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By Paul Hsu, Mara C. Bryant, Teodocia M. Hayes-Bautista, Keosha R. Partlow, and David E. Hayes-Bautista
California And The Changing
American Narrative On Diversity,
Race, And Health
ABSTRACT
The historical narrative on diversity, race, and health would
predict that California’s population change from 22 percent racial/ethnic
minority in 1970 to 62 percent in 2016 would lead to a massive health
crisis with high mortality rates, low life expectancy, and high infant
mortality rates—particularly given the state’s high rates of negative social
determinants of health: poverty, high school incompletion, and
uninsurance. We present data that suggest an alternative narrative: In
spite of these negative factors, California has very low rates of mortality
and infant mortality and long life expectancy. This alternative implies
that racial diversity may offer opportunities for good health outcomes
and that community agency may be a positive determinant. Using
national-level mortality data on racial/ethnic groups, we suggest that new
theoretical models and methods be developed to assist the US in
achieving high-level wellness as it too becomes “majority minority.”
Examining the path of health care
reform—from the Institute of Med-
icine’sCrossing the Quality Chasm
report1to the Affordable Care Act
and the Robert Wood Johnson
Foundation’s Culture of Health2—reveals the
need for a paradigm shift from disease and ill-
ness at the individual level to the promotion of
health and wellness at the societal level. Similar-
ly, the attempt to reform health care at the same
time that the US population approaches a “ma-
jority-minority”profile requires a paradigm shift
in how the health care field conceptualizes diver-
sity, race, and health. The experience of one
state—California—with health care reform while
also experiencing a demographic shift—from
22 percent minority in 19703to 62 percent mi-
nority in 20164—provides a natural experiment
whose outcome can help inform policy makers
on how to create a culture of health as their
populations become increasingly diverse.
People rely on narratives to communicate
experiences—including the experience of health
disparities—in meaningful, coherent ways.5Nar-
rative makers select and emphasize certain as-
pects of the experiences to promote particular
definitions of a problem.6Therefore, the way a
problem is framed narratively can influence
health policy.7For example, some health policy
narratives present alcohol abuse or obesity as the
result of individual choices and hence guide pol-
icy formation toward individual-level interven-
tions, such as encouraging members of the
target population to depend on their willpower
and self-discipline to achieve better health
outcomes.8
This article first explores the historical narra-
tive on diversity, race, and health—a narrative
that frames racial/ethnic health disparities as a
public crisis—and two of its key aspects: health
outcomes for which diversity is health dysfunc-
tion, and social determinants of health that are
obstacles to good health outcomes. It then exam-
ines California’s experience with an emerging
alternative narrative about diversity, race, and
health, which characterizes diversity as a health
opportunity and focuses on social determinants
that facilitate health. The article concludes with
doi: 10.1377/hlthaff.2018.0427
HEALTH AFFAIRS 37,
NO. 9 (2018): 1394–1399
©2018 Project HOPE—
The People-to-People Health
Foundation, Inc.
Paul Hsu (paulhsu@ucla.edu)
is an adjunct assistant
professor in the Department
of Medicine, University of
California Los Angeles (UCLA)
David Geffen School of
Medicine.
Mara C. Bryant is operations
executive at Adventist Health
White Memorial, in Los
Angeles.
Teodocia M. Hayes-Bautista is
a Graduate Medical Education
mentor/consultant at
Adventist Health White
Memorial.
Keosha R. Partlow is director
of the Urban Health Institute,
Charles R. Drew University of
Medicine and Science, in Los
Angeles.
David E. Hayes-Bautista is a
distinguished professor in the
Department of Medicine,
UCLA David Geffen School of
Medicine.
1394 Health Affairs September 2018 37:9
Health Equity
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policy implications and suggestions for further
research to increase understanding of this alter-
native narrative and its implications for an in-
creasingly diverse US population.
The History Of The Narrative On
Diversity, Race, And Health
During the Great Society years (1965–80), re-
searchers and policy analysts described minority
dysfunction (broken families, unemployment,
poverty, low education levels, and so on) as
the product of decades of discrimination and
segregation. Beginning with the Reagan years
(1980–92) and continuing to the present, a
new group of researchers and analysts has de-
scribed minority dysfunction as the result of bad
personal values leading to bad personal choices.
Through both eras, the narrative of minority
dysfunction went largely unchallenged, and this
narrative now undergirds much health care re-
search.9
Health Outcomes: Diversity As Health
Dysfunction The historical narrative holds that
nonwhite racial/ethnic populations, sometimes
called minorities or populations of color, present
poorer health outcomes than white populations
do.10 In announcing its action plan to reduce
racial/ethnic health disparities in 2011, the De-
partment of Health and Human Services ob-
served that the then “recently released Centers
for Disease Control and Prevention (CDC) re-
port, Health Disparities and Inequalities, demon-
strates that African American, Hispanic, Asian
American, and American Indian and Alaska Na-
tive populations suffer higher mortality rates
than other populations.”11
Joyce Buckner-Brown and coauthors translate
this into policy-actionable terms: “Poor people
and people of color are more likely to live shorter
and sicker lives, and are less likely to survive a
host of chronic illnesses.”12(pS12) The narrative in-
sists that racial/ethnic disparities stubbornly
persist, even though the overall health of Amer-
icans has improved.10 Both minority and non-
minority poor people suffer worse health out-
comes, but because minority communities have
a higher percentage of people living in poverty,
race and poverty have become intertwined.13
Social Determinants Of Health: Obstacles
To Good Health Outcomes For decades, low
income and education at the individual level
have been considered obstacles that result in
poor health outcomes at the individual level.14
The literature has reconceptualized these indi-
vidual-level determinants as societal-level fac-
tors that are associated, for example, with em-
ployment; housing; air quality; transportation;
public safety; green space; and access to fresh,
healthy food.15 Anita Chandra and coauthors
suggest that once social obstacles have been
addressed, healthier communities become
possible.16
Reframing The Narrative From
California’s Experience
The narrative based on these two framing prem-
ises would lead one to expect that California,
with a 62 percent “minority”population, would
be one of the unhealthiest states in the nation. In
reality, however, our data show that California is
one of the leaders in health indicators and
healthy communities. This suggests that the cur-
rent narrative has failed to properly conceptual-
ize and frame health developments in the state as
it shifted to a largely minority population. Cal-
ifornia’s experience, therefore, suggests two al-
ternative premises.
Health Outcomes: Diversity As High-Level
Health Functioning Diversity can offer oppor-
tunities for health care reform, especially im-
proving population health. As of 2016, Califor-
nia’s population was quite diverse—39 percent
Latino, 6 percent African American, 13 percent
Asian/Pacific Islander, 3 percent multiracial,
and less than 1 percent American Indian/Alaska
Native4—and this great diversity did not equate
to massive health dysfunction.
According to our data, California’s overall
health profile was far better than that of the
United States as a whole: California had lower
death rates, longer life expectancy, and lower
infant mortality rates (exhibit 1). Moreover, this
better-than-national health profile was driven by
strong results from the diverse population
groups, particularly Latinos and Asian/Pacific
Islanders. Both non-Hispanic whites and African
Americans (together accounting for 44 percent
of the state’s population)4had higher mortality
rates and shorter life expectancies than the state
norm, while Latinos and Asian/Pacific Islanders
(52 percent of the state’s population)4had lower
death rates and longer life expectancies than the
state norm. American Indian/Alaska Natives
(less than 1 percent of the state’s population)
also had lower death rates than the state norm,
but their life expectancies were slightly shorter
than the state’s.
All of California’s population groups except
African Americans have infant mortality rates
that are lower than national rates. The nuances
of the African American rate must be under-
stood. African-born immigrant women giving
birth in the US have a low infant mortality rate—
equivalent to that of non-Hispanic white
women17—while the high infant mortality rate
of US-born African-origin women may be associ-
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ated with accumulated perceptions of racial dis-
crimination.18
California’s leading position in its health
profile—that is, generally low death rates, long
life expectancy, and low infant mortality rates
compared to the US as a whole—clearly is not
being held back by the fact that Latinos are the
largest racial/ethnic group, making up 39 per-
cent of the population.
Social Determinants Of Health: Facilita-
tors Of Good Outcomes California has higher
percentages of adults without insurance, living
in poverty, and without a high school education,
compared to national averages. This is because
Latinos have higher rates of uninsurance, pover-
ty, and low education. These common social de-
terminants would be expected to yield poor Lati-
no health outcomes. Yet Latinos in California
have better health outcomes than non-Hispanic
whites, who enjoy higher levels of insurance,
income, and education.
Poverty and low levels of education (not being
a high school graduate) traditionally have been
considered to be powerful predictors of adverse
health outcomes—perhaps as important as race/
ethnicity itself.19–21 The online appendix shows
the results of linear regressions involving the
effects of poverty and low education on low birth-
weight in non-Hispanic white, Latino, and Afri-
can American births in California in 2008–13.22
While both income and education do appear to
be powerful predictors of differences in birth-
weight between non-Hispanic whites and Afri-
can Americans, the same variables have little
predictive power for Latino rates of low-birth-
weight births. A similar lack of predictive power
for Latino health outcomes has been seen in
death rates and behavioral areas such as drink-
ing, smoking, and drug use.23
Implications For The Nation
Race As An Opportunity For High-Level
Health Outcomes Accounting for nearly two-
thirds of the country’s inhabitants, trends
among non-Hispanic whites drive the US death
rate; interestingly, though, their death rate is
slightly higher than the national rate (747.7
versus 729.9 deaths per 100,000 population)
(exhibit 2). The African American rate (853.9
deaths per 100,000 population) is higher than
that of non-Hispanic whites. But the three re-
maining groups—Latinos, American Indian/
Alaska Natives, and Asian/Pacific Islanders—
have death rates that are quite a bit lower
(27.7 percent, 18.6 percent, and 45.8 percent
lower, respectively) than the national rate.
Place Matters The state with the lowest age-
adjusted mortality rate is Hawaii, followed by
California, New York, Connecticut, and Minne-
sota. The five states have a combined average
mortality rate of 630.3 deaths per 100,000 pop-
ulation. The state with the highest rate is Mis-
sissippi, followed by West Virginia, Alabama,
Kentucky, and Oklahoma, for a combined aver-
age rate of 923.9 deaths per 100,000 population.
The bottom five states have a combined average
rate that is 46.6 percent higher than that of the
Exhibit 1
Selected outcomes for the United States, California, and racial/ethnic groups within California
Within California
Outcome US California
Non-Hispanic
white Latino
African
American
Asian/Pacific
Islander
American Indian/
Alaska Native
Age-adjusted all-cause death rates per
100,000 populationa729.9 619.1 686.4 514.4 807.6 394.5 380.2
Life expectancy at birth (years)b78.9 80.8 79.8 83.2 75.1 86.3 80.2
Infant mortality per 1,000 live birthsc6.0 4.7 3.9 4.6 9.4 3.8 5.9
Uninsurance rate for the nonelderly
(ages 0–64)d16.9% 20.2% 11.0% 34.7% 18.9% 15.9% 23.3%
Adults with incomes below the federal
poverty leveld13.5% 14.2% 10.2% 19.1% 22.6% 11.7% 21.3%
Adults ages 21 and older who did not
graduate from high schoold13.4% 18.3% 5.7% 39.6% 11.5% 13.7% 18.2%
SOURCE Authors’analysis of data from the sources indicated. aNational Center for Health Statistics. Health, United States, 2016: with chartbook on long-term trends in
health (see note 24 in text). bLewis K, Burd-Sharps S. American human development report: the measure of America 2013–2014 [Internet]. Brooklyn (NY): Measure of
America of the Social Science Research Council. Indicator Tables, American human development index by state, total population 2010; [cited 2018 Aug 8]. Available from:
https://www.measureofamerica.org/wp-content/uploads/2013/06/MOA-III.pdf. cMatthews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013
period linked birth/infant death data set. National Vital Statistics Reports [serial on the Internet]. 2015;64(9):1–30. Table 2, Infant mortality rates, by race and
Hispanic origin of mother: United States and each state, Puerto Rico, and Guam, 2011–2013 linked files; [cited 2018 Aug 8]. Available from: https://www.cdc.gov/
nchs/data/nvsr/nvsr64/nvsr64_09.pdf. dCensus Bureau. American Community Survey, 2008–13.
Health Equity
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top five.24 Place definitely matters.
Based on these data, race combines with place
in unexpected ways. While the historical narra-
tive holds that race is an “innate, individual”
characteristic,25 the “place of the race”may mat-
ter more. The combined average African Ameri-
can death rate in the top five states is 682.8
deaths per 100,000 population. In contrast,
the combined average non-Hispanic white death
rate in the bottom five states is 921.9 deaths. The
African American death rate is 25.9 percent low-
er in the top five states than the non-Hispanic
white rate in the bottom five states.24 The place of
the race definitely matters, perhaps even more
than race or place alone.
Place, Race, And Diversity The “high”and
“low”markers in each column of exhibit 2 show
the range of variation for each racial/ethnic
group by state: the state with the highest death
rate is at the top, while the state with the lowest is
at the bottom. The death rate for all people was
highest in Mississippi and lowest in Hawaii. But
each racial/ethnic group has different states for
highest and lowest death rates: For non-Hispanic
whites, the highest state is West Virginia, and the
lowest is the District of Columbia. Interestingly,
for Latinos, the highest state is Hawaii, and the
lowest is West Virginia.24
While the historical narrative paints diversity
as an indicator of health dysfunction, the alter-
native narrative emerging out of California’s ex-
perience is that diversity may offer overlooked
opportunities to build a culture of health and
wellness. For example, Latinos have lower smok-
ing rates than non-Hispanic whites, so efforts to
prevent uptake may be more appropriate in that
minority community, compared to efforts on ces-
sation in the non-Hispanic white population.26
Community Agency As A Social Determi-
nant Not only do Latinos have high rates of
poverty, uninsurance, and lack of a high school
degree in California, but Latino communities in
the state suffer from a severe shortage of Latino
physicians: There are only 50 Latino physicians
per 100,000 Latino population, compared to 390
non-Hispanic white physicians per 100,000 non-
Hispanic white population.27 While the historical
narrative would predict dire health outcomes
given these woeful social determinants, the
emerging narrative points to other social deter-
minants that may facilitate health.
One important social determinant is a com-
munity’s exercise of its agency—that is, its ability
to take action on the world around it. As Califor-
nia was beginning its massive demographic shift
in the 1970s, many of its minority communities’
needs were not addressed by mainstream health
providers. The Latino community (among
others) exercised agency by creating an alterna-
tive system of health care and policy, indepen-
dent from then-existing public and private enti-
ties. As of 2018 more than 1,300 nonprofit,
community-based clinics provide services to un-
derserved communities.28 Some of these clinics
are quite large, such as La Clínica de la Raza—
which operates out of twenty-eight sites in
Alameda, Contra Costa, and Solano Counties.29
AltaMed (formerly known as the Barrio Free
Clinic)30 operates twenty-nine sites in Los An-
geles and Orange Counties31 and enrolled more
people in Covered California (the state’s insur-
ance Marketplace) than any other entity in the
state in 2014 and 2015.30
Many of these community clinics began in
the early 1970s—decades before the Institute of
Medicine’s“quality chasm”report—with a vision
of healthy, empowered communities that were
capable of addressing upstream causes of poor
health, including low-wage employment, poorly
functioning educational systems, unhealthy liv-
ing conditions, high-risk behaviors, immigra-
tion status, and gender identity. Cross-ethnic
coalitions created policy groups such as the
Alameda Health Consortium,32 the California
Pan-Ethnic Health Network,33 and the California
Primary Care Association,28 whose activities
created the mandates for patient governance
on their boards in the 1970s—those activities
also led to the passage of SB-853, the Health Care
Exhibit 2
Age-adjusted deaths per 100,000 population in the US, by racial/ethnic group, 2013–15
SOURCE Authors’analysis of data from National Center for Health Statistics. Health, United States,
2016:withchartbookonlong-termtrendsinhealth(seenote24intext).NOTE The whiskers indicate
the states with the highest and lowest rates.
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Language Assistance Act of 2003.34 New health-
oriented foundations created in the 1990s—
including the California Endowment,35 Cal
Wellness,36 and California Health Care Founda-
tion37—have chosen to work closely with these
alternative organizations.
Community agency may also be at work in less
formal institutional ways that also facilitate good
health outcomes in spite of individual poverty
and poor education. One possible noninstitu-
tional way that has received some research atten-
tion is the so-called barrio advantage: the oft-
observed finding that daily life in poor, but
densely populated, Latino barrios has significant
protective effects on individuals beyond individ-
ual factors such as income, education, and rates
of insurance coverage.38 This benefit has been
observed in much better-than-expected breast
cancer outcomes,39 cardiovascular health,40
birthweight and infant health,41 mental health,42
and fall risk in the elderly.43 The barrio advantage
warrants further research as a social determi-
nant that facilitates good health outcomes.
Conclusion
Over the next thirty to forty years, the US popu-
lation as a whole will become a “majority-minor-
ity”one.44 California’s experience with diversity,
race, and health calls for the development of new
theoretical models and analytic methods that
are better able to identify and track health dis-
parities in large, very diverse populations. We
suggest creating a new set of models based on
the epidemiology of diversity, which would be
better able to manage the nuances of race, place,
and diversity than the current models that are
based on an outdated narrative of minority dys-
function.
For example, our data show that low income
and education have little predictive power for
low birthweight among Latinos. The anomalous-
ly positive health outcomes for Latinos (low mor-
tality rates, long life expectancy, and low infant
mortality rates) do not fit the narrative of minor-
ity dysfunction and are not explainable by any of
our current models of minority health. In most
research, after the Latino anomalies are noted,
they are often shunted aside as a paradox that
cannot be explained by analysts.45
This article has used the experience of “minor-
ity”racial/ethnic groups in California as a basis
for developing an alternative narrative that can
widen the framing of discussions of health equity
from a narrative of public health crisis to one of
public health opportunity. ▪
The authors gratefully acknowledge the
support of Adventist Health White
Memorial’s Center for Hispanic Health.
NOTES
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4California Department of Finance
[Internet]. Sacramento (CA): The
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