Race and Health Levels

Race and Health Levels
A look a minority health status in the United States

Evidence of Disparities

The Facts

U.S. Health Care in General is Low: Life expectancies for White women in the U.S. lag behind 15 other countries. [source]
Dental Care: For people 25 years and older, 64% of Whites, 47% of Blacks, and 46% of Hispanics had seen a dentist within the previous year. [source]
Heart Disease (Leading Cause of Death): All groups save Blacks (49% higher) have lower death rates than Whites. [source] Whites have seen a more rapid decline in death rates for heart disease than all other groups.
Cancer (Second Leading Cause of Death): All groups save Blacks have lower death rates than Whites--by about 35%. Cancer rates have been rising for all racial groups. The Black/White difference in cancer rates has gone from negligible to 35%. [source]
Pneumonia (6th Leading Cause of Death): Blacks, Native Americans/Alaska Natives, and Hispanics have higher death rates than whites, while the death rates for Asian or Pacific Islanders were lower. [source] Declines in death rates due to pneumonia were most significant between 1960 and 1980, which, along with other evidence, suggests that the Civil Rights Movement had a positive impact on health levels for Blacks. [source]
Diabetes (7th Leading Cause of Death): Blacks, Native Americans/Alaska Natives, and Hispanics have higher death rates than whites, while Asians or Pacific Islanders was slightly lower. [source]
HIV/AIDS (8th Leading Cause of Death): Rates for Blacks and Hispanics are much higher. The Black/White difference is 475%, and the Hispanic/White difference is 126%. These statistics have increased since 1990. Rates for Native Americans or Alaska Natives, and Asians or PI, on the other hand are much lower. The Asian or Pacific Islander/White difference is 31%. [source]
Chronic Liver Disease (10th Leading Cause of Death): In 1950, death rates were higher for Whites than for Blacks. Today, they are slightly lower for Whites than for Blacks, but rates overall have only changed slightly. [source]
Mental Health: Blacks have comparable or better rates than Whites on other indicators of mental health! (1). Studies show few differences between the groups in rates of either current or lifetime psychiatric disorders, however, Blacks do have higher rates than Whites of anxiety disorders, especially phobias. [source]

While the disparities in death rates are striking, it is important to also take into consideration the severity and progression of a disease. Higher death rates for minorities tend to reflect both higher levels of ill health and greater severity of disease. For example, 43% of white males had a 5-year survival rate for cancer compared to 32% of black males. The rates of survival have increased for both groups, but at a faster rate for Whites than for Blacks. There is some variation by type of cancer. [source] Black females are less likely to get breast cancer, but are more likely to die from it, due to detection at a more advanced stage of the cancer for Blacks than for Whites. [source] Subgroup variations must also be taken into consideration, because they affect all of the above facts. For example, a black person could have been raised in the northern U.S., the southern U.S., Kenya, Jamaica, or Haiti, to mention a few. There could be differences in culture that affect that black person's lifestyle, and consequently his/her health. Furthermore, there could be genetic differences between the subgroups that make a particular group more or less susceptible to a disease. [source] While about 75% of known genetic factors do not vary from human to human, 95% of the variation exists within racial subgroups! [source]

Accounting details affect all of the above facts as well. Misrepresentation of race on death certificates is one possible factor. For example, 40% of cancer patients registered with the Indian Health Service as Native Americans or Alaska Natives were misidentified in the cancer surveillance registry. The denominators of all of these statistics are also affected by inaccuracies in the US census. [source]

Disparities in Health Care
General Findings

Minorities seem to receive less and inferior health care than whites (Williams, 1994; Ford and Cooper, 1995)
Minorities are less likely to receive higher technology services/procedures (Escarce et al., 1993; Goldberg et al., 1992)
Controlling for socio-economic status, Latinos underutilize mental health services (Ruiz, 1993; Ginzburg, 1991; Vega et al., 1999)
Controlling for "need", minorities get less or inferior care (Peterson et al., 1997; Bach et al., 1999; Shapiro et al., 1999)

Representative Studies
Many studies emphasize the role of language barriers in contributing to disparities in the quality of healthcare received. Tai-Seale et al., (2001) looked at racial and ethnic differences in pediatric care assessment. They used data from the National Consumer Assessment of Health Plans Survey (CAHPS) Benchmarking Database (NCBD) 1.0 Child Surveys, which were telephone and mail surveys in Arkansas, Kansas, Minnesota, Oklahoma, Vermont, and Washington of 9540 children enrolled in Medicaid managed care. From this data, they created regression models with the following dependent and independent variables, and results:

Dependent Variables
- Ratings of Care
  - Personal doctor or nurse rating
  - Specialist rating
  - Health care rating
  - Health plan rating
- Reports of Care
  - Getting needed care
  - Timeliness of care
  - Provider communication
  - Staff helpfulness
  - Plan service
Independent variables
- Parent's race/ethnicity
- Hispanic and Asian parent's language
- Parent's gender (0 = female, 1 = male)
- Parent's age (18-34, 35-54, 55+)
- Parent's education (less than high school, high school graduate, 1+ years of college)
- Children's health status (excellent, very good, good, fair, poor)
Results
- Asian-other language had worse reports of care than whites, and worse ratings than whites.
- Asian-English did not differ significantly from whites for reports of care, but had better ratings than whites for specialist and plan-service.
- Hispanic-Spanish had worse reports of care than whites for timeliness of care, provider communication, staff helpfulness, and plan service, but had better ratings than whites for personal doctor, specialist, and plan service.
- Hispanic-English did not differ significantly from whites for reports of care or ratings.
- African Americans had worse reports of care than whites for getting needed care, timeliness of care, and plan service.
- American Indians had worse reports of care than whites for getting needed care, timeliness of care, provider communication, and plan service, and worse ratings than whites for personal doctor and plan/service.
- Why the discrepancy between reports of care and ratings of care?
  - Reports of care might be more objective and capture real differences in care, while rating might be more subjective because they are influenced by expectations, and racial/ethnic minorities have lower expectations.

This problem with communication in health care is formally called statistical discrimination, defined more explicitly as the following: disparities in the receipt of health care might arise from poor communication between the patient and the doctor. Thus, the greater the communication disparity, the more the doctor must rely on his own perception of a racial/ethnic group in general to interpret the symptoms.

More recent studies have focused on the effects of managed care on health disparities. Balsa and McGuire (2001) looked at this influence of managed care (HMO's), and found that mandatory enrollment in managed care for Medicaid recipients increases the disparities between whites and blacks. Gathering data from a stratified sample of Aid to Families with Dependent Children (AFDC) beneficiaries in a waiver county (Section 1915b of the Social Security Act) during fiscal year 1993, they calculated the difference in differences in service use between white and black beneficiaries over time within the waiver county. They found that there is a differential reduction in the relative use of physician service and inpatient services among black beneficiaries, and propose three reasons for this increase in disparities.

Medicaid beneficiaries can only choose from network providers, decreasing the number of providers from which he/she can choose. Medicaid contracts with independent practice associations (IPAs), whose physicians might have private practices that are not located near African American residential areas, so blacks have to travel further.
IPA physicians continue to run their own private practice in addition to treating Medicaid patients. If their non-Medicaid patient load is high, IPA physicians will have to choose between white and black Medicaid patients for the limited time left to treat Medicaid patients in general. Racial prejudice (Schulman et al., 1999) and institutional racism (Fullilove 1998 ; Lancet 1999) might reduce the quantity of service provided to blacks.
Race might be used as an indicator of potential risk factors, making physicians more likely to not want to take a patient in a capitated environment. (e.g., blacks would be thought of having risk factor of inadequate prior treatment, which will lead to higher treatment costs in the future)