Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received.

In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients' and providers' attitudes, expectations, and behavior are analyzed.

How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider-patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.

Contents

• THE NATIONAL ACADEMIES
• COMMITTEE ON UNDERSTANDING AND ELIMINATING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE
• REVIEWERS
• ACKNOWLEDGMENTS
• Abstract
• EXECUTIVE SUMMARY
• 1. Introduction and Literature Review
  • STUDY CHARGE AND COMMMITTEE ASSUMPTIONS
  • THE RELATIONSHIP BETWEEN RACIAL AND ETHNIC DISPARITIES IN HEALTH STATUS AND HEALTHCARE
  • WHY ARE RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE IMPORTANT?
  • EVIDENCE OF RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
  • HIV/AIDS
  • SUMMARY
• 2. The Healthcare Environment and Its Relation to Disparities
  • THE HEALTH, HEALTH INSURANCE, AND LANGUAGE STATUS OF RACIAL AND ETHNIC MINORITY POPULATIONS
  • RACIAL ATTITUDES AND DISCRIMINATION IN THE UNITED STATES
  • THE CONTEXT OF HEALTHCARE DELIVERY FOR RACIAL AND ETHNIC MINORITY PATIENTS – AN HISTORICAL OVERVIEW
  • A BRIEF HISTORY OF LEGALLY SEGREGATED HEALTHCARE FACILITIES AND CONTEMPORARY DE FACTO SEGREGATION
  • THE SETTINGS IN WHICH RACIAL AND ETHNIC MINORITIES RECEIVE HEALTHCARE
  • THE HEALTHCARE PROFESSIONS WORKFORCE IN MINORITY AND MEDICALLY UNDERSERVED COMMUNITIES
  • THE PARTICIPATION OF RACIAL AND ETHNIC MINORITIES IN HEALTH PROFESSIONS EDUCATION
  • SUMMARY
• 3. Assessing Potential Sources of Racial and Ethnic Disparities in Care: Patient- and System-Level Factors
  • A MODEL: SOURCES OF HEALTHCARE DISPARITIES
  • PATIENT-LEVEL VARIABLES – PREFERENCES, MISTRUST, TREATMENT REFUSAL, BIOLOGICAL DIFFERENCES, AND OVERUSE OF SERVICES
  • HEALTH SYSTEMS-LEVEL VARIABLES
  • SUMMARY
• 4. Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter
  • Medical Decisions Under Time Pressure with Limited Information
  • Healthcare Provider Prejudice or Bias
  • Patient Response: Mistrust and Refusal
  • Conclusion
• 5. Interventions: Systemic Strategies
  • Legal, Regulatory, and Policy Interventions
  • Health Systems Interventions
  • Patient Education and Empowerment
• 6. Interventions: Cross-Cultural Education in the Health Professions
  • Background
  • Cross-Cultural Communication: Links to Racial/Ethnic Disparities in Healthcare
  • The Foundation and Emergence of Cross-Cultural Education
  • Approaches to Cross-Cultural Education
  • Summary
• 7. Data Collection and Monitoring
  • Obstacles to Racial/Ethnic Data Collection
  • The Federal Role in Racial, Ethnic, and Primary Language Health Data
  • Other Data Sources to Assess Healthcare Disparities
  • Models of Measuring Disparities in HealthCare
  • Data Needs and Recommendations
• 8. Needed Research
  • Understanding Clinical Decision-making and the Roles of Stereotyping, Uncertainty, and Bias
  • Understanding Patient-level Influences on Care
  • Understanding the Influence of Healthcare Systems and Settings on Care for Minority Patients
  • Understanding the Roles of non-Physician Health Professionals
  • Assessing Healthcare Disparities Among non-African American Minority Groups
  • Assessing the Effectiveness of Intervention Strategies
  • Developing Methods for Monitoring Healthcare Disparities
  • Understanding the Contribution of Healthcare to Health Outcomes and the Health Gap Between Minority and non-Minority Americans
  • Mechanisms to Improve Research on Healthcare Disparities
• References
• Paper Contributions
  • RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT: A REVIEW OF THE EVIDENCE AND A CONSIDERATION OF CAUSES
  • UNDERSTANDING AND ELIMINATING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE BACKGROUND PAPER RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE: A BACKGROUND AND HISTORY
  • THE RATIONING OF HEALTHCARE AND HEALTH DISPARITY FOR THE AMERICAN INDIANS/ALASKA NATIVES
  • PATIENT-PROVIDER COMMUNICATION: THE EFFECT OF RACE AND ETHNICITY ON PROCESS AND OUTCOMES OF HEALTHCARE
  • The Culture of Medicine and Racial, Ethnic and Class Disparities in Health Care
  • THE CIVIL RIGHTS DIMENSION OF RACIAL AND ETHNIC DISPARITIES IN HEALTH STATUS
  • Racial and Ethnic Disparities in Healthcare: Issues in the Design, Structure and Administration of Federal Healthcare Financing Programs Supported Through Direct Public Funding
  • THE IMPACT OF COST CONTAINMENT EFFORTS ON RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE: A CONCEPTUALIZATION
  • RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE: AN ETHICAL ANALYSIS OF WHEN AND HOW THEY MATTER
• Appendix A Data Sources and Methods
• Appendix B Literature Review
• Appendix C Federal-level and Other Initiatives to Address Racial and Ethnic Disparities in Health Care
• Appendix D Racial disparities in Health Care: Highlights From Focus Group Findings
• Appendix E Committee and Staff Biographies

Support for this project was provided by the Office of Minority Health, U.S. Department of Health and Human Services. Additional support for data collection activities was provided by The Commonwealth Fund and the Henry J. Kaiser Family Foundation. The views presented in this report are those of the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care and are not necessarily those of the funding agencies.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.