Race, Ethnicity, and the Health Care System: Public Perceptions and Experiences

Abstract

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

Full text

MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)Lillie-Blanton et al. / Public Perceptions
Race, Ethnicity, and the Health Care System:
Public Perceptions and Experiences
Marsha Lillie-Blanton
Mollyann Brodie
Diane Rowland
Drew Altman
The Henry J. Kaiser Family Foundation
Mary McIntosh
Princeton Survey Research Associates
To assess the public’s perceptions and attitudes about racial and ethnic differences in
health care, the Kaiser Family Foundation surveyed a nationally representative sample of
3,884 whites, African Americans, and Latinos in 1999. The survey found that the major-
ity of Americans are uninformed about health care disparities—many were unaware that
blacks fare worse than whites on measures susch as infant mortality and life expectancy,
and that Latinos are less likely than whites to have health insurance. Views on whether
the health system treats people equally were strikingly different by race. For example,
most minority Americans perceive that they get lower quality care than whites, but
most whites think otherwise. Nonetheless, more minority Americans were concerned
about the cost of care than racial barriers. Efforts to eliminate disparities will need to
improve public awareness of the problems as well as address racial and financial barriers
to care.
Since the mid-1960s, the United States has made tremendous progress in
reducing barriers to health care facing racial and ethnic minority Americans.
Separate and very unequal systems of health care that were commonplace a
few decades ago are now only a part of this nation’s history. This progress is
largely attributable to enforcement of provisions of the Civil Rights Act of 1964,
which prohibited discrimination in institutions receiving federal funds, and
the enactment of Medicare and Medicaid in 1965, which reduced financial bar-
Medical Care Research and Review, Vol. 57 Supplement 1, (2000) 218-235
© 2000 Sage Publications, Inc.
218

riers to care for minority and nonminority elderly and low-income Ameri-
cans. Despite these achievements, there is mounting evidence that racial and
ethnic disparities persist in the use of preventive and life-saving medical tech-
nologies. A recently released review and synthesis of the literature on the topic
(Mayberry et al. 1999) as well as several studies released since that report
(Bach et al. 1999; Ayanian, Cleary, et al. 1999; Ayanian, Weissman, et al. 1999)
provide considerable evidence that racial disparities in medical care persist
even among persons with similar health coverage, income, and health status.
This article provides insights on the public’s perceptions of the health and
health care experiences of two of this nation’s largest racial and ethnic minor-
ity population groups: African Americans and Latinos. With an estimated one
in four Americans (about 67 million) now classified by the U.S. Census as a
member of a racial or ethnic minority group, disparities in access to health care
take on a broader level of national importance. Higher birth rates and immi-
gration among minority populations are reshaping the face of America. By the
year 2025, the U.S. Census estimates that people of color will represent about
one third of all Americans. As such, the health of minority Americans is a criti-
cal component of the nation’s health.
Public perceptions and misperceptions about racial and ethnic differences
in health and access to health care can shape public opinion about whether a
problem exists and influence the actions of policy makers in addressing the
problem. To explore the public’s perceptions of the linkages between race and
medical care and whether these views differ depending on respondents’ racial
and ethnic background, this article reviews findings from a national survey to
answer the following questions: (1) To what extent is the public aware of
racial/ethnic differences in health and health care access? (2) Do whites, Afri-
can Americans, and Latinos differ in their perceptions of how race and/or rac-
ism affect the health care system? (3) To what extent do individuals perceive
that they (or someone they know) have been treated unfairly because of their
race or ethnic background? and (4) What do African Americans and Latinos
perceive as major problems facing them in the health care system?
NEW CONTRIBUTION
This study presents new data on the public’s knowledge of and attitudes
about racial and ethnic differences in health and health care. To our knowl-
edge, it is the first national survey focused on these issues. Several studies and
national surveys have explored racial/ethnic differences in satisfaction with
health services and the health system overall (Blendon et al. 1989, 1995; Har-
ris and Associates 1993). In addition, a 1995 survey conducted by the Kaiser
Family Foundation, Harvard University’s School of Public Health, and The
Lillie-Blanton et al. / Public Perceptions 219

Washington Post (1996) assessed racial differences in perceptions of the eco-
nomic realities facing Africans Americans and Latinos in areas such as
employment, education, and health. This survey expands on that earlier work
with a focus on health and health care issues. The survey asks whites about
their perceptions of the health care experiences of African Americans and
Latinos, and African Americans and Latinos are asked to give a self-assess-
ment of their own experiences. The survey data, therefore, allow a comparison
of the extent to which whites and these two minority population groups agree
or disagree on their perceptions about the impact of race in the health care
system.
DATA AND METHODS
The survey results are based on telephone interviews with a nationally rep-
resentative sample of 3,884 adults 18 and older living in telephone households
in the continental United States, including interviews with 1,479 white
non-Latinos, 1,189 African Americans, and 983 Latinos. Some questions in this
survey were asked only of a random half sample of respondents (the
unweighted numbers of respondents are noted on the tables). Interviews were
completed in both English and Spanish according to the preferences of the
respondent. The survey was designed and analyzed by the authors, and the
fieldwork was conducted from July 7, 1999, through September 19, 1999, by
Princeton Survey Research Associates.
The sample was designed to produce a representative sample of telephone
households in the continental United States. The sample is based on a dispro-
portionately stratified random-digit sample of telephone numbers. A dispro-
portionate rather than a proportionate stratified sample was used so that the
final sample of completed interviews would contain a disproportionately
large number of African American and Latino respondents. Of the residential
numbers in the sample, 72 percent were contacted by an interviewer, and 69
percent agreed to cooperate with the screener questions. Ninety-three percent
were found eligible for the interview. Furthermore, 98 percent of eligible
respondents completed the interview. Therefore, the final response rate is 49
percent.
The data are weighted in analysis to remove the disproportionality of the
selection rates by stratum and to make the data fully representative. The
demographic weighting parameters are derived from a special analysis of the
most recently available Census Bureau Annual Demographic File (from the
March 1998 Current Population Survey). This analysis produced population
parameters for the demographic characteristics of households with adults 18
or older, which are then compared with the sample characteristics to construct
220 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)

sample weights. The results have been weighted to adjust for variations in the
sample relating to region of residence, sex, age, race, and education. (The anal-
ysis only included households in the continental United States where there is a
telephone in the household for comparability to the sample design used for
this survey.) The weights are derived using an iterative technique that simul-
taneously balances the distributions of all weighting parameters.
The stratification of the sample, the unequal probabilities of selection, and
poststratification preclude us from using simple random sampling formulas
to estimate the precision or variance of the survey estimates. We calculated the
effects of the complex sample design on the statistical efficiency of the sample
so that an adjustment can be incorporated into tests of statistical significance
when using these data. This so-called general design effect represents the loss
in statistical efficiency that results from systematically undersampling
(through sample design and nonresponse) parts of the population of inter-
est.1We multiply the standard error of a statistic by the square root of the
design effect when computing tests of statistical significance to account for
the greater error we introduce by our sampling strategy. Thus, for example,
the formula for computing the 95 percent confidence interval around a per-
centage is
196 1
.()
××
−
design effect unweighted
pp
n.
The square root of the design effect for the total sample is 2.11. Using this as
an example, we calculate the 95 percent confidence interval for results ex-
pressed as percentages in this study as plus or minus 3 percentage points for
results near 50 percent based on the total sample. This contrasts with plus or
minus 2 percentage points, which is what the margin of sampling error would
be for a simple random sample of 3,884 interviews. Applying a similar logic to
each of the key subgroups of white non-Latinos, African Americans, and Lati-
nos produces the following margin of sampling error for each subgroup:
Sample Margin of Error Square Root of Deff
Total 3 2.11
Latinos 6 1.67
Whites 4 1.55
African Americans 4 1.82
Similarly, in conducting analysis of differences in estimated population
proportions to detect statistical differences between the responses of the key
Lillie-Blanton et al. / Public Perceptions 221

subgroups, we included the design effect for each population in the analysis to
be certain to account for the larger standard errors given our sampling strategy.
RESULTS
Knowledge of Racial Differences in Health and Health Care Access. The
majority of Americans are unaware of black-white gaps in at least two mea-
sures of health status that have been widely reported in the news (see Fig-
ure 1). In 1997, infant mortality among blacks was 2 12 times higher than
among whites (14.2 per 1,000 black infants born versus 6.0 per 1,000 white in-
fants born), and blacks in 1996, on average, lived 6.6 years less than whites.
However, the survey found that a majority of white Americans (54 percent)
are not aware that infant mortality is higher for black infants than for whites
(39 percent think it is the same, 6 percent think it is better, and 9 percent do not
know). Strikingly, 58 percent of African Americans have the same
misperception (42 percent think black infant mortality is the same as whites, 8
percent think it is better, and 8 percent do not know). The majority of white
222 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)
FIGURE 1 “How Do You Think the Average African American Compares to
the Average White Person in Terms of . . . ?”
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).

and African Americans also have the same misperceptions about life expec-
tancy. Most whites and African Americans are unaware that life expectancy is
shorter for blacks.2
Similarly, many Americans are unaware of racial and ethnic differences in
health insurance, which is a well-documented determinant of one’s ability to
access health care (Hoffman 1998). In 1998, African Americans were nearly
twice as likely as whites (24 vs. 14 percent) to be uninsured, and Latinos were
212
times as likely as whites (37 vs. 14 percent) to be uninsured (Kaiser Com-
mission on Medicaid and the Uninsured 2000 ). As one might expect, African
Americans (p< .001 vs. whites) are somewhat more aware of these differences
than are whites. However, the survey found that most whites (57 percent) and
a sizable proportion of African Americans (41 percent) believe that African
Americans, on average, have health insurance at least comparable to whites or
say they do not know how African American’s fare in terms of health insur-
ance (see Figure 2). There is little difference in awareness between Latinos and
whites, with Latinos (46 percent) being no more aware than whites (52 per-
cent, n.s.) that Latinos, on average, are less likely than whites to have health
insurance.
Not surprisingly, whites, African Americans, and Latinos with at least a
college education were less likely than persons with fewer years of educa-
Lillie-Blanton et al. / Public Perceptions 223
FIGURE 2 “How Do You Think the Average African American and Latino
Compares to the Average White Person in Terms of . . . ?”
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).

tion to be unaware of documented racial and ethnic differences in health and
health care. For example, about 3 in 10 college-educated whites (29 percent)
and college-educated African Americans (28 percent) were unaware that infant
mortality is higher for African Americans compared to 68 percent and 66 per-
cent, respectively, of whites and African Americans with a high school educa-
tion or less. Similarly, about one third of college-educated whites (35 percent)
and college-educated Latinos (35 percent) were unaware that Latinos are less
likely to have health insurance than whites compared to 63 percent and 50 per-
cent, respectively, of whites and Latinos with a high school education or less.
Despite the role levels of education play in people’s understanding, a sizable
minority of those with college degrees still lack awareness about these key
issues.
Perceptions of the Influence of Race and Racism. The public’s views on
the extent to which race and/or racism affect the health care system was as-
sessed using a number of questions. To establish a broader context for these
findings, respondents were asked to assess the extent to which racism is a
problem in various sectors of society: health care, housing, education, and the
workplace. For purposes of this survey, racism was defined as “people being
treated worse than others because of their race or ethnicity.”
About three out of four whites (68 percent), African Americans (80 percent),
and Latinos (75 percent) say racism is either a major or minor problem in
health care. These proportions do not differ greatly in health care, education,
and the workplace. Housing is the only sector of society in which the propor-
tion that say racism is a major or minor problem is larger than in health care (78
vs. 70 percent). However, the public views racism as less of a major problem in
health care than in other sectors of society, which is a perception that may or
may not reflect the reality of the health care system. On average, 19 percent of
the public (16 percent of whites, 35 percent of African Americans, and 30 per-
cent of Latinos) say racism is a major problem in health care compared to an
average of 31 to 35 percent that say racism is a major problem in other sectors
of society (see Figure 3).
As expected from past survey results, whites and African Americans differ
considerably in their views on the extent to which racial or ethnic background
influences how one is treated by the health system. About 6 in 10 (62 to 60 per-
cent) African Americans believe that race or ethnic background affects
whether a person can get needed routine medical care, specialized treatments
or surgery, or health insurance (see Table 1). In contrast, nearly half (ranging
from 44 to 47 percent, p< .001) of whites express the opposite view or say they
do not know. Findings are similar when the question is asked somewhat dif-
ferently but more specifically stated—that is, whether our health system treats
224 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)

people unfairly based on their race or ethnicity (see Table 1). A majority of
African Americans (56 percent) say the health system very or somewhat often
treats people unfairly based on their race or ethnicity. Most whites (54 percent,
p< .01), on the other hand, believe that racial or ethnic background rarely
affects how the system treats people (43 percent) or say they do not know if it
does (11 percent).
The views of Latinos on whether race affects one’s treatment in the health
system are somewhat in between those of African Americans and whites (see
Table 1). About half of Latinos believe that race or ethnic background affects
whether a person can get needed routine medical care (54 percent), special-
ized treatments or surgery (51 percent), or health insurance (56 percent). Also,
51 percent of Latinos and about 46 percent of whites say the health system very
or somewhat often treats people unfairly based on their race or ethnicity.
The three racial and ethnic groups have more similar views on whether
money or health insurance affects how people are treated in the health system
(see Table 1). At least two thirds of whites, African Americans, and Latinos
report that the health care system treats people unfairly because of how much
money they have or whether they have health insurance. However, Latinos
Lillie-Blanton et al. / Public Perceptions 225
FIGURE 3 “How Big a Problem is Racism in Different Areas?”
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).
Note: Responses of “do not know” not shown.

226 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)
TABLE 1 Perceptions of the Influence of Race in Health Care (in percentages)
African
Whites Americans Latinos
(n= 1,479) (n= 1,189) (n= 983)
Total 100 100 100
“How often does race or ethnic background
affect whether a person can get . . . ?”
Routine medical care when they need it
Very/somewhat often 46 62a,b 54a
Not too often/never 47 35 41
Do not know 6 4 4
Specialized treatments or surgery when they need it
Very/somewhat often 48 62a,b 51
Not too often/never 44 34 45
Do not know 8 4 4
Health insurance to pay for medical care
Very/somewhat often 47 60a56a
Not too often/never 45 36 40
Do not know 7 3 3
“How often do you think our health care system
treats people unfairly based on . . . ?”
What their race/ethnic background is
Very/somewhat often 46 56a51
Not too often/never 43 38 43
Do not know 11 5 5
How much money they have
Very/somewhat often 70 72 64
Not too often/never 26 25 32
Do not know 4 3 4
Whether or not they have health insurance
Very/somewhat often 69 72 69
Not too often/never 24 24 28
Do not know 7 4 3
Whether they are male or female
Very/somewhat often 26 34 32
Not too often/never 67 59 65
Do not know 7 7 4
How well they speak English
Very/somewhat often 57 55b72a
Not too often/never 30 37 26
Do not know 13 8 2

are significantly more likely than whites (p< .001) or African Americans (p<
.001) to report that the health system treats people unfairly based on how well
they speak English.
Particularly striking are racial and ethnic differences in views about the
quality of health care obtained by African Americans and Latinos (see Fig-
ure 4). About two thirds of African Americans (64 percent, p< .001 vs. whites)
and more than half (56 percent, p< .001 vs. whites) of Latinos believe they
receive lower-quality health care than do whites. By contrast, most whites
believe that African Americans and Latinos receive the same quality of care as
they do. Furthermore, African Americans do not perceive that they have the
same level of access to care for specific conditions as do whites. A majority (56
percent) of African Americans surveyed believe that African Americans with
heart disease are less likely than whites to get specialized medical procedures
and surgery, compared to 33 percent of whites (p< .001) who believe this to be
true. Similarly, the majority of African Americans (64 percent) believe they are
less likely than whites to get the newest medicines and treatments for HIV/
AIDS, compared to 43 percent of whites (p. < 001) who believe this to be true.
Moreover, African Americans and Latinos have little confidence that the
health care system they have come to know will be different in the future (see
Figure 5). Nearly two thirds (65 percent) of African Americans and more than
half (58 percent) of Latinos report that they are concerned that they may be
treated unfairly when seeking medical care in the future. In contrast, less than
a quarter (22 percent) of whites express such concerns.
Lillie-Blanton et al. / Public Perceptions 227
TABLE 1 continued
African
Whites Americans Latinos
(n= 1,479) (n= 1,189) (n= 983)
Total 100 100 100
Whether they are overweight
Very/somewhat often 36 48a50a
Not too often/never 51 44 40
Do not know 13 8 10
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).
Note: Sample sizes are unweighted.
a. Differs from whites at p< .05.
b. Differs from Latinos at p< .05.

228 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)
FIGURE 4 Perceptions of Quality of Care Others Receive Compared to
Whites when Getting Health Care Services
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).
FIGURE 5 Concern that in the Future When Seeking Medical Care “You or a
Family Member Will Be Treated Unfairly Specifically Because of
Your Race or Ethnic Background”
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).
Note: Responses of “do not know” not shown.

Personal Experiences with Being Treated Unfairly. The gaps we see in per-
ceptions about the nature and extent of problems in health care related to an
individual’s race and ethnicity may be due, in part, to differences in the actual
experiences of whites, African Americans, and Latinos. When thinking specif-
ically about their personal health care visits with doctors or other health care
providers, African Americans and Latinos are more likely than whites to say
they felt they had been judged unfairly or treated with disrespect due to a vari-
ety of personal characteristics (see Table 2). For example, 16 percent of African
Americans and 20 percent of Latinos compared with 9 percent of whites say
they were judged unfairly or treated with disrespect by a health care provider
because of their ability to pay for care (p< .01). Latinos are particularly affected
by language, with one in seven (14 percent) (compared with 5 percent of Afri-
can Americans and 1 percent of whites) saying they personally have been
treated badly by a health care provider based on how well they speak English
(p< .001).
Further evidence of differences in the experiences of whites and minority
Americans is provided when individuals are asked if they, a family member,
or a friend have been treated unfairly by the medical system because of their
race and ethnicity. African Americans (14 percent) and Latinos (13 percent) are
considerably more likely than are whites (1 percent, p< .001) to say that they
have personally had such experiences. Furthermore, these differences persist
Lillie-Blanton et al. / Public Perceptions 229
TABLE 2 Perceptions of Being Personally Treated Unfairly
African
Whites Americans Latinos
(n= 1,479) (n= 1,189) (n= 980)
Percentage who say that they have felt that
a doctor or health provider judged them
unfairly or treated them with disrespect
because of
Their ability to pay for the care 9 16a20a
Their race or ethnic background 1 12a15a
The type of health insurance they have or
because they do not have health insurance 10 14b21a
How well they speak English 1 5a,b 14a
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (Conducted July-September, 1999).
Note: Sample sizes are unweighted.
a. Differs from whites at p< .05.
b. Differs from Latinos at p< .05.

when asked more broadly about a family member or a “friend or someone
they know.” Altogether, more than a third of African Americans (35 percent)
and Latinos (36 percent) compared to 15 percent of whites (p< .001) say that
they, a family member, a friend, or someone they know has been treated
unfairly in seeking medical care due to their race or ethnicity (see Figure 6).
Role of the Site of Care in Perceptions of Being Treated Unfairly. To assess
whether perceptions of racial and ethnic inequalities in health care are related
to where people get their care, we compared the usual sources of medical care
for those who had negative perceptions (i.e., said the health care system
very/somewhat often treats people unfairly based on their race) with those
who did not believe this to be true. The major usual sources of medical care
identified by respondents were doctor’s office (64 percent), clinic or health
center (20 percent), health maintenance organization (6 percent), hospital
emergency room or outpatient department (7 percent), and other/do not
know (2 percent). We found that the usual sources of medical care did not dif-
fer significantly between those who perceived that people were treated un-
fairly and those who did not hold this belief. This finding also did not vary sig-
nificantly for whites, African Americans, or Latinos.
230 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)
FIGURE 6 Experience With Being Treated Unfairly When Seeking Medical
Care Because of Race or Ethnic Background
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).
Note: Responses of “do not know” not shown.

Major Problems Facing Minority Americans in the Health System. Afri-
can Americans and Latinos recognize that factors other than race and ethnic
background also influence the health care obtained in the United States (see
Figure 7). While more than two thirds of African Americans (82 percent) and
Latinos (71 percent) cite racial and ethnic barriers to care as either a major or
minor problem for the average African American and Latino, financial barri-
ers to care are cited as a major problem by a larger share of both population
groups. Seventy-one percent of African Americans and 63 percent of Latinos
cite barriers related to the cost of health insurance and needed medical care as
a major problem facing the average African American and Latino. In contrast,
40 percent of African Americans and only 28 percent of Latinos cite racial bar-
riers as a major problem.
Racial barriers to care are considered a major problem by roughly the same
percentage of each population group that cites concerns about the availability
of health services in their neighborhood. Among African Americans, about 45
percent cite the availability of neighborhood health providers and 40 percent
cite racial barriers to care as major problems. Among Latinos, about 33 percent
Lillie-Blanton et al. / Public Perceptions 231
FIGURE 7 “For the Average African American and Latino, How Big a Prob-
lem is . . . ?”
Source: Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care: Public Perceptions
and Experiences, October 1999 (conducted July-September, 1999).

cite the availability of neighborhood health providers and 28 percent cite
racial and ethnic barriers to care as major problems.
DISCUSSION
This first national survey of the public’s perceptions on race and the health
care system provides considerable evidence that most African Americans and
Latinos and a sizable share of whites recognize that race continues to be a bar-
rier in access to care. Nonetheless, issues regarding racial inequalities in health
appear to take a back seat to public debate over inequalities in other sectors of
society. In housing and employment, for example, public outcry about racial
inequalities has led to court actions and legislation (such as the Fair Housing
Act or the Equal Employment Opportunities Act) that sought to remedy seem-
ingly intractable racial barriers. In health, issues of racial inequalities surface
cyclically onto the public policy agenda but have failed to be the focus of
long-term policy initiatives or public interest. The Department of Health and
Human Services, as a follow-up to President Clinton’s Initiative on Race, has
refocused its attention on disparities in the nation’s health. The department
has set an ambitious national goal of eliminating racial and ethnic disparities
in six health areas by the year 2010. Whether this renewed attention will result
in sustained efforts remains to be seen.
The survey findings give some indication of the extent to which percep-
tions about inequalities in health may drive the public’s and policy makers’
attention to this issue. One explanation for the lack of ongoing attention to health
disparities may be related to the lack of public awareness that differentials
persist. The survey found that a large percentage of Americans—including
many minority Americans—did not know that blacks generally fare worse
than whites in infant mortality or that Latinos fare worse than whites in terms
of health insurance coverage. Attention to racial differences in health may
also be shaped by the perception of many Americans that race or ethnicity
rarely affects how one is treated by the health system. On this point, the survey
shows that African Americans generally see the health system through a dif-
ferent lens than that of whites. While more than half of African Americans
believe that race affects an individual’s health care; more than half of whites
have the opposite view or do not perceive that they are knowledgeable
enough to have an opinion. These very different perceptions could have major
implications for whether the public identifies health disparities as a priority
issue and, of course, to their receptivity to new initiatives or educational cam-
paigns to reduce disparities in needed health care.
232 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)

The survey findings support previous studies that have shown that minor-
ity Americans are more distrustful of the health care system than are whites.
Findings that most African Americans and Latinos think they receive lower
quality care than whites and also have concerns about being treated fairly are
particularly troubling. They provide an indication that African Americans
and Latinos lack confidence that the health care system provides them with
the same treatment as is provided to whites. Moreover, the finding that the
usual sources of medical care did not differ significantly between those who
perceive racial inequalities in health care and those who do not suggests that
the factors driving these perceptions are not unique to one type of service
delivery site. Lack of confidence or trust in the health care system can be a
strong motivator of behavior and can compromise a provider-patient relation-
ship. It also can affect the timeliness with which an individual seeks care or
compliance with a provider’s instructions for care. Thus, efforts may be
needed to address perceived as well as real barriers to care. If individuals lack
confidence that they will be treated fairly, they may not take full advantage of
opportunities that have been or will be created to improve their access to
health care.
In sum, although the public’s awareness of racial differences in health and
health care may be marginal at best, the public is not unaware that the United
States remains a very race-conscious society, and the health care system is no
exception. Nonetheless, more African Americans and Latinos are concerned
about the affordability of health coverage and care than racial barriers to care.
These findings underscore the problems facing many households in America
with rising health care costs. The complexity of the story being told through
this survey is apparent from what may seem to be contradictory findings.
There is an acknowledgment that race continues to matter in the health sys-
tem, but the economic burden of health care is of concern to a larger share of
minority Americans.
The challenge for those who seek remedies is to improve awareness of
problematic racial differences in health and health care access and to encour-
age initiatives to reduce these differences. Whites need to be more aware of the
real-life circumstances and situations that face members of racial and ethnic
minority groups in this country when they seek treatment. Similarly, members
of racial and ethnic minority groups need to be more aware of disparities so
that they can be more proactive in obtaining needed care. Reducing racial and
ethnic differentials will require both a better understanding of the factors that
contribute to poorer health and health care access and systematic efforts to
address these factors.
Lillie-Blanton et al. / Public Perceptions 233

NOTES
1. The design effect is a function of three numbers:
the sample size (unweighted) N,
the sum of the weights squared ()Σw2,
and the sum of the squared weights Σw2.
The design effect is calculated as
[]
Nww÷÷()ΣΣ
22
2. We chose not to discuss perceptions of Latinos’ health indices because lingering
questions about the accuracy of vital statistics data on Hispanic origin gave us rea-
son to be concerned about asserting who is informed or not well informed based on
these data. However, for readers interested in drawing their own conclusions, we
have included the findings in this note. When asked how do you think the average
Latino compares to the average white person, the following responses were re-
corded:
Latino infant mortality
Whites: 35 percent say worse off, 45 percent say just as well off, 3 percent say
better off, and 17 percent say do not know or refuse;
Latinos: 38 percent say worse off, 51 percent say just as well off, 6 percent say
better off, and 5 percent say do not know or refuse.
Latino life expectancy
Whites: 34 percent say worse off, 46 percent say just as well off, 3 percent say
better off, and 17 percent say do not know or refuse;
Latinos: 36 percent say worse off, 53 percent say just as well off, 7 percent say
better off, and 4 percent say do not know or refuse.
REFERENCES
Ayanian, J. Z., P. D. Cleary, J. S. Weissman, and A. M. Epstein. 1999. The Effect of Pa-
tients’ References on Racial Differences in Access to Renal Transplantation. New
England Journal of Medicine 341 (22): 1661-1669.
Ayanian, J. Z., J. S. Weissman, S. Chasan-Taber, and A. M. Epstein. 1999. Quality of Care
by Race and Gender for Congestive Heart Failure and Pneumonia. Medical Care 37
(12): 1260-69.
Bach, P. B., L. D. Cramer, J. L. Warren, and C. B. Begg. 1999. Racial Differences in the
Treatment of Early-State Lung Cancer. New England Journal of Medicine 341 (16):
1198-1200.
234 MCR&R 57 (Supplemental: Racial and Ethnic Inequities, 2000)

Blendon, R. J., L. H. Aiken, H. E. Freeman, and C. R. Corey. 1989. Access to Medical Care
for Black and White Americans: A Matter of Continuing Concern. Journal of the
American Medical Association 261:278-81.
Blendon, R. J., A. C. Scheck, K. Donelan, C. A. Hill, M. Smith, D. Beatrice, and D.
Altman. 1995. How White and African Americans View Their Health and Social
Problems. Journal of the American Medical Association 273(4).
Harris, Louis, and Associates. 1993. The Kaiser/Commonwealth Fund Health Insur-
ance Survey II, Study no. 932010. Unpublished data.
Hoffman, C. 1998. Uninsured in America: A Chartbook. The Kaiser Commission on
Medicaid and the Uninsured. The Henry J. Kaiser Family Foundation.
Kaiser Commission on Medicaid and the Uninsured. 2000. Uninsured in America.
KeyFacts (No. 1340).
Kaiser Family Foundation/The Washington Post/Harvard University Survey Project.
1995. The Four Americas: Government and Social Policy through the Eyes of Amer-
ica’s Multi-racial and Multi-ethnic Society (No. 1105).
Mayberry, M. M., F. Mili, I. G. Vaid, , A. Samadi, E. Ofili, M. S. McNeal, P. A. Griffith, and
G. LaBrie. 1999. Racial and Ethnic Differences in Access to Medical Care. ASynthe-
sis of the Literature. Morehouse Medical Treatment Effectiveness Center.
Morehouse School of Medicine.
Lillie-Blanton et al. / Public Perceptions 235