CHAPTER 10 - DISPARITIES
|NOTE: Charts and graphs for this chapter are listed in the right column of the page.|
Content Last Updated: 6/17/2010 8:22:12 PM
Graphics Last Updated: 5/12/2010 10:11:07 PM
Originally written by Lisa Swirsky, Alliance for Health Reform. Revised April 2010 by Brian Smedley, Joint Center for Political and Economic Studies.
This chapter was made possible by the Robert Wood Johnson Foundation.
- About one-third of Americans identify themselves as racial and ethnic minorities. This number is expected to climb to more than half of the population by 2042.1
- Among children younger than five, almost half (47 percent) were of a minority group in 2008. A quarter of children under five were Hispanic. 2
- A 2009 study estimated that the direct medical costs associated with health inequities totaled $229 billion for the years 2003 to 2006. 3
- Adding the indirect costs associated with health inequities—such as lost wages and productivity and lost tax revenue—the total costs of health inequities and premature death for the nation was $1.24 billion in the same time span.4
- The health reform law of 2010 requires all federally funded health care and public health programs to collect and report data on race, ethnicity, socioeconomic status, health literacy and primary language to the U.S. Department of Health and Human Services.
- In addition, the law includes a provision that would standardize the collection of data addressing health disparities in Medicaid and the Children’s Health Insurance Program (CHIP).
Disparities in health and health care between whites and racial and ethnic minorities have persisted for decades, despite the earnest efforts of health services professionals, governments and non-government groups.
But a growing focus on the problem of racial and ethnic health and health care disparities, including provisions of the 2010 health reform law, offers promise that solutions do indeed exist.
About one-third of Americans identify themselves as racial and ethnic minorities.5 This number is expected to climb to more than half of the population by 2042.6 Among children under age 5, almost half are of minority groups today.7
This trend already has important implications for the health and health care of the nation. An inescapable fact is that the health status of some racial and ethnic minority groups continues to lag behind that of whites. For example:
- While the life expectancy gap between the African Americans and whites has narrowed slightly in the last two decades, African Americans still can expect to live 6 to 10 fewer years than whites, and face higher rates of illness and mortality. 8
- The prevalence of diabetes among American Indians and Alaska Natives is more than twice that for all adults in the United States; 9
- Hispanic and Vietnamese women as twice as likely as white women to face cervical cancer.10
- African Americans experience rates of infant mortality that are 2.5 times higher than for whites. 11
These racial and ethnic health disparities are reduced, but persist, when researchers control for differences in income and education level. For example, higher levels of education among mothers is associated with lower risk for giving birth to low birth-weight infants among all racial and ethnic groups, but racial and ethnic disparities exist when comparing mothers at the same education level. White women with less than a high school education are approximately 40 percent less likely to give birth to a low birth-weight baby than African-American women with a college degree or higher.12
Causes of Health Disparities
Most experts agree that the causes of health disparities are multiple and complex; no single explanation satisfactorily explains why disparities are persistent across such a wide range of health measures. Certainly, access to health care and the quality of health care are important factors, but they don’t explain why some groups face greater risks for poor health in the first place.
One of the most important predictors of health is socioeconomic status, commonly measured by educational attainment, income, wealth, occupation, or a combination of these factors. In general, the higher one’s socioeconomic status, the better one’s health. Socioeconomic status is thought to affect health in many ways, such as by increasing access to health-enhancing resources.
Because some racial and ethnic minorities are disproportionately clustered in lower socioeconomic tiers, socioeconomic differences are a major factor contributing to health disparities. An important exception is the so-called “Hispanic Epidemiologic Paradox" (also known as the “Immigrant Health Paradox”), whereby new immigrants are found to have generally better health than U.S.-born individuals of the same socioeconomic status (see text box).
Some research has documented racial or ethnic differences in health risks and health risks behaviors that may also contribute to health disparities. Adult African Americans, for example, have higher rates of obesity and overweight (69 percent among all adults) than whites (54 percent), and American Indians and Alaska Natives are more likely to smoke than whites (29 percent vs. 22 percent).13
Recent research, however, suggests that where one lives and works can powerfully shape health. Neighborhood conditions, for example, can directly affect health as a result of factors such as environmental degradation and pollution, poor housing conditions, and stress resulting from crime or violence.
Neighborhoods also indirectly affect health by shaping health behaviors. For example, research shows that when people lack geographic access to grocery stores, they are less likely to eat fresh fruits and vegetables than people who have grocery stores in their community. 14 Many of these problems—environmental degradation, insufficient access to stores selling healthful products, high levels of crime and violence, inadequate access to parks and recreational facilities—tend to cluster in racial and ethnic minority communities.
Disparities in Access to Health Care and Health Care Quality
Despite facing a higher risk for disease and disability, many racial and ethnic minorities have a harder time accessing appropriate health care than whites. When they do, the quality of the care they receive tends to be lower than for whites.
The annual National Healthcare Disparities Report (NHDR), published by the federal Agency for Healthcare Research and Quality, has consistently shown that African Americans and Latinos, suffer from poorer quality of care and worse access to care than whites on a number of indicators. 15 Likewise, care and access are worse for people with lower incomes than for people with higher incomes, although this disparity is improving somewhat over time.16
The 2009 report finds, for example, that Hispanics had poorer access to care than non-Hispanic whites on five out of six core measures, and people with low incomes had worse access than higher-income people on all access measures.17
In terms of health care quality, African Americans experienced poorer care relative to whites on half of the report’s 20 quality measures (such as the use of evidence-based health care guidelines), and low-income people received lower quality care relative to higher income people on 75 percent of the report’s quality measures.18
When AHRQ assessed these trends over time, they found that for Hispanics, two-thirds of measures of quality of care did not improve over time (i.e., the gap either stayed the same or increased).19 For African Americans and Asians, the situation was even worse; about three-fourths of quality measures didn’t improve.20
Many factors contribute to these health care disparities. Where a person lives, what language she speaks, and her household income are only some of the characteristics that can contribute to disparities in health care access and quality.
One of the most important predictors of the timeliness and quality of health care is health insurance. While federal law requires that hospital emergency departments treat all patients regardless of insurance status, the requirement extends only to the point that the patient is stablized. What’s more, these are often poor settings for routine or primary care. In addition, a lack of health insurance can result in delayed or poor quality care.
Racial and ethnic minority and immigrant communities are disproportionately uninsured, making them especially vulnerable to health crises. For example, while 10.8 percent of non-Hispanic white Americans were uninsured in 2008, 30.7 percent of Hispanics, 19.1 percent of African Americans, and 17.6 percent of Asian Americans and Pacific Islanders were uninsured. 21
In addition to disparities in insurance, a growing body of research demonstrates that health care remains “separate and unequal” on the basis of race and ethnicity. One study looked at 123 teaching hospitals and found clear disparities in the treatment of minorities. When the researchers dug deeper, they concluded that “an underlying cause of disparities may be that minority patients are more likely to receive care in lower performing hospitals.” 22 Another study found that black Medicare beneficiaries are 35 percent more likely than whites to be admitted to hospitals with high mortality rates.23
In other words, minority patients were more likely than whites to receive treatment in hospitals that may have been short-staffed, had inadequate budgets or a lack of technical support. (Click here to see text box, “Variations by Race and by Place.”)
Linguistic and cultural barriers are another significant impediment to health care for those who don’t speak English well, or at all. Title VI of the Civil Rights Act provides that any organization receiving federal funding must ensure that individuals with limited English proficiency have access to the organization’s programs and services.
In 2000, the Department of Health and Human Services Office for Civil Rights issued “Standards for Culturally and Linguistically Appropriate Services.” Four of the 14 standards are requirements for all recipients of federal funds, including this standard: “Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.”24
But language services are underfunded compared to the need. Safety net providers serving linguistic minorities must deal with a host of challenges related to language, including lack of capable interpreters, problems in making referrals to specialists, and a lack of needed forms and patient education materials in the patient’s language.25
Another factor in racial disparities may be access to a “medical home,” an approach to care in which patients are assigned to a physician or other primary care provider who is in charge of coordinating care among the many physicians and specialists that a patient might see. Having a regular source of health care – a local physician, clinic or health center that patients can consider their “medical home” – is important, particularly for individuals who face or are at risk for chronic illness.
When patients are able see a health care provider consistently, they are better able to build trusting relationships, ask questions and give and receive information. Patients who lack a regular source of health care often report miscommunication, misdiagnoses, and greater frustration about their ability to receive needed care.26 Those more likely to report lacking a regular source of care include the uninsured and underinsured, many racial and ethnic minorities, people who are not proficient in English, those who live in rural communities and those who have low incomes.
Yet another factor that may contribute to health care disparities—although more controversial than the factors discussed above—is the possibility of bias or prejudice on the part of health care providers. Experimental studies demonstrate that physicians can hold negative beliefs about minority patients. These studies have found that minority patients are presumed by doctors to be more likely to abuse drugs or alcohol and to be less educated. They aren’t expected to comply with physicians’ instructions, to want an active lifestyle or to participate in rehabilitation if prescribed.
Doctors consider white patients to be more “pleasant” and “rational” than black patients, and to prefer white patients as “the kind of person I could see myself being friends with.” These kinds of stereotypes and biases are often unconscious, the IOM reported, but nonetheless can influence physicians’ decisions regarding when and what treatments to offer.27
The Impact of the Health Reform Law
The new health reform law is likely to have at least a modest impact toward eliminating health and health care disparities, according to many experts.
The law is expected to help 32 million uninsured Americans receive insurance coverage. The law’s provisions increasing access are likely to benefit racial and ethnic minorities especially because of their current over-representation among the ranks of the uninsured. (See the health reform, employer-sponsored coverage and Medicaid chapters for details.)
The law also takes steps toward improving the geographic accessibility of health care providers and clinics in medically underserved areas. It expands funding for federally qualified community health centers, which focus on providing health care in health care shortage areas and have been found to provide high-quality care for diverse patient populations.
The law also expands federal health professions programs that offer incentives, such as loan repayment, to doctors, dentists, and nurses who agree to work in underserved communities for a minimum number of years. In addition, the law creates incentives for hospitals and clinics to expand the “medical home” model described above.
To address the inconsistent quality of health care, the new law includes provisions to establish standard measures of quality, support for comparative effectiveness research on interventions and procedures, and transparency in reporting of quality data, all of which have potential to address quality disparities. (See the quality chapter for details.)
Several researchers and policy analysts have suggested that better federal data collection is necessary to understand when and under what circumstances disparities in health care access and quality occur, and to monitor for changes in overall health disparities. To that end, the new law requires all federally funded health care and public health programs to collect and report data on race, ethnicity, socioeconomic status, health literacy and primary language to the Department of Health and Human Services.. In addition, the law includes a provision that would standardize the collection of data addressing health disparities in Medicaid and the Children’s Health Insurance Program (CHIP).
The new law also is expected to help improve and focus research on health disparities at the National Institutes of Health (NIH) by elevating the National Center on Minority Health and Health Disparities to an institute, a move that will put the office on par with other NIH institutes and increase research resources for both intramural and extramural research on health disparities.
Perhaps more importantly, given recent research suggesting that health gaps can be most effectively closed by addressing social and economic inequality, the new law offers several provisions to enhance federal prevention and public health efforts. The law creates a National Prevention, Heath Promotion and Public Health Council to promote health-related polices across multiple sectors and agencies at the federal level—including health, agriculture, education, labor, and transportation. The law also promotes the use of health impact assessments, which gauge the potential health impact of new policies and programs in a range of sectors, such as housing, transportation, education, and the like; supports community transformation grants for developing infrastructure that supports healthy lifestyles; funds a five-year national public health campaign on oral health, with an emphasis on racial and ethnic disparities; and strengthens maternal and child home visiting programs, which have been demonstrated to be effective in reducing infant mortality and improving child health outcomes.
Despite the law’s helpful provisions, it does not remove the five-year ban on new immigrants’ eligibility for public health insurance programs such as Medicaid. In addition, the law explicitly excludes undocumented immigrants from participation in any of the law’s new programs, such as the health insurance exchanges. These and other issues will likely remain contentious as policymakers examine the law’s impact on health disparities.
TIPS FOR REPORTERS
- Look at state health care reform efforts to see whether and how they are addressing the issue of disparities.
- Don’t overlook private sector activities around the issues of disparities. What are health plans doing to collect and analyze data on race and ethnicity, and how are they using these data to reduce disparities? What are private hospital systems and physician groups doing to address the issue of disparities?
- Monitor how racial and ethnic groups are categorized as the population becomes increasingly more diverse and as intermarriage between racial groups become more common. Are federal programs, state administered programs, health plans, hospitals and physicians adapting to demographic changes appropriately in their approach to disparities?
- Consider whether successful quality improvement strategies are being adopted by providers that serve minority populations. Are community health centers and public hospitals able to adopt IT systems that enable better quality improvement and care coordination?
- If you’d like to write stories about health disparities but your editor is less than enthusiastic, point him or her to a March 2009 survey by the Kaiser Family Foundation and the Association of Health Care Journalists (AHCJ). Among AHCJ members responding, 69 percent said U.S. news media in general give too little coverage to health disparities. In contrast, 52 percent said there’s too much coverage of consumer/lifestyle health. Click here to see the survey and a webcast of its release.
- Is the new health care reform law effective in reducing disparities? What kind ofsteps will be needed to improve the law’s impact?
- Disparities and immigration — what are the effects of federal immigration reforms? Will tighter restrictions increase disparities? Would loosening restrictions on access to federal health programs for children decrease disparities?
- Disparities and the economic downturn — how are minorities faring in the face of an economic downturn? What is happening to the safety net providers (e.g., public hospitals and community health centers) where minorities often receive care? What happens to those without insurance who gain it in a downturn as they become poor enough to qualify for Medicaid?
- Take a look at the annual National Healthcare Disparities Report put out by the Agency for Healthcare Research and Quality ( www.ahrq.gov) and see how the data compare with those of previous years. The report usually comes out in February or March.
EXPERTS AND WEBSITES
Lu Ann Aday , Lorn Baine Distinguished Professor Emeritus in Public Health and Medicine, University of Texas, 713/500-9177, firstname.lastname@example.org
Paul Akio Kawata , Executive Director, National Minority AIDS Council, 202/483-6622
Michael Barr , Vice President for Practice Advocacy and Improvement, American College of Physicians, 202/261-4500, email@example.com
Anne Beal , President, The Aetna Foundation, 860/273-0123, BealA@aetna.com
Joseph Betancourt , Director, Disparities Solution Center, Massachusetts General Hospital, 617/724-9713
Gregg Bloche , Professor of Law, Georgetown Law Center, 202/662-9123
Suzanne Bronheim , Senior Policy Analyst, National Center for Cultural Competence, 202/687-8914
Carol Brunson Day , President, National Black Child Development Institute, 202/833-2220, cbday@NBCDI.org
Olivia Carter-Pokras , Professor, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, 410/706-0463
Janet Corrigan , President, National Quality Forum, 202/783-1300, firstname.lastname@example.org
Gem Daus , Policy Director, Asian and Pacific Islander American Health Forum, 202/466-7772
Michelle Doty , Associate Director of Research, The Commonwealth Fund, 212/606-3800, email@example.com
Jose Escarce , Director, Data and Methods Core, Center for Population Health and Health Disparities, RAND Corporation, 310/393-0411 x7189
Adolph Falcon , Vice President for Science and Policy, National Alliance for Hispanic Health, 202/387-5000
Dan Hawkins , Vice President, Federal, State, and Public Affairs, National Association of Community Health Centers, 301/347-0400 x3001, firstname.lastname@example.org
Martha Hill , Dean, School of Nursing, Johns Hopkins University, 410/955-7544
Eleanor Hinton-Hoytt , President and Chief Executive Officer, Black Women's Health Imperative, 202/548-4000, email@example.com
Ashish Jha , Associate Professor of Health Policy and Management, School of Public Health, Harvard University, 617/432-5551
Jean Krause , Executive Vice President and Chief Executive Officer, American College of Physicians Foundation, 877/208-4189, firstname.lastname@example.org
Risa Lavizzo-Mourey , President & CEO, Robert Wood Johnson Foundation, 888/631-9989, email@example.com
Marsha Lillie-Blanton , Vice-President in Health Policy, Kaiser Family Foundation, 202/347-5270
Barbara Lyons , Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202-347-5270, firstname.lastname@example.org
Atiba Madyun , Division Director, National Black Caucus of State Legislators, 202/624-5457, email@example.com
Tom Miller , Resident Fellow, American Enterprise Institute, 202/862-5886, firstname.lastname@example.org
Allen Nelson , Special Advisor to the CEO, American College of Physicians, 703/385-3360, email@example.com
Gary Puckrein, President and Chief Executive Officer, National Minority Quality Forum, 202/223-7560
Diane Rowland , Executive Vice President, Kaiser Family Foundation, 202/347-5270, firstname.lastname@example.org
Leonard Rubenstein , Executive Director, Physicians for Human Rights, 202/728-5335 x306
Sarah Scholle , Assistant Vice President of Research and Analysis, National Committee for Quality Assurance, 202/955-3500
Hilary Shelton , National Health Director, NAACP Division of Health Advocacy, 410/580- 5672
Bruce Siegel , Research Professor, Department of Health Policy, George Washington University, 202/994-8616
Jonathan Skinner , Professor of Economics, Dartmouth College, 603/646-2535, email@example.com
Stephen Somers , President, Center for Health Care Strategies, 609/528-8400, firstname.lastname@example.org
Judith Stein , Executive Director, Center for Medicare Advocacy, 860/456-7790, email@example.com
Mara Youdelman , Staff Attorney, National Health Law Program, 202/289-7661, firstname.lastname@example.org
Ruth Zambrana , Professor and Graduate Director in Women's Studies, University of Maryland, 301/405-0451
Francis Chesley , Director, Office of Extramural Research, Education, and Priority Population, Agency for Healthcare Research and Quality, 301/427-1449
Garth Graham , Deputy Assistant Secretary for Minority Health, Department of Health and Human Services, 240/453-2882, email@example.com
Trent Haywood , Deputy Chief Medical Officer, Centers for Medicare and Medicaid Services, 410/786-1034
John Ruffin , Director, National Center on Minority Health and Health Disparities, National Institutes of Health, 301/402-1366, firstname.lastname@example.org
Elsie Scott , President and CEO, Congressional Black Caucus Foundation, 202/263-2800
Daniel Thomas , CEO, DTF International Economics, 301/871-2624, email@example.com
Eduardo Aguilu , Deputy Chief Executive Officer, Latin American Health Institute, 617/350-6900
Carmella Bocchino ,Senior Vice President, Clinical Affairs and Strategic Planning, America's Health Insurance Plans, 202/778-3200, firstname.lastname@example.org
Millicent Gorham , Executive Director, National Black Nurses Association, 301/589-3200, email@example.com
Mary Grealy , President, Healthcare Leadership Council, 202/452-8700, firstname.lastname@example.org; email@example.com (assistant)
Romana Hasnain-Wynia , Vice President, Research, Health Research and Educational Trust, 312/422-2643
Karen Ignagni , President and CEO, America's Health Insurance Plans, 202/778-3200, firstname.lastname@example.org
Charles Kahn , President, Federation of American Hospitals, 202/624-1500
Sister Carol Keehan , President, Catholic Health Association, 202/296-3993
Jackie Noyes , Associate Executive Director, American Academy of Pediatrics, 202/347-8600, email@example.com
Elena Rios , President, National Hispanic Medical Association, 202/628-5895, firstname.lastname@example.org
Michael Rodgers , Vice President for Public Policy and Advocacy, Catholic Health Association, 202/296-3993, email@example.com
Roger Schwartz , Legislative Counsel and Director of State Affairs, National Association of Community Health Centers, 202/296-0158
Dong Suh , Policy and Planning Director, Asian Health Services, 510/986-6830 x262
Reed Tuckson , Senior Vice President, UnitedHealth Group, 952/936-1253, firstname.lastname@example.org
Bernard Tyson , Senior Vice President, Health Plan and Hospital Operations, Kaiser Permanente, 510/271-2659, email@example.com
Agency for Healthcare Research and Quality www.ahrq.gov/research/mentalix.htm
Alliance for Health Reform www.allhealth.org
Alliance of Community Health Plans www.achp.org
American Academy of Pediatrics www.aap.org
American College of Physicians www.acponline.org
American Medical Association www.ama-assn.org
America's Health Insurance Plans www.ahip.org
Asian and Pacific Islander American Health Forum www.apiahf.org
Asian Health Services www.ahschc.org
Black Women's Health Imperative www.blackwomenshealth.org
Catholic Health Association www.chausa.org
Center for Health Care Strategies www.chcs.org
Center on Budget and Policy Priorities www.cbpp.org
Centers for Medicare and Medicaid Services www.cms.hhs.gov
The Commonwealth Fund www.commonwealthfund.org
Congressional Black Caucus Foundation www.cbcfinc.org
Cross Cultural Training, White Memorial Medical Center http://18.104.22.168/physicians/medical_education/residencies/family/curriculum.php
Dartmouth College Dept. of Economics www.dartmouth.edu/~economic
DHHS Office of Minority Health www.omhrc.gov
George Washington University Department of Health Policy www.gwhealthpolicy.org
Georgetown University Law Center www.law.georgetown.edu
Harvard School of Public Health www.hsph.harvard.edu
Health Research and Educational Trust www.hret.org
Healthcare Leadership Council www.hlc.org
Institute of Medicine www.iom.edu
John Hopkins University School of Nursing www.son.jhmi.edu
Joint Center for Political and Economic Studies www.jointcenter.org
Kaiser Commission on Medicaid and the Uninsured www.kff.org/about/kcmu.cfm
Kaiser Family Foundation www.kff.org
Kaiser Foundation Health Plan Inc. www.kaiserpermanente.org
Latin American Health Institute www.lhi.org
Massachusetts General Hospital www.mgh.harvard.edu
NAACP Division of Health Advocacy www.naacp.org/advocacy/health/
National Alliance for Hispanic Health www.hispanichealth.org
National Association of Community Health Centers www.nachc.com
National Association of Public Hospitals www.naph.org
National Black Caucus of State Legislators www.nbcsl.org
National Black Child Development Institute www.nbcdi.org
National Black Nurses Association www.nbna.org
National Center for Cultural Competence http://gucchd.georgetown.edu/nccc/
National Center on Minority Health and Health Disparities www.ncmhd.nih.gov
National Committee for Quality Assurance www.ncqa.org
National Governors Association www.nga.org
National Health Law Program www.healthlaw.org
National Hispanic Medical Association www.nhmamd.org
National Immigration Law Center www.nilc.org
National Medical Association www.nmanet.org
National Minority AIDS Council www.nmac.org
National Minority Quality Forum www.nmqf.org/home.aspx
National Quality Forum www.qualityforum.org
Physicians for Human Rights www.phrusa.org
RAND Corporation www.rand.org
Robert Wood Johnson Foundation www.rwjf.org
UnitedHealth Group www.unitedhealthgroup.com
Univ. of Texas School of Public Health www.sph.uth.tmc.edu
University of Maryland Dept. of Women's Studies www.womensstudies.umd.edu
University of Maryland School of Medicine Dept. of Epidemiology and Preventive Medicine
Wellpoint Health Networks, Inc. www.wellpoint.com
1 U.S. Census Bureau (2008). “An Older and More Diverse Nation by Midcentury.” News release, Aug. 14. ( www.census.gov/Press-Release/www/releases/archives/population/012496.html ).
2 U.S. Census Bureau (2009). “Census Bureau Estimates Nearly Half of Children Under 5 are Minorities.” News release, May 14. (www.census.gov/Press-Release/www/releases/archives/population/013733.html)
3 LaViest T, Gaskin D, and Richard P. (2009). The Economic Burden of Health Inequalities in the United States, p. 1. Washington, DC: The Joint Center for Political and Economic Studies, available at http://www.jointcenter.org/hpi/sites/all/files/Burden_Of_Health_FINAL_0.pdf.
4 LaViest T, Gaskin D, and Richard P. (2009). The Economic Burden of Health Inequalities in the United States, p. 1. Washington, DC: The Joint Center for Political and Economic Studies, available at http://www.jointcenter.org/hpi/sites/all/files/Burden_Of_Health_FINAL_0.pdf.
5 U.S. Census Bureau (2008). “An Older and More Diverse Nation by Midcentury.” News release, Aug. 14. (www.census.gov/Press-Release/www/releases/archives/population/012496.html).
6 U.S. Census Bureau (2008). “An Older and More Diverse Nation by Midcentury.” News release, Aug. 14. ( www.census.gov/Press-Release/www/releases/archives/population/012496.html ).
7 U.S. Census Bureau (2009). “Census Bureau Estimates Nearly Half of Children Under 5 are Minorities.” News release, May 14. (www.census.gov/Press-Release/www/releases/archives/population/013733.html)
8 Mead H, Cartwright-Smith L, Jones K, Ramos C, Woods K, and Siegel B. (2008). Racial and Ethnic Disparities in U.S. Health Care: A Chart Book, p. 20. New York: The Commonwealth Fund, available at http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf.
9U.S. Department of Health and Human Services. (2009). Health Disparities: A Care for Closing the Gap, p. 1, available at http://www.healthreform.gov/reports/healthdisparities/index.html.
10 Ibid, p. 2.
11 Mead et al., 2008, p. 20.
12 National Center for Health Statistics, U.S. Department of Health and Human Services. (2010), Health, United States, 2009, Washington, DC: U.S. Government Printing Office, p. 165, available at http://www.cdc.gov/nchs/data/hus/hus09.pdf.
13 Mead et al., 2008, p. 20.
14 Treuhaft S and Karpyn A. (2010). The Grocery Gap: Who Has Access to Food and Why it Matters, p. 7. Oakland, CA: PolicyLink, available at http://www.policylink.org/atf/cf/%7B97C6D565-BB43-406D-A6D5-ECA3BBF35AF0%7D/FINALGroceryGap.pdf.
15 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, pgs. 3-9. Rockville, MD: U.S. Department of Health and Human Services, available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
16 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, pgs. 234,237. Rockville, MD: U.S. Department of Health and Human Services, available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
17 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, p.4. Rockville, MD: U.S. Department of Health and Human Services, available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
18 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, p.3. Rockville, MD: U.S. Department of Health and Human Services, available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
19 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, p.219. Rockville, MD: U.S. Department of Health and Human Services, available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
20 Agency for Healthcare Research and Quality. (2010). National Healthcare Disparities Report, 2009, p.188,194. Rockville, MD: U.S. Department of Health and Human Services, available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
21 U.S. Census Bureau (2009). “Health Insurance Coverage: 2008.” Table 7. People Without Health Insurance Coverage by Selected Characteristics: 2007 and 2008. (www.census.gov/hhes/www/hlthins/hlthin08/p60no236_table7.pdf)
22 Hasnain-Wynia, Romana; Baker, David W.; Nerenz, David and others (2007). “Disparities in Health Care Are Driven by Where Minority Patients Seek Care.” Archives of Internal Medicine, Vol. 167, June 25, p. 1237. ( http://archinte.ama-assn.org/cgi/content/full/167/12/1233).
23 Vaughan Sarrazin, Mary and others (2009). “Racial Differences in Hospital Use After Acute Myocardial Infarction: Does Residential Segregation play a Role?” Health Affairs, March 3. (www.healthaffairs.org).
24 HHS Office of Minority Health. “National Standards on Culturally and Linguistically Appropriate Services.” ( www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15).
25 Barrett, Sharon E.; Dyer, Carley; Westpheling, Kathie (2008). “Language Access: Understanding the Barriers and Challenges in Primary Care Settings. Perspectives from the Field.” Association of Clinicians for the Underserved. p. 1-4, June 16. ( http://www.healthlaw.org/library/item.198372-Language_Access_Understanding_the_Barriers_and_Challenges_in_Primary_Care_S ).
26 Henry J. Kaiser Family Foundation, Key Facts: Race, Ethnicity, and Health Care (Menlo Park, CA: Henry J. Kaiser Family Foundation, June 2003).
27 Institute of Medicine. (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Smedley BD, Sith, AY, and Nelson AR (Eds.). Washington, DC: National Academies Press.