Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 103
RACIAL AND ETHNIC DISPARITIES IN
Arturo Vargas Bustamante
Leo S. Morales
Alexander N. Ortega
•Understand the deﬁnition of disparity in health care
•Learn how patient-, provider-, and system-level factors contribute to
•Understand the role of historical context causing disparities in health
•Learn about efforts to reduce and eliminate disparities
•Understand how the ACA addresses disparities
Racial and ethnic disparities in health care pervade the American health
care system. In 1999, the U.S. Congress commissioned a report on
the health care quality and experiences of racial and ethnic minorities in
the United States, which resulted in the Institute of Medicine’s (IOM’s)
seminal report Unequal Treatment: Confronting Racial and Ethnic Disparities
in Health Care (IOM, 2003). An earlier report on the quality of health care
in the United States identiﬁed six aims for improving performance of the
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 104
104 Chapter Four: Racial and Ethnic Disparities in Health Care
health care system: safety, effectiveness, patient-centeredness, timeliness,
efﬁciency, and equity (IOM, 2001). Equity, as deﬁned by the IOM, is the
delivery of health services of equal quality to all individuals, regardless of
such personal characteristics as gender, socioeconomic status, geographic
location, and race or ethnicity. Despite the increasing awareness of health
care disparities facing various racial and ethnic groups in the United
States, several reviews of the scientiﬁc literature document the existence
of racial and ethnic disparities in the processes and outcomes of care for
a variety of diseases and clinical conditions, including cancer, HIV/AIDS,
and chronic conditions such as cardiovascular disease and diabetes, as well
as in the delivery of preventive care services (Department of Health and
Human Services [DHHS], 2010). For example, the National Healthcare
Disparities report published by the AHRQ since 2003 has consistently
found that blacks, Latinos/Hispanics, Asians, and American Indians and
Native Alaskans were more likely than whites to receive lower-quality
care across a range of quality-of-care indicators (DHHS, 2010). Thus, the
existence of disparities in health care represents a failure of the American
health care system and signals the need for attention and reform.
Addressing racial and ethnic disparities in health care is of growing
importance because the population of the United States is more diverse
than ever. Between 2010 and 2050, the Latino population is expected to
increase from 16 to 30 percent as a percentage of the U.S. population,
the Asian and Paciﬁc Islander population is expected to grow from 4
to 9 percent, while the black population is expected to remain at 12
percent of the U.S. population (U.S. Census Bureau, 2009; Ortman &
Guarneri, 2009). Over the same period, the non-Latino white population
is expected to decrease from 65 percent to 46 percent as a percentage of
the U.S. population. If racial and ethnic minorities continue to receive
lower-quality care, then in the coming years a substantial portion of the
U.S. population will have suboptimal health status, which will in turn lower
labor market productivity and increase national health care spending
(Bound, Waidmann, Schoenbaum, & Bingenheimer, 2003).
We begin this chapter by deﬁning our view of disparities in care. Next,
we review some of the historical factors speciﬁc to racial and ethnic groups
that have contributed to the patterns of disparities we observe today. In
the following sections, we summarize some of the evidence documenting
health care disparities by racial and ethnic groups. In the ﬁnal sections
of the chapter, we summarize a number of ongoing initiatives to reduce
disparities in care.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 105
Deﬁnition of Disparity in Health Care 105
Deﬁnition of Disparity in Health Care
A distinction can be made between disparity in health and disparity in health
care. The former refers to racial and ethnic differences in morbidity and
mortality and is inﬂuenced by a variety of factors (social, environmental,
behavioral, and biological), only one of which is health care. With recent
advances in human genomics, much more attention is being given to the
genetic basis for racial and ethnic disparities in health (Fine, Ibrahim, &
Thomas, 2005). Disparities in health are discussed in Chapter Three. In
this chapter, we focus on disparities in health care.
Researchers have adopted various perspectives on disparities in health
care over time (Carter-Pokras & Baquet, 2002; Braveman, 2006; Adler &
Rehkopf, 2008; Vargas Bustamante, & Chen, 2011). Some have viewed
all the differences in health care between racial and ethnic groups as
constituting disparities. From this point of view, differences in the use of
services are viewed as disparities regardless of coexistent differences in
access to care, insurance coverage, personal preferences, clinical need, or
clinical appropriateness. It has been suggested that in some cases lower
use of services may constitute an advantage, in particular where overuse is
thought to lead to excess morbidity or mortality.
Others have taken a narrower perspective, deﬁning disparity as a
difference in care that is not accounted for by a difference in access to
care, personal preference, clinical need, or clinical appropriateness (see
Figure 4.1). In this narrower view, two groups of factors are identiﬁed
as being responsible for disparities in care. The ﬁrst is the group of
system-level factors such as the structure of health care systems and the
legal and regulatory environment in which those systems operate. These
may also include structural factors such as underfunding of hospitals that
predominantly serve minority patients or organizational characteristics
such as inadequate workforce diversity or the absence of policy and
procedures that promote culturally competent care. The second group of
factors is discrimination at the patient-provider level, whether it takes the
form of prejudice or unconscious stereotyping.
Few datasets include information on quality of care, race and ethnicity,
and patient needs. Moreover, few of these sources differentiate between
the effects of structural or legal and regulatory factors on the one hand and
discrimination on the other. Hence, most of the existing literature tends
to support the view that disparities in health care are a result of a myriad of
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 106
106 Chapter Four: Racial and Ethnic Disparities in Health Care
factors including patient preferences and behaviors, provider constraints
and practices, and system or institutional policies (see Figure 4.2).
Many patient-related factors are associated with access to and utiliza-
tion of health care. Some of these factors are more salient to minority
patients. Patient perception of health status, views of speciﬁc diseases
and the patient’s ability to accept and cope with illness are all associated
with health care use. These points of view on health may be shaped by
FIGURE 4.1. Institute of Medicine model of disparities in health care
Quality of health care
Operation of health care
systems and legal and
Source: Institute of Medicine, 2003.
FIGURE 4.2. Factors related to health care use and their synergies
Health care use
Provider factorsPatient factors
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 107
Deﬁnition of Disparity in Health Care 107
individual’s cultural or traditional beliefs and practices. In addition, psy-
chosocial constructs such as readiness for change, perceived self-efﬁcacy,
self-reliance, and fatalism are all related to individual decision making
(Ortega & Alegr´
ıa, 2002; Lorig & Holman, 2003; Wolff et al., 2003; Green
et al., 2008). These attitudes in turn determine whether a patient will seek
care, adhere to providers’ recommendations, and successfully achieve
desired outcomes. Patient trust, level of comfort with medical providers,
and satisfaction with care are important factors for entry into the health
care system as well for its continued use (Sheppard, Zambrana, & O’Malley,
2004; Shi & Stevens, 2005). Individuals’ previous experiences with care
providers as well as the broader minority communities’ history with the
health care system also inﬂuence patients’ attitudes toward providers and
the health care system.
A number of racial and ethnic minorities in the United States come
from socioeconomically disadvantaged communities and households with
lower education and income levels. On the other hand, White males from
afﬂuent socioeconomic backgrounds are overrepresented in the medical
establishment. Accordingly, discordance between patient and provider
demographics prevails (Vargas Bustamante & Chen, 2011). It is reasonable
to believe that most providers feel more comfortable communicating with
patients who share similar socioeconomic backgrounds. Researchers have
asserted that how providers communicate and understand their patients is
likely to inﬂuence the effectiveness and continuity of care. Stereotyping or
misunderstanding patients due to such differences may lead to inaccurate
or inappropriate clinical decision making. For instance, Schulman and
colleagues—using a sample survey of more than seven hundred physicians
in videotaped, scripted interviews on their recommendations for chest pain
management—found that black women were less likely to be referred for
cardiac catheterization than white men (Schulman et al., 1999). They also
suggest that race and gender play signiﬁcant and synergistic roles in how
providers manage their patients.
Recently, researchers have explored the role of unconscious bias
among physicians. Social psychologists posit a dual process theory in
which individuals hold attitudes and beliefs on two levels of consciousness:
explicit attitudes and beliefs, which are readily available for recall and can
be reported, and implicit or unconscious, automatic attitudes and beliefs
that exist outside of conscious awareness (Greenwald, Poehlman, et al.,
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 108
108 Chapter Four: Racial and Ethnic Disparities in Health Care
2009). Unconscious bias refers to social attitudes and stereotypes about
certain demographics or groups of people that are formed outside of
their own conscious awareness and are thus ‘‘hidden’’ attitudes and beliefs
(Dovidio, Kawakami, & Gaertner, 2002). An individual can hold egalitarian
beliefs and unconscious biases simultaneously. Implicit or unconscious
preferences and stereotypes are pervasive across populations and topics
(Nosek et al., 2007). Implicit race attitudes are related to perceptions
of a persons’ trustworthiness (Stanley, Sokol-Hessner, Banaji, & Phelps,
2011). In sensitive areas such as interracial attitudes and beliefs, implicit
attitudes are better predictors of the behaviors of discrimination than
self-reported attitudes (Greenwald, Poehlman, Uhlman, & Banaji, 2009).
In response to racial and ethnic disparities in health care, researchers
have been studying implicit and explicit racial bias among physicians and
have found that physicians hold implicit racial biases similar to others in
society. One exploratory study found that African American physicians
showed no unconscious racial bias for either white or African Americans,
while physicians of other races and ethnicities showed a strong implicit
pro-white preference (Sabin, Nosek, Greenwald, & Rivara, 2009).
Provider communication is associated with patient satisfaction, adher-
ence to recommendations, and health outcomes, which may have conse-
quential effects on the type of service sought (emergency versus primary
ıa, Selby, Schmittdiel, Grumbach, & Quesenberry,
2000; Betancourt & Maina, 2004; Johnson, Roter, Powe, & Cooper, 2004;
Betancourt, Green, Carrillo, & Park, 2005). Providers who communicate
effectively with their patients and are sensitive to the process tend to
have patients who are satisﬁed and informed of their health issues; more
important, such patients are more likely to follow through with treatment
and continue to seek primary care services (Johnson et al., 2004; Saha,
Komaromy, Koepsell, & Bindman, 1999). Hence, it is important to exam-
ine the role of providers in the process, particularly as patient-provider
communications become more diverse, with the increasing participation
of nonphysician medical providers such as nurses, physician assistants,
pharmacists, community health workers, and ofﬁce staff.
Finally, some argue that racial disparities in medical treatment are
rooted in discrimination on the part of providers and health care systems,
while others disagree and posit that there is insufﬁcient empirical evidence
to show that the disparities are due to conscious or subconscious discrimi-
nation (Epstein & Ayanian, 2001). Nonetheless, abundant evidence shows
that disparities in health care are persistent, are deep-seated, and exist
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 109
Historical Overview of Disparities in Medical Care 109
across many medical disciplines, practices, and populations, including
children, adults, and the elderly.
System factors have also been implicated in health care disparities. Lack
of health insurance coverage among Latinos has been associated with
uncertainty over family health care expenditures, potentially ruinous out-
of-pocket payments, and lower health care access and utilization (Monheit
& Vistnes, 2000; Waidmann & Rajan, 2000; Hadley, 2003; Hargraves
& Hadley, 2003; Zuvekas & Taliaferro, 2003). Difﬁculties in navigating
through a complex health care system and understanding bureaucratic
procedures have been cited as major barriers to receiving quality health
care for both low-income and racial and ethnic minorities (Betancourt,
2006). For example, patients who are without knowledge or tools required
to access primary health care may delay seeking care or may resort to using
urgent care or emergency room services. This problem is exacerbated in
individuals with more serious conditions requiring secondary or tertiary
care, where they would have to access complex systems of specialty care and
follow-up (Scheppers, van Dongen, Dekker, Geertzen, & Dekker, 2006).
Structural and environmental conditions within clinical care settings
and health care sites that serve racial and ethnic minorities may also
contribute to health care disparities. The decline in funding for public
clinics and community hospitals that predominantly serve racial and
ethnic minorities leads to increased wait times for appointments, crowded
facilities, and understafﬁng and negatively affects the quality of care (Hsiao,
Knight, Kappel, & Done, 2011; Vargas Bustamante & Chen, 2011).
Historical Overview of Disparities in Medical Care
The historical and contemporary causes of health care disparities differ for
each racial and ethnic group, given their unique experiences in the United
States. While there may be overlapping reasons or commonalities among
the groups, the histories of African Americans, Latinos, Asian and Paciﬁc
Islanders, and Native Americans have distinct paths and trajectories leading
to the health care disparities they face. Deﬁning and distinguishing the
major forces that have inﬂuenced the emergence of health care disparities
for these groups would allow health professionals and policymakers to
identify appropriate policy and practice solutions speciﬁc to these groups.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 110
110 Chapter Four: Racial and Ethnic Disparities in Health Care
Factors Related to Disparities among African Americans
The Tuskegee Syphilis Study, a forty-year study of untreated syphilis in black
men from Alabama conducted by the U.S. Public Health Service, is typically
cited as the central reason for nonparticipation of many African Americans
in medical studies and for their reluctance to seek needed health care.
However, the legacy of distrust of and mistreatment by the medical
establishment among minorities predates the Tuskegee study (Gamble,
1997). Minorities, particularly African Americans, have a long history of
segregation in medical care and of receiving poor-quality care (Smith,
1999). Inequity in medical care began with racial segregation and slavery
in American history. Slaves were able to obtain care only in slave hospitals,
which were typically staffed by other slaves, slave owners, and their family
members (Gamble, 1997; Smith, 1999). After emancipation, the federal
government set up more than ninety hospitals for the emancipated slaves,
but only one (Howard University Medical Center) remained open until
the end of the 1800s (Smith, 1999). In segregated America, no one took
responsibility for the delivery of care for African Americans. In the late
1800s, African American physicians led efforts to establish black hospitals,
starting with the Provident Medical Center in Chicago (Gamble, 1991).
However, in the early 1900s African Americans were excluded from
mainstream professional medical societies as well as from most medical
schools. In fact, in 1900 only seven medical schools were training physicians
of color. Moreover, public health departments and medical societies did
not begin taking responsibility for the health of African Americans until
they were deemed a threat to the health of whites; thus, the type of care
delivered was generally in the form of hygiene control and treatment of
In addition to these historic factors that contribute to health care dis-
parities faced by African Americans, researchers have identiﬁed a variety
of other contemporary risk factors (recall Chapter Three). For example,
African Americans in the United States are disproportionately represented
among the poor and people who live in inner-city neighborhoods. Socioe-
conomic status and race are associated with a slew of disease risk factors,
among them access to primary health care, behaviors (diet, smoking, and
physical activity), access to resources and social capital, and environmental
and psychosocial stressors. Minority and low-income populations are also
less likely to receive effective public health and prevention messages that
could help increase their awareness.
Studies have found that African Americans are less likely to have private
insurance and more likely than whites to be publicly insured, underinsured,
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 111
Historical Overview of Disparities in Medical Care 111
or uninsured (Kaiser Commission on Medicaid and the Uninsured, 2004).
This is an important risk factor, because private insurance coverage is
associated with better access to primary care, continuity of care, site of
care, and the type and quality of care received, whereas publicly and
uninsured patients often receive inadequate and poor-quality care.
Factors Related to Disparities among Latinos
Latinos make up a diverse group of people who trace their roots to several
countries of origin that have distinct histories and political ties to the
United States. Much like other ethnic groups in the United States, Latinos
have a range of immigration and migration patterns. For instance, many
Latinos in the Southwest have a family history that can be traced in the
region to the time following the Treaty of Guadalupe Hildalgo, well before
the colonization of the American Southwest. Puerto Ricans have a history
in the United States that dates back to the Jones Act in 1917 (almost
twenty years after the Treaty of Paris ended the Spanish-American War),
stipulating that Puerto Rico was a U.S. territory whose inhabitants were
entitled to U.S. citizenship. Other Latino groups from the Americas and
the Caribbean have immigration histories that arise from refugee status,
as with the Cubans who sought refuge in the United States after the Bay of
Pigs ﬁasco in the 1960s.
Given the changing demographics of the United States, the signif-
icance of issues related to Latinos’ health care access and use can be
expected to rise. According to recent census data, Latinos make up
approximately 16 percent of the total population (U.S. Census Bureau,
2009). Within the Latino population, those of Mexican and Puerto Rican
descent make up the two largest groups, accounting for 65.5 percent and
9.1 percent respectively of the entire U.S. Latino population (not includ-
ing the 3.9 million U.S. citizens in Puerto Rico). Latinos also make up
the largest minority group of children and adolescents. Census data show
Latinos constituting 22 percent (or sixteen million) of the U.S. population
under the age of eighteen.
Studies document that compared to non-Latino Whites, Latinos tend
to have worse access to health care, worse morbidity as a result of lack
of medical care or treatment, and poorer quality of care. Many factors
have been implicated in disparities in access to and quality of care for
Latinos. Some studies have reported that Latinos, compared to non-
Latino whites, have low rates of insurance coverage, usually as a result of
noncitizen status or low-wage employment that does not provide employer-
based health insurance; have worse geographic access to care, usually
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 112
112 Chapter Four: Racial and Ethnic Disparities in Health Care
because of migration or living on farms or in rural areas; and receive low-
quality care, usually because of language discordance between them and
their medical providers (Vargas Bustamante & Chen, 2012). Disparities
in insurance and access differ, however, within Latino subgroups. For
instance, Puerto Ricans born on the island are citizens by birth, facilitating
circular migration and qualifying them for certain federal and state health
programs (Medicaid, SCHIP, and Medicare).
Latinos have a high presence in public insurance programs, mainly
in Medicaid (IOM, 2003). Medicaid is characterized by higher per capita
resource constraints and stricter limits on covered services, which are
the indicators of poor access and lower quality of care. Low Medicaid
capitation payments have been linked to restricted provider networks,
limiting the pool of available providers for its beneﬁciaries, including
minorities (Tai-Seale, Freund, & LoSasso, 2001).
Spanish-speaking populations in the United States face a language
barrier that can affect the quality of care through poor communication
with physicians and other medical care providers. As a result, there can be
deﬁcient or inaccurate transfer of important information such as details
of disease symptoms, consequences of treatment or lack of treatment,
and medication regimens, all of which can lead to ineffective disease
management or prevention. Many Latinos delay seeking care until their
condition is severe. Such delays, coupled with the need for effective
medical interpreters and culturally and linguistically competent providers,
make Latinos more vulnerable, potentially more expensive to treat, and
more complicated to manage than other ethnic groups who are more
ﬂuent English speakers (IOM, 2003).
Factors Related to Disparities among Asians, Paciﬁc Islanders,
and Native Hawaiians
Similar to the Latino population, the Asian, Paciﬁc Islander, and Native
Hawaiian population is a heterogeneous population from different
countries with diverse cultures, histories, and health statuses. While Native
Hawaiians became part of the United States through the colonization of
Hawaii, Asian and Paciﬁc Islanders have a long history of immigration
to the United States dating back to the late 1800s. The ﬁrst large-scale
immigration occurred in 1848, during the Gold Rush in California
with the migration of large groups of Chinese. Subsequently, Chinese
immigrants continued to ﬁll labor demands by working on sugarcane farms
in Hawaii, in various other service occupations, and also as laborers for the
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 113
Historical Overview of Disparities in Medical Care 113
transcontinental railroad. Similarly, other ethnic groups such as Japanese
and Filipinos experienced their own waves of migration. The passage
of the Immigration and Nationality Act of 1965 eliminated the national
origins quota system and opened up immigration to previously excluded
South Asian and Southeast Asian groups. More recently, the United States
has seen a growth in refugee migrant populations of Laotians, Hmong,
Since 2000, the Asian American and Paciﬁc Islander (AAPI) population
in the United States has increased by 45 percent, surpassing the growth rate
of other racial and ethnic groups (API Health Forum, 2012). The largest
subgroups within the Asian population are Chinese, Indian, Filipino, and
Vietnamese. Hawaiians, Samoans, and Guamanians represent the largest
subgroups of the Paciﬁc Islander population. While many AAPI subgroups
have achieved high rates of education, income, homeownership, and social
capital relative to non-Latino whites, substantial disparities still exist within
this community. For example, while 60 percent of Asians aged twenty-ﬁve to
twenty-nine reported having a college degree, after disaggregating the data
only 18 percent of Native Hawaiians and Paciﬁc Islanders and 7 percent of
Hmongs had attained a college education (National Center for Education
Statistics, 2012). In addition, although Asians, Paciﬁc Islanders, and Hawai-
ians have high rates of employment, Asian Americans with a college degree
were more likely to be unemployed in comparison to non-Latino whites
(Austin, 2010). Finally, the Hmong, Laotian, and Cambodian communities
continue to face high rates of poverty, ranging from 35 to 65 percent, in
comparison to the national average of 17 percent (National Commission
on Asian American and Paciﬁc Islander Research in Education, 2008).
These socioeconomic variations within the AAPI population dispel
the ‘‘model minority’’ myth that has been popularized by mainstream
American society and by many policymakers (Chen & Hawks, 1995). This
myth holds that AAPI groups have successfully acculturated to the U.S.
lifestyle and achieved the ‘‘American dream,’’ which masks many AAPIs’
experiences of discrimination, prejudice, and limited access to resources,
which in turn affect their access to health care. The heterogeneity of
the Asian, Paciﬁc Islander, and Hawaiian population poses several com-
plexities that inﬂuence the health care disparities experienced by this
community. According to U.S. Census data, 38 percent of AAPIs do not
speak English ﬂuently, and many subgroups have lower rates of English
proﬁciency compared to other groups (Ponce et al., 2009; U.S. Census,
2003). Language barriers, along with the lack of bilingual service providers
and translated health materials, have been cited as major barriers to care
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 114
114 Chapter Four: Racial and Ethnic Disparities in Health Care
(Ngo-Metzger, Sorkin, & Phillips, 2009). Equally important is the need
to provide culturally competent care to diverse groups of Asians, Paciﬁc
Islanders, and Hawaiians, who have unique beliefs regarding health behav-
iors, outcomes, and treatment. In addition, although rates of health care
insurance are high for the overall Asian population, speciﬁc subgroups
(such as the recently arrived Hmong, Laotian, and Cambodian subgroups)
with lower education levels, higher rates of poverty, and unemployment
rely on public insurance or remain uninsured, which negatively affects
their access to and receipt of health care services (OMH, 2012).
Factors Related to Disparities among American Indians and Alaska Natives
While comprising of only 2 percent of the entire U.S. population, American
Indians and Alaska Natives have the longest history in the United States
of any racial and ethnic group. At the time of the arrival of European
settlers, scholars estimate the population of these groups to have been
approximately thirty-four million, but warfare and colonization, foreign
diseases, and cultural dislocation have reduced this community to roughly
ﬁve million people (U.S. Census Bureau, 2009). The American Indian
and Native Alaskan population is also culturally diverse; the U.S. federal
government ofﬁcially recognizes 566 tribes as sovereign nations (Bureau
of Indian Affairs, 2012). In addition, there is a high level of geographic
dispersion, with only 22 percent living on federal reservations. The states
with the largest native populations include California, Oklahoma, and
Social disparities and economic disadvantage have long been major
factors in the health care disparities facing American Indians and Alaska
Natives. Lower rates of education have translated into high rates of
unemployment and poverty for this community. In terms of educational
attainment, 77 percent have earned a high school diploma by the age
of twenty-ﬁve, compared to 99 percent of non-Latino whites, and 13
percent have earned college degrees, compared to 31 percent of non-
Latino whites (OMH, 2012). Twenty-eight percent of American Indians
and Alaska Natives live at or below the federal poverty line, in comparison
to 9.9 percent of non-Latino whites (OMH, 2012). As has been shown with
other racial and ethnic groups, living in poverty contributes to poor health
behaviors and limited access to social resources that promote health. Loss
of cultural traditions, language, and native lands has also been attributed
to the decline in health and escalation in health care disparities.
The Indian Health Service, the only federal health care system specif-
ically established for a racial or ethnic group, has faced challenges in
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 115
Scientiﬁc Evidence of Disparities in Health Care 115
providing quality and accessible health care (Families USA, 2010). As a
part of the treaties established in 1787, members of federally recognized
tribes were guaranteed health care by the U.S. government, and the Indian
Health Service (IHS) was established in 1955 to fulﬁll this commitment.
However, only 57 percent of American Indians and Alaska Natives are
serviced directly by the IHS, and members face signiﬁcant restrictions on
where they can access services and the extent of care they can receive (US
Commission on Civil Rights, 2004). Moreover, direct services from IHS are
mostly provided on or near reservations, leaving the 66 percent of natives
who do not live on reservations to access care through limited Urban
Indian Health programs. However, due to underfunding and structural
barriers, 37 percent of all Native Americans receive no services from the
IHS (Urban Indian Health Institute, 2004).
Traditional insurance access is also a major barrier for American
Indians and Alaska Natives. According to a report by the Kaiser Commission
on Medicaid and the Uninsured, 43 percent of American Indians have
employer-sponsored health insurance, in comparison to 73 percent of non-
Latino whites, while 27 percent rely on public insurance programs such
as Medicaid and Medicare, with nearly a quarter of the American Indian
population remaining uninsured. As discussed previously, the IHS provides
care for all qualiﬁed American Indians, but barriers to access place these
uninsured individuals at risk of delaying care and not receiving services.
Moreover, the complexity of both IHS and public insurance programs and
lack of awareness are major barriers to receiving requisite care, even for
qualiﬁed American Indians and Native Alaskans (US Commission on Civil
Scientiﬁc Evidence of Disparities in Health Care
In this section we review some of the evidence supporting the existence
of disparities in health care. Because the literature on disparities in care
is extensive, spanning several decades, we have selected several condition-
speciﬁc areas of research for our review: cardiovascular disease, cancer,
renal disease and transplantation, HIV/AIDS, obesity, diabetes, asthma,
and mental health. These areas were selected for a variety of reasons.
Cardiovascular disease, cancer, renal disease and transplantation, and
HIV/AIDS were selected because they are among the most studied areas
of racial and ethnic disparities in care. Asthma, obesity, and diabetes were
selected because various racial and ethnic subgroups are disproportion-
ately affected by these conditions. Finally, because the other areas included
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 116
116 Chapter Four: Racial and Ethnic Disparities in Health Care
in this review focus on physical domains of health status, we elected to
include mental health.
Coronary artery disease (CAD) and acute myocardial infarction (AMI) are
the most analyzed topics among studies of racial and ethnic disparities
in care. Due to data limitations and elevated risk, the most frequently
studied groups are African Americans, Latinos, and whites. Although
blood pressure and cholesterol screening are common among both African
Americans and whites, one study using seven federal datasets found that
hospitalization rates for hypertension, angina, and congestive heart failure
were higher for African Americans compared to whites across almost all
age groups, suggesting that screening and preventive care are insufﬁcient
to prevent heart disease in African Americans (Holmes, Arispe, & Moy,
2005). Similar ﬁndings in congestive heart failure hospitalization rates
have also been found for Latinos and Native Americans in comparison to
non-Latino whites (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005).
In addition, from 1999 to 2006 blood pressure control and cholesterol
levels have improved in the United States; however, disparities persist
among African Americans and Latinos compared to non-Latino whites
(McWilliams, Meara, Zaslavsky, & Ayanian, 2009).
Studies of racial and ethnic disparities in cardiovascular disease have
become increasingly sophisticated in their control and adjustment for
confounders (Geiger, 2003). African Americans are less likely than whites
to be catheterized; when it is done, they are 20 to 50 percent less likely to
undergo a revascularization procedure. They are also less likely to receive
beta-blockers, thrombolytic drugs, or aspirin when these interventions are
indicated. There are similar ﬁndings for Latinos, as studies have found
that they receive less blood pressure control, aspirin, beta-blockers, and
assessments of left ventricular function (Correa-de-Araujo et al., 2006;
Hicks et al., 2004).
In addition, racial and ethnic minorities are less likely to receive
advanced and expensive treatments and therapies for cardiovascular dis-
ease conditions. African Americans are less likely than whites to undergo
cardiac catheterization and revascularization, less likely to be given newer
antiplatelet agents during hospitalization, and less likely to receive lipid-
lowering agents and smoking cessation counseling at time of hospital
discharge (Sonel et al., 2005). In addition, African Americans and Lati-
nos were less likely to receive cardiac resynchronization therapy with
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 117
Scientiﬁc Evidence of Disparities in Health Care 117
deﬁbrillation, even when they met clinical guidelines for receiving that
treatment (Farmer et al., 2009).
The role of race in clinical decision making regarding cardiovascular
disease has also been investigated. In one study where a committee of
cardiologists and cardiothoracic surgeons made decisions about coronary
artery bypass grafting (CABG) versus angioplasty for 938 patients after
catheterization—decisions based only on a presentation by a cardiology
fellow, and thus effectively blinded to the patient’s race—the rate of
revascularization was similar for African Americans and whites, though
African Americans were more likely to receive angioplasty and whites
more likely to receive CABG (Okelo et al., 2001). A study that included
Medicare patients treated for myocardial infarction in 4,609 hospitals
found that on average African Americans were treated at ‘‘hospitals with
lower-quality medical treatment but higher-quality surgical treatment.’’
Nevertheless, ‘‘African Americans received fewer surgical treatments than
whites admitted to the same hospital’’ (Barnato, Lucas, Staiger, Wennberg,
& Chandra, 2005). In a similar study conducted in New York state, African
Americans and AAPIs who underwent CABG received treatment from
lower-quality hospitals and surgeons compared to whites (Rothenberg,
Pearson, Zwanziger, & Mukamel, 2004).
Studies of racial and ethnic disparities in cancer incidence and preva-
lence, screening, stage at diagnosis, as well as treatment and survival have
been attributed to a range of factors, among them differences in tumor
biology, genetics, cultural differences and folk beliefs, socioeconomic sta-
tus, problems of access to continuity of care, physician practice style and
communication with patients, and interaction among all of these factors
For several types of cancers, racial and ethnic minorities are less likely
to receive screenings and early diagnosis, which is essential for effective
treatment and survivorship. One study that analyzed national cancer data
found that only 52 percent of Native American women, 57 percent of
Asian women, 62.6 percent of Latina women, and 68.2 percent of African
American women had received a mammogram in the past two years,
compared to 72 percent among non-Latino white women (Ward et al.,
2004). The same study found that rates of Pap smears were similar among
African American women (83.9 percent) and non-Latino white women
(85.5 percent); however, rates were lower for Latinas (77.9 percent),
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 118
118 Chapter Four: Racial and Ethnic Disparities in Health Care
American Indians and Alaska Natives (78.4 percent), and Asians (68.2
percent). As a result, non-Latino white women are more likely to receive
a breast cancer diagnosis when the cancer is in the localized stage as
opposed to African American, Latina, and American Indian women, who
have high rates of diagnoses in the regional stage. The same is true for
cervical cancer, where Asian women are more likely to be diagnosed with
invasive cervical cancer, followed by African American and Latina women.
Variation in cancer treatment has also been found in several reports
and studies. Shavers and Brown found that, after controlling for clinical
factors, African American women are less likely than white women to
receive breast-conserving surgery (BCS) and radiation. After undergoing
BCS, African American women and women from other racial and eth-
nic minority groups are less likely than whites to have radiation therapy
(Shavers & Brown, 2002). In addition, Latina women were less likely to
receive reconstructive surgery, and they report being less satisﬁed with
their breast cancer treatment in comparison to African American and
non-Latino white women (Katz et al., 2005). Similar patterns according to
race and ethnicity were found for men and women with colorectal cancer.
Both Latinos and African Americans have been shown to be treated less
aggressively than non-Latino whites with similar disease, even after adjust-
ing for insurance coverage, hospital type, and comorbidities (Elston Lafata,
Cole Johnson, Ben-Menachem, & Morlock, 2001; Roetzheim et al., 2000).
Diabetes disproportionately affects racial ethnic minorities, including Lati-
nos, African Americans, and Native Americans; however, the literature
highlights several gaps in care facing these groups. Successful treatment
and management of diabetes includes healthy eating and nutrition edu-
cation, eye exams, foot inspections, prescription drug and/or insulin
therapies, cholesterol and blood pressure monitoring, and glucose control.
In one review of seventy-eight articles relating to diabetes treatment
and management, ﬁndings suggested that glycemic and blood pressure
control was worse for racial and ethnic minorities in comparison to non-
Latino whites (Kirk et al., 2006). Patient adherence and behaviors, provider
practices, and health care systems all contribute to disparities in diabetes
treatment faced by minority patients. For example, African American
patients were found to be less adherent to medication and in turn to have
less metabolic control, although the effect of race was still independent of
adherence (Schectman, Nadkarni, & Voss, 2002). Similarly, a meta-analysis
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 119
Scientiﬁc Evidence of Disparities in Health Care 119
of several articles found that A1C levels were found to be higher among
Latinos in comparison to non-Latino whites, but the causes of elevated
levels were unknown (Kirk et al., 2008).
In addition, racial and ethnic minorities face more complications
from diabetes when compared to non-Latino whites, which highlights
failures in treatment and management. Common complications cited
in the literature include glaucoma, cataract, neuropathy, cardiovascular
disease, kidney disease, and mental health disease. One study examining
insured patients found that Latinos, Asians, and African Americans had a
higher likelihood of end-stage renal disease in comparison to non-Latino
whites in the sample (Karter et al., 2002). In addition, diabetic African
Americans have experienced higher rates of blindness, amputations, and
amputation-related mortality, while Latinos have higher prevalence of
retinopathy. Finally, Latinos, African Americans, and Native Americans
have higher risks of diabetes-associated mortality compared to non-Latino
whites (Peek, Cargill, & Huang, 2007).
Renal Disease and Transplantation
African Americans and Native Americans have the highest incidence of risk
of illness and death from end-stage renal disease (ESRD) among racial and
ethnic minorities. Among Native Americans, for example, the rate is four
times that for whites. This is due to more hypertension, diabetes, and sickle
cell disease among African Americans, diabetes among Native Americans,
and less access to or use of early primary care interventions among
both groups. The two main treatments for ESRD are dialysis and renal
transplantation. Although Medicare speciﬁcally supports ESRD treatment,
kidney transplantation rates vary by race (Eggers, 1995). Studies have
shown that Asians, Latinos, and women initiate dialysis treatment later.
Reasons for differences in transplant rates involve numerous factors,
including race. One study found that Latinos and Asians on a transplant
list were less likely to receive a kidney in comparison to non-Latino
whites and African Americans, after controlling for severity of the disease
(Mathur, Schaubel, Gong, Guidinger, & Merion, 2010). In addition, many
studies show that patient preferences, including refusal of and disinterest
in transplantation, is an important contributing factor (Geiger, 2003).
A study that examined physicians’ beliefs about racial differences in
referral for renal transplantation related that whereas physicians did not
view patient-physician communication and trust as important reasons for
racial differences in care, African American patients were less likely than
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 120
120 Chapter Four: Racial and Ethnic Disparities in Health Care
white patients to report receiving some or a lot of information about
transplantation (55 percent versus 74 percent; Ayanian et al., 2004).
Over the past two decades, infections with HIV and progression to
AIDS have disproportionately affected African Americans and Latinos.
For example, in 2002 HIV/AIDS was the sixth leading cause of death
among African Americans and tenth leading cause of death among Latino
males, whereas it was not among the ten leading causes of death for
non-Latino white males (Hoyert and Xu, 2012). Evidence from various
studies indicate that racial and ethnic minorities are less likely than whites
to receive various medications or to undergo some diagnostic procedures,
though they vary by source of care (Geiger, 2003).
African American and Latina women have been shown to receive
highly active antiretroviral therapy (HAART) less often than non-Latino
white women after controlling for potential confounders (Lillie-Blanton
et al., 2010). Similarly, a review of the literature found mixed effects in rela-
tion to the inﬂuence of race on the use of antiretrovirals and prophylaxis
for opportunistic infection (Palacio, Kahn, Richards, & Morin, 2002). Pos-
sible reasons for the differences include misconceptions about HIV/AIDS
among racial and ethnic minorities, distrust of health authorities, and
‘‘prescribing habits’’ of providers.
Additionally, many studies have found difﬁculties in physician-patient
communication in HIV/AIDS cases, particularly in discussing decisions
about end-of-life care and resuscitation (Haas et al. 1993) and when
there was racial or ethnic discordance between patient and physician.
One study found that African Americans with white physicians were less
likely to receive protease inhibitors when compared to racially concordant
physician-patient pairs (King, Wong, Shapiro, Landon, & Cunningham,
Finally, patient practices and beliefs are important factors in explaining
disparities in HIV treatment. Appointment nonadherence was found to
be an important factor in virologic failure, and it partially explained
disparities in virologic failure between African American and white patients
(Mugavero et al., 2009). Patient mistrust and conspiracy beliefs are also a
factor. A study found that 27 percent of 520 African American adults in ten
randomly selected census tracts agreed with the statement ‘‘HIV/AIDS is
a man-made virus that the federal government made to kill and wipe out
black people,’’ and an additional 23 percent were undecided (Klonoff &
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 121
Scientiﬁc Evidence of Disparities in Health Care 121
Asthma is a major health problem across many socioeconomic and racial
and ethnic categories. However, African Americans and Latinos, especially
Puerto Ricans, share a disproportionate burden. Asthma is the most com-
mon chronic condition afﬂicting children in the United States Among
children, African Americans and Latinos have worse morbidity and African
Americanshave higher mortalitydue to asthmathan all otherracial or ethnic
groups of children (Akinbami, Moorman, & Liu, 2011). The asthma death
rate among African Americans is approximately three times more compared
to whites (Akinbami, Moorman, & Liu, 2011). Between the ages of ﬁve and
thirty-four (when asthma is easier to distinguish from other causes of ven-
tilatory impairment), African Americans experience an asthma mortality
rate approximately three to ﬁve times higher than that of whites (Akin-
bami, Moorman, & Liu, 2011). Multiple risk factors have been implicated
for asthma morbidity and mortality for racial and ethnic minorities: tobacco
smoke exposure, obesity, air pollution, house dust mite allergens, cock-
roaches,and cat hair (Luder, Melnik, & DiMaio,1998; Gilliland, et al., 2000).
An elevated level of severe asthma and related hospitalization among
inner-city minority children is associated with features of health care
and treatment, such as inadequate use of long-term controller steroid
medications and overuse of quick-acting reliever drugs such as albuterol
(Ortega & Calderon, 2000). Researchers have observed that poor asthma
management and control among racial and ethnic minorities is associated
with a variety of factors, including poor provider-patient communication,
deﬁcient access to and use of high-quality and effective primary care, poor
perceived patient and family efﬁcacy to manage asthma, and perceived
inadequate treatment efﬁcacy by patients and their families (Ortega &
Improving the access and utilization of mental health services has been
a top health policy priority in the United States. The attention to mental
health care comes from increasing awareness that many people who meet
diagnostic criteria for mental illness do not seek or obtain needed care. Sev-
eral studies have demonstrated that minorities, particularly African Ameri-
cans and Latinos, are less likely to use mental health services than whites. In
the U.S. Surgeon General’s (2001) supplement ‘‘Mental Health: Culture,
Race, and Ethnicity,’’ it is noted that ethnic and racial minorities have less
access to mental health care than whites, and that they are less likely to
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 122
122 Chapter Four: Racial and Ethnic Disparities in Health Care
receive needed care and stay in care. The reasons for minorities’ underuse
of mental health services are multifactorial. Considerable attention in
mental health services research has focused on the role of payment and
insurance. Many people in the United States lack sufﬁcient insurance cover-
age to cover mental health; many health plans also limit the number of visits
people may have over a period of time. Further, some plans require costly
copayments or do not allow people to go out of plan networks to ﬁnd suit-
able providers. Other barriers include lack of access to providers who speak
the same language, especially for low-acculturated Latinos. There are also
accessibility factors, such as location and awareness of available services.
A growing body of literature indicates that other factors in addition
to payment mechanisms for mental health disparity may also be in play.
For example, researchers are focusing on factors such as health beliefs,
knowledge of mental health problems, and coping mechanisms such as
self-reliance and social networks (Ortega & Alegr´
ıa, 2002). For example,
two reports of island Puerto Ricans demonstrated a high level of psychi-
atric disorder but also high denial and self-reliance (Ortega & Alegr´
2002; Ortega & Alegr´
ıa, 2005). Denial can be a maladaptive coping strat-
egy, especially if it results in little or no usage of needed mental health
care. The extent to which denial is more or less prevalent in minority
populations relative to nonminority populations is unknown. For Latinos,
some researchers have focused on the role of families and social networks
in protecting members from morbidity (Pescosolido, Wright, Alegr´
Vera, 1998). Other factors that have been examined as potential determi-
nants of mental health care disparities for all minorities include stigma,
discrimination, and racism.
Due to these factors, racial and ethnic minorities face multiple dispari-
ties in mental health treatment, including limited access to care and lower
quality of care. Among both nondepressed and depressed individuals,
Asians, Latinos, and African Americans were less likely to access mental
health services in comparison to non-Latino whites (Alegr´
ıa et al., 2008).
In addition, Asians and African Americans received lower-quality care
when compared to non-Latino whites.
In response to the ever-growing body of literature documenting the
existence of racial and ethnic disparities in care, there have been and
continue to be numerous efforts to address those disparities. Examples of
these efforts exist in the public and private sectors of U.S. society.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 123
Future Directions 123
For the past thirty years, Healthy People, an initiative developed by
the U.S. Department of Health and Human Services, has been outlining
the national priorities for improving Americans’ health. Healthy People
2000 included ‘‘reducing health disparities’’ as one of its major goals.
Ten years later, Healthy People 2010 went one step further, with a goal
of ‘‘eliminating health disparities’’ (DHHS, 2000). More speciﬁcally, the
objectives target improving access to care and increasing immunizations
as major objectives. Despite the declaration of these public efforts, studies
that reviewed the progress toward Healthy People 2010 goals found mixed
results in terms of improving health care access and immunizations for
racial and ethnic minorities (Sonik, Stein-Wexler, Rogers, Coulter, &
Wootton-Gorges, 2010). With the recognition that health care disparities
continue to be a major issue, Healthy People 2020 has expanded this goal
to ‘‘achieve health equity, eliminate disparities, and improve the health of
all groups’’ according to the Ofﬁce of Minority Health (OMH, 2012).
The Department of Health and Human Services has similarly called
for the reduction in health disparities facing racial and ethnic minority
groups and has integrated Ofﬁces of Minority Health in federal agencies
under its leadership. In addition, the department organizes the Federal
Interagency Health Equity Team that assembles leaders across DHHS and
eleven other federal agencies to coordinate and maximize the effective-
ness of the many federal efforts to eliminate disparities and to identify and
evaluate new opportunities for eliminating disparities. Finally, the DHHS
Disparities Action Plan, developed in 2011, provides strategic objectives
over the next ﬁve years aimed at guiding agencies under DHHS to
reduce health care disparities for racial and ethnic minorities (minority-
Also, directed by Congress, the Agency for Healthcare Quality and
Research has produced a yearly National Healthcare Disparities Report
since 2003 documenting variations in quality of care by racial and ethnic
groups. This report draws on data from numerous national surveys, includ-
ing the Medical Expenditure Panel Survey, the National Health Interview
Survey, the National Immunization Survey, the National Ambulatory Care
Survey, and many others. The purpose of this report is to highlight areas
of greatest need and track reduction in disparities over time.
In addition to monitoring efforts and goal-setting strategies, vari-
ous government and private agencies have attempted to address health
and health care disparities through expansion of health access and pro-
vision of care to racial and ethnic minorities. The Health Resources
and Services Administration (HRSA)-supported health centers provide
infrastructure support and often funding to various safety-net providers
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 124
124 Chapter Four: Racial and Ethnic Disparities in Health Care
such as community clinics that provide care to the uninsured, low-income,
and disadvantaged individuals. In 2010, these health centers served 19.5
million patients across the United States, where 92 percent were below 200
percent of the federal poverty guideline and 62.3 percent were racial and
ethnic minorities (OMH, 2012).
Diversifying the health care workforce and promoting cultural compe-
tency have also been major initiatives of the last twenty years. Established in
1972, the National Health Service Corps places physicians, nurses, dentists,
and health personnel in Health Professional Shortage Areas in exchange
for scholarship and loan repayment programs (DHHS, n.d.). Also, various
public and private efforts have aimed to provide more opportunities for
minority students to pursue careers in medicine, nursing, dentistry, and
public health. For example, Title VII of the Public Health Services Act
supports the training of over ten thousand underrepresented graduates,
residents, and faculty in various health professional ﬁelds (American Public
Health Association, 2009). In addition, the Ofﬁce of Minority Health has
established national standards on Culturally and Linguistically Appropri-
ate Services (CLAS), which guide health care organizations and providers
in offering care to racial and ethnic minorities and other underserved
communities (OMH, n.d.).
Finally, the Patient Protection and Affordable Healthcare Act (ACA),
which passed in 2010, includes several provisions directly and indirectly
intended to improve racial and ethnic disparities in health care through
data collection and reporting, insurance coverage, cultural competence,
access to health care, quality improvement, and research (Andrulis, Sid-
diqui, Purtle, & Duchon, 2010). While the full impact of these efforts is still
unclear as health care reform is still being implemented, various initiatives
already set into motion are projected to signiﬁcantly reduce racial and
ethnic health disparities.
First, the expansion of insurance and health care coverage will address
signiﬁcant barriers to care faced by racial and ethnic minorities. As pre-
viously discussed, compared to non-Latino whites, African Americans,
Latinos, some subgroups of Asian and Paciﬁc Islanders, and Native Amer-
icans are more likely to be uninsured. Through Medicaid expansion
included in ACA, the creation of state-based health insurance exchanges,
and employer-based health insurance reforms, an estimated thirty-two
million individuals will gain access to health insurance (Kaiser Family
Foundation, 2011). The ACA also sets out to improve access to care by
providing funding and improving the infrastructure of health care sys-
tems that serve racial and ethnic minorities. For example, community
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 125
health centers, which predominantly serve racial and ethnic minority and
low-income patients, will receive $11 billion starting in 2011 to support
expansion of operational capacity and capital improvements (National
Association of Community Health Centers, 2010).
Strengthening and establishing centers to coordinate efforts to
improve health and care for racial and ethnic minorities is also a priority
of the ACA. In 2010, the National Center for Minority Health and
Health Disparities (NCMHD) was transitioned to the National Institute
on Minority Health and Health Disparities (NIMHD), which gives the
institute discretion to develop research priorities and funding allocations
for research focused on minorities and health disparities. In addition,
federal agencies under the Department of Health and Human Services;
the Agency for Healthcare Research and Quality (AHRQ); the Centers
for Disease Control and Prevention (CDC); the Centers for Medicare
and Medicaid Services (CMS); the Food and Drug Administration (FDA);
the Health Resources and Services Administration (HRSA); and the
Substance Abuse and Mental Health Services Administration (SAMHSA),
in the Department of Health and Human Services, are mandated to
create Ofﬁces of Minority Health to coordinate their efforts and initiatives
regarding racial and ethnic minorities (OMH, n.d.).
Finally, much is still not understood about the nature and causes of
health care disparities facing racial and ethnic minorities and effective solu-
tions, therefore the ACA includes several provisions to improve research
and develop effective interventions. One of the major efforts implemented
in the law is the requirement to collect and utilize race, ethnicity, lan-
guage, sex, and disability data in research studies and in monitoring
efforts so that policymakers, practitioners, and researchers have a more
holistic picture of the needs of various populations and subgroups (DHHS,
2010). To improve the quality of care for racial ethnic minorities, the law
also establishes a Patient-Centered Outcomes Research Institute (PCORI)
to independently investigate clinical effectiveness of medical interventions
and programs for diseases, disorders, and health conditions, with a focus on
what works for racial and ethnic minorities (Washington & Lipstein, 2011).
According to the medical and public health literature, disparities in health
care system are prevalent, with racial and ethnic minorities receiving
lower-quality care in a variety of health care settings and across a range of
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 126
126 Chapter Four: Racial and Ethnic Disparities in Health Care
medical conditions. A number of factors account for disparities in care,
ranging from legal and structural factors to patient and provider factors.
From a historical perspective, these ﬁndings are not surprising; racial
and ethnic minorities have experienced discrimination and segregation
in health care settings since the founding of the United States. Although
efforts to address racial and ethnic disparities in care are multiple and
ongoing, minority patients continue to have suboptimal health status,
which will in turn affect labor market productivity and national health care
spending. With the growing size of minority populations in the United
States, addressing disparities in care is a paramount health policy issue.
DisparityinhealthcareAccording to the Institute of Medicine
(IOM), ‘‘disparity is any difference not due to clinical need or
preferences for health care services’’ (IOM, 2003).
EquityAccording to the IOM, equity or equal treatment can be
deﬁned as the ‘‘delivery of health services of equal quality to all
individuals regardless of personal characteristics as gender,
socioeconomic status, geographic location, race or ethnicity’’
1. Discuss what is meant by disparities in health care, both in terms of the
relationship of disparities in health care and disparities in health, and
in terms of what constitutes a disparity in health care.
2. Discuss the role that personal preference and medical appropriateness
play in causing disparities in health care.
3. Discuss the role of patient provider communications in causing and
also in alleviating disparities in health care.
4. Discuss the history of segregation in medical care of African American
patients, physicians, and nurses and how this history might affect
current racial and ethnic disparities in the delivery and receipt of
5. Discuss some of the efforts currently underway to address disparities in
care, including the ACA.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 127
Further Reading 127
6. Discuss what might be done in your community to address disparities
in health care.
Aguirre-Molina, M., Molina, C. W., & Zambrana, R. E. (2001). Health issues in the Latino
community. San Francisco: Jossey-Bass.
This book summarizes health issues among Latino populations in the United States.
It includes causes of and statistics on health care disparities affecting Latinos.
Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus &
Well-written book by a journalist that describes the interactions between a Hmong
family with an epileptic daughter and the health care system. This book illustrates
how poor doctor-patient communication due to divergent cultural beliefs can result
in poor health outcomes.
Gamble, V. N. (1995). Making a place for ourselves: The black hospital movement. New York:
Oxford University Press.
This book examines the roles of black physicians and nurses, black community
organizations, local and federal governments, and major health care organizations
in the creation and demise of black hospitals from 1920 to 1945.
Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities
in health care. Washington, DC: National Academies Press.
This report summarizes the literature on health care disparities and makes recom-
mendations for addressing them. This is a landmark report issued by the National
Institute of Medicine. (2012).How far have we come in reducing health disparities? Progress
since 2000: Workshop summary. Washington, DC: National Academies Press.
Building upon previous IOM reports on health care quality and unequal treatment,
the IOM held a workshop on April 8, 2010, that discussed progress toward addressing
health disparities and focused on the success of various federal initiatives to reduce
health disparities. This report summarizes the IOM workshop and explains the
progress in the ﬁeld since 2000.
LaVeist, T. A. (2005). Minority populations and health: An introduction to health disparities
in the United States. San Francisco: Jossey-Bass.
This book describes racial and ethnic disparities in health and its causes, including
disparities in health care. This book’s main strength is that it includes a lot of
descriptive statistics on minority health drawn from various sources.
Smith, D. B. (1999). Health care divided: Race and healing a nation. Ann Arbor: University
of Michigan Press.
This book is a chronicle from 1920 to the present of racial segregation and
discrimination in health care in the United States.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 128
128 Chapter Four: Racial and Ethnic Disparities in Health Care
U.S. Department of Health and Human Services. (2012). 2011 National healthcare
disparities report. Rockville, MD: U.S. Department of Health and Human Services,
Agency for Healthcare Research and Quality.
National report of health care disparities issued yearly by the Agency for Healthcare
Research and Quality. This report uses indicators of quality of care drawn from
various sources and reported by race and ethnicity.
White, A. A., III, & Chanoff, D. (2011). Seeing patients: Unconscious bias in health care.
Boston: Harvard University Press.
This book uses the story of one of the authors, Gus White, as a way to talk about
unconscious biases and their consequences in the medical profession and beyond.
White is an orthopedic surgeon who grew up in Tennessee under Jim Crow, went
to Ivy League schools, and was the only and ﬁrst black medical student in most of
those places. He was the ﬁrst black chief resident at Yale, the only black surgeon
in Vietnam, and the ﬁrst black chief of service in a Harvard teaching hospital.
The authors use an autobiographical approach, showing how Dr. White’s life spans
an enormous change in American race relations. They also show how great the
disparities still are and make the case for ‘‘culturally competent’’ medical training.
Williams, R. A. (Ed.). (2011). Healthcare disparities at the crossroads with the healthcare
reform. New York: Springer Science +Business Media.
This volume addresses how the Affordable Care Act addresses the problem of health
care disparity and analyzes the beneﬁts and shortcomings of the law as it relates to
Adler, N. E., & Rehkopf, D. H. (2008). U.S. disparities in health: Descriptions, causes,
and mechanisms. Annual Review of Public Health,29 , 235–252.
Akinbami, L. J., Moorman, J. E., & Liu, X, (2011). Asthma prevalence, health care use,
and mortality: United States, 2005-2009. National health statistics reports; no 32.
Hyattsville, MD: National Center for Health Statistics.
X. L. (2008). Disparity in depression treatment among racial and ethnic minority
populations in the United States. Psychiatric Services,59 (11), 1264–1272.
American Public Health Association. (2009). Public Health Services Act Title VII and VIII:
Why are these programs so important? Retrieved from http://www.apha.org
Andrulis, D. P., Siddiqui, N. J., Purtle, J. P., & Duchon, L. (2010). Patient Protection
and Affordable Care Act of 2010: Advancing health equity for racially and ethnically diverse
populations. Washington, DC: Joint Center for Political and Economic Studies.
Austin, A. (2010). Hidden disadvantage: Asian American unemployment and the
Great Recession. Washington, DC: Economic Policy Institute. Retrieved from
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 129
Ayanian, J. Z., Cleary, P. D., Keogh, J. H., Noonan, S. J., David-Kasdan, J. A., &
Epstein, A. M. (2004). Physicians’ beliefs about racial differences in referral for
renal transplantation. American Journal of Kidney Diseases,43(2), 350–357.
Barnato, A. E., Lucas, F. L., Staiger, D., Wennberg, D. E., & Chandra, A. (2005). Hospital-
level racial disparities in acute myocardial infarction treatment and outcomes.
Medical Care,43(4), 308–319.
Betancourt, J. R. (2006). Cultural competency: Providing quality care to diverse
populations. Consultant Pharmacist,21(12), 988 – 995.
Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural competence
and health care disparities: Key perspectives and trends. Health Affairs,24(2),
Betancourt, J. R., & Maina, A. W. (2004). The Institute of Medicine Report ‘‘unequal
treatment’’: Implications for academic health centers. Mount Sinai Journal of
Medicine,71, 314 – 321.
Bound, J., T. Waidmann, T., Schoenbaum, M., & Bingenheimer, J. B. (2003). The
labor market consequences of race differences in health. Milbank Quarterly,81(3),
Braveman, P. (2006). Health disparities and health equity: Concepts and measurement.
Annual Review of Public Health,27 (1), 167 –194.
Bureau of Indian Affairs. (2012). Retrieved from http://www.bia.gov/FAQs/index.htm.
Carter-Pokras, O., & Baquet, C. (2002). What is a ‘‘health disparity’’? Public Health
Reports,117 (5), 426 –434.
Chen, M. S., & Hawks, B. l., (1995). A debunking of the myth of healthy Asian Americans
and Paciﬁc Islanders. American Journal of Health Promotion,9(4), 261 –268.
Correa-de-Araujo, R., Stevens, B., Moy, E., Nilasena, D., Chesley, F., & McDermott, K.
(2006). Gender differences across racial and ethnic groups in the quality of care for
acute myocardial infarction and heart failure associated with comorbidities. Women’s
Health Issues,16 (2), 44–55.
Dovidio, J. F., Kawakami, K., & Gaertner, S. L. (2002). Implicit and explicit prejudice
and interracial interaction. Journal of Personality and Social Psychology,82(1), 62 – 68.
Eggers, P. W. (1995). Racial differences in access to kidney transplantation. Health Care
Financial Review,17 (2), 89 –103.
Elston Lafata, J., Cole Johnson, C., Ben-Menachem, T., & Morlock, R. J. (2001).
Sociodemographic differences in the receipt of colorectal cancer surveillance care
following treatment with curative intent. Medical Care,39 (4), 361 – 372.
Epstein, A. M., & Ayanian, J. Z. (2001). Racial disparities in medical care. New England
Journal of Medicine,344(19), 1471–1473.
Families USA. (2010). Health reform: Help for American Indians. and Alaska Natives
(Issue Brief). Washington, DC: Author.
Farmer, S. A., Kirkpatrick, J. N., Heidenreich, P. A., Curtis, J. P., Wang, Y., & Groeneveld,
P. W. (2009). Ethinic and racial disparities in cardiac resynchronization therapy.
Heart Rhythm,6(3), 325 –331.
Fine, M. J., Ibrahim, S. A., & Thomas, S. B. (2005). The role of race and genetics in
health disparities research. American Journal of Public Health,95(12), 2125– 2128.
Gamble, V. N. (1991). The Provident Hospital project: An experiment in race relations
and medical education. Bulletin of the History of Medicine,65 (4), 457–475.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 130
130 Chapter Four: Racial and Ethnic Disparities in Health Care
Gamble, V. N. (1997). Under the shadow of Tuskegee: African Americans and health
care. American Journal of Public Health,87 (11), 1773 –1778.
Geiger, H. J. (2003). Racial and ethnic disparities in diagnosis and treatment: A review
of the evidence and a consideration of causes. In B. D. Smedley, A. Y. Stith, & A. R.
Nelson (Eds.), Unequal treatment: Confronting racial and ethnic disparities in health care.
Washington DC: National Academies Press.
Gilliland, F. D., Berhane, K., McConnell, R., Gauderman, W. J., Vora, H. Rappaport,
E. B., . . . Peters, J. M. (2000). Maternal smoking during pregnancy, environmental
tobacco smoke exposure and childhood lung function. Thorax,55(4), 271–276.
Green, A., Peters-Lewis, A., Percac-Lima, S., Betancourt, J. R., Richter, J. M., Janairo, M.
P., . . . Atlas, S. J. (2008). Barriers to screening colonoscopy for low-income Latino
and white patients in an urban community health center. Journal of General Internal
Greenwald, A. G., Poehlman, T. A., Uhlman, T. A., & Banaji, M. R. (2009). Understand-
ing and using the Implicit Association Test: III. Meta-analysis of predictive validity.
Journal of Personality and Social Psychology,97 (1), 17–41.
Haas, J. S., Weissman, J. S., Cleary, P. D., Goldberg, J., Gatsonis, C., Seage, G. R., III,, . . .
Epstein, A. M. (1993). Discussion of preferences for life-sustaining care by persons
with AIDS: Predictors of failure in patient-physician communication. Archives of
Internal Medicine,153(10), 1241–1248.
Hadley, J. (2003). Sicker and poorer: The consequences of being uninsured—a review
of the research on the relationship between health insurance, medical care use,
health, work, and income. Medical Care Research Review,60(2 Suppl), 3S–112S.
Hargraves, J. L., & Hadley, J. (2003). The contribution of insurance coverage and
community resources to reducing racial/ethnic disparities in access to care. Health
Services Research,38(3), 809–829.
Hicks, L. S., Fairchild, D. G., Horng, M. S., Orav, E. J., Bates, D. W., & Ayanian, J.
Z. (2004). Determinants of JNC VI guideline adherence, intensity of drug therapy,
and blood pressure control by race and ethnicity. Hypertension,44(4), 429 – 434.
Holmes, J. S., Arispe, I. E., & Moy, E. (2005). Heart disease and prevention: Race and
age differences in heart disease prevention, treatment, and mortality. Medical Care,
43(3 Suppl), I33 – I41.
Hoyert, D. L., Xu, J. Q. (2012). Deaths: Preliminary data for 2011. National vital statistics
reports; vol 61 no 6. Hyattsville, MD: National Center for Health Statistics.
Hsiao, W. C., Knight, A. G., Kappel, S., & Done, N. (2011). What other states can learn
from Vermont’s bold experiment: Embracing a single-payer health care ﬁnancing
system. Health Affairs,30(7), 1232– 1241.
Institute of Medicine (IOM). (2001). Crossing the quality chasm. Washington, DC:
National Academies Press.
Institute of Medicine (IOM). (2003). Unequal treatment: Confronting racial and ethnic
disparities in health care. Washington, DC: National Academies Press.
Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. A. (2004). Patient race/ethnicity
and quality of patient–physician communication during medical visits. American
Journal of Public Health,94(12), 2084 – 2090.
Kaiser Commission on Medicaid and the Uninsured. (2004). Health insurance coverage
in America. Washington, DC: Kaiser Family Foundation.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 131
Kaiser Family Foundation. (2011). Summary of the Affordable Care Act. Menlo Park:
Karter, A. J., Ferrara, A., Liu, J. Y., Moffet, H. H., Ackerson, L. M., & Selby, J. V. (2002).
Ethnic disparities in diabetic complications in an insured population. Journal of the
American Medical Association,287 (19), 2519–2527.
Katz, S. J., Lantz, P. M., Paredes, Y., Janz, N. K., Fagerlin, A., Liu, L., & Deapen, D.
(2005). Breast cancer treatment experiences of Latinas in Los Angeles County.
American Journal of Public Health,95(12), 2225– 2230.
King, W. D., Wong, M. D., Shapiro, M. F., Landon, B. E., & Cunningham, W. E. (2004).
Does racial concordance between HIV-positive patients and their physicians affect
the time to receipt of protease inhibitors? Journal of General Internal Medicine,19 (11),
Kirk, J. K., Bell, R. A., Bertoni, A. G., Arcury, T. A., Quandt, S. A. & Goff, D. C., Jr.,
(2006). Ethnic disparities: Control of glycemia, blood pressure, and LDL cholesterol
among U.S. adults with type 2 diabetes. Annals of Pharmacotherapy,39(9), 1489–1501.
Kirk, J. K., Passmore, L. V., Bell, R. A., Narayan, K. M., D’Agostino, R. B., Jr.,
Arcury, T. A., & Quandt, S. A. (2008). Disparities in A1C levels between Hispanic
and non-Hispanic white adults with diabetes: A meta-analysis. Diabetes Care,31(2),
Klonoff, E. A., & Landrine, H. (1999). Do blacks believe that HIV/AIDS is a government
conspiracy against them? Preventive Medicine,28 (5), 451–457.
Lillie-Blanton, M., Stone, V. E., Snow Jones, A., Levi, J., Golub, E. T., Cohen, M. H.,
. . . Wilson, T. E. (2010). Association of race, substance abuse, and health insurance
coverage with use of highly active antiretroviral therapy among HIV-infected women,
2005. American Journal of Public Health,100(8), 1493–1499.
Lorig, K., & Holman, H. (2003). Self-management education: History, deﬁnition,
outcomes, and mechanisms. Annals of Behavioral Medicine,26 (1), 1 – 7.
Luder, E., Melnik, T. A., & DiMaio, M. (1998). Association of being overweight with
greater asthma symptoms in inner city black and Hispanic children. Journal of
Pediatrics,132(4), 699– 703.
Mathur, A. K., Schaubel, D. E., Gong, Q., Guidinger, M. K., & Merion, R. M. (2010).
Racial and ethnic disparities in access to liver transplantation. Liver Transplantation,
16(9), 1033– 1040.
McWilliams, J. M., Meara, E., Zaslavsky, A. M., & Ayanian, J. Z. (2009). Differences in
control of cardiovascular disease and diabetes by race, ethnicity, and education:
U.S. trends from 1999 to 2006 and effects of Medicare coverage. Annals of Internal
Medicine,150 (8), 505–515.
Mensah, G. A., Mokdad, A. H., Ford, E. S., Greenlund, K. J., & Croft, J. B. (2005). State
of disparities in cardiovascular health in the United States. Circulation,111(10),
Monheit, A. C., & Vistnes, J. P. (2000). Race/ethnicity and health insurance status:
1987 and 1996. Medical Care Research and Review,57 (Suppl 1), 11 –35.
Mugavero, M. J., Lin, H. Y., Allison, J. J., Giordano, T. P., Willig, J. H., Raper, J. L.,
. . . Saag, M. S. (2009). Racial disparities in HIV virologic failure: Do missed visits
matter? Journal of Acquired Immune Deﬁciency Syndrome,50 (1), 100 –108.
ıa, J. L., Selby, J. V., Schmittdiel, J., Grumbach, K., & Quesenberry, C. P.,
Jr., (2000). Racial and ethnic differences in a patient survey: Patients’ values,
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 132
132 Chapter Four: Racial and Ethnic Disparities in Health Care
ratings, and reports regarding physician primary care performance in a large health
maintenance organization. Medical Care,38 (3), 300–310.
National Association of Community Health Centers. (2010). Community health centers
and health reform: Summary of key health center provisions. Bethesda, MD: Author.
National Center for Education Statistics. (2012). Higher Education: Gaps in Access and
Persistence Study, U.S. Department of Education, Washington, D.C.
National Commission on Asian American and Paciﬁc Islander Research in Education.
(2008). Asian Americans and Paciﬁc Islanders—Facts, Not Fiction: Setting the Record
Straight. Steinhardt Institute for Higher Education Policy, Asian/Paciﬁc/American
Institute at NYU, and College Board.
Ngo-Metzger, Q., Sorkin, D. H., & Phillips, R. S. (2009). Healthcare experiences of
limited English-proﬁcient Asian American patients: A cross-sectional mail survey.
Patient,2(2), 113 – 120.
Nosek, B. A., Smyth, F. L., Hansen, J. J., Devos, T., Lindner, N. M., Ranganath, K. A.,
. . . Greenwald, A. G. (2007). Pervasiveness and correlates of implicit attitudes and
stereotypes. European Review of Social Psychology,18, 36– 88.
Ofﬁce of Minority Health. (2012). HHS Action Plan to Reduce Racial and Ethnic Health
Disparities, U.S. Department of Health and Human Services, Washington D.C.
Ofﬁce of Minority Health. (n.d.-b). The National CLAS Standards. Retrieved from
Okelo, S., Taylor, A. L., Wright, J. T., Jr., Gordon, N., Mohan, G., & Lesnefsky, E.
(2001). Race and the decision to refer for coronary revascularization: The effect of
physician awareness of patient ethnicity. Journal of the American College of Cardiology,
38(3), 698 – 704.
Ortega, A. N., & Alegr´
ıa, M. (2002). Self-reliance, mental health need, and the use of
mental healthcare among island Puerto Ricans. Mental Health Services Research,4(3),
Ortega, A. N., & Alegr´
ıa, M. (2005). Denial and its association with mental health care
use: A study of island Puerto Ricans. Journal of Behavioral Health Services Research,
32(3), 320 –331.
Ortega, A. N., & Calderon, J. G. (2000). Pediatric asthma among minority populations.
Current Opinion in Pediatrics,12(6), 579– 583.
Ortman, J. M., & Guarneri, C.E. (2009). United States population projections: 2000 to 2050.
Washington DC: U.S. Census Bureau.
Palacio, H., Kahn, J. G., Richards, T. A., & Morin, S. F. (2002). Effect of race and/or
ethnicity in use of antiretrovirals and prophylaxis for opportunistic infection: A
review of the literature. Public Health Reports,117 (3), 233 –232.
Peek, M. E., Cargill, A., & Huang, E. S. (2007). Diabetes health disparities: a systematic
review of health care interventions. Medical Care Research and Review,64(5 Suppl),
Pescosolido, B. A., Wright, E. R., Alegr´
ıa, M., & Vera, M. (1998). Social networks and
patterns of use among the poor with mental health problems in Puerto Rico. Medical
Care,36 (7), 1057 – 1072.
Ponce, N. A., Tseng, W., Ong, P., Shek, Y. L., Ortiz, S., & Gatchell, M. (2009). The state
of Asian American, Native Hawaiian and Paciﬁc Islander health in California report.Los
Angeles: UCLA Center for Health Policy Research.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 133
Roetzheim, R. G., Pal, N., Gonzalez, E. C., Ferrante, J. M., Van Durme, D. J., & Krischer,
J. P. (2000). American Journal of Public Health,90(11), 1746–1754.
Rothenberg, B. M., Pearson, T., Zwanziger, J., & Mukamel, D. (2004). Explaining
disparities in access to high-quality cardiac surgeons. Annals of Thoracic Surgery,
78(1), 18 – 24.
Sabin, J., Nosek, B. A., Greenwald, A., & Rivara, F. P. (2009). Physicians’ implicit and
explicit attitudes about race by MD race, ethnicity, and gender. Journal of Health Care
for the Poor and Underserved,20 (3), 896–913.
Saha, S., Komaromy, M., Koepsell, T. D., & Bindman, A. B. (1999). Patient-physician
racial concordance and the perceived quality and use of health care. Archives of
Internal Medicine,159 (9), 997 – 1004.
Schectman, J. M., Nadkarni, M. M., & Voss, J. D. (2002). The association between
diabetes metabolic control and drug adherence in an indigent population. Diabetes
Scheppers, E., van Dongen, E., Dekker, J., Geertzen, J., & Dekker, J. (2006). Potential
barriers to the use of health services among ethnic minorities: A review. Family
Schulman, K. A., Berlin, J. A., Harless, W., Kerner, J. F., Sistrunk, S., Gersh, B. J., . . .
Escarce, J. J. (1999). The effect of race and sex on physicians’ recommendations for
cardiac catheterization. New England Journal of Medicine,340 (8), 618 –626.
Shavers, V. L., & Brown, M. L. (2002). Racial and ethnic disparities in the receipt of
cancer treatment. Journal of the National Cancer Institute,94(5), 334–357.
Sheppard, V. B., Zambrana, R. E., & O’Malley, A. S. (2004). Providing health care to
low-income women: A matter of trust. Family Practice,21(5), 484 – 491.
Shi, L., & Stevens, G. D. (2005). Disparities in access to care and satisfaction among
U.S. children: The roles of race/ethnicity and poverty status. Public Health Reports,
120(4), 431 – 441.
Smith, M. B. (1999). Primary care: Choices and opportunities for racial/ethnic minority
populations in the USA and UK—a comparative analysis. Ethnicity and Health,4(3),
Sonel, A. F., Good, C. B., Mulgund, J., Roe, M. T., Gibler, W. B., Smith, S. C., Jr., . . .
Peterson, E. D. (2005). Racial variations in treatment and outcomes of black and
white patients with high-risk non-ST-elevation acute coronary syndromes: Insights
from CRUSADE (Can Rapid Risk Stratiﬁcation of Unstable Angina Patients Suppress
Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?).
Sonik, A., Stein-Wexler, R., Rogers, K. K., Coulter, K. P., & Wootton-Gorges, S. L. (2010).
Follow-up skeletal surveys for suspected non-accidental trauma: Can a more limited
survey be performed without compromising diagnostic information?. Child Abuse &
Neglect,34(10), 804–806. doi: http://dx.doi.org/10.1016/j.chiabu.2010.03.002
Stanley, D. A., Sokol-Hessner, P., Banaji, M. R., & Phelps, E. A. (2011). Implicit
race attitudes predict trustworthiness judgments and economic trust decisions.
Proceedings of the National Academy of Sciences of the USA,108(19), 7710– 7715.
Tai-Seale, M., Freund, D., & LoSasso, A. (2001). Racial disparities in service use
among Medicaid beneﬁciaries after mandatory enrollment in managed care: A
difference-in-differences approach. Inquiry,38(1), 49 –59.
Kominski c04.tex V2 - 09/23/2013 11:29 A.M. Page 134
134 Chapter Four: Racial and Ethnic Disparities in Health Care
Urban Indian Health Institute. (2004). The Health Status of Urban American Indians
and Alaska Natives Retrieved from http://www.uihi.org/wp-content/uploads/2007
U.S. Census Bureau. (2009). 2009 National population projections. Washington, DC:
U.S. Commission on Civil Rights. (2004). Evaluating the Native American Health Care
System, Washington D.C. Retrieved from: http://www.usccr.gov/pubs/nahealth
U.S. Department of Health and Human Services. (2000). Healthy People 2010: What are
its goals? Retrieved from http://www.healthypeople.gov/2010/About/goals.htm
U.S. Department of Health and Human Services. (2010). 2010 National healthcare
disparities report. Rockville, MD: Agency for Healthcare Research and Quality.
U.S. Department of Health and Human Services. (n.d.). Key facts about the National
Health Service Corps. http://www.hhs.gov/recovery/programs/nhsc/nhscfact
U.S. Surgeon General. (2001). Mental health: Culture, race, and ethnicity. Rockville, MD:
Substance Abuse and Mental Health Services Administration.
Vargas Bustamante, A., & Chen, J. (2011). Physicians cite hurdles ranging from lack of
coverage to poor communication in providing high-quality care to Latinos. Health
Affairs (Millwood),30(10), 1921 – 1929.
Vargas Bustamante, A., & Chen, J. (2012). Health expenditure dynamics and years of
U.S. residence: Analyzing spending disparities among Latinos by citizenship/nativity
status. Health Services Research,47 (2), 794–818.
Waidmann, T. A., & Rajan, S. (2000). Race and ethnic disparities in health care access
and utilization: An examination of state variation. Medical Care Research and Review,
57(Suppl 1), 55–84.
Ward, E., Jemal, A., Cokkinides, V., Singh, G., Cardinez, C., Ghafoor, A., & Thun, M.
(2004). Cancer disparities by race/ethnicity and socioeconomic status. CA: A Cancer
Journal for Clinicians,54(2), 78– 93.
Washington, A. E., & Lipstein, S. H. (2011). The Patient-Centered Outcomes Research
Institute: Promoting better information, decisions, and health. New England Journal
of Medicine,365(15), e31.
Wolff, M., Bates, T., Beck, B., Young, S., Ahmed, S. M., & Maurana, C. (2003). Cancer
prevention in underserved African American communities: Barriers and effective
strategies—a review of the literature. Wisconsin Medical Journal ,102(5), 36–40.
Zuvekas, S. H., & Taliaferro, G. S. (2003). Pathways to access: Health insurance, the
health care delivery system, and racial/ethnic disparities, 1996–1999. Health Affairs
(Millwood),22(2), 139 – 153.