Racial and Ethnic Disparities in Racial and Ethnic Disparities in Health and Health Care: Why the Health and Health Care: Why the

Gaps?Gaps?

Brian D. Smedley, Ph.D.Brian D. Smedley, Ph.D.The Opportunity AgendaThe Opportunity Agenda

Age-Adjusted Death Rates by Sex, Age-Adjusted Death Rates by Sex, Race, and Hispanic Origin, 2002Race, and Hispanic Origin, 2002

0

200

400

600

800

1000

1200

1400

1600

All White Black Latino AI/ AN Asian

FemaleMale

Per 100,000 resident population

Source: Health, United States, 2004

Age-Adjusted Death Rates per 100,000 for Age-Adjusted Death Rates per 100,000 for Selected Causes of Death by Race and Selected Causes of Death by Race and Ethnicity, 2002Ethnicity, 2002

0

50

100

150

200

250

300

350

Heart Disease Cerebro-vascular

Cancer Diabetes

WhiteBlack HispanicNative AmericanAsian American

Source: Health, United States, 2004

Low birthweight by education and Low birthweight by education and race or ethnicity, United States, 2002race or ethnicity, United States, 2002

Source: Health, United States, 2004

0

2

4

6

8

10

12

14

16

18

White, nonHispanic

Black, non Hispanic Hispanic Native Peoples Asian or PacificIslander

perc

enta

ge o

f live b

irth

s w

ith k

now

n b

irth

weig

hts <12 years of education

12 years of education

13 or more years ofeducation

What Factors Contribute to Racial What Factors Contribute to Racial and Ethnic Health Disparities?and Ethnic Health Disparities?

Socioeconomic inequalitySocioeconomic inequality Residential segregation and Residential segregation and

environmental living conditionsenvironmental living conditions Stress, coping, health risk and Stress, coping, health risk and

health-seeking behaviorshealth-seeking behaviors Differences in access to health Differences in access to health

carecare Differences in health care quality, Differences in health care quality,

even at equal levels of accesseven at equal levels of access

Racial and Ethnic Differences in Racial and Ethnic Differences in Access to Care and Quality of CareAccess to Care and Quality of Care

Minorities are more likely to be un- Minorities are more likely to be un- or underinsuredor underinsured

Minorities are more likely to live in Minorities are more likely to live in medically underserved medically underserved communitiescommunities

Minorities are more likely to Minorities are more likely to experience cultural and linguistic experience cultural and linguistic barriers to carebarriers to care

Evidence of Racial and Ethnic Evidence of Racial and Ethnic Disparities in Healthcare, Even When Disparities in Healthcare, Even When “Access” is Similar“Access” is Similar

Cardiovascular DiseaseCardiovascular Disease – African Americans – African Americans are less likely to receive appropriate are less likely to receive appropriate diagnostic tests, medications, or to diagnostic tests, medications, or to undergo bypass surgeryundergo bypass surgery

CancerCancer – African Americans receive less – African Americans receive less aggressive treatmentsaggressive treatments

Kidney DiseaseKidney Disease – African Americans less – African Americans less likely to be told about, evaluated for, or to likely to be told about, evaluated for, or to receive kidney transplantationreceive kidney transplantation

HIV/AIDS HIV/AIDS – Minorities less likely to receive – Minorities less likely to receive antiretroviral or other state-of-the-art antiretroviral or other state-of-the-art treatmentstreatments

What are potential sources of What are potential sources of disparities in care?disparities in care?

Health systems-level factors – financing, Health systems-level factors – financing, structure of care; cultural and linguistic structure of care; cultural and linguistic barriers; and the inequitable distribution barriers; and the inequitable distribution of health care resourcesof health care resources

Patient-level factors – including patient Patient-level factors – including patient preferences, refusal of treatment, poor preferences, refusal of treatment, poor adherenceadherence

Disparities arising from the clinical Disparities arising from the clinical encounter – biases and stereotypingencounter – biases and stereotyping

Health Care – Still Separate Health Care – Still Separate and Unequal in Some Areas?and Unequal in Some Areas?

0

5

10

15

20

25

30

35

40

Percent in "lower tier" nursing homes

Blacks

Whites

Nationwide, 40% of Nationwide, 40% of African American nursing African American nursing home residents live in home residents live in lower-tier facilities—lower-tier facilities—compared to 9% of white compared to 9% of white nursing home residentsnursing home residents

Lower-tier nursing homes Lower-tier nursing homes have a high concentration have a high concentration of Medicaid residents, of Medicaid residents, very limited resources, very limited resources, inadequate staffing, and inadequate staffing, and lower quality scoreslower quality scores

CMS provides CMS provides performance “bonuses” performance “bonuses” for top-performing for top-performing nursing homes, but does nursing homes, but does not provide additional not provide additional resources to assist lower-resources to assist lower-tier facilitiestier facilities

““Patients” experiencing symptoms of heart Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)disease, from Schulman et al. (1999)

““Patients” experiencing symptoms of heart Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)disease, from Schulman et al. (1999)

ConclusionsConclusions Racial and ethnic disparities in Racial and ethnic disparities in health statushealth status are are

persistent, and are caused by multiple factors that persistent, and are caused by multiple factors that have roots in historic and contemporary have roots in historic and contemporary disadvantagedisadvantage

Health care access and quality for many Health care access and quality for many communities of color is poorer than should be communities of color is poorer than should be toleratedtolerated

Health care services remain “separate and Health care services remain “separate and unequal” in many areasunequal” in many areas

Evidence of racial disparities in many clinical Evidence of racial disparities in many clinical services persists, even when insurance and other services persists, even when insurance and other factors are equalfactors are equal