Health Status

Some racial and ethnic minorities experience higher rates of chronic and disabling illnesses, infectious diseases, and mortality than white Americans. As depicted in Figure 2-1, African Americans have the highest rates of morbidity and mortality of any U.S. racial and ethnic group. The mortality rate for African Americans is approximately 1.6 times higher than that for whites – a ratio that is identical to the black/white mortality ratio in 1950 (Williams and Rucker, 2000). American Indians and Alaska Natives also experience higher mortality rates than whites, accompanied by low life expectancy. And while other racial and ethnic minorities experience lower overall mortality rates than whites, these data mask both inter-group variation (e.g., among Hispanics, Puerto Ricans experience higher infant mortality rates than whites [National Center for Health Statistics, 2000]), and an elevated burden of disease among some groups for specific causes of mortality. As depicted in Figure 2-2, some causes of mortality, such as diabetes, disproportionately affect African-American, Hispanic, and American Indian/Alaska Native populations. In addition, some subpopulations of racial and ethnic groups experience an elevated incidence and mortality due to specific diseases. Alaska Natives experience the highest rates of colon and rectal cancers of any racial or ethnic group in the United States (Institute of Medicine, 1999b). Korean Americans have the highest rates of stomach cancer (48.9 per 100,000 population) among U.S. males, followed by Japanese Americans (30.5 per 100,000 population; Institute of Medicine, 1999b). Similarly, Vietnamese- American women experience the highest incidence of cervical cancer in the United States, at rates nearly six times higher than that of white women (Institute of Medicine, 1999b).

Figure 2-1

Age-Adusted Death Rates for All Causes of Death by Race and Hispanic Origin: United States, 1950-1998 SOURCE: Health, United States, 2000 (2001)

FIGURE 2-2

: Age-Adjusted Death Rates for Selected Causes of Death by Race and Hispanic Origin: United States, 1950-1998 SOURCE: Health, United States 2000 (2001)

Insurance Status

Racial and ethnic minority Americans are significantly less likely than white Americans to possess health insurance (see Figures 2-3 and 2-4). The problem is particularly acute among the working poor and individuals who have no employment-based insurance, and among whom minorities, particularly Hispanic Americans, are over-represented. Lack of insurance poses the most significant barrier to care. Insurance status, perhaps more than any other demographic or economic factor, determines the timeliness and quality of healthcare, if it is received at all (Institute of Medicine, 2001b).

FIGURE 2-3.

. Probablility of being uninsured for population under age 65, by race and ethnicity SOURCE: Hoffman and Pohl, 2000

FIGURE 2-4

Sources of health insurance for population under age 65, by race and ethnicity, 1999. NOTE: Numbers may not ad to 100 percent due to respondents reporting more than one source of coverage and due to rounding. SOURCE: Fronstin, 2000

Asian Americans and Pacific Islanders

Some of the ethnic subgroups among Asian Americans and Pacific Islanders (API) have disproportionately high rates of uninsurance (Brown et al., 2000a; Hoffman and Pohl, 2000). Rates vary considerably, although generally, only 64% of API populations have job-based health insurance, compared with nearly three-fourths of whites (73%). Nearly one-fourth of API populations are uninsured (see Figure 2-3). Generally, rates of public insurance are lower for Asian Americans and Pacific Islanders, except for some Southeast- Asian subpopulations (Brown et al., 2000a).

Within API subgroups, Korean Americans are least likely to have health insurance. Less than half have job-based insurance (49%), while over one-third (34%) are uninsured and 14% receive Medicaid or other publicly funded insurance. Similarly, South East Asian (e.g., Vietnamese, Cambodian, Laotian) and South Asian (e.g. Indian, Pakistani, Bangladeshi) populations are disproportionately uninsured (27% and 22%, respectively). Less than half (49%) of South East Asians have job-based insurance, while nearly seven in ten South Asians (69%) have job-based insurance. Two in ten Chinese American and Filipino American families are uninsured (The Henry J. Kaiser Family Foundation, 2000). These data are depicted in Figure 2-5.

FIGURE 2-5

- Health Insurance Coverage by Asian American and Pacific Islander Subgroups vs. Whites (Ages 0-64), 1997 SOURCE: Kaiser Family Foundation, 2000

Hispanic Americans

Hispanic Americans face greater barriers to health insurance than all other U.S. racial and ethnic groups. The probability of being uninsured among Hispanic Americans is 35 percent, compared with 17.5 percent for the general population (Hoffman and Pohl, 2000). This disparity, depicted in Figures 2-3 and 2-4, largely results from the lack of job-based insurance provided to Hispanic Americans, who disproportionately work in blue-collar and service- oriented jobs. The vast majority (87%) of uninsured Hispanics are in working families, yet only 43% of Hispanics receive health insurance through work. Further, nearly one-third of Hispanics (30%) work for an employer who does not offer health insurance to workers (The Henry J. Kaiser Family Foundation, 2000). The high rate of uninsurance among Hispanics is also a reflection of a lower-than-average rate of participation in publicly funded health plans. In families with incomes less than the federal poverty level, 45 percent of all Hispanics are uninsured, compared with 32 percent of non-Hispanic whites (Fronstin, 2000). Differing eligibility standards may play a significant role in the lower rates of coverage for Hispanics under some publicly funded insurance plans, as many state and federal guidelines do not permit coverage for extended family members or families where married spouses live in the same household.

Hispanic subgroups vary in rates and sources of insurance coverage. Cuban Americans experience the highest rates of job-based or other private insurance (65%), and along with Puerto Ricans, are least likely to be uninsured (21%). Less than half of Puerto Rican, Central and South American-descendent, and Mexican Americans have job-based or other private insurance (45%, 46% and 44%, respectively), and over one-third of Puerto Rican Americans (34%) are insured by Medicaid or other publicly funded programs. More than 4 in 10 Central and South American descendent-Americans are uninsured (42%), as are 38% of Mexican Americans. These data are displayed in Figure 2-6.

FIGURE 2-6

: Health Insurance Coverage Among Latino Subgroups (Ages 0-64), 1997 SOURCE: The Kaiser Family Foundation, 2000

Linguistic Barriers

Many racial and ethnic minority Americans experience language barriers. These barriers range from low or no English proficiency to limited proficiency in speaking, reading or comprehending English. In healthcare settings, these linguistic barriers can present significant challenges to both patients and providers, despite federal regulations that encourage and support the use of interpreters (Office of Civil Rights, U.S. Department of Health and Human Services, 2000). According to the 1990 U.S. Census, 14 million people living in the United States have no or limited English-language skills (data from the 2000 Census are not available as of this writing). These populations can be found throughout the United States, although they are disproportionately represented in large urban centers and in five states (more than 10% of the population in California, New York, Texas, New Mexico, and Hawaii have limited English-language skills [Woloshin et al., 1995]). Nearly 8 million individuals (7,741,259) live in linguistically isolated households, e.g., households in which no person over age 14 years of age speaks English “very well” (U.S. Bureau of the Census, 1993). The percentage of individuals living in linguistically isolated households for each racial and ethnic group is depicted in Figure 2-7.

FIGURE 2-7

: Percentage Linguistically Isolated Households, by Race and Ethnicity, United States, 1990 SOURCE: U.S. Bureau of the Census, 1993

Asian Americans and Pacific Islanders

Large segments of Asian American and Pacific Islander communities face linguistic isolation. According to 1990 U.S. Census estimates, more than 1.5 million Asian or Pacific Islander Americans live in linguistically isolated households. Over half of Laotian, Cambodian, and Hmong families are linguistically isolated, while between 26-42% of Thai, Chinese, Korean, and Vietnamese families live in similar conditions. Figure 2-8 displays the percentage of Asian American households that are linguistically isolated.

FIGURE 2-8

- Percentage of Asian Americans That Are Linguistically Isolated, by Subgroup SOURCE: U.S. Bureau of the Census, 1990 General Population Characteristics

Racial Attitudes and Relations

“Often times, the system gets the concept of black people off the 6 o'clock news, and they treat us all the same way. Here's a guy coming in here with no insurance. He's low breed.” (African-American patient)

Racial attitudes and relations in recent decades have been characterized by both progress and strife. Sociologist Lawrence Bobo (2001) notes five trends regarding racial attitudes and race relations in this period that offer, at times, a conflicting picture of race in America. The first, more positive trend is that Americans' attitudes toward the goals of integration and equality have improved steadily over the past three decades. Second, this trend has not resulted in increasing public support for policies or other significant efforts to improve educational, employment, housing, and other opportunities for U.S. racial and ethnic minorities. Third, white Americans continue to express support for negative stereotypes of minority groups in surprisingly large numbers, even though few of these individuals would identify themselves as bigoted or racist. Fourth, white and non-white Americans differ significantly in their perception of the prevalence of racial discrimination in the United States. Finally, minorities' attitudes regarding race relations suggest a deepening level of alienation from U.S. society.

Regarding the first trend, Bobo notes that racial attitudes in America have improved significantly over the past 50 years. In the 1940s, for example, opinion surveys indicated that over two-thirds of white Americans endorsed the view that African-American and white children should attend separate schools, a view that was reflected in both formal policy and practice. Over half of respondents felt that public transportation should be segregated by race, and that whites should receive preference over minorities in access to jobs. By 1995, 96% of white Americans expressed the view that black and white children should be allowed to attend the same schools. Similarly, by the 1970s, few whites endorsed the view that public transportation should be segregated, or that whites should receive preferential treatment in hiring. In 1965, slightly more than 60% of whites stated that they would not move if a black family moved next door; by 1995, well over 90% shared this belief. Bobo concludes that over time, “support for principles of racial equality and integration has been sweeping and robust. So much so, that it is reasonable to describe it as a change in fundamental norms with regard to race” (Bobo, 2001, p.273).

Despite these positive overall trends, Americans' attitudes cannot be characterized as wholly egalitarian with regard to racial minorities, particularly when asked about policies and practices that might increase their direct contact with minority groups. For example, while the vast majority of Americans support school integration in principle, when asked whether they would send their own children to integrated schools, support declines as the degree of contact with minorities increases. When asked if they would object to sending their children to a school with a “few” black children, over 90% of whites report no objection. If black children constituted half of the school enrollment, support dips to approximately three-quarters of respondents. If the school is presented as “mostly black,” support falls to below 50%. While these trends have remained fairly stable since the mid-1970s, white support for sending their children to “mostly black” schools has fallen to below 40% at various points, particularly in the early and mid-1980s. Similarly, the percentage of white respondents who report that they would move should their neighborhood become integrated increases linearly with the proportion of blacks as residents (Bobo, 2001).

In addition, a substantial proportion of white Americans continue to endorse negative stereotypes about minorities. The 1990 General Social Survey (GSS) revealed that whites viewed blacks more negatively relative to whites on a number of dimensions, including intelligence (54% rated blacks as less intelligent in relation to whites), industriousness (62% rated blacks as lazier than whites), propensity towards violence (56% rated blacks as more prone to violence), and preference for living on public assistance (78% rated blacks as preferring to live off of welfare as compared with whites). Whites also rated Hispanics more negatively in relation to whites along the same dimensions, as 31% of whites gave Hispanics a low rating relative to whites in intelligence, 47% rated Hispanics as “lazier” than whites, 54% rated Hispanics as more prone to violence, and 59% believed that Hispanics are more likely than whites to prefer to live off of welfare (Bobo, 2001). It should be noted, however, that these percentages may be conservative due to tendencies among the general public to respond in a socially desirable, non-racist manner.

Negative stereotyping of minorities is not limited to African Americans and Hispanics. A recent survey commissioned by the Committee of 100 to study Americans' attitudes toward Asian Americans found that at least 1 in 4 Americans holds decidedly negative attitudes toward Chinese Americans, and an additional 43% hold “somewhat negative” attitudes. Many responses suggested that a significant segment of Americans fear Chinese Americans' influence and power; over one-third (34%) of respondents believe that Chinese Americans have “too much influence in the U.S. high technology sector,” while 23% believe that Chinese Americans have “too much power in the business world.” Nearly one in three (32%) respondents believe that Chinese Americans “always like to be at the head of things,” and nearly 1 in 4 believes that Americans are losing jobs at the hands of Chinese Americans. Nearly 1 in 3 believe that Chinese Americans are more loyal to China than to the United States, and 46% of those surveyed believe that “Chinese Americans passing on information to the Chinese government is a big problem.” Respondents who endorsed 5 or more of the 12 negative stereotypes posed about Chinese Americans – 25% of the sample – were found to hold overwhelmingly negative attitudes toward Chinese Americans. These respondents, who tended to have lower levels of education, lower incomes, and were more likely from the South, believe in large majorities – ranging from 68% to 73% - that Chinese Americans “don't care what happens to anyone but their own kind,” and are “taking away too many jobs from Americans” (Edsall, 2001).

Not surprisingly, white and non-white Americans hold widely diverging views of the prevalence of racial discrimination. A 1995 poll, for example, found that nearly nine in ten African Americans (88%) felt that police treat blacks unfairly, compared with 47% of whites (Schuman et al, 1997). In another poll, slightly over one in five whites (22%) but 57% of African Americans endorsed the view that blacks are discriminated against “a lot” (ABC News/Lifetime Television, 1999). Bobo (2001) cites a survey that finds African Americans to be three times as likely as whites to feel that there is “a lot” of discrimination against blacks in attaining “good-paying” jobs. Nearly 70% of African Americans endorsed this view, compared with slightly more than 20% of whites. Interestingly, 40% of Hispanics and slightly over 10% of Asian Americans supported this view. When asked whether Hispanics face “a lot” of discrimination in getting good-paying jobs, Hispanics (60%) were three times as likely as whites (20%) and one and a half times as likely as African Americans to endorse this view. Bobo (2001) summarizes these data, stating, “[minorities] not only perceive more discrimination, they also see it as more ‘institutional' in character . . . [whereas] many whites tend to think of discrimination as either mainly a historical legacy of the past or as the idiosyncratic behavior of the isolated bigot” (Bobo, 2001, p. 281).

Strikingly, white Americans' perceptions of minorities appear to be based on inaccurate notions of racial progress. A national survey conducted by the Washington Post, The Henry J. Kaiser Family Foundation, and Harvard University revealed that “whether out of hostility, indifference or simple lack of knowledge, large numbers of white Americans incorrectly believe that blacks are as well off as whites in terms of their jobs, incomes, schooling, and healthcare” (Morin, 2001, p. 1). Over seven in ten (71%) white Americans surveyed expressed the view that African Americans enjoy the same or greater opportunities than whites; 65% of whites endorse this view with respect to Hispanics. In terms of income, 42% of whites surveyed believe that African Americans are better off or about the same as the “average white person,” and nearly half (49%) believe that African Americans have similar or higher levels of education. Half of surveyed whites endorsed the view that African Americans hold similar or better jobs than whites. More than six in ten (61%) whites believe that African Americans have equal or better access to healthcare as whites, and nearly half (48%) of these respondents believe than Hispanics have equal or better access to healthcare (Morin, 2001). All of these responses are inaccurate with respect to major demographic data collected by the U.S. Bureau of the Census and other data sources, as outlined in this chapter.

The following sections illustrate that despite the more optimistic view of some that unfair treatment on the basis of race is rare, racial discrimination persists in a wide range of important aspects of American life.

Racial Discrimination

“I felt that because of my race that I wasn't serviced as well as a Caucasian person was. The attitude that you would get. Information wasn't given to me as it would have [been given to] a Caucasian. The attitude made me feel like I was less important. I could come to the desk and they would be real nonchalant and someone of Caucasian color would come behind me and they'd be like ‘Hi, how was your day?'” (African-American participant).

Mortgage Lending

African-American and Hispanic applicants for conventional home mortgages are rejected at rates greater than twice that of white applicants (U.S. Department of Housing and Urban Development, 1999). But are these disparities due to minorities' generally lower credit ratings and lower income–important predictors of loan outcomes that are themselves by-products of past discrimination?

After controlling for measures of creditworthiness, such as loan type, property and credit, data compiled by the Federal Reserve Bank of Boston revealed large differences in loan denial rates between minority and white applicants. Hispanic and African-American applicants faced an 80% greater likelihood of loan denial. The Urban Institute reanalyzed these data and replicated the finding that creditworthiness or technical factors could not explain the disparity. These researchers concluded that “the Boston Fed Study results provide such strong evidence of differential denial rates (other things being equal) that they establish a presumption that discrimination exists, effectively shifting the ‘burden of proof' to lenders” (Turner and Skidmore, 1999, p. 12).

A 1999 Urban Institute study of mortgage lending practices found that minorities face discrimination in several stages of the mortgage lending process. Paired testers sought loans using similar credit histories, incomes and financial histories, and presented the same mortgage needs. Overall, minorities received less information about loan products and were accorded less time with lending officers. Further, they were quoted higher lending rates than whites in most of the cities where tests were conducted. Potentially discriminatory practices began at early stages of the loan process, such as pre-application inquiries, and persisted through to the loan approval stage (Turner and Skidmore, 1999).

Housing Discrimination

Despite the presence of fair housing and anti-discrimination laws, American cities remain starkly segregated by race. Massey (2001), in an analysis of the largest 30 U.S. cities, finds that residential segregation is most profound and consistent over time among African Americans, and is less prominent, but still significant among Hispanic and Asian-American families. Using the indices of dissimilarity (the relative number of minorities who would have to change geographic locations so that an even racial distribution could be achieved) and isolation (the percentage of minorities residing in the geographic unit of the average minority individual), Massey found that, on average, African Americans live in communities that are overwhelmingly African American, with dissimilarity indices averaging 77.8 in northern cities and 66.5 in southern cities (indices above 60 are considered high). In six metropolitan areas (Chicago, Cleveland, Detroit, Gary, New York, and Newark), isolation indices for African Americans are 80 or more, indicating that in these cities, the average African American lives in a neighborhood that is more than 80% black. Further, other measures indicate that many African-American communities are characterized by “hypersegregation;” that is, African Americans tend to be concentrated in compact, densely packed, contiguous tracks in central cities. Black residents in these areas are unlikely to ever come into contact with non-blacks in their neighborhoods or in adjoining neighborhoods, and would have “little direct experience with the culture, norms, and behaviors of the rest of American society, and have few social contacts with members of other racial groups” (Massey, 2001, p. 410).

Patterns of segregation among Hispanic and Asian-American populations, in contrast, are less stark than that of African Americans. The dramatic increase of both Asian and Hispanic immigrants to the United States has led to large concentrations of these populations in some urban areas, but other segments of these populations have achieved remarkable levels of integration with whites. In several cities with large Hispanic populations, such as Brownsville and McAllen (Texas) and Miami (Florida), Hispanic segregation is high, with isolation indices averaging 77.2. This suggests that more than 3 of 4 Hispanics lacks regular neighborhood contact with individuals from other racial and ethnic backgrounds. In cities that are not majority Hispanic, concentration of Hispanics is less likely, with dissimilarity indices averaging 49.6 (suggesting that about half of communities in these cities are segregated by race and ethnicity) and isolation indices averaging 45.1 (both are in the moderate range). Asian- American segregation indices are quite moderate, with dissimilarity indices averaging 40.6 and isolation indices averaging 20.6 (Massey, 2001).

These patterns of segregation are not merely the product of socioeconomic differences, Massey notes. Segregation of African Americans, for example, occurs independently of social class. African-American families earning at least $50,000 annually are as likely to live in neighborhoods as segregated as those in which African-American families earning less than $2,500 per year reside. Further, the most affluent African Americans are even more segregated than lower-income Asian American and Hispanic families; blacks earning more than $50,000 annually live in more segregated conditions than Asian-American or Hispanic families earning less than $2,500 annually (Massey, 2000).

Importantly, segregation does not appear to result merely from the choices of African-American and other minority groups to live apart from white Americans. Polling data indicate that African Americans strongly endorse the idea of residential integration, and would prefer to live in racially mixed neighborhoods. Virtually all African Americans endorse the statement that “black people should have a right to live wherever they can afford to,” and over 70% would vote for a community law to enforce this right (Bobo, Schuman, and Steeh, 1986). Nearly 90% of African Americans state that they would be willing to live in any racially mixed area (Farley et al., 1994).

Similarly, most white Americans endorse the view that housing opportunities should be open to all and that housing discrimination should be abolished. In practice, however, white Americans' attitudes shift significantly with increasing residential segregation, as measured by polling data and patterns of movement after previously all-white neighborhoods become integrated. Farley et al. (1994) asked white residents in the Detroit metro area if they would feel uncomfortable in a neighborhood where 7% of the residents were black; 13% of respondents reported that they would be unwilling to enter such a neighborhood. When the percentage of black residents is presented as one-fifth of the total, one-third of whites reported that they would be unwilling to enter. If 30% of residents are African American, 59% of whites reported that they would be unwilling to move in, 44% reported that they would feel uncomfortable, and 29% reported that they would try to leave if they lived in such a neighborhood. If 50% of residents are African American, 73% of whites report that they would not want to live in the neighborhood, 65% reported that they would feel uncomfortable, and 53% would try to leave. In actual practice, the presence of smaller percentages of African Americans in previously all-white neighborhoods initiates a pattern of destabilization whereby whites tend to leave in large numbers. Summarizing studies of neighborhood racial transformation, Massey (2000) notes that the presence of one African-American family among every five white families tends to fuel a process of neighborhood turnover; in some cases, this turnover has accelerated when African Americans have numbered as few as three percent of a neighborhood (Massey, 2001).

Despite the existence of federal laws barring discrimination in housing, racial discrimination appears to be a key mechanism preventing neighborhood integration. Prior to passage of the 1968 Fair Housing Act, racial discrimination was institutionalized in the real estate industry and was widely practiced. Today, Massey (2001) states, minority home seekers, particularly African Americans, are more likely than not to face discrimination when attempting to purchase or rent a home. This discrimination occurs largely in the form of subtle, covert barriers. Housing audit studies, for example, provide a powerful means of assessing the likelihood of discriminatory practices. Auditors are trained to present comparable needs and desires in home purchases or rental properties, and are provided with similar socioeconomic traits. These studies, according to Massey, consistently indicate that housing discrimination has persisted in the years following passage of the Fair Housing Act. The U.S. Department of Housing and Urban Development's (HUD) Housing Discrimination Study, for example, was conducted in twenty audit sites around the United States and revealed that white auditors were, on average, provided with 45% more housing options in the rental market and 34% more options in the sales market than black auditors. In addition, whites were shown additional units 65% more often than blacks. Subtle “steering” of minority auditors away from predominantly white neighborhoods increased the likelihood of discrimination to 60%; in total, between 60% and 90% of the housing shown to white auditors were not shown to comparable black auditors (Yinger, 1995). For Hispanics, the likelihood of discriminatory treatment was equally high, as Hispanic auditors faced unfavorable treatment 43% of the time when seeking rental units, and 45% of the time when seeking to purchase a home (Fix, Galster, and Struyk, 1993).

White auditors also received greater assistance in obtaining credit; in 46% of encounters, whites received more favorable credit assistance in sales transactions and were offered more favorable terms in 17% of rental transactions. In addition, greater credit assistance was provided to whites; of all instances in which agents discussed a fixed-rate mortgage, 89% were with white auditors, as were 91% of instances in which adjustable-rate loans were discussed (Yinger, 1995).

These findings have been replicated in several other housing audit studies conducted in different locations in the United States. Galster (1990) found that racial steering occurred in approximately 50% of transactions, and that “selective commentary” from agents was common (including positive comments provided to white auditors regarding predominantly white neighborhoods that are not provided to African-American auditors). While housing audits have largely focused on the possibility of discrimination against African Americans, a few studies suggest that Hispanics face similar discrimination, particularly among darker-skinned Hispanics or those who identify themselves as mixed European and Indian ancestry (Massey, 2001). The consistency of these findings, coupled with data noting persistent racial segregation in the vast majority of Americans communities, prompts Massey to conclude, “rather than declining in significance, race remains the dominant organizing principle of U.S. urban housing markets” (2001, p.420).

The consequences of such segregation for individual health status are significant (Williams, 2001; Massey, 2001). Many community resources that affect health, including access to employment and educational opportunities, are inequitably distributed; a close association exists between a group's spatial position in society and its socioeconomic opportunities. For example, some communities are characterized by better schools, safer streets, better public services, fewer environmentally based health hazards, and better access to quality healthcare. African Americans, regardless of income, tend to be segregated in neighborhoods characterized by fewer of these resources and higher levels of health risks. “Compared with whites of similar socioeconomic status,” Massey (2001) notes, “blacks tend to live in systematically disadvantaged neighborhoods, even within suburbs” (2001, p. 392).

Employment

Audit studies using matched pairs of minority and non-minority auditors have also revealed consistent patterns of discrimination in hiring. As in housing audit studies, these studies carefully match testers on such attributes as educational level and personality characteristics, and carefully coach testers to ensure consistent responses to typically job interview questions. Fix, Galster, and Struyk (1993), for example, report findings from two studies of housing discrimination that assessed unfavorable treatment encountered by qualified job applicants responding to advertisements in major newspapers for entry-level positions. The first, conducted in San Diego and Chicago, assessed unfavorable treatment of Hispanics compared with white applicants. Because this study was part of a larger project assessing the potential adverse impact of new immigration legislation that banned the hiring of undocumented aliens, Hispanic testers were selected who “looked Hispanic and had definite accents” (Fix, Galster, and Struyk, 1993, p. 19). The second study, conducted in Chicago and Washington, D.C., assessed potential discriminatory treatment of African-American applicants relative to whites. Findings revealed that opportunity denial (defined as the denial of opportunity to obtain an application, obtain an interview, or receive an offer of employment) occurred 20% of the time in black-white audits and 31% of the time in Hispanic-Anglo audits, across all study sites. In other words, in nearly one-third of instances Hispanic applicants were denied an application, denied an interview, or did not receive an offer of employment while the matched white auditor received the opposite outcome.

Criminal Justice

What is the Relationship Between Racial and Ethnic Disparities in Healthcare And Broader Racial Attitudes and Discrimination?

The study committee considered studies of racial and ethnic discrimination in sectors outside of healthcare as an important aspect of the evidence base to better understand the contexts in which care is delivered to racial and ethnic minority patients. These data are not meant to imply that inferences can be drawn from this literature regarding possible discrimi nation in healthcare settings. To the contrary, most social scientists agree that individuals with higher levels of education (such as healthcare professionals) generally hold more egalitarian attitudes than less educated individuals and abhor racial or ethnic prejudice and discrimination. In addition, as will be noted in later sections of this report, healthcare professionals are sworn to beneficence, and the vast majority are drawn to their disciplines out of feelings of compassion and a strong desire to heal. Data on the persistence of racial and ethnic discrimination in other sectors of American life are important, however, because they are likely to affect the clinical encounter and process of healthcare delivery in at least three ways:

• experiences of discrimination, whether real or perceived, are experiences that minority patients are likely to bring to the clinical encounter, and are thereby likely to shape their expectations, attitudes and behaviors toward providers and health systems;
• minority patients encountering health systems are likely to interact with many individuals in addition to healthcare providers, such as administrative and clerical staff, who may be expected to mirror social attitudes and trends regarding race and ethnicity;
• healthcare providers, like all other individuals, are likely influenced in their racial and ethnic attitudes by broader social trends.

Historical Determinants of the Contemporary Minority Health Professions Workforce

During the post-Reconstruction period, several “Negro” medical schools and hospitals emerged. Eight medical schools for African Americans were established between 1865 and 1910 [Howard University Medical School, Washington, D. C. (1868); Meharry Medical College, Nashville, Tennessee (1876); Leonard (Shaw) Medical School, Raleigh, North Carolina (1882-1915); Louisville National Medical College, Louisville, Kentucky (1887-1911); Flint Medical College, New Orleans, Louisiana (1889-1911); Knoxville Medical College, Knoxville, Tennessee (1895-1910); the Medical Department of the University of West Tennessee (1900-1923); and Chattanooga National Medical College, Chattanooga, Tennessee (ca.1902)] (Cobb, 1981). At least nine northern medical schools had admitted blacks by 1860. As a result, by l895 there were approximately 385 black doctors, 7% of whom had been trained in white medical schools. Numbers of African Americans graduating from white institutions gradually increased, and in 1905, 14.5% of the country's 1,465 black physicians were from white medical schools (Duke University Medical Center, 1999).

Training black health professionals was essential to African- American communities during the prolonged post-Reconstruction period of crushing poverty, poor health status and inadequate or absent healthcare (Byrd and Clayton, this volume). Abraham Flexner's 1910 report on the status of minority health and minority health professionals reinforced this need. Flexner severely criticized medical education in the United States, noting that many U.S. medical schools had poor facilities, inadequate faculty with little scientific basis for instruction, and functioned principally as “diploma mills.” These proprietary schools offered after-hours education and training, and contributed to the tension regarding the social and professional place for inexpensive medical education and primary care (Martensen, 1995). These tensions have not been completely resolved today. In this climate, the medical establishment was agitating for control and educational reform. More than 200 medical schools were founded in the United States between 1800 and 1900 (Stevens, Goodman, & Mick, 1978. At the end of the 20^th century, the United States had the highest physician-to-population ratio in the world (Smith, 1999). Flexner believed strongly in the German scientific tradition he had experienced at the new Johns Hopkins University and suggested in the report that only university-based medical schools were appropriate for the responsibility and challenge of training physicians. Regarding the education of Negro physicians, he reports:

“The medical care of the Negro race will never be wholly left to Negro physicians. Nevertheless, if the Negro can be brought to feel a sharp responsibility for the physical integrity of his people the outlook for their mental and moral improvement will be distinctly brightened. The practice of the Negro doctor will be limited to his own race, which in turn will be cared for better by good Negro physicians than poor white ones. But the physical well-being of the Negro is not only of moment to the Negro himself. Ten million of them live in close contact with sixty million whites. Not only does the Negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the ignorant and unfortunate white contaminates him. Self-protection not less than humanity offers weighty counsel in this matter; self-interest seconds philanthropy. The Negro must be educated not only for his sake, but for ours. He is, as far as human eye can see, a permanent fact in the nation. He has his rights and due and value as an individual; but he has, besides, the tremendous importance that belongs to a potential source of infection and contagion.

The pioneer work in educating the race to know and practice fundamental hygiene principles must be done largely by the Negro doctor and Negro nurse. It is important they both be sensibly and effectively trained at the level at which their services are now important. The Negro is perhaps more easily "taken in" than the white; and as his means of extricating himself from a blunder are limited, it is all the more cruel to abuse his ignorance through any sort of pretense. A well-taught Negro sanitarian will be immensely useful; an essentially untrained Negro wearing an M.D. degree is dangerous.” (Flexner, 1910, as quoted in Smith, 1999, p. 15).

The Flexner report had an enormous impact on medical education and the entire healthcare delivery system. The American Medical Association and major philanthropic organizations closed ranks behind the report. The AMA's Council on Medical Education pushed states to restrict eligibility for state licensure to physicians graduating from approved medical schools (Smith, 1999). Within a few years the number of medical schools was reduced from approximately 155 to 70 (Smith, 1999). The curriculum was lengthened, entrance requirements were raised, and the scientific content of the curricula was increased (Byrd and Clayton 2000). These reforms were costly and many institutions were unable to survive the changes demanded by reformers. These changes, however, forever altered the class background of those trained to become physicians. Many poorer, part-time, and night students found economic barriers to medical education insurmountable, and the proportion of students from working-class and poor families remained steady at approximately 15% for most of the 20th century (Ziem, 1977). Medical education therefore was largely limited to a predominantly upper-class, white, and male population (Ziem, 1977).

This increase in training costs had profound effects on the availability of doctors, particularly in the African-American community. In fact, the physician-to-population ratio among black Americans in 1974, twenty years after the Brown v. Board of Education Supreme Court decision that outlawed segregation in schools was worse than in the 1940s (Blackwell, 1977). Further hampering black progress, integration of the nation's medical schools was not seriously addressed until a decade after the 1954 Brown v. Board of Education decision. In 1948, for example, one-third of all medical schools were officially closed to blacks and many more failed to accept a single black student until two decades later (Raup and Williams, 1964).

By 1920, only two black medical schools remained, Howard University Medical School and Meharry Medical College (Smith, 1999). The closure of the other black medical schools dramatically reduced the community resource that produced many of their primary care physicians. These closures ensured that the segregation of healthcare in hospitals, in the health professions, and the professional societies would become entrenched in U.S. society. While the black population made up about 10% of the total population in the mid-1950s, for example, black physicians made up only about 2.2% of all physicians (Reitzes, 1958). The nation's overall physician-to-population ratio was 1 to 770. For the nonwhite population, however, the physician-to-population ratio was 1 to 4,567, and the black physician-to-population ratio was 1 to 3,736 (Reitzes, 1958). This disparity was not surprising, given that the burden of training black healthcare professions increasingly fell to only a few institutions. In 1956, 74% of all black medical students attended Howard or Meharry (Ziem, 1977). It was not until 1969 that all of the nation's medical schools enrolled more black students than did Howard or Meharry alone (Ziem, 1977).

During the late 19th and early 20th century, black physicians and community leaders had built their own hospitals in several cities around the country. Many of these hospitals served as major training centers for black health professionals. Medical specialists were in very short supply in the black communities, and access to white hospitals – even for those doctors who graduated from white medical schools – was limited. For African-American physicians, acquiring specialty training or hospital expertise was rare, because these doctors were denied opportunities to access specialty training (Byrd & Clayton, 2000). Failure to acquire the requisite credentials automatically excluded blacks from academic medicine and prestigious hospital staff appointments.

To compound these problems, organized medicine and local specialty societies failed to open doors for minorities to gain equal footing in the profession. The American Medical Association's (AMA) refusal to require its affiliates to desegregate until the mid-1960s made it virtually impossible for most black physicians to gain privileges at white hospitals because local society membership was a prerequisite (Byrd & Clayton, 2001). Smith (1999) described a fear among black medical leaders that the American College of Surgeons standardization efforts could eventually eliminate black hospitals and black medical professionals. In response, the black medical leadership formed its own organization, the National Medical Association (NMA), which was founded in 1895. Blacks were, in effect, excluded from AMA affiliates and the existing medical establishment, unable to fully open the doors to training opportunities until the Civil Rights Era.

Impact of Community Health Centers on Healthcare in Minority and Medically Underserved Areas

During the 1960s, several new federal efforts were developed to increase healthcare services in poor communities. To this end, services such as the National Health Service Corps and the Community and Migrant Health Centers Program were initiated to help strengthen the workforce in medically underserved communities (Heinrich, 2000). By 1996, 625 community health centers (CHCs) provided services at over 3,900 sites (COGME, 1998). Today, these facilities serve underserved rural areas, migrant and seasonal farm worker communities, and urban communities. These federally funded CHCs include four programs: community health centers, migrant health centers, healthcare for the homeless, and healthcare for residents of public housing (COGME, 1998). CHC services are provided by primary care and other physician specialists, nurse practitioners, physician assistants, certified nurse midwives, dentists, and psychiatrists.

The vast majority (approximately two-thirds) of patients served by CHCs are non-white (COGME, 1998). In some communities, CHCs are the predominant source of care. In others, local governments have created and funded primary care clinics using the federal CHC model, helping to fill the void left by a lack of office-based providers. By the mid-1990s, rates of Hispanic visits to community health centers were 700% higher than for whites. For black, non-Hispanic individuals, visits to CHCs were 550% higher than white, non-Hispanic visits (Table 2-2).

Table 2-2.

. Number of Primary Care Visits Made to Primary Care Delivery Sites in the United States in 1994.

The CHC model has proven effective not only in increasing access to care, but also in improving health outcomes for the often higher-risk populations they serve. The continuity of care has been found to be better in CHCs than in hospital outpatient departments or physician offices, and a study examining preventable hospitalizations among medically underserved communities found that in communities served by federally qualified health centers, rates of preventable hospitalizations were lower than in communities not serviced by these centers (Epstein, 2001). Patients in underserved areas served by these centers had 5.8 fewer preventable hospitalizations per 1,000 population over three years than those in underserved areas not served by a federally qualified health center.

While CHCs were developed on the premise that they would service all patients regardless of their ability to pay, limited federal subsidies have forced many clinics to reduce the amount of uncompensated care they provide. Between 1981 and 1991, federal funding increased at half the rate of increase in the urban consumer price index for medical care (Rosenbaum & Dievler, 1992, as cited in COGME, 1998). Changes in the cost of medical technology, shift of services from inpatient to outpatient settings, and Medicare's Prospective Payment System have placed a strain on many hospitals. While most have remained operational, approximately 5% of non-federal community hospitals closed between 1985 and 1988, a rate two to three times higher than in the preceding four years (GAO, 1990). Concerned about loss of their Medicaid patient base, many CHCs have begun participating in managed care arrangements. By 1996, almost half (45%) of CHCs participated in such arrangements (Shi et al., 2000). This shift has generated fears among some that these centers will be less able to serve patients who need care the most, with declines in Medicaid reimbursement and increased difficulty providing non-reimbursable services under managed care (GAO 1995, Shi et al., 2000). In fact, recent studies suggest that CHCs provide care to a smaller proportion of uninsured patients, while they are serving increasing proportions of Medicaid patients under managed care (Shi et al., 2001).

Demographics of Healthcare Providers

The historical antecedents of physician and other healthcare provider training, as discussed above, significantly shape the current landscape of health professions education and the healthcare workforce. In this section, data on the demographic profile of healthcare providers that work primarily in racial and ethnic minority communities is reviewed.

Nurses

In 2000, 12.3 percent of registered nurses were racial and ethnic minorities. Nearly five percent of all nurses self-reported as African American, 3.5% as Asian, 2% as Hispanic, .5% as American Indian/Alaska Native, .2% as Native Hawaiian/Pacific Islander, and 1.2% reported being of two or more racial backgrounds. A larger percentage (86.4%) of minority nurses were employed in nursing, as compared with 81% of white, non-Hispanic nurses. Minority nurses were also more likely to work full-time (National Survey of Registered Nurses, 2000).

Geographically, there are distinct patterns of practice between the minority and non-minority nursing workforce (Table 2-3). Recent estimates revealed that black nurses were more likely to practice in the south and middle Atlantic regions of the country. Hispanic nurses were represented in higher proportions in the west and east south-central areas. Asian/Pacific Islander nurses were more likely to be found practicing in the Pacific and mid-Atlantic states. The west southcentral and Mountain areas of the United States were the sites with the highest percentages of American Indian and Alaskan Native nurses. The most common employment setting for minority as well as non-minority nurses was in hospitals (National Survey of Registered Nurses, 2000).

Table 2-3.

Percent Distribution of Registered Nurse Population in Each Geographic Area by Racial/ Ethnic Background: March 1996.

Impact of International Medical Graduates (IMGs) on the Workforce in Minority Communities

An important phenomenon began to emerge during the 1930s and 1940s that would have a profound effect on the healthcare provided to racial and ethnic minorities, as the numbers of international medical graduates (IMGs) securing residency training positions in U.S. hospitals, especially those serving underserved urban and rural communities, began to increase sharply. Between 1933 and 1940, the composition of the 5,056 immigrant physicians admitted to the United States was predominantly European (Stevens, Goodman, & Mick, 1978). By the 1960s, however, immigration policies had changed such that visas were easily attainable and institutions were beckoning Third World IMGs to the United States for training because of a perceived short supply of physicians (Stevens, Goodman, & Mick, 1978). This movement was occurring as courts ended federally sponsored hospital segregation and as Medicare and Medicaid legislation was passed by Congress. Concurrently, the Civil Rights era laid the groundwork for significant changes in access to healthcare facilities and services for racial and ethnic minorities as well as for the poor and elderly.

The 1967 report of the National Advisory Commission on Health Manpower (NACHM) sparked renewed efforts to recruit IMGs when it declared a national shortage of physicians (COGME, 1998). The geographic maldistribution of physicians that had been systematically discussed for over 30 years as a problem became a public agenda item. By and large, health professionals had chosen to locate and practice in affluent urban and suburban communities, while large numbers of minorities and the poor had limited access to care. The NACHM report was one of several that led to the rapid expansion of existing undergraduate medical education programs as well as the creation of new medical schools.

Three decades later, the number of students graduating from United States medical schools doubled and the number of IMGs who entered residency training programs each year almost doubled between 1988 and 1994, from 3,600 to 6,700 (COGME, 1996). The number of first- year residency positions filled increased to 140% of the yearly U.S. medical school graduates. The physician-to population ratio (excluding resident physicians) increased by 65%, from 115 to 190 physicians per 100,000 (COGME, 1996). Most of this increase was in the medical specialties, increasing the specialist physician-to-population ratio 121% from 56 to123 specialists per 100,000 population (COGME, 1996).

Healthcare expenditures also rose dramatically during this period. Federal spending for all health services just before Medicare and Medicaid was enacted in 1965 was $4 billion, rising to $15.7 billion in 1970, $33.8 billion in 1975, and $65.7 billion in 1980. During the same period of time, state and local spending increased from the pre-Medicare/Medicaid level of $4.8 billion to $31.3 billion. The poor greatly increased their use of healthcare services. By 1976, poor children averaged 65% more physician office visits, poor adults averaged 27% to 33% more visits, and the elderly poor averaged 18% more visits than in 1964. In fact, the poor in each age group increased their use of health facilities more than the non-poor (DHHS, 1980), contributing to the increased demand for healthcare professionals.

Today, IMGs are a significant part of the U.S. health workforce. The number of residency positions filled by IMGs in 1998-99 was 25,415, or more than one-fourth (26%) of all residents on duty in U.S. hospitals in 1998-99 (COGME, 1999). Many work in minority and medically underserved communities, where few other physicians choose to practice. Verghese (1994) and White (1993) concluded that individual IMGs have established themselves as critical providers of healthcare services in selected rural underserved areas. Most, however, locate in large cities, and practice in urban underserved areas. They are disproportionately distributed in teaching hospitals with high percentages of Medicaid low-pay or no-pay patients. Sixteen percent of all teaching hospitals had an entire resident staff consisting of greater than 40% IMGs (MedPAC, 1999). A detailed survey of the healthcare providers working in nine of the poorest neighborhoods in New York City revealed that greater than 70% of the physicians were graduates of foreign medical schools (Community Service Society of New York, 1998). The data also revealed that only 24% of the practicing physicians were board certified, while the citywide average was 64%. Many other investigators (Fosset et al., 1990; Mitchell, 1991; Mitchell & Cromwell, 1980; Perloff et al., 1986) have documented that physicians in urban areas who accept Medicaid patients are more likely to be foreign medical graduates and are less likely to be board certified than those who do not accept Medicaid. Ginzberg (1994) summarized his study of healthcare for the poor in four of the nations largest cities:

A long-term trend of abandonment and avoidance by physicians had drained the low-income neighborhoods in all four metropolitan areas of private practitioners; physician-population ratios were as low as 1: 10, 000 to 1: 15, 000, in contrast to affluent neighborhoods with ratios of 1: 300 or even higher. Moreover, the majority of practitioners serving the poor consisted of foreign medical graduates, many with indifferent professional competence and language problems that impeded effective communication. Deterred by the low reimbursement rates paid by state Medicaid programs…the majority of U.S. trained physicians refused to accept Medicaid patients or limited the numbers they were willing to treat, leaving the field to group practices with questionable standards (Medicaid mills) that thrived on volume throughput (Ginzberg, 1994, p.1465).

While from varied geographic locations around the globe, the largest share of IMGs working in the United States today are from South Asian nations. Table 2-4 illustrates the country of origin for the top 10 countries with the highest number of medical graduates in the United States.

Table 2-4.

. Top 10 Countries with Highest Proportion of Medical Graduates in the U.S.

The cultural, racial, and ethnic diversity of IMG healthcare providers, who constitute more than 25% of the resident physicians in the /U.S., is broad. Most are new to this country and are learning to live within its vast sociocultural complexities, while also trying to learn to deal with an ambiguous welcome into the U.S healthcare delivery system with its own rigid, complex and demanding subculture (Stevens, Goodman, & Mick, 1978). As these authors note, two-thirds of IMGs are unprepared for the experience, having relied upon friends or family for advice. Many do not have the luxury of selecting a hospital in which to practice; rather, they accept the job that is offered. Often IMGs enter the United States thinking of themselves as “internationally mobile scientists” with knowledge and skills that are transferable anywhere in the world, only to be jolted by the reality of being treated as an alien or outsider inside the hospital (Steven, Goldman, and Mick, 1978). In one survey (Steven, Goldman, and Mick, 1978), 13% of IMGs felt that they were inadequately informed about the location of the American hospitals, including the fact that many large hospitals are in high-poverty areas of major cities. For others, complex malpractice claims and standards may pose problems, as well as large case loads, documentation requirements, long hours, a fast pace, and language difficulties.

The 12^th CoGME Report (1999) observed that “when physician and patient differ with respect to race, ethnicity, language, religion and values, ensuring fair, equitable, and culturally sensitive care is more challenging.” The opportunity for miscommunication and cultural gaffes between IMGs and minority patients abound and could be manifest in the way healthcare services are provided or received by the communities served. This cultural configuration has existed for nearly 50 years in many of the largest metropolitan teaching hospitals serving millions of racial and ethnic minorities. However, this racial/ethnic interface has been inadequately studied to determine the impact it has on minority patients' perceptions of their healthcare experience, utilization of services, trust, compliance, health status, and quality of care.