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Memorandum To: From: Date: Re:

TBD Jetmir Troshani Date goes here

Cultural and Racial inequality in Health Care

Outline: 1. 2. 3. 4. 5.

Executive summary; Overview; Discussion; Recommendations; Conclusions. Executive summary

“Overwhelming facts reveals that racial and cultural minority groups are more likely to receive poorer quality health care than white Americans, even when factors such as insurance status are controlled” (American College of Physicians 2010). As the country’s population continues to grow and diversify, the health care system will have to change and adjust to meet the needs of an increasingly multicultural patient base. The statistical and anecdotal facts of racial injustice in American healthcare are undeniable. Studies done since 2003 by ACP shows systemic in addition to clinical discrimination, health practitioners, legislators, and normal citizens can no longer ignore the fact that America focuses on the color of one’s skin and the national origin of one’s ancestors still largely determine the quality of health care a consumer receives (American College of Physicians 2008; Urban Institute (2005). America thought that the issue of racial injustice and inequity was long gone, but it is shocking that the vice still endures largely, not only in the common platforms, politics and socials, but in a more critical issue like health care. After controlling the differences among the races in socioeconomic status, health insurance, access to


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health care and geographic differences, the statistical facts still demonstrates that Blacks and Latinos still get lesser and substandard medical attention than their counterparts, the whites, irrespective of whether those services are for treatment of cardiovascular disease, chronic diseases, mental illness, child medical care or HIV/AIDS. Comparing these minority groupings (African Americans, Native Americans, Asian Americans, and Latinos) with the white Americans, they are more vulnerable to chronic illnesses, higher mortality rates, and worst health effects (Bardach 2009). Among the disease-specific examples of racial and ethnic disparities in the U.S. is the cancer incidence rate among Blacks that is 10 percent more than among the white Americans (Barrett, Dyer and Westpheling 2008; Kettl 2007). Also, adult Blacks and Latinos are almost twice more than Whites prone to diabetic complications. Although African Americans, Latinos and Native Americans suffer and succumb to diabetes more often than then whites, research show the disease is not well handled among minorities. Paradoxically, Black, Native and Hispanic Americans have more medical attention services than do whites for those undesirable medical attentions, for instance amputations, and cesarean section among others. Although these are necessary attentions, they are considered undesirable because a patient would rather avoid them if at all they had an option, for instance many patients would prefer to keep a leg if it could be made healthy, rather than going for an amputation. Undisputedly, ignoring these injustices would take the efforts of social scientists, researchers, health care providers, legislators, environmentalists, clergy, and patients among others to adequately attend to the matter (Lurie and Dubowitz 2007;


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Schlotthauer et al. 2008; Zuckerman et al. 2008). Although the issue is multi-sided, this paper looks at the policy solutions available. Overview/Background Lexically, health inequalities refer to the gap in the quality and accessibility of medical attention among racial, ethnic, socio-economic groupings. Almost as long as there have been hospitals in America, there have been racial disparities in the health care system. The first hospital founded in the U.S. was the Pennsylvania General Hospital, established in Philadelphia in 1751 from private funds, donated for the care of the less-fortunate and the mentally unstable. In the beginning of its operations, records from Pennsylvania General did not show that any patients other than whites were admitted for care. The institution was, in fact called the “First Anglo Hospital”1 in the U.S. nevertheless, historical records reveals that the institution eventually began to admit non-Caucasian patients. Beginning in 1825 and 1829 respectively, Pennsylvania General began to record the “color” and “national origin” of admitted patients, confirming that the hospital at some point began offering services to both Black and white patients (Baker et al. 1996). In fact, before end of slavery in America, the judicial record reveals that African-Americans got a significant healthcare whenever need be; their health influenced their monetary value as property of slave-owners. After the Civil War, giving access to African Americans took on a different dimension. Waves of Blacks migrating from the south began to mount pressure on health care amenities to serve Black and white patients the same. During the Reconstruction, racial segregation, surfaced both within healthcare institution used by both the non-native American and

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More reading from Grumbach, K. and Mendoza, R. (2008) and American College of Physicians. (2006).


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white patients, professional, and physicians, and in the structure of the hospital industry itself. Martin Luther King, Jr. quotes that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane” (as cited in ACP 2004). Ever since overt racial disparities has grown and still looms. Arguably, health disparity starts shortly after conception. One pointer of a child's healthy birth, making other lifetime outcomes more probable to be successful, is whether mothers get early medical care at pregnancy. 25% of African-American women do not receive prenatal attention at the first trimester, while 11% of white women get none (American College of Physicians 2007; Bach et al. 2004; Dorn et al. 2008). For African-American women, 6% do not receive prenatal attention, but only 2% of white women, one third the number of 27 blacks, get no or too-late care. Considering infant mortality during the first year of life, there are 14 deaths for African-American and six for native Americans/1,000 live births. However, proper prenatal care likely could have prevented some of these deaths. Infant mortality and morbidity are enduring, thus the high rate of African-American infant mortality shows the probability of a similarly higher rate of black infants who survive with unhealthy conditions that make school and lifetime success more difficult. It is these disparities in pregnancy and childbirth, which are eventually reflected in racial inequality (Winkleby et al. 1992). Discussion Inequality of access to health care in the adequacy of care different cultural and racial groups get can include: 

Difficulties with patient-practitioner communication. In delivering medical care, communication is essential so as to administer proper and effectual treatment and attention in disregard to racial group. As miscommunication could lead to


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inaccurate analysis, wrong medication, and failure to get a follow-up attention. As Flores (2007) describes, “Cross-cultural differences in information-seeking patterns, communication styles, perceptions of health risk, and ideas about prevention of disease [have] an impact on health.” In the US language barrier is even worse, especially among the non-natives groups. Statistically, “less than half of non-English speakers who say they need an interpreter during health care visits report having one. In addition, communication barriers crop up from the lack of cultural understanding on the part of white providers for their minority patients” (Halbert et al. 2006). 

Practitioner inequity. In some cases the medical care practitioners either unconsciously or consciously attends to some racial patients in a different way than other patients. Some studies show that racial minority patients are “less likely than whites to receive a kidney transplant once on dialysis. Critics argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences” (Institute of Medicine 2004).

Lack of preventive care. According to the 2009 National Healthcare Disparities Report, “uninsured Americans are less likely to receive preventive services in health care, for instance racial minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic people”2. “Many people of colored skin are facing poor health care than whites from the

cradle to the grave, in terms of greater rates of infant mortality, chronic diseases and disability, and pre-mature death” (Peterson and Yancy 2009). These health 2

As cited in U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion (2007).


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disparities take a significant human toll, but in addition inflict a huge economic weight on America. A recent research conducted shows that the direct health costs, that is, related with health inequalities, extra costs of medical services incurred due to the greater burden of diseases suffered by the minority groups-was more than US$250B in the period between 2003 and 2006. Aggregating the indirect costs related with health inequalities, for instance foregone salaries and yield and foregone tax revenue, the total costs of health inequalities for the country was US$1.24B in the same duration (Kettl and Fesler, 2009). With the inception of Obama administration, things are looking bright. With the enactment of the Health Reform Law, this will see more than 32 million uninsured Americans, the majority being the minorities get insurance coverage. These laws will avert insurance companies from exploiting new enrollees and rejecting claims due to the earlier conditions and more medical care providers will get more incentives to work in “medically underserved communities, among other expected benefits. These legislations will improve the current state of health care for people of colour, who are disproportionately un- and under-insured and who face greater barriers than whites to receiving high-quality care, even when insured” (Herbert et al. 2008). A research commissioned by the Institute of Medicine (2002) estimated that: “over 886,000 deaths could have been prevented from 1991 to 2000 if African Americans had received the same care as whites. The main differences were due to lack of insurance, inadequate insurance, and poor service for the minority patients.” Recommendations Youdelman (2007) and Smedley (2008) argue that “The correlation between socioeconomic position and health, is a pervasive correlation, which is seen across periods of time, across places in the world, and across groups… and it is almost


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invariably in the same direction,” as socioeconomic position increases, health improves. Youdelman opines that although there are various means to explain health inequalities (from a racial and ethnical dimension, socio-economics, and geography) socioeconomic inequalities should take center stage in the health policy talk, because application of some policy functions can worsen this issue. However, according to Schillinger et al. (2003) ‘race is not an issue’ when it comes to matters of health inequity. He notes that the income differences across racial groups, exposure to social and economic adversity over the time and subjection to prejudice and institutional bigotry can influence the health of the minorities in several ways. Schillinger et al. (2003) “underscores this by revealing that majority of the socio-economic group of black women have almost or even higher rates of infant mortality, low birth-weight, hypertension and obesity than the lowest socioeconomic group of white women.” Blendon et al. (2008) emphasize on the use of specific approaches to contain racial disparities and urges that the health policy should be redefined so as to take account other sectors of the community, which have health impacts. It is noticeable that the minority groups face distinctive and intricate challenges in modern policy environment, from crisis alertness and response to equal access to proper medical attention. Recognizing the situation, those representing these groups should join forces and put forward a strong voice in addressing these intricate (Williams and Jackson 2005). To reduce the health inequalities, more emphasis should be made on evidence-based techniques modeled to overcome the groups struggle against medical and public health research, together with:


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Result-orientation: research entrenched in a community background modeled to achieve substantial outcomes and attain the optimal performance.

Community collaboration: partnering “with” the groups, instead of giving things “to” them;

Ethnical tolerance: models custom-made for community demands and reaches; Notably, equity of access to quality health care cannot be guaranteed

through uniformity in a multicultural community, but through cultural sensitivity in delivery of medical care is equally necessary in achieving this equality. In ascertaining cultural tolerance, we should find if the current delivery of health care is impartial, and if it is as it is, then know how to reverse the situation. A more practically approach in dealing with this is “ethnic match” 3 which seems to have a remarkable effect on the patients and providers in terms of access and utilization of health care services. In America, Barrett, Dyer and Westpheling (2008) observe that the more the minorities’ workers working in a mental institution, the higher the utilization rate by the minorities. Moreover, many surveys have revealed that an “ethnic match” between patient and the practitioner normally increase utilization rate while reducing the dropout rate. However, in addressing such inequalities numerous viable options have been raised. These options range from simple and realistic to involving a whole change to the system. Blanton et al (2002) notes “improvements in quality of care can simply begin with multilingual information, link workers, appropriate diets to a multi-faith approach in hospital.” While on the other hand, U.S. Department of Health and Human Services Office of Disease Prevention and Health

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See more discussion on “ethnic match” by Barret, S. R. et al. (2008). Health Literacy Practices in Primary Care Settings: Examples from the Field. Washington, DC: The Commonwealth Fund.


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Promotion (2008) advocates for “anti-racism service delivery” which involves “ensuring that providers are reflective of ethno-racial communities and knowledgeable about issues of race, gender, power and privilege, that people of color are involved in planning, implementing and evaluating these services and that services are appropriate to the needs of communities of color” 4. However, the provisions made on the health reform law do not assure an answer the health care inequalities issue, as going by studies having health insurance doesn’t assure access to quality medical services neither does it considerably better health services. Instead, it is notable that health disparities continue due to differences in the neighbourhoods of the minority and non-minority groups. Racial and cultural minority groups are more probable than white Americans to live in segregated, poverty-ridden populations, people who have ever since experienced lack of health care resources (Zuvekas and Taliaferro, 2003). Even worse, majority of these people stare at a host of health dangers, for instance a lot of environmental stressors, and an influx fast food outlets and liquor shops and have rather countable health-conscious investments, for instance grocery outlets. One’s environment has a considerable effect on his/her general health status. 25% of preventable diseases globally are associated to poor environmental quality. Reschovsky and O’Malley (2008) recommend that “The government at all levels can improve health opportunities by stimulating public and private investment to help make all communities healthier. It can achieve this by providing incentives to improve neighbourhood food options, by aggressively addressing environmental degradation, and by de-concentrating poverty from inner-cities and rural areas through smart housing and transportation policy.” Many of these strategies are highly 4

Also cited by Kaiser Family Foundation (2006).


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cost-effective; however addressing health inequities that are the outcome of environmental stressors can be a complex and challenging task. Moreover, policymakers should come up with a set of measures to track environmental stressors and how they impact on the health inequities of racial and cultural minority groups (Gaskin et al. (2007). According to the American College of Physicians, although America has made some tremendous advances towards achieving health care equality, a lot still needs to be done. "Closing the disparity gap is not only morally and professional imperative, it remains a glaring civil rights injustice that must be addressed," the ACP (2010) says. Improved communication is one of the core issues in bridging the inequality gulf in a country where approximately a quarter of the inhabitants are not native English speakers. Also, given that by the year 2042, according to the U.S. Census Bureau, “half of America’s population will be people of colour, it is imperative that we be prepared to address the health needs of an increasingly diverse population”5. It is also recommended that all third‐party payers, such as Medicare, pay for the services of interpreters, and “language services”. In addition, medical professionals should be trained to have racial and ethnical tolerance so they appreciate the medical care practices and misunderstandings harboured by racial and ethnic minority groups (Hoffman and Tolbert 2006). “Organizations that set standards for medical education”, the ACP (2010) reports, “are becoming believers in this kind of training — an encouraging sign of progress. To create a more diverse physician workforce, we should strengthen the

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Cited by James, C. et al. (2009). Putting Women’s Health Care Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level. Kaiser Family Foundation. Retrieved from http://www.kff.org/minorityhealth/upload/7886.pdf


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education of minority students, especially in math and science, at all levels to create a larger pool of qualified minority applicants for medical school.� Similarly, medical schools should enrol and retain more minority faculty. One nagging societal ills highlighted in the ACP report is the advertisement of tobacco and alcoholic products, and fast foods to minority groups. Conclusion Racial and cultural inequities in health care emerge from the interaction of many intricate factors, including past and current discrimination in health care, genetics, unequal educational opportunity, income and health care access disparities, cultural beliefs, and community systems. Bridging the disparity gulf is not easy, but it is a moral imperative that appropriate resources should be made to address these differences.


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Reference list ACP. (2004). Language Access in Health Care: Statement of Principles. ACP. Retrieved from http://www.acponline.org/advocacy/where_we_stand/access/language.p df. American College of Physicians. (2008). Achieving Affordable Health Insurance Coverage for all Within Seven Years: A Proposal from America’s Internists. Philadelphia: American College of Physicians. American College of Physicians. (2007). Achieving A High Performance Health Care System With Universal Access: What The USA Can Learn From Other Countries, 2007. Philadelphia: American College of Physicians. American College of Physicians. (2006). Language Services for Patients with Limited English Proficiency: Results of a National Survey of Internal Medicine Physicians. Philadelphia: American College of Physicians.


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American College of Physicians. (2010). Racial and ethnic disparities in health care, updated 2010. Philadelphia: American College of Physicians. Bach P et al. (2004). Primary Care Physicians Who Treat Blacks and Whites. NEJM, 351, 575-584. Baker, D. W. et al. (1996). Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA, 275, 783-788. Bardach, E. (2009). A Practical Guide to Policy Analysis: The Eightfold Path to More Effective Problem Solving, 3rd Edition. New York/London: Chatham House Publishers, Seven Bridges Press, LLC. Barrett, S., Dyer, C. and Westpheling, K. (2008). Language Access: Understanding the Barriers and Challenges in Primary Care Settings. Perspectives from the Field. McLain, VA: Association of Clinicians for the Underserved. Barret, S. R. et al. (2008). Health Literacy Practices in Primary Care Settings: Examples from the Field. Washington, DC: The Commonwealth Fund. Barrett, S., Dyer, C. and Westpheling, K. (2008). Language Access: Understanding the Barriers and Challenges in Primary Care Settings. Perspectives from the Field. McLain, VA: Association of Clinicians for the Underserved. Betancourt, J. et al. (2005). Cultural Competency and Health Care Disparities: Key Perspectives and Trends. Health Affairs, 24, 499-505. Blanton, L. et al. (2002). Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. New York: Kaiser Family Foundation and American College of Cardiology.


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Blendon, R. et al. (2008). Disparities in Physician Care: Experiences and Perceptions of a Multi-Ethic America. Health Affairs, 27, 507-517. Dorn, S. et al. (2008). Medicaid, SCHIP, and Economic Downturn: Policy Changes and Policy Responses. Kaiser Family Foundation. Retrieved from http://www.kff.org/medicaid/upload/7770.pdf Flores, G. (2007). Language Barriers to Health Care in the United States. NEJM, 355, 229-231. Gaskin, D. et al. (2007). Examining Racial and Ethnic Disparities in Site of Usual Source of Care. Journal of the National Medical Association, 99, 22-30. Grumbach, K. and Mendoza, R. (2008). Disparities in human Resources: Addressing the Lack of Diversity in the Health Professions. Health Affairs, 27, 413-422. Halbert, C. H. et al. (2006). Racial Differences in Trust in Health Care Providers. Arch Inten Med, 166, 896-901. Herbert P. et al. (2008). When Does A Difference Become a Disparity? Conceptualizing Racial and Ethnic Disparities in Health. Health Affairs, 374-382. Hoffman, C. and Tolbert, J. (2006). Health savings Accounts and High Deductible Health Plans: Are They An Option for Low-Income Families? Kaiser Family Foundation. Retrieved from http://www.kff.org/uninsured/upload/7568.pdf Institute of Medicine. (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press.


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Institute of Medicine. (2004). Health Literacy: A Prescription to End Confusion. Washington: National Academies Press. James, C. et al. (2009). Putting Women’s Health Care Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level. Kaiser Family Foundation. Retrieved from http://www.kff.org/minorityhealth/upload/7886.pdf Kaiser Family Foundation. (2006). Supplemental Coverage Among Medicare Beneficiaries, by Race/Ethnicity, 2006. Kaiser Family Foundation. Retrieved from http://facts.kff.org/chart.aspx?ch=519 Kettl, F. and Fesler, J. (2009). The Politics of the Administrative Process, 4th Edition. Washington, D.C.: CQ Press. Kettl, D. F. (2007). System Under Stress: Homeland Security and American Politics, 2nd Edition. Washington, D.C.: CQ Press. Lurie N. and Dubowitz T. (2007). Health Disparities and Access to Health. JAMA, 1118-1121. Peterson, E. and Yancy C. W. (2009). Eliminating Racial aand Ethnic Disparities in Cardiac Care. NEJM. 360, 1172. Reschovsky, J. and O’Malley, A. S. (2008). Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care? Health Affairs, 27, w222-w231. Schillinger, D. et al. (2003). Closing the Loop: Physician Communication with diabetic Patients Who Have Low Health Literacy. Arch Int Med, 163, 8390. Schlotthauer, Y. et al. (2008). Evaluating Interventions to Reduce Health Care Disparities: An RWJF Program. Health Affairs, 27, 568.


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Smedley, B. (2008). Moving Beyond Access: Achieving Equity in State Health Care Reform. Health Affairs, 27, 447-455. Williams, D. and Jackson, P. (2005). Social Sources of Racial Disparities in Health. Health Affairs, 24(2), 325-334. Winkleby, M. et al. (1992). Socioeconomic Status and Health: How education, Income, and Occupation Contribute to Risk Factors for Cardiovascular Disease. Am Journal Public Health, 82, 816. Urban Institute (2005). Going Without: America’s Uninsured Children. Washington: Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/files/newsroom/ckfresearchreportfinal.pdf U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Health Literacy – Fact Sheet: The Basics. Retrieved from http://www.health.gov/communication/literacy/quickguide/factsbasic.htm #one U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. (2008). Health Literacy – Strategies: Improve the Usability of Health Information. Retrieved from http://www.health.gov/communication/literacy/quickguide/healthinfo.htm# three Youdelman, M. (2008). The Medical Tongue: U.S. Laws and Policies on Language Access. Health Affairs, 27, 424-433. Youdelman, M. (2007). Medicaid and SCHIP Reimbursement Models for Language Services. Washington DC: National Health Law Program.


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Zuckerman, P. et al. (2008). Racial and Ethnic Disparities in the Treatment of Dementia Among Medicare Beneficiaries. Journal of Gerontology, 63B(5), S328–33. Zuvekas, S.H. and Taliaferro, G. S. (2003). Pathways to Access: Health Insurance, The Health Care Delivery System, And Racial/Ethnic Disparities, 1996-1999. Health Affairs, 22, 139-153.

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