Health Disparities: A Primer for Public Health Social Workers

Abstract

In 2001, the U.S. Department of Health and Human Services published Healthy People 2010, which identified objectives to guide health promotion and to eliminate health disparities. Since 2001, much research has been published documenting racial and ethnic disparities in healthcare. Although progress has been made in eliminating the disparities, ongoing work by public health social workers, researchers, and policy analysts is needed. This paper focuses on racial and ethnic health disparities, why they exist, where they can be found, and some of the key health/medical conditions identified by the U.S. Department of Health and Human Services to receive attention. Finally, there is a discussion of what policy, professional and community education, and research can to do to eliminate racial and ethnic disparities in healthcare.

KEYWORDS:

• Health disparities
• public health social work
• minority health

Introduction

Despite continued advances in healthcare in the United States, more individuals from racial and ethnic minority groups lack adequate access to care (Eisenberg & Power, 2000), receive poorer-quality care, have poorer health outcomes, and more often die from treatable causes than Whites (Smedley, Stith, & Nelson, 2003). African Americans, Hispanics, and Asian Americans experience greater barriers to receiving primary care (Shi, 1999) and are less likely to have a usual source of care than Whites (Weinick, Zuvekas, & Cohen, 2000). Racial and ethnic minority group members are likewise less likely than Whites to have health insurance, have fewer choices of where to receive care, and are more likely to receive care in hospital emergency rooms (Collins, Hall, & Neuhaus, 1999).

In order to further develop an understanding of health disparities and what social workers need to know to help eliminate them, this article will focus on four areas: defining health disparities, investigating their origins, identifying some of the most common health conditions in which disparities exist, and describing what can be done to ameliorate them.

WHAT ARE HEALTH DISPARITIES AND WHY DO THEY EXIST?

Health disparities can be seen as persistent differences in health conditions and illness rates that cut across many illness categories and demographic groups. The disparities exist in different contexts and are rooted in the discriminatory and inequitable distribution of healthcare resources (Smedley et al., 2003). As such disparities are perpetuated by various systems (including health services, their administrative processes, utilization reviewers, and participating healthcare professionals), which have resulted because of the failure of the United State healthcare system to provide quality healthcare to all individuals regardless of race and ethnicity (Smedley et al., 2003).

Some researchers have argued that consumer attributes play a large role in health disparities by pointing out that racial and ethnic minority patients are more likely to refuse recommended services (Sedlis et al., 1997), adhere poorly to treatment regimens, and delay seeking appropriate healthcare (Mitchell & McCormack, 1997), which may have resulted from negative prior interactions with healthcare systems, poor cultural matches between patients and their healthcare providers, incomplete understanding of provider instructions, or a lack of knowledge of how best to access and use healthcare services (McGuire & Miranda, 2008; Sarkar, Fisher, & Schillinger, 2006). Still others have argued that provider bias (Balsa & McGuire, 2003) and prejudice (Dovidio, Brigham, Johnson, & Gaertner, 1996) have greatly exacerbated health disparities and that providers are less apt to devote necessary time with minority patients (McGuire & Miranda, 2008).

Ethical dilemmas have also been seen as factors leading to disparities and have become significant challenges in which providers are expected to adhere to the highest ethical standards of service that mandate fairness and compassion while serving as managers of vital yet limited healthcare resources (Smedley et al., 2003). Healthcare providers' decisions may result in allocating more resources to some individuals than to others (Fiske, 1998). Bureaucratic systems including HMOs, managed care organizations, and public insurers (for example, Medicare and Medicaid) have disrupted traditional community-based care with providers who are familiar with the language (Flores, 2006) and culture of ethnic minority communities (Larrison, Velez-Ortiz, Hernandez, Piedra, & Goldberg, 2010; Leigh, Lillie-Blanton, Martinez, & Collins, 1999).

WHERE DO RACIAL AND ETHNIC HEALTHCARE DISPARITIES EXIST?

Assessing disparities in health outcomes and mortality is difficult for many researchers and practitioners who often must make their decision into which racial and ethnic group a health consumer falls based on their interactions with the consumer. Consequently, the validity of their assessments0 is often doubtful. Despite this problem, almost all researchers have found differences in quality of healthcare and outcomes across all racial and ethnic groups compared to Whites. One question becomes which healthcare issues should be addressed. The federal government has identified 28 focus areas (Healthy People 2010) of which seven will be addressed in this paper: heart disease and stroke; cancer; HIV/AIDS; respiratory diseases; diabetes; maternal, infant, and child health; and mental health and mental disorders.

Heart Disease and Stroke

Studies of racial and ethnic differences in cardiovascular care provide some of the most convincing evidence of healthcare disparities (Ayanian, Weissman, Chasen-Tabor, & Epstein, 1999; Smedley et al., 2003). Even after controlling for variations in insurance status and income, African Americans, relative to Whites and in some cases Hispanics, are less likely to receive appropriate cardiac medication (Canto et al., 2000; Ramsey, Goff, Wear, Labarthe, & Nichaman, 1997) or to undergo coronary artery bypass surgery (Petersen, Wright, Peterson, & Daley, 2002) and are more likely to have delayed follow-up for ongoing care (Edelman, Gao, & Mosca, 2008).

The Institute of Medicine (Smedley et al., 2003) found that White patients were nearly four times more likely than African American patients to receive cardiac bypass surgery, which helps to explain the greater mortality among African American patients (Peterson et al., 1997). White Americans were also 62% more likely than Mexican Americans to have received appropriate medication (Smedley et al., 2003).

Several researchers have attempted to control for socioeconomic status by studying racial and ethnic disparities in cardiac care provided in VA settings, which treat patients regardless of the their income or insurance status. Taylor, Meyer, Morse, and Pearson (1997) found no differences in rates of catheterization procedures between White and non-White patients in 125 military hospitals. Likewise, Mickelson, Blum, and Geraci (1997) found no differences between White and Hispanic patients in receipt of cardiovascular procedures following acute myocardial infarction. However, others (Mirvis, Burns, Gaschen, Cloar, & Graney, 1994; Sedlis et al., 1997; Whittle, Conigliaro, Good, & Lofgren, 1993) found African American patients less likely to receive cardiovascular procedures in Veterans' hospitals.

Others found that African Americans in other care facilities were half as likely as Whites to undergo necessary bypass surgery or angioplasty (Laouri et al., 1997), carotid imaging (Oddone et al., 1999), and technological monitoring (Williams, Zimmerman, Wagner, Hawkins, & Knaus, 1995). Even among patients whose care is covered by nationalized health plans, as in England (which offers universal access and free care), patients from minority groups still receive fewer clinical services (Hemingway et al., 2001). In a prospective study of patients seen in London hospitals who were deemed “appropriate” for cardiovascular procedures, Hemingway et al. (2001) found that non-White patients were more likely to receive only medical, noninvasive treatment, rather than bypass surgery.

Although disparities in care have persisted for many years, the magnitude of the disparities decreased between 1979 and 2004, which is likely due to declines in risk factors, such as tobacco use, and to the increase in protective factors such as exercise and weight control (Brown, Ross, Lopez, Thornton, & Kiros, 2008), income (Gerber et al., 2008), and a usual source of care (Dark & Ezenkwele, 2007; Edelman et al., 2008).

Cancer

Studies of racial disparities in cancer diagnosis and treatment are less clear and consistent than in cardiac care. Many oncology studies rely on data that use crude or incomplete indicators of treatment type received or do not control for comorbid factors. Moreover, studies of the variations in the extent of cancer among patients are rarely well-controlled, thus limiting evaluating the comprehensiveness.

There are, however, clear indications that disparities exist. African Americans experience the highest rates of mortality from cancer of any other U.S. racial or ethnic group. Asian Americans are also more likely to have higher rates of cancer, whereby subpopulations experience rates of stomach, liver, and cervical cancers that are well above national averages. The reasons may reflect socioeconomic differences, differences in health-related risk factors, environmental degradation, and direct and indirect consequences of discrimination (Linder, Marko, & Sexton, 2008; Weaver, 2010; Williams, 1999).

Moreover, despite National Institutes of Health (NIH) initiatives to include racial and ethnic minority group members and individuals with disabilities in cancer studies, data involving minority group members are still few (Ka'opua & Holden, 2010; Newman, Roff, & Weinberg, 2008; Wisdom et al., 2010). The lack of minority group member participation in turn may explain why racial and ethnic minorities receive diagnoses at later stages of cancer (Mitchell & McCormack, 1997), further confounding efforts to assess the quality of treatment and explaining in part the significant racial differences in the receipt of appropriate cancer diagnostic tests (McMahon et al., 1999), treatments (Imperato, Nenner, & Will, 1996), and analgesics (Bernabei et al., 1998).

With regard to reproductive cancers, African American and Hispanic women were less likely than White women to undergo screening and other more sophisticated tests (Sabatino et al., 2008) in combination with mastectomy and rehabilitative support services following surgery. Merrill, Merrill, and Mayer (2000) assessed the receipt of surgery or radiation therapy among 8,119 White and African American women with invasive cervical cancer and concluded that African American more than White women did not receive either radiation therapy or surgery.

African American men have a significantly higher incidence of prostate cancer, receive diagnoses at younger ages and at more advanced stages, and have higher mortality rates from prostate cancer than do White men (Husaini et al., 2008). Imperato et al. (1996) found that rates of prostatectomy were lower among African Americans than among Whites. Although the incidence for testicular cancer remains very low, the highest annual percentage change was observed among African Americans (Holmes et al., 2008).

Despite a 20% higher incidence of colorectal cancer, screenings for colorectal cancer have not increased during this century except for among higher-income and insured individuals (Jerant, Fenton, & Franks, 2008; Trivers, Shaw, Sabatino, Shapiro, & Coates, 2008). Among patients with primary tumor and no metastasis, African Americans, Hispanics, and Asian Americans were less likely than Whites to undergo a major procedure for treatment of colorectal cancer, to be treated by a board-certified physician, or to receive post-treatment surveillance care (Elston Lafata, Cole Johnson, Ben-Menachem, & Morlock, 2001; McMahon et al., 1999).

HIV/AIDS

With the exception of the years between 1991 and 1999, the incidence of HIV has continued to rise in the United States (Nakashima & Fleming, 2003). Between 1981 and 1995 the predominant group of individuals who contracted the virus was non-Hispanic, gay, White, and male. Between 2001 and 2004, there was a change in the demographics of HIV as the number of individuals who contracted the virus via heterosexual contact increased from 10% to 30%. Another change in the demographic of newly infected individuals was the increase in African Americans, who made up 51% of all cases diagnosed between 2001 and 2004; since 2004 the rate has leapt to 76.3 per 100,000 population and among Hispanics to 29.5 per 100,000. The data are rather unreliable because an estimated 252,000 to 312,000 people in the United States are unaware that they are infected and possibly transmitting HIV to others (Glynn & Rhodes, 2005).

At this time, women and people of color account for a higher proportion of AIDS incidence and mortality than men and Whites. In 2003, women accounted for 27% of the estimated cases (Steele, Richmond-Reese, & Lomax, 2006). Surveillance data indicate that HIV incidence among African American women is 4 times that among Hispanic women and more than 20 times that among White women. There is no evidence to suggest that African American women are more likely to have unprotected sex or multiple sex partners or to use drugs than are women of other racial/ethnic groups; however, African American women are more likely to have risky sex partners and African American men are less likely to disclose their same-sex behaviors than are White men (Tillerson, 2008). Of those infected with HIV, females and people of color are less likely to be prescribed a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor and thus have lower survival rates than others (Moore, Stanton, Gopalan, & Chaisson, 1994; Reif, Whetten, & Thielman, 2007; Shapiro et al., 1999).

With respect to the risk of progression from HIV to AIDS, intravenous drug users, people of color, men, and older individuals rather than Whites, women, and younger persons were at greater risk (Hall, McDavid, Ling, & Slogget, 2006). The likelihood of death within 3 years after receiving an AIDS diagnosis was significantly greater for African Americans, American Indians, and Hispanics compared with Whites (Hall, Byers, Ling, & Espinoza, 2007; Osborn, Paasche-Orlow, Davis, & Wolf, 2007).

The situation is different in cases where care is equal among all patients. In VA hospitals, the overall survival rate was similar for African American and White patients. Survival during and after the first hospitalization for HIV in VA settings did not significantly differ for Whites and African Americans, possibly indicating similar effectiveness in care for HIV (Giordano et al., 2006). Despite this somewhat positive outlook, others conclude that the stability of race differentials has been shown to persist after controlling for a person's economic standing (Ellen, Kohn, Bolan, Shiboski, & Krieger, 1995), number of sexual partners (Ellen, Aral, & Madger, 1998), admission to juvenile detention facilities (Mertz, Voigt, Hutchins, & Levine, 2002), use of injection drugs (Latka et al., 2001), age, gender, education, and insurance coverage (Shapiro et al. 1999).

Regardless of the mode of transmission, many African Americans and people of other minority backgrounds indicate that they are uncomfortable seeking care, are unsure of how to access care, and feel stigmatized in their communities for reaching out to care providers (Taveras et al., 2007; Thomas, Carter, Torrone, & Levandowski, 2008; Torrone, Levandowski, Thomas, Isler, & Leone, 2010).

Respiratory Diseases

Respiratory diseases continue to plague many people, particularly inner-city residents and those of lower socioeconomic status (Clement, Jones, & Cole, 2008). Asthma, one of the most common respiratory diseases (Shanawani, 2006), is slightly more common among African Americans than other groups and is often cited as the most frequent reason for preventable hospital admissions among young children (Miller, 2000; Fiore, Olson, Hanrahan, & Anderson, 2000). Generally, African American children have about 4 times the risk of hospitalization compared to White children of comparable age and sex, whereas Hispanic children have about twice the risk compared to their White peers (Wallace, Denk, & Kruse, 2004).

African Americans are more likely to receive treatment for asthma in emergency departments and to use inhaled bronchodilator medications than inhaled corticosteroids, suggesting that management of the disease has focused more on acute symptom control as opposed to suppression of chronic airway inflammation. In fact Blixen, Tilley, Havstad, and Zoratti (1997) surveyed African American patients treated in emergency departments for access to care and concluded that the disease was poorly managed, fewer than half used NIH-recommended prophylactic anti-inflammatory medication, and a majority managed symptoms with an inhaled beta-agonist inhaler. Shanawani (2006) reported that geographic distance from specialists, life demands and challenges, and assumptions on the part of primary care physicians that low-income patients would be unable to maintain compliance have emerged as issues.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and continues to increase among African Americans (Dransfield & Bailey, 2006). At this time it is unclear whether biological or genetic predisposition, socioeconomic factors, or environmental living conditions and air pollutants in urban communities are more likely factors than other issues (Institute of Medicine, 1999).

Progress has been made, however, on the incidence and rates of pulmonary care. Between 1997 and 2003, the proportion of people who have ever had asthma decreased by 2%. During this same time period, the proportion of people 18 years and older who have ever had asthma and reported ever receiving formal education increased from 8.4% to 12.4%. The rates for COPD likewise declined from 123.9 per 100,000 population in 1999 to 118.9 per 100,000 population in 2002 (Healthy People 2010).

To continue making gains in pulmonary care, Satcher and Rust (2006) advocate for increased surveillance and monitoring, research into causes and potential cures, and rapid cycle testing to reduce or eliminate disparities. Clement et al. (2008) argue that effective interventions for disease control must circumvent barriers to care and provide comprehensive and structured programs emphasizing asthma control, use of therapy, education, and regular assessment.

Diabetes

Diabetes is fast becoming an epidemic in communities of color (Cowie et al., 2003). In the United States, diabetes was listed as the sixth leading cause of death in 2002 (Anderson & Smith, 2005). Racial and ethnic minority group members have experienced not only a greater increase in the prevalence in diabetes but also higher rates of complications and mortality (Harris, 2001; Lanting, Mackenbach, Lamberts, & Bootsma, 2005). In 2005, the projected prevalence of diabetes among individuals aged 20 and older was 8% among Whites, 14% among Hispanics, 15% among African Americans, and 18% among American Indians and Alaska Natives (Meneghini, 2008), with the largest increase in the prior decade being among American Indians and Asian Americans (Mokdad et al., 2000) and the current highest risk group being Hispanics (Fernandez, 2007; Perez-Escamilla & Putnik, 2007; Sundquist & Winkleby, 2000).

With respect to complications from diabetes, Feinglass, Abadin, Thompson, and Pearce (2008) found that African Americans were more likely than Whites to undergo bilateral amputation of the lower limbs. Kim, Sinco, and Kieffer (2007) concluded that women with a history of gestational diabetes mellitus had inadequate access to care. African Americans, Hispanics, and Native Americans experience a 50% to 100% greater burden of illness and mortality due to diabetes than White Americans, are more likely to undergo amputation than White patients, and experience more end-stage renal disease and diabetic neuropathy than White Americans (Lavery et al., 1996).

Relative to Whites, African Americans, and in some cases, Hispanics, are less likely to receive peritoneal dialysis and kidney transplant (Epstein et al., 2000; Gaylin et al., 1993; Kasiske, London, & Ellison, 1998), even when variations in such factors as insurance status, income, age, comorbid conditions, and symptom expression are taken into account. The average waiting time for African American patients awaiting kidney transplant is almost twice as long as for White patents (Garg, Diener-West, & Powe, 2001; Young & Gaston, 2000), and African American male patients were significantly less likely than White males to report wanting a transplant (Ayanian, Cleary, Weissman, & Epstein, 1999; Alexander & Sehgal, 1998).

Maternal, Infant, and Child Health

Infant mortality rates in the United States have declined in all racial and ethnic groups (Wingate & Alexander, 2006) due to reduced rates in teen pregnancy and increased prenatal care (Eberhardt, Ingram, & Makuc, 2001), which due to enhancements in the treatment of high-risk, low–birth weight infants (Wingate & Alexander, 2006) have helped to improve birth outcomes for infants in all racial and ethnic groups.

Despite these improvements, however, racial and ethnic disparities exist at all levels of care and perinatal stages. Rates of premature birth and low–birth weight infants have not declined but continue to impact many mothers of all ages, particularly from racial and ethnic minority groups (Collins et al., 1999; Howell, Pettit, & Kingsley, 2005; Mor, Alexander, Kogan, Kieffer, & Ichiho, 1995) who are more apt to lack adequate insurance (Alexander, Tompkins, Allen, & Hulsey, 1999) and access to reproductive health services (Ely & Dulmus, 2010; Nearns & Forthofer, 2010). In fact, African American mothers, who are more likely to be uninsured, were less likely to have prenatal screenings including amniocentesis and ultrasonography (Brett, Schoendorf, & Kiely, 1994), likely resulting in higher rates of cesarean delivery than in White women (Aron, Gordon, DiGiuseppe, Harper, & Rosenthal, 2000). Consequently, these improvements may not help to promote the overall downturn in prematurity rates among all women, just those who are more adequately insured (Ramos, Jurkowski, Gonzalez, & Lawrence, 2010; Alexander & Slay, 2002).

Beyond medical technology, neighborhood characteristics have had a large effect on birth outcomes: distressed urban neighborhoods were found to significantly increase the risk of entry into later prenatal care and of poor birth outcomes (Ellen, Mijanovich, & Dillman, 2001; Lane, Webster, et al., 2008; Lane, Keefe, et al., 2008; Perloff & Jaffee, 1999; Wingate & Alexander, 2006).

Mental Health

The U.S. Surgeon General has determined that racial and ethnic disparities in mental healthcare are pronounced (U.S. Department of Health and Human Services, 2001). Typically, minority group members are more likely than Whites to delay or fail to seek mental health treatment (Fiske, 1998). Once in care, they are less likely to receive the best available treatment for various mental health conditions (Wang, Berglund, & Kessler, 2000; Young, Klap, Sherbourne, & Wells, 2001) or to receive care by board-certified certified, clinicians who specialize in evidence-based medicine (Bach, Pham, Schrag, Tate, & Hargraves, 2004).

Some of the factors leading to disparities include distrust of health professionals, cultural barriers, cooccurring disorders, income, and primary reliance on family members and the faith community in meeting mental health needs (Martin et al., 2010; Nelson, 2006). Among adults with a documented need for mental healthcare, 37.6% of Whites received care while only 22.4% of Hispanics and 25.0% of African Americans received it (Wells, Klap, Koike, & Sherbourne, 2001).

Interestingly, others have found that minority group members have equal or better mental health than White Americans (Beals et al., 2005; McGuire & Miranda, 2008); however, the psychological symptoms for those with mental health diagnoses are often worse (U.S. Department of Health and Human Services, 2001).

In general, differences between African Americans and Whites in mental health service use and expenditures have remained unchanged since 2000 (Cook, McGuire, & Miranda, 2007). However, African Americans have poorer mental health outcomes than Whites have (Williams, 2006), drop out of treatment and use emergency department services more, enter mental health treatment at a more advanced stage of mental illness, and received misdiagnoses more often than Whites with severe and persistent mental disorders (Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005; Martin et al., 2010; Nelson, 2006; Westermeyer & Janca, 1997; Williams et al., 2007).

For Hispanics, disparities in mental healthcare appear to have risen sharply between 1993 and 2002 and to have remained stable since. However, expenditures for mental healthcare for Hispanics are 58% less than for Whites (Cook et al., 2007) and have remained unchanged since 2000 (Blanco et al., 2007; Cook et al., 2007). The differences in access to care may in part be due to difficulties experienced by Hispanics with access to preferred modes of treatments, low frequency of cultural patient-clinician matching due to a dearth of Hispanic clinicians, and the lack of linguistic and cultural competence of clinicians from other backgrounds (Dwight-Johnson, Lagomasino, Aisenberg, & Hay, 2004; Schur & Albers, 1996; Wells et al., 2001).

WHAT ARE EDUCATORS TO DO?

The Institute of Medicine (Smedley et al., 2003) states that students pursuing careers in healthcare must learn to identify the basic causes of health disparities so as to be prepared to work with diverse populations. In order to begin this effort, cross-cultural education in healthcare should focus on cultural sensitivity (the attitudes and beliefs providers have of various racial and ethnic groups), knowledge (the content of a professional discipline and how the content is relevant to people of various racial and ethnic groups), and skills (the methods of practice that have been taught using didactic and experiential approaches to help alleviate the medical conditions that impact people of various racial and ethnic groups). It is essential that data are collected on healthcare access and utilization by patients' race, ethnicity, socioeconomic status, and primary language (Smedley et al., 2003; Lurie, Jung, & Lavizzo-Mourey, 2005). Licensing exams in the various health professions should test for performance measures on working with disparate racial and ethnic groups. Continuing education of healthcare providers should focus on helping providers develop ongoing one-to-one interactions tailored to the culture and health literacy of community members (Meneghini, 2008).

Lay helpers, religious leaders, and community health workers can serve as liaisons between service providers and healthcare consumers to provide patient education and contribute to the coordination of care and in turn educate the providers about community members' needs (Rodney, Clasen, Goldman, Markert, & Deane, 1998). They can also help with logistic issues, such as providing transportation, to increase the use of preventive and primary care services (Brownstein, Cheal, Ackermann, Bassford, & Campos-Outcalt, 1992; Earp & Flax, 1999; Jackson & Parks, 1997), which in turn may improve the quality of healthcare and reduce costs (Witmer, Seifer, Finocchio, Leslie, & O'Neil, 1995), enhance the interactions between healthcare providers and healthcare recipients, improve treatment adherence and compliance and appointment attendance (Manson, 1988), and increase satisfaction with services (Carrasquillo, Orav, Brennan, & Burstin, 1999; David & Rhee, 1998; Derose & Baker, 2000; Larrison et al., 2010).

IMPLICATIONS FOR RESEARCH, EDUCATION, AND POLICY

The evidence base from which to better understand and eliminate disparities in care is not clear (Gehlert et al., 2010). Several broad areas of research are needed to clarify how race and ethnicity are associated with disparities in the process, structure, and healthcare outcomes. Research must provide a better understanding of the contribution of patient, provider, and institutional characteristics on the quality and outcomes of care for racial and ethnic groups of fewer numbers. Strategies of how to better understand and surmount barriers to research on healthcare disparities is sorely needed. This research must consider the range of influences on patients' and providers' attitudes and expectations in doctor visits, clinical decision making processes used by healthcare providers and the influence of patient demographics in these processes, as well as the nature and quality of communication, particularly between patients and providers.

Research and innovation should identify effective means to harness new technologies, such as health informatics to aid interpretation, evaluate cross-cultural education in the health professions, and develop and implement training programs for healthcare providers on key intervention strategies in reducing healthcare disparities. Other concerns include the protection of patient information and resistance from healthcare providers, institutions, insurers, and patients themselves to data collection.

Attempts to control for differences in socioeconomic status are inconsistent, with some researchers employing patient income or education as the sole indicators and others using proxy variables such as estimates of income on the basis of patients' ZIP code information. Most studies control for insurance status, but some combine data (for example, HMO or fee for service) or difference sources of insurance coverage (for example, public versus private). Some studies have explicitly examined differences in where racial and ethnic groups receive care (for example, public versus private healthcare settings) and clinical factors such as stage of illness presentation. Adequate assessment of these factors, however, is often limited by a lack of sufficient information in the administrative claims data upon which many studies are based (Smedley et al., 2003).

Further, most studies (with the exception of several studies of cardiovascular care) lack comparison to standards of appropriate care, leaving open the question of whether the intensity of care received was sufficient given the type and severity of illness. With the exception of a few large studies conducted in ethnically diverse regions of the United States, such as California and New York, few studies have assessed whether disparities exist for smaller ethnic and racial groups. Moreover, few studies have examined subgroup differences within these populations. These issues are particularly salient for Hispanic and Asian American subgroups (Kim & Keefe, 2010), whose healthcare may be complicated by linguistic and cultural differences, immigration status, and other access-related issues. Finally, more such research is needed to assess the relative contribution of access-related factors (for example, insurance status), other socioeconomic status and geographic variables (for example, patients' education, income, and the availability of healthcare providers in a community), and racial and ethnic differences in healthcare preferences and attitudes to determine the extent of disparities in care.

To obtain as clear a picture as possible of racial and ethnic disparities, it would be helpful to report racial and ethnic data by federally defined categories and to use subpopulation groups where possible by collecting, reporting, and monitoring patient care data by health plans—both public and private—to evaluate intervention efforts and assess potential civil rights violations.

SUMMARY

To date, only a handful of several hundred studies find no racial and ethnic differences in healthcare. When statistically controlling for various factors including socioeconomic status, disparities by race and ethnicity in healthcare continue to emerge. Although progress has been made in some areas, there are still many other health areas where much work is needed. Public health social workers, researchers, and health policy analysts will continue to be called upon to help eliminate the ongoing disparities so that all Americans have access to needed healthcare.