to white Americans, and are more likely
to be covered via Medicaid or other publicly funded insurance (see Figure
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85
HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
2-4). In addition, African Americans are almost twice as likely as non-
Hispanic whites to be uninsured. High rates of uninsurance among this
population occur despite the fact that over 8 in 10 African Americans are
in working families, as a disproportionate percentage of African Ameri-
cans work in jobs that provide no heath insurance (The Henry J. Kaiser
Family Foundation, 2000a). As illustrated in Figure 2-3, the probability of
being without health insurance coverage for African Americans is 22.8
percent, compared with 17.5 percent in the general population.
American Indians and Alaska Natives
The U.S. government is obligated through treaty and federal statutes
to provide healthcare to members of federally recognized American In-
dian tribes. This trust, however, has not been fully met, for several rea-
sons. The federal Indian Health Service (IHS) provides healthcare ser-
vices primarily on Indian reservations, which are home to only a minority
of American Indians (as few as 30%), as the majority of the population
currently lives in urban or other non-reservation areas (Brown et al., 2000).
To obtain IHS care, Indians must travel to their home reservation. Not
surprisingly, a large majority (80%) of American Indians and Alaska Na-
tives report no access to IHS facilities (The Henry J. Kaiser Family Foun-
dation, 2000a). Although the federal government contracts with a num-
ber of urban Indian health organizations to provide services, such federal
support is often limited. In general, the agency’s resources (slightly over
$2 billion was appropriated to the agency in fiscal year 1998) are far below
needs. In fiscal year 1997, for example, the agency reported $1,430 in per
capita expenditures, a figure that is 1.4 to 2.8 times below the per capita
spending of other federal health programs and agencies such as Medicaid
($3,369) and the Veterans Administration ($5,458) (National Indian Health
Board, 2001).
Figure 2-3 indicates that nearly one-third of American Indians and
Alaska Natives (32.8%) lack health insurance, compared with 17.5% in the
general population. Slightly less than half of American Indians and
Alaska Natives have job-based health insurance, while one quarter re-
ceive Medicaid insurance and a similar proportion are uninsured or re-
port only IHS coverage (The Henry J. Kaiser Family Foundation, 2000).
Asian Americans and Pacific Islanders
Some of the ethnic subgroups among Asian Americans and Pacific
Islanders (API) have disproportionately high rates of uninsurance (Brown
et al., 2000; Hoffman and Pohl, 2000). Rates vary considerably, although
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86 UNEQUAL TREATMENT
generally, only 64% of API populations have job-based health insurance,
compared with nearly three-fourths of whites (73%). Nearly one-fourth
of API populations are uninsured (see Figure 2-3). Generally, rates of
public insurance are lower for Asian Americans and Pacific Islanders, ex-
cept for some Southeast-Asian subpopulations (Brown et al., 2000).
Within API subgroups, Korean Americans are least likely to have
health insurance. Less than half have job-based insurance (49%), while
over one-third (34%) are uninsured and 14% receive Medicaid or other
publicly funded insurance. Similarly, South East-Asian (e.g., Vietnamese,
Cambodian, Laotian) and South-Asian (e.g. Indian, Pakistani, Bangla-
deshi) populations are disproportionately uninsured (27% and 22%, re-
spectively). Less than half (49%) of South East-Asians have job-based in-
surance, while nearly seven in ten South-Asians (69%) have job-based
insurance. Two in ten Chinese-American and Filipino-American families
are uninsured (The Henry J. Kaiser Family Foundation, 2000b). These
data are depicted in Figure 2-5.
Other Public
Job-Based
Medicaid/Other Public
Uninsured
100
90
Health Insurance Coverage (percent)
80
70
60
50
40
30
20
10
0
Chinese Filipino Korean South East Japanese South White
Asian Asian
FIGURE 2-5 Health insurance coverage by Asian-American and Pacific-Islander
subgroups vs. whites (Ages 0-64), 1997. SOURCE: The Henry J. Kaiser Family
Foundation, 2000b.
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HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
Hispanic Americans
Hispanic Americans face greater barriers to health insurance than all
other U.S. racial and ethnic groups. The probability of being uninsured
among Hispanic Americans is 35 percent, compared with 17.5 percent for
the general population (Hoffman and Pohl, 2000). This disparity, depicted
in Figures 2-3 and 2-4, largely results from the lack of job-based insurance
provided to Hispanic Americans, who disproportionately work in blue-
collar and service-oriented jobs. The vast majority (87%) of uninsured
Hispanics are in working families, yet only 43% of Hispanics receive
health insurance through work. Further, nearly one-third of Hispanics
(30%) work for an employer who does not offer health insurance to work-
ers (The Henry J. Kaiser Family Foundation, 2000b). The high rate of
uninsurance among Hispanics is also a reflection of a lower-than-average
rate of participation in publicly funded health plans. In families with
incomes less than the federal poverty level, 45 percent of all Hispanics are
uninsured, compared with 32 percent of non-Hispanic whites (Fronstin,
2000). Differing eligibility standards may play a significant role in the
lower rates of coverage for Hispanics under some publicly funded insur-
ance plans, as many state and federal guidelines do not permit coverage
for extended family members or families where married spouses live in
the same household.
Hispanic subgroups vary in rates and sources of insurance coverage.
Cuban Americans experience the highest rates of job-based or other pri-
vate insurance (65%), and along with Puerto Ricans, are least likely to be
uninsured (21%). Less than half of Puerto Rican, Central and South
American-descendent, and Mexican Americans have job-based or other
private insurance (45%, 46% and 44%, respectively), and over one-third of
Puerto Rican Americans (34%) are insured by Medicaid or other publicly
funded programs. More than 4 in 10 Central and South American descen-
dent-Americans are uninsured (42%), as are 38% of Mexican Americans.
These data are displayed in Figure 2-6.
Linguistic Barriers
Many racial and ethnic minority Americans experience language barri-
ers. These barriers range from low or no English proficiency to limited
proficiency in speaking, reading or comprehending English. In healthcare
settings, these linguistic barriers can present significant challenges to both
patients and providers, despite federal regulations that encourage and sup-
port the use of interpreters (Office of Civil Rights, U.S. Department of Health
and Human Services, 2000). According to the 1990 U.S. Census, 14 million
people living in the United States have no or limited English-language skills
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88 UNEQUAL TREATMENT
Uninsured
Medicaid
Job-Based
100
Health Insurance Coverage (percent)
90
80
70
60
50
40
30
20
10
0
Central and Cubans Mexicans Puerto Ricans
South Americans
FIGURE 2-6 Health insurance coverage among Latino subgroups (Ages 0-64),
1997. SOURCE: The Henry J. Kaiser Family Foundation, 2000b.
(data from the 2000 Census are not available as of this writing). These popu-
lations can be found throughout the United States, although they are dis-
proportionately represented in large urban centers and in five states (more
than 10% of the population in California, New York, Texas, New Mexico,
and Hawaii have limited English-language skills [Woloshin et al., 1995]).
Nearly 8 million individuals (7,741,259) live in linguistically isolated house-
holds, e.g., households in which no person over age 14 speaks English “very
well” (U.S. Bureau of the Census, 1993). The percentage of individuals
living in linguistically isolated households for each racial and ethnic group
is depicted in Figure 2-7.
Hispanic or Latino
More than 1 in 4 (25.3%) Hispanic individuals in the United States
live in a linguistically isolated household. These include 4,560,000 indi-
viduals in over 1.5 million households. In addition, nearly 8 million His-
panic Americans (7,716,000) do not speak English “very well” (U.S. Bu-
reau of the Census, 1993). Given recent population shifts (e.g., an increase
in foreign-born Hispanic immigrants), it is likely that these figures grossly
underestimate the number of Hispanic Americans with limited or low
English proficiency.
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89
HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
30
27.3
26.8
25.8
25
20
Percent
15
10
5.2
5 3.2
1.3
1
0
All Wh Afr Am As His Oth
ian
ica
Ho pa
ite, eri er
nA nic
can
use or Ra
no Pa
me ce
n-H
ho Ind cifi
lds rica
isp ian c Is
n
an ,E lan
ic ski de
mo r
,o
rA
leu
t
FIGURE 2-7 Percentage linguistically isolated households, by race and ethnicity,
United States, 1990. SOURCE: U.S. Bureau of the Census, 1993.
American Indian and Alaska Native
More than one in 20 American Indians or Alaska Natives lives in a
household in which no adolescent or adult speaks English “very well.”
According to the 1990 U.S. Census, 281,990 persons aged five years or
older speak one of the American Indian languages at home; half of these
(142,886) speak Navajo. Nearly 170,000 American Indians or Alaska Na-
tives do not speak English “very well,” and over 32,000 American Indian
or Alaska Native households are linguistically isolated (U.S. Bureau of
the Census, 1993).
Asian Americans and Pacific Islanders
Large segments of Asian-American and Pacific Islander communities
face linguistic isolation. According to 1990 U.S. Census estimates, more
than 1.5 million Asian or Pacific Islander Americans live in linguistically
isolated households. Over half of Laotian, Cambodian, and Hmong fami-
lies are linguistically isolated, while between 26%-42% of Thai, Chinese,
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90 UNEQUAL TREATMENT
Korean, and Vietnamese families live in similar conditions. Figure 2-8
displays the percentage of Asian American households that are linguisti-
cally isolated.
Healthcare Providers
Many healthcare providers are acutely aware of the impact of lan-
guage barriers and other cultural differences and how these factors affect
their healthcare practice. In a recent survey of physicians who participate
in the “Healthy Families” programs, L.A. Care (the local health authority
of Los Angeles County) found that 71% of providers believe that language
and culture are important in the delivery of care to patients. Slightly over
half (51%) believe that their patients did not adhere to medical treatments
as a result of cultural or linguistic barriers. Yet, over half of these provid-
ers (56%) report not having had any form of cultural competency training
(Cho and Solis, 2001).
RACIAL ATTITUDES AND DISCRIMINATION
IN THE UNITED STATES
“There are those that don’t get promoted because of their race or whatever. The
reason [may be because] they’re not well liked by administration or it may be
just that they [administrators] don’t want that person in that setting because of
their race—that is out there. Racism is alive and well, and those of us who think
that it’s not are living in some kind of dream world.” (African-American nurse)
“I’ve had both positive and negative experiences. I know the negative one was
based on race. It was [with] a previous primary care physician when I discov-
ered I had diabetes. He said, ‘I need to write this prescription for these pills, but
59.8
54.7
51.5
42.1
35.1
34.8
26.6
14.8
11.2
7.2 8.1
1
n
n
n
an
e
i
se
an
e
n
an
g
a
ia
oa
ia
es
es
ia
on
Th
ne
di
re
di
ai
an
ot
an
m
m
m
In
bo
Ko
aw
hi
La
m
na
Sa
H
p
C
an
am
ua
Ja
H
et
i
As
G
Vi
C
FIGURE 2-8 Percentage of Asian Americans that are linguistically isolated,
by subgroup. SOURCE: U.S. Bureau of the Census, 1990 General Population
Characteristics.
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114 UNEQUAL TREATMENT
were lower than in communities not serviced by these centers (Epstein,
2001). Patients in underserved areas served by these centers had 5.8
fewer preventable hospitalizations per 1,000 population over three years
than those in underserved areas not served by a federally qualified
health center.
While CHCs were developed on the premise that they would service
all patients regardless of their ability to pay, limited federal subsidies have
forced many clinics to reduce the amount of uncompensated care they
provide. Between 1981 and 1991, federal funding increased at half the
rate of increase in the urban consumer price index for medical care
(Rosenbaum and Dievler, 1992, as cited in COGME, 1998). Changes in the
cost of medical technology, shift of services from inpatient to outpatient
settings, and Medicare’s Prospective Payment System have placed a strain
on many hospitals. While most have remained operational, approxi-
mately 5% of non-federal community hospitals closed between 1985 and
1988, a rate two to three times higher than in the preceding four years
(GAO, 1990). Concerned about loss of their Medicaid patient base, many
CHCs have begun participating in managed care arrangements. By 1996,
almost half (45%) of CHCs participated in such arrangements (Shi et al.,
2000). This shift has generated fears among some that these centers will
be less able to serve patients who need care the most, with declines in
Medicaid reimbursement and increased difficulty providing non-reim-
bursable services under managed care (GAO, 1995; Shi et al., 2000). In
fact, recent studies suggest that CHCs provide care to a smaller propor-
tion of uninsured patients, while they are serving increasing proportions
of Medicaid patients under managed care (Shi et al., 2001).
THE HEALTHCARE PROFESSIONS WORKFORCE IN MINORITY
AND MEDICALLY UNDERSERVED COMMUNITIES
Demographics of Healthcare Providers
The historical antecedents of physician and other healthcare provider
training, as discussed above, significantly shape the current landscape of
health professions education and the healthcare workforce. In this sec-
tion, data on the demographic profile of healthcare providers that work
primarily in racial and ethnic minority communities is reviewed.
Physicians
Minority medical graduates, including African Americans, Asian
Americans, Hispanics, and American Indians, represent 9% of the country’s
physicians. Of these 9%, one-third (33.3%) is African American, 40.1% are
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HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
Asian American, one-fourth (24.9%) is Hispanic, and 1.8% is American In-
dian (AAMC, 2000). These minority graduates are more likely to work in
states with large minority populations, such as California, New York, and
Texas (AAMC, 2000). Underrepresented racial and ethnic minorities (Afri-
can Americans, Mexican Americans/Chicanos, mainland Puerto Ricans,
and American Indians/Native Americans) represent a smaller subset of this
population, as less than 6% of the U.S. physician workforce is composed of
individuals from these backgrounds. Significantly, well over 1 in 4 Ameri-
cans is African American, Hispanic, or American Indian/Alaska Native
(U.S. Bureau of the Census, 2000).
Minority physicians are more likely than their non-minority peers to
work in hospital-based practices. Whereas only 1 in 5 (21.4%) of all physi-
cians nationally work in hospital-based practices, nearly one-third (32.1%)
of African American physicians, over half (50.3%) of Asian American phy-
sicians, over 1 in 3 (35%) of Hispanic physicians, and nearly 2 in 5 (39.3%)
of American Indian/Alaska Native physicians work in such settings.
Non-minority physicians are more likely to work in office-based prac-
tices, as 3 in 5 (60.5%) work in such settings, compared with 55.7% of
African Americans, 40.8% of Asian Americans, 54.8% of Hispanics, and
53.1% of American Indian/Alaska Natives. Minority physicians are far
more likely than non-minorities to be residents or fellows, owing to the
generally younger age of minority physicians (AAMC, 2000). In terms of
specialty practice, minorities are more likely to be found in family prac-
tice (11.5% of African American, 12.7% of Hispanic, and 24.7% of Ameri-
can Indian/Alaska Native physicians are family practitioners, compared
with 9.9% of all physicians), obstetrics-gynecology (12.1% of African
American, 8.3% of Hispanic, and 7.3% of American Indian/Alaska Native
physicians are found in OB/GYN, compared with 6% of all physicians),
and pediatrics (10.1% of African American and 11.1% of Hispanic physi-
cians are pediatricians, compared with 8.7% of all physicians), but are
poorly represented in other specialties, such as cardiology, surgery, and
psychiatry (AAMC, 2000).
Among physicians participating in managed care arrangements,
Asian-American physicians are more likely to be in solo practice (56%),
while African-American physicians are more likely to practice in staff-
model HMOs (19%), white physicians are more likely to be in group prac-
tice (45%), and Latino physicians were more likely to be in a hospital- or
clinic-based practice (25%). Latino physicians are least likely to have man-
aged care patients compared with physicians of other racial or ethnic
groups, even after controlling for their lower rate of board certification.
Twenty-six percent of Latino physicians had no managed care patients
compared with 10% for African-American physicians, 13% for white phy-
sicians, and 14% for Asian physicians (Mackenzie et al., 1999).
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116 UNEQUAL TREATMENT
Nurses
In 2000, 12.3 percent of registered nurses were racial and ethnic mi-
norities. Nearly 5% of all nurses self-reported as African American, 3.5%
as Asian, 2% as Hispanic, 0.5% as American Indian/Alaska Native, 0.2%
as Native Hawaiian/Pacific Islander, and 1.2% reported being of two or
more racial backgrounds. A larger percentage (86.4%) of minority nurses
were employed in nursing, as compared with 81% of white, non-Hispanic
nurses. Minority nurses were also more likely to work full-time (U.S.
Health Resources and Services Administration, 2001).
Geographically, there are distinct patterns of practice between the
minority and non-minority nursing workforce (Table 2-3). Recent esti-
mates revealed that black nurses were more likely to practice in the south
and middle Atlantic regions of the country. Hispanic nurses were repre-
sented in higher proportions in the west and east south-central areas.
Asian/Pacific Islander nurses were more likely to be found practicing in
the Pacific and mid-Atlantic states. The west south-central and Mountain
areas of the United States were the sites with the highest percentages of
American Indian and Alaskan Native nurses. The most common employ-
ment setting for minority as well as non-minority nurses was in hospitals
(U.S. Health Resources and Services Administration, 2001).
Impact of International Medical Graduates (IMGs)
on the Workforce in Minority Communities
An important phenomenon began to emerge during the 1930s and
1940s that would have a profound effect on the healthcare provided to
racial and ethnic minorities, as the numbers of international medical
graduates (IMGs) securing residency training positions in U.S. hospitals,
especially those serving underserved urban and rural communities, be-
gan to increase sharply. Between 1933 and 1940, the composition of the
5,056 immigrant physicians admitted to the United States was predomi-
nantly European (Stevens, Goodman, and Mick, 1978). By the 1960s, how-
ever, immigration policies had changed such that visas were easily attain-
able and institutions were beckoning Third World IMGs to the United
States for training because of a perceived short supply of physicians
(Stevens, Goodman, and Mick, 1978). This movement was occurring as
courts ended federally sponsored hospital segregation and as Medicare
and Medicaid legislation was passed by Congress. Concurrently, the Civil
Rights era laid the groundwork for significant changes in access to
healthcare facilities and services for racial and ethnic minorities as well as
for the poor and elderly.
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TABLE 2-3 Percent Distribution of Registered Nurse Population in Each Geographic Area by Racial/Ethnic
Background: March 1996
East West East West
New Middle South South South North North
Race/Ethnicity U.S. England Atlantic Atlantic Central Central Central Central Mountain Pacific
Estimated RN population
in area 2,558,874 176,951 443,846 460,460 141,705 215,200 452,080 198,952 137,739 331,941
White (non-Hispanic) 89.7 96.5 86.8 87.4 92.1 85.6 93.9 96.6 92.4 83.5
Black (non-Hispanic) 4.4 1.3 5.6 7.3 6.3 5.0 2.8 1.4 1.1 3.1
Asian/Pacific Islander 3.4 0.8 5.4 2.7 0.5 3.8 2.0 0.5 1.7 8.3
American Indian/Alaska
Native 0.5 0.1 0.2 0.2 0.3 1.3 0.3 0.6 1.4 0.7
2.5 3.5
Hispanic 1.6 0.4 1.2 1.4 0.5 3.7 0.7 0.5
Other 0.7 0.8 1.0 1.0 0.2 0.5 0.4 0.4 0.8 1.0
SOURCE: National Sample Survey of Registered Nurses, March 2000.
HEALTHCARE ENVIRONMENT AND ITS RELATION TO DISPARITIES
117
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118 UNEQUAL TREATMENT
The 1967 report of the National Advisory Commission on Health
Manpower (NACHM) sparked renewed efforts to recruit IMGs when it
declared a national shortage of physicians (COGME, 1998). The geo-
graphic maldistribution of physicians that had been systematically dis-
cussed for over 30 years as a problem became a public agenda item. By
and large, health professionals had chosen to locate and practice in afflu-
ent urban and suburban communities, while large numbers of minorities
and the poor had limited access to care. The NACHM report was one of
several that led to the rapid expansion of existing undergraduate medical
education programs as well as the creation of new medical schools.
Three decades later, the number of students graduating from United
States medical schools doubled and the number of IMGs who entered
residency training programs each year almost doubled between 1988 and
1994, from 3,600 to 6,700 (COGME, 1996). The number of first-year resi-
dency positions filled increased to 140% of the yearly U.S. medical school
graduates. The physician-to-population ratio (excluding resident physi-
cians) increased by 65%, from 115 to 190 physicians per 100,000 (COGME,
1996). Most of this increase was in the medical specialties, increasing the
specialist physician-to-population ratio 121% from 56 to 123 specialists
per 100,000 population (COGME, 1996).
Healthcare expenditures also rose dramatically during this period.
Federal spending for all health services just before Medicare and Medic-
aid was enacted in 1965 was $4 billion, rising to $15.7 billion in 1970, $33.8
billion in 1975, and $65.7 billion in 1980. During the same period of time,
state and local spending increased from the pre-Medicare/Medicaid level
of $4.8 billion to $31.3 billion. The poor greatly increased their use of
healthcare services. By 1976, poor children averaged 65% more physician
office visits, poor adults averaged 27% to 33% more visits, and the elderly
poor averaged 18% more visits than in 1964. In fact, the poor in each age
group increased their use of health facilities more than the non-poor (U.S.
Department of Health and Human Services, 1980), contributing to the in-
creased demand for healthcare professionals.
Today, IMGs are a significant part of the U.S. health workforce. The
number of residency positions filled by IMGs in 1998-99 was 25,415, or
more than one-fourth (26%) of all residents on duty in U.S. hospitals in
1998-99 (COGME, 1999). Many work in minority and medically under-
served communities, where few other physicians choose to practice.
Verghese (1994) and White (1993) concluded that individual IMGs have
established themselves as critical providers of healthcare services in se-
lected rural underserved areas. Most, however, locate in large cities, and
practice in urban underserved areas. They are disproportionately distrib-
uted in teaching hospitals with high percentages of Medicaid low-pay or
no-pay patients. Sixteen percent of all teaching hospitals had an entire
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resident staff consisting of greater than 40% IMGs (MedPAC, 1999). A
detailed survey of the healthcare providers working in nine of the poorest
neighborhoods in New York City revealed that greater than 70% of the
physicians were graduates of foreign medical schools (Bellochs and
Carter, 1990). The data also revealed that only 24% of the practicing phy-
sicians were board certified, while the citywide average was 64%. Many
other investigators (Fosset et al., 1990; Mitchell, 1991; Mitchell and
Cromwell, 1980; Perloff et al., 1986a) have documented that physicians in
urban areas who accept Medicaid patients are more likely to be foreign
medical graduates and are less likely to be board certified than those who
do not accept Medicaid. Ginzberg (1994) summarized his study of
healthcare for the poor in four of the nations largest cities:
A long-term trend of abandonment and avoidance by physicians had
drained the low-income neighborhoods in all four metropolitan areas of
private practitioners; physician-population ratios were as low as 1: 10,000
to 1: 15,000, in contrast to affluent neighborhoods with ratios of 1: 300 or
even higher. Moreover, the majority of practitioners serving the poor con-
sisted of foreign medical graduates, many with indifferent professional
competence and language problems that impeded effective communica-
tion. Deterred by the low reimbursement rates paid by state Medicaid
programs…the majority of U.S. trained physicians refused to accept Med-
icaid patients or limited the numbers they were willing to treat, leaving the
field to group practices with questionable standards (Medicaid mills) that
thrived on volume throughput (Ginzberg, 1994, p. 1465).
While from varied geographic locations around the globe, the largest
share of IMGs working in the United States today are from South Asian
nations. Table 2-4 illustrates the country of origin for the top 10 countries
with the highest number of medical graduates in the United States.
TABLE 2-4 Top 10 Countries with Highest Proportion of Medical
Graduates in the United States
Country Percentage of the U.S. IMG Population
India 19.5%
Pakistan 11.9%
Philippines 8.8%
Ex-USSR 3.1%
Egypt 2.6%
Dominican Republic 2.5%
Syria 2.5%
United Kingdom 2.4%
Germany 2.3%
Australia 2.1%
SOURCE: The Educational Commission for Foreign Medical Graduates, 1992.
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120 UNEQUAL TREATMENT
The cultural, racial, and ethnic diversity of IMG healthcare providers,
who constitute more than 25% of the resident physicians in the United
States, is broad. Most are new to this country and are learning to live
within its vast sociocultural complexities, while also trying to learn to deal
with an ambiguous welcome into the U.S healthcare delivery system with
its own rigid, complex and demanding subculture (Stevens, Goodman,
and Mick, 1978). As these authors note, two-thirds of IMGs are unpre-
pared for the experience, having relied upon friends or family for advice.
Many do not have the luxury of selecting a hospital in which to practice;
rather, they accept the job that is offered. Often IMGs enter the United
States thinking of themselves as “internationally mobile scientists” with
knowledge and skills that are transferable anywhere in the world, only to
be jolted by the reality of being treated as an alien or outsider inside the
hospital (Stevens, Goodman, and Mick, 1978). In one survey (Stevens,
Goodman, and Mick, 1978), 13% of IMGs felt that they were inadequately
informed about the location of the American hospitals, including the fact
that many large hospitals are in high-poverty areas of major cities. For
others, complex malpractice claims and standards may pose problems, as
well as large caseloads, documentation requirements, long hours, a fast
pace, and language difficulties.
The 12th CoGME Report (1999) observed that “when physician and
patient differ with respect to race, ethnicity, language, religion and val-
ues, ensuring fair, equitable, and culturally sensitive care is more chal-
lenging.” The opportunity for miscommunication and cultural gaffes be-
tween IMGs and minority patients abound and could be manifest in the
way healthcare services are provided or received by the communities
served. This cultural configuration has existed for nearly 50 years in many
of the largest metropolitan teaching hospitals serving millions of racial
and ethnic minorities. However, this racial/ethnic interface has been in-
adequately studied to determine the impact it has on minority patients’
perceptions of their healthcare experience, utilization of services, trust,
compliance, health status, and quality of care.
THE PARTICIPATION OF RACIAL AND ETHNIC
MINORITIES IN HEALTH PROFESSIONS EDUCATION
“I heard an Anglo doctor complaining that his daughter is having trouble get-
ting into medical school. Then another doctor jumps in, another Anglo, “Oh
don’t worry about it. I know the admissions coordinator. I’ll get her in. I’ll give
him a call and she’ll be in.” When does a Hispanic or black student have those
advantages, the connections? I certainly didn’t have any connections, and I still
don’t have any connections. I couldn’t get my son into medical school if I tried.”
(Hispanic physician)
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“When I was in medical school I had a racist comment by one of the white stu-
dents. He said the only reason why you’re here, it wasn’t said to me but I
overheard it, the only reason why black students are here is because they’re black
and this that and the other. What was really interesting was that OK, sure I’m
black, but I don’t take the black test, I don’t take the black boards, we take the
same exams.” (African American physician)
In the late 1960s, many U.S. medical colleges and other health profes-
sions organizations began a concerted effort to expand opportunities for
careers in the health professions to ethnic minorities who, for a variety of
historic, social, political, and economic reasons, had not previously en-
joyed such opportunities. The Association of American Medical Colleges
(AAMC) and other groups actively encouraged member institutions to
improve outreach programs and matriculation efforts targeted to minor-
ity students, in the hope that their rates of participation in health profes-
sions would achieve parity with the proportion of racial and ethnic mi-
norities in the U.S. population (Nickens and Ready, 1999). This goal was
established not only because its attainment would help to rectify inequi-
ties in educational opportunities, but also because of a growing apprecia-
tion that minority healthcare professionals are more likely to work in mi-
nority and medically underserved communities, thereby addressing a
growing public health need.
By 1974, 10% of all medical school matriculants were underrepre-
sented minorities (AAMC, 2000). This proportion decreased significantly
in the wake of the U.S. Supreme Court’s Bakke decision in 1976, but other
efforts, such as AAMC’s “Project 3000 by 2000,” initiated in 1990, resulted
in significant increases that exceeded 1974 levels. Between 1990 and 1994,
the number of underrepresented minority (URM) students increased
36.3% to 2014 students, or 12.4% of the total number of medical school
matriculants. Since that time, however, the number and proportion of
new URM medical school enrollees has declined significantly. Enroll-
ment of African-American students in medical schools, for example, de-
clined 8.7% between 1994 and 1996 (Carlisle and Gardner, 1998). The
greatest declines have occurred in public medical schools, which prior to
1996 enrolled a greater proportion of URM students than private institu-
tions. Over 60% of public institutions experienced declines in URM stu-
dent enrollment since 1994—a collective decrease of 9.1% in minority stu-
dent matriculation at these institutions—while only 44% of private
medical schools experienced such declines (Carlisle and Gardner, 1998).
While the reasons for these declines are complex, some evidence in-
dicates that the declines have immediately followed significant policy
shifts regarding affirmative action and higher education admissions pro-
cedures. Several legislative and judicial challenges to affirmative action
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122 UNEQUAL TREATMENT
policies in 1995, 1996, and 1997 (notably, the Fifth District Court of Ap-
peals finding in Hopwood v. Texas, the California Regents decision to ban
race or gender-based preferences in admissions, and passage of the Cali-
fornia Civil Rights Initiative [Proposition 209] and Initiative 200 in Wash-
ington state) have forced many higher education institutions to abandon
the use of race and gender as factors in admissions decisions. Subse-
quently, public medical schools in California, Louisiana, Mississippi, and
Texas (the latter three states are subject to the Hopwood ruling) accounted
for 44% of the decrease in URM matriculation in medical schools nation-
wide (Carlisle and Gardner, 1998a). In 1997, African-American student
enrollment in Texas’ public medical schools dropped 54% (Carlisle and
Gardner, 1998b). And among California’s public and private medical
schools, URM enrollment declined 32% in 1998 from its peak in the mid-
1990s (Grumbach et al., 2001). Because of the large minority populations
in these states, much of the nationwide decline in URM enrollment re-
flects the trends noted above, while more modest minority enrollment
declines in states unaffected by legislative or judicial rulings may reflect
administrators’ greater caution or perceived pressure to scale back affir-
mative admissions policies.
This decline in the numbers of underrepresented minority students in
health professions education programs raises significant concerns regard-
ing the ability of the healthcare workforce to address the nation’s future
health service needs. Racial and ethnic minorities are four times more
likely to receive care from non-white physicians than white physicians
(Moy and Bartman, 1995). Further, racial and ethnic minority physicians
are more likely to practice in minority and medically underserved com-
munities. A study of physicians’ practices in California found that on
average, over half (52%) of patients in the practices of African-American
physicians were African American, compared with nine percent among
non African-American physicians. Among Hispanic physicians, average
caseloads approached 55% Hispanic patients, compared with 20% among
non-Hispanic physicians (Komaromy, Grumbach, Drake, et al., 1996). Yet
African-American and Hispanic physicians constitute less than 6% of the
physician workforce.
The racial/ethnic diversity of health professionals also has broader
implications for health service costs and improvements in the quality of
care. For example:
• Healthcare professionals from racial and ethnic minority groups
have generally been more successful in recruiting minority patients to
participate in clinical research. Such efforts are critical to link scientific
advancements with quality service delivery in underserved communities.
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• The quality of healthcare depends as much on physicians’ scien-
tific competence as on an understanding of cultural, social, and economic
factors that influence the health of patients, the ways in which they seek
care, and their response to medical treatment. Racial and ethnic diversity
of health professions faculty and students helps to ensure that all students
will develop the cultural competencies necessary for treating patients in
an increasingly diverse nation (Association of American Medical Colleges,
1998).
• Racial and ethnic minorities disproportionately receive medical
care in hospital emergency settings. Such care is more costly than routine
medical care and preventive health services. Healthcare professionals
from minority and underserved communities may be better poised to tai-
lor preventive health and primary care programs and services to minority
populations, thereby reducing associated costs.
SUMMARY
Racial and ethnic disparities in healthcare emerge from an historic
context in which healthcare has been differentially allocated on the basis
of social class, race, and ethnicity. Unfortunately, despite public laws and
sentiment to the contrary, vestiges of this history remain and negatively
affect the current context of healthcare delivery. And despite the consid-
erable economic, social, and political progress of racial and ethnic minori-
ties, evidence of racism and discrimination remain in many sectors of
American life. This persistent pattern of inequality suggests that inter-
ventions to eliminate disparities must be comprehensive and sustained,
and that raising public and healthcare provider awareness of the problem
is an important first step. Toward this end, a number of public and pri-
vate organizations have developed educational campaigns targeted to-
ward healthcare consumers, their providers, policymakers, and other
“stakeholders.” These efforts include, but are not limited to: the public
education efforts of U.S. DHHS, which recently launched its “Closing the
Health Gap” campaign to heighten awareness of health disparities; Di-
versity Rx, which provides a clearinghouse of information on language,
culture, and improving healthcare services for minorities; and The Henry
J. Kaiser Family Foundation, which has developed a number of publica-
tions targeted to the general public regarding healthcare disparities.
Finding 2-1: Racial and ethnic disparities in healthcare occur in the
context of broader historic and contemporary social and economic
inequality, and evidence of persistent racial and ethnic discrimina-
tion in many sectors of American life.
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Recommendation 2-1: Increase awareness of racial and ethnic dispari-
ties in healthcare among the general public and key stakeholders.
Public education to increase awareness of racial and ethnic dispari-
ties in healthcare is an important first step toward eliminating these
disparities. Media campaigns and other educational efforts to in-
crease awareness of disparities should be targeted to broad audiences,
including healthcare consumers, payors, providers, and health sys-
tems administrators.
Recommendation 2-2: Increase healthcare providers’ awareness of
disparities.
Organizations responsible for the education, training, and licensure
of health and medical professionals should develop special initia-
tives to increase levels of awareness of healthcare disparities among
current and future healthcare providers.
Representative terms from entire chapter:
medical schools
