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Ethnic minority populations comprise large segments of the US population and are growing especially rapidly. Their use of healthcare services is relatively low. Certain factors accounting for racial and ethnic disparities are well understood but others remain to be determined. Identifying and overcoming barriers to healthcare is important to insure an equitable distribution of healthcare related resources in order to promote equal well-being in all sectors of the population. Problems in minority access to healthcare are evident in other developed countries as well, though not as pervasively as in the United States.
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1. Ethnic Minority Populations: Size, Growth, and Risk
Black Americans make up at least 12.5 percent of the United States population, not allowing for a probable census undercount (O’Hare et al. 1991). The black population is relatively young and represented only about 8 percent of the 65 and over population in 1995, because of a persistently higher mortality rate that reverses only in very old age (‘crossover eﬀect’).
Persons of Hispanic heritage made up about 11 percent of the United States population in 1996 (del Pinal and Singer 1997). The Hispanic population consists of a number of diverse groups, including Cuban Americans, Puerto Ricans, persons from Central and South American countries, and, by far the largest group, comprising almost two-thirds of the Hispanic population, Mexican Americans. The Hispanic population is growing especially rapidly due to immigration and diﬀerential birth rates and a high proportion of children and youth. According to current projections (del Pinal and Singer 1997), Hispanics by 2050 will comprise about 24 percent of the United States population.
In 1997 about 4 percent of the US population was Asian American (Lee 1998), up from 3 percent in 1990 and 2 percent in 1980. Asian Americans make up about 2 percent of persons 65 years and older, and are projected to make up 7 percent in 2050 (Treas 1995). The increase reﬂects a shift in immigration policy in 1965 toward the elimination of national quotas, and the arrival of successive waves of refugees from the Vietnam war (Lee 1998). American Indians and Alaska Natives are made up of more than 550 tribes recognized by the federal government and Alaska Native Villages, the largest of which are the Navajo and Cherokee. In 1990 there were almost 2 million American Indians and Alaska Natives, more than twice as many as were counted in the mid-1970s (Norton in press). They comprise about 0.4 percent of persons 65 years of age and older and are expected to increase to a proportion of 0.6 percent by 2050 (Treas
2. Socioeconomic Distress
Among the most important diﬀerences between racial and ethnic groups are those in education, occupational status, and income—that is, in socioeconomic standing (Krieger et al. 1997). Poverty is especially inﬂuential. Over a number of years, African and Native American families have been roughly three times as likely as white families to have incomes placing them below the federally established poverty line. The disparity is even greater when considering extreme poverty—family incomes at a level less than half of the poverty threshold—and is also large when considering children and the elderly. The eﬀects of poverty are compounded by diﬀerences in total value of accumulated assets, or total wealth (O’Hare et al. 1991). Many minority poor live among other people who are poor in areas in which such individuals and families are found in high concentrations. The neighborhoods tend to be distressed, marked by high rates of unemployment, homelessness, crime, and substance abuse, with few local resources to help oﬀset these problems (Wilson 1987).
3. Access to Healthcare and Health Services
Minority access to and patterns of receiving healthcare are problematic. Levels and occasions of use have been best documented among African Americans.
Despite relatively poor health status and higher rates of illness and mortality, African Americans make fewer visits for ambulatory care than whites. Moreover, their visits are considerably more likely than those of whites to be made to hospital outpatient and emergency departments than to physicians’ oﬃces (National Center for Health Statistics 1996).
Excess emergency treatment of minorities appears to be more selective in other developed countries than in the United States. Investigators studying the West Midlands in the United Kingdom (Gilthorpe et al. 1998), for example, found that Black children and older Indian and Bangladeshi men and women were more likely than Whites to be admitted to hospital on an emergency basis with asthma-related suﬀering. The diﬀerence occurred despite a lack of evidence indicating underlying racial and ethnic diﬀerences in the prevalence of asthma. Disproportionate emergency care is not pervasive, however.
Latinos and Asian Americans enjoy better health status when considering indicators of morbidity and mortality, although on overall ratings of health status, Latinos were more likely to indicate ‘fair poor’ health and less likely to indicate ‘excellent’ health. African Americans in the study closely resembled Latinos in pattern of perceived health status (Weigers and Drilea 1996). Despite considering themselves less healthy than Whites, however, Latinos and African Americans have proven less likely to make use of ambulatory medical care (National Center for Health Statistics 1996).
Most groups receive healthcare not only at relatively low levels but also in less than optimal ways. Problems are especially evident in receiving routine and preventive care. When pregnant, women from almost all minority groups are less likely than whites to receive prenatal care during the ﬁrst trimester (National Center for Health Statistics 1996).
Racial and ethnic disparities such as these are less common in other developed countries than in the United States. A study conducted in Amsterdam (Reijneveld 1998) found that in keeping with relatively poor health, immigrants from Turkey and Morocco made relatively heavy use of primary care and other health services. Thus, the pattern of minority–white diﬀerences is opposite that found in the United States. In another study, researchers investigating birth records from three hospitals in East London (Collins et al. 1997) compared the pregnancies of African, West Indian, and European White women. West Indian and African women were more likely than European White women to have delivered low birthweight infants, but they had not received less prenatal care.
Related to these problems is the lack for many minorities in the United States of a continuing, single point of access—a usual source of healthcare. In 1996, 76.3 percent of whites had an oﬃce-based usual source of care, whereas only 63.6 percent of African Americans and 57.9 percent of Latinos had a comparable usual source. The disparities are greater still when considering children under age 18.
4. Factors Aﬀecting Minority Access
To a notable extent, problems in access can be attributed to a lack of health insurance coverage. African Americans and Latinos are notably less likely than others to have health insurance. Disparities are found both among males and females and are greatest among children and young adults (National Center for Health Statistics 1996).
Because in the United States health insurance often is provided as a beneﬁt of employment, diﬀerences between racial and ethnic groups in insurance coverage are tied to diﬀerences in patterns of labor force participation. Minority persons are more likely to be unemployed and, if employed, to work in jobs that fail to provide health insurance. The problem is particularly acute among Hispanic males, only 49.7 percent of whom had job-related healthcare coverage in 1996.
Diﬀerences in rates of insurance coverage would be greater still but for widespread availability and use of publicly-supported insurance programs, especially Medicaid. Medicaid is a federal-state program supporting healthcare to the poor. In keeping with their higher rates of poverty, minorities are more likely than whites to be covered by Medicaid; blacks and Hispanics are more than twice as likely as whites to be covered (Banthin and Cohen 1999). Medicaid beneﬁts vary from state to state and in some areas they provide only minimal coverage.
Also, many private oﬃce-based healthcare providers do not accept Medicaid as a source of payment and are unavailable to minority and other low-income patients. Moreover, minorities are over-represented in many inner city and rural areas in which oﬃce-based medical providers are found less often than in other areas perceived to be more hospitable (Perloﬀ et al. 1997). In this manner, geography and ﬁnancing help to dictate minority under-representation in oﬃce-based practice as a usual source of care.
Minority beliefs and attitudes toward illness and toward seeking healthcare have been proposed as another explanation for minority–white diﬀerences in healthcare. Conceivably, some minority communities believe that healthcare is less desirable or necessary than whites do, or exhibit a greater preference for religious or holistic alternatives to scientiﬁc medicine. Put another way, competing ‘explanatory models’ (Kleinman 1978) of health and illness might lead minority group members away from mainstream healthcare providers and toward alternative sources of help. However, Snowden et al. (1997) found that blacks and whites diﬀered on few attitudes toward the importance of insurance coverage and use of healthcare, and that the attitude diﬀerences failed to explain substantial diﬀerences in receiving outpatient medical care, although the study did not touch on possible underlying diﬀerences in how symptoms of illness are recognized and interpreted in the ﬁrst place.
The attitudes of healthcare providers and their sensitivity to ethnic and cultural diﬀerences have been invoked to explain diﬀerences in healthcare. Critics have stressed the existence of mistrust and a lack of comprehension on the part of some healthcare providers to beliefs, behavior patterns, and linguistic patterns prevalent in many minority communities and the mutual alienation of patients and providers which can result (e.g., Kavanagh and Kennedy 1992). They have called for a ‘culturally competent’ healthcare practice which would seek to overcome social distance as a barrier.
Unlike members of other minority groups, many Native Americans are eligible for a government-sponsored system of healthcare earmarked for their use. The Indian Health Service (HIS) and Urban Indian Health Programs oﬀer various forms of healthcare, although the greater part of the eﬀort is directed toward primary care. In recent years the budgetary limitations have caused the HIS to curtail its oﬀerings (Manson 1998). In moving toward self-determination, many tribes have assumed direct control of local programs, including those providing healthcare. We know little about levels and types of care provided under any of these arrangements (Manson 1998).
5. Future Directions
Although the role of ﬁnancing as a barrier to equal provision of healthcare is well established, the situation demands a nuanced and comprehensive understanding. Puzzles remain. When asked whether they had experienced any diﬃculty or delay in obtaining healthcare, more Hispanics than whites indicated the existence of such a problem, but fewer African Americans so indicated (Weinick et al. 1997). Among persons experiencing a problem, many more Hispanics than whites reported an inability to aﬀord care, but only slightly more African Americans so indicated. Other concerns, including location and receptivity of providers, and knowledge and willingness to seek care of patients, must be taken into account.
There is also a need for greater understanding of exactly which members of ethnic minority populations are unlikely to seek healthcare. Greater reluctance to use the health care system might be linked not only to socioeconomic standing, but also to factors such as country of birth and language preference—many minorities are immigrants and refugees—as well as adherence to traditional cultural beliefs and practices.
More eﬀort should be made to learn from international comparisons. The experience of minorities in the United States appears to diﬀer from that of minorities in other developed countries. Explanations should be sought by pinpointing key diﬀerences in the structure of national and local healthcare delivery systems. All such considerations and approaches should be employed to provide a comprehensive explanation.
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