CHAPTER 10 - DISPARITIES
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Content Last Updated: 11/16/2012 4:14:59 PM
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Originally written by Lisa Swirsky, Alliance for Health Reform, and revised by Brian Smedley, Joint Center for Political and Economic Studies, and Bill Erwin, Alliance for Health Reform. Updated by Michael Berger of the Alliance on November 12, 2012.
This chapter was made possible by the Robert Wood Johnson Foundation.
More than one-third of those in the United States identify themselves as racial and ethnic minorities.1 Racial and ethnic minorities account for more than half of the uninsured population in the country.2 In 2011, 11.1 percent of white Americans were without health insurance. In contrast, 19.5 percent of black Americans, 16.8 percent of Asian Americans, and 30.1 percent of Hispanics were uninsured.3 As many as 83,000 deaths each year are attributed to racial and ethnic health disparities.4 The annual National Healthcare Disparities Report, published by the federal Agency for Healthcare Quality and Research, has consistently shown that blacks and Latinos suffer from poorer quality care and worse access to care than whites on a number of indicators.5
- Foreign-born Hispanics are 55 percent less likely to have a regular medical doctor when compared to native-born non-Hispanic whites. Foreign-born whites are 58 percent less likely than native-born whites to have visited a health care professional in the past 12 months.6
- Infants born to non-Hispanic black women are up to three times more likely to die than infants born to non-Hispanic white women. American Indian and Alaska Native infants are up to two and a half times more likely to die from Sudden Infant Death Syndrome (SIDS). 7
- Rates of preventable hospitalization increase as income decreases.8
- The Patient Protection and Affordable Care Act of 2010 (ACA) contains a number of provisions designed to help reduce racial and ethnic disparities in care.9 Reaching the objectives set out by Healthy People 2020 would dramatically reduce racial and ethnic disparities in access to care.10
Even though racial and ethnic minorities comprise about one-third of the U.S. population, they account for more than 50 percent of the uninsured in the United States.11 Racial and ethnic minorities now make up more than half of all children born in the country. The racial and ethnic minority population is expected to climb to more than half of the population in 2042.12 As so-called minorities collectively become the majority of the U.S. population, we can expect Congress, state governments and localities to give more and more attention to their health needs.
Certainly, more attention is needed. Disparities in health care of racial and ethnic minorities in the U.S. vs. non-Hispanic whites have persisted for decades, despite the earnest efforts of health services professionals, governments and non-government groups. The annual National Healthcare Disparities Report, published by the federal Agency for Healthcare Research and Quality (AHRQ), has consistently shown that blacks and Latinos suffer from poorer quality of care and worse access to care than whites on a number of indicators.
According to the latest report from the AHRQ, the quality of care that minority groups received was worse than the care that whites received. For 41 percent of quality measures, blacks received worse care, for 30 percent of quality measures, Asians and American Indians/Alaska Natives (AI/ANs) received worse care, and for 39 percent of measures, Hispanics received worse care. 13 A slight silver lining is that across all quality measures used in the AHRQ report, 60 percent showed slight improvement between 2010 and 2011.14
When it comes to access to care, researchers found that a majority of core measures did not improve for blacks and American Indians/Alaska Natives compared with whites, or for Hispanics compared to non-Hispanic whites. However, a majority of access measures did improve for Asians compared to whites. 15 (See chart, “Access and Quality Measures Not Improving for Various Racial and Ethnic Groups.”)
One positive step toward reducing disparities was the elevation of the former National Center on Minority Health and Health Disparities to a full-fledged institute of the National Institutes of Health in 2010, as part of the Patient Protection and Affordable Care Act (ACA).16
CAUSES OF DISPARITIES
Disparities are attributed to a number of factors. Where a person lives, what language she speaks, and her household income are only some of the characteristics that can contribute to differences in the way different racial and ethnic minorities receive care.
Where You Get Your Care
While research suggests that some providers treat racial and ethnic minorities differently than whites, there is growing evidence that some disparities are largely the result of where minorities receive care.
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.”17
A 2011 study found that Hispanics, blacks and Asians were more likely than whites to get certain surgical procedures in hospitals that performed a low volume of such surgeries. This increases the risk of adverse outcomes during and after surgery. Similarly, Medicaid patients were more likely than Medicare patients to get surgery in lower-volume hospitals, as were uninsured patients compared with patients with health coverage.18
A 2010 study looking for racial differences in hospital admissions found that older blacks living in “socially disadvantaged” areas were less likely than whites to get coronary artery bypass (CABG) surgery in top-ranked hospitals.19
It seems that patients at a particular hospital are treated similarly, regardless of race. But minority patients are more likely than whites to go to hospitals that may have been short-staffed, had inadequate budgets or lacked technical support. Supporting this view, another study looking at hospital inpatient discharge data from 13 states found that blacks, Hispanics and Asians received the same standard of care as whites within the same hospitals.20
And the study involving older blacks, mentioned above, found no disparities for blacks in general undergoing bypass surgery (in contrast to older blacks). In fact, for emergency treatment after a heart attack, blacks were more likely than whites to get care in a top-ranked hospital.21
Health Insurance Status
Uninsured people and those with inadequate insurance are more likely to have worse quality of care and poor health outcomes than those with adequate insurance.22 Approximately 30.1 percent of Hispanics, 19.5 percent of blacks, and 16.2 percent of Asians were classified as uninsured in 2011, compared to approximately 11.1 percent of non-Hispanic whites.23 Hispanics, who comprise 16.7 percent of the U.S. population, accounted for over 30 percent of the uninsured in 2011.24 (See chart, “People Without Health Insurance Coverage by Selected Characteristics: 2010 and 2011”)
The Affordable Care Act will reduce the number of uninsured people in the U.S. by 30 million,25 according to the most recent Congressional Budget Office (CBO) estimates. This will help minorities who are U.S. citizens or in the U.S. legally. But the law will not affect access to care for undocumented immigrants. CBO estimates that of the 30 million likely to remain uninsured in 2022, approximately 8.5 million will be undocumented immigrants.26
Healthy People 2020, a ten year effort led by the U.S. government to improve the nation’s health, has a goal of health coverage for all by 2020.27 In the past two decades, Healthy People programs have aimed to address health disparities in the United States. Healthy People 2000 had a goal to reduce health disparities for Americans. Healthy People 2010 aimed to eliminate health disparities. Now, the goal of Healthy People 2020 is to “achieve health equity, eliminate disparities, and improve the health of all groups.”28
Language Access Barriers
Linguistic and cultural barriers are another significant impediment to health care for those who don’t speak English well, or at all.
More than 24 million people in the United States have limited English proficiency. More than 55 million people, almost one person in five, speak a language other than English at home.29 30 (See chart, “Selected Languages Other Than English Spoken at Home.”)
Along with impeding communication between health care provider and patient, linguistic and cultural barriers contribute to the underutilization of available services. They also make it hard for patients to adhere to recommended care, and lead to negative patient experience and reduced quality of care. 31
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.
The federal Hill-Burton Act requires that all facilities receiving Hill-Burton funds must post in English and Spanish the facility’s community service obligations, including the right of anyone in the facility’s service area to receive care regardless of race, color, national origin or creed. If 10 percent or more of the households in a facility’s service area usually speak a language other than English or Spanish, the community service obligations must be posted in that language too.32
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 required 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.”33
In addition, all states and the District of Columbia have laws on the books designed to make access to health care easier for those speaking a language other than English.34 Despite these safeguards for those with limited English proficiency, 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.35
In addition to race and ethnicity, other factors contribute to disparities in care. Research demonstrates a positive correlation between socioeconomic status (SES) and health status. Those with higher income, education or occupational status tend to have better health status than others.36 And blacks and Hispanics on average have lower incomes and less education than do whites.37 As income decreases, rates of preventable hospitalizations go up.38
Dr. Camara Jones of the National Center for Chronic Disease Prevention and Health Promotion points out that addressing social determinants of health involves collaboration among many actors outside the health care system, including those in the education, housing, labor, justice, transportation, agriculture and environmental sectors.39
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.
In a 2007 study, “Closing the Divide: How Medical Homes Promote Equity in Health Care,” The Commonwealth Fund found that minorities with medical homes experienced no disparities in receiving preventive care reminders.40 The Affordable Care Act encourages medical homes through a program of grants and contracts41 and provides extra compensation for care delivered through medical homes.42
Some researchers believe physician behavior can contribute to disparities.43 Studies have found evidence of provider racism in the treatment of patients in cardiac care, for example.44 45 A 2009 study found that blacks being treated for high blood pressure have shorter visits with their physicians and less patient–physician communication than do whites.46 Analysis of the U.S. Behavioral Risk Factor Surveillance System project found that blacks who have experienced discriminatory treatment report overall poorer health.47
Housing segregation is a major contributor to disparities. For minorities, this leads to reduced opportunities for socioeconomic advancement, negative health behaviors, and more exposure to environmental hazards and segregated health care settings. Socioeconomic status does not completely account for housing segregation; blacks and Latinos have more limited choices of neighborhoods because of housing discrimination.48 Blacks are more likely to report being in poor health if they live in a neighborhood that is highly segregated racially.49
Whether a person was born in the U.S. or elsewhere makes a difference in health status. Immigrants to the U.S., regardless of race or ethnicity, tend to have better health than their U.S.- born counterparts. This advantage declines, however, the longer the person stays in the U.S. 50
Disparities in Nursing Home Care
The racial disparities noted above in hospitals have also been found in nursing homes. A 2007 study found that blacks are more likely than whites to live in nursing homes that have serious deficiencies and lower staffing ratios, especially in the Midwest.51
Blacks and Hispanics are more likely than whites to live in skilled nursing facilities that have a large percentage of Medicaid residents. This makes these minorities especially vulnerable to Medicaid cutbacks, potentially affecting their access to such facilities, as states struggle to balance their budgets.52
Health Reform and Disparities
The ACA contains several provisions that could help reduce disparities:53
- Workforce diversity and cultural competency – The law encourages greater ethnic and racial diversity in the health professions. It also improves cultural competency training for health care providers.Health plans will be required to use language services in underserved communities.
- Preventive care – The law requires Medicare and some private insurance plans to cover recommended preventive services such as check-ups, cancer screenings and immunizations without any additional out-of-pocket payments from patients.
- Chronic disease management – The law offers financial incentives for providers grouping themselves into coordinated care teams, called Accountable Care Organizations, which can better manage chronic conditions than individual practitioners. This will be helpful to minorities, who are at higher risk than whites for conditions such as diabetes, kidney disease, heart disease and some cancers.
- Coverage for those with pre-existing conditions – Every state now has a new program offering insurance at affordable rates for those with pre-existing health conditions, as long as they’ve been uninsured for at least six months.
- Community health centers – The ACA increases funding for community health centers, which provide primary care services to people regardless of their ability to pay.
- Data collection – The law requires collection and reporting of data on race, ethnicity, sex, primary language and disability status. It also requires collection of data on access to care and treatment for people with disabilities.54 (See text box “Racial and Ethnic Data Collection” for more discussion.)
Kaiser Permanente Centers of Excellence in Culturally Competent Care -- Kaiser Permanente operates nine sites that are designed to show “how trained staff respectfully integrate issues of culture, race and ethnicity during a member’s visit.” Three centers specialize in culturally sensitive care for African-Americans, two concentrate on care for Latinos, one focuses on care of people with disabilities, and one is especially set up to care for Armenians. Said Ronald Knox, senior vice president and chief diversity officer at Kaiser Permanente, “Simply put, diversity is how we achieve our mission and how we grow our business.”55
REACH US Coalition -- In Genesee County, Michigan, a new initiative, the REACH US Coalition, is building on the successes of a past project, Genesee County REACH 2010. The REACH US Coalition is a part of the Racial and Ethnic Approaches to Community Health programs (REACH) with the Centers for Disease Control and Prevention (CDC). In Genesee County, REACH 2010 aimed at reducing infant mortality, particularly among the African-American population. As a result of the program, the infant mortality rate among African Americans dropped from 23.5 deaths per 1,000 live births to a record low of 15.2 deaths. The disparity ratio between African American infant mortality compared with white infant morality dropped from 3.6 to 2.4. The new REACH US Coalition plans to conduct Community Action Plan activities in several communities throughout Michigan and the United States.56
National Health Plan Collaborative to Reduce Disparities and Improve Quality – A coalition of nine health plans has made important strides toward collecting racial and ethnic data to improve health care. Members of the group, called the National Health Plan Collaborative to Reduce Disparities and Improve Quality, were initially worried that working together to collect race-specific data could expose them to liability and anti-trust problems. The group overcame these fears and all participating plans have been gathering data either directly (i.e., patients identifying their race or ethnicity) or indirectly (i.e., based on patient’s surname or place of residence). Supporters include the Robert Wood Johnson Foundation and the Agency for Health Care Research and Quality. 57
“Help Me Grow” Program in Connecticut -- Funded by the State of Connecticut’s Children’s Trust Fund, “Help Me Grow” provides well-child assessments and clinical referrals. Importantly, the program also sets up referrals to non-clinical services, such as parent education classes, parent support groups and church-related activities. These referrals are especially important to black and Hispanic parents, who are much more likely than white parents to have child-raising “vulnerability factors.”58
LIKELY POLICY DEBATES
Medicare Provider Payments
Congress has put forth efforts to make Medicare provider payment more dependent on quality and less dependent on volume of services delivered. While such a payment change is likely critical in order to promote sustainable high quality care, some researchers think these kinds of payment reforms could inadvertently aggravate disparities by reducing income to providers in minority communities.59
For example, the 2006 Tax Relief and Health Care Act established a voluntary physician quality reporting system for the care of Medicare patients.60 The ACA extends this system beyond 2010. In addition, the ACA provides incentives for providers who group themselves into Accountable Care Organizations and meet quality targets.61 The president’s deficit reduction commission report calls for payments to doctors “based on quality instead of quantity of services.”62
TIPS FOR REPORTERS
- What is your state government doing to address the issue of disparities? For a synopsis of state laws dealing with assisting non-English speakers in health care settings, go to http://goo.gl/EiOmY.
- 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? Has the Affordable Care Act’s provisions on ethnic and racial data collection made a difference in how providers in your state are gathering such data?
- Monitor how racial and ethnic groups are categorized as the population becomes increasingly more diverse and as intermarriage between racial groups becomes more common. Are federal programs, state administered programs, health plans, hospitals and physicians adapting to demographic changes appropriately in their approaches 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. Go to http://goo.gl/xChdE tosee the survey and a webcast of its release.
- Is the Affordable Care Act helping reduce disparities in your state?
- Would loosening restrictions on access to federal health programs for undocumented immigrants decrease disparities?
- What has happened during the recession to safety net providers (e.g., public hospitals and community health centers) – the places where minorities often receive care? What happens to those who gain insurance 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.
Racial and Ethnic Data Collection
Those hoping to reduce racial and ethnic health care disparities depend on accurate data to help them identify specific problems and subgroups facing them. Toward this end, there have been some efforts to standardize the way race and ethnicity data are collected. The Office of Management and Budget, for example, has determined basic racial and ethnic categories for federal statistics and programs.63
Despite this determination, federal programs face many barriers in obtaining this type of information. Medicaid, a joint state and federal program, must rely on states for race and ethnicity data, but states vary in the ability of their information systems to collect them. States tend to collect the data from enrollees on a voluntary basis, often offering a limited number of race and ethnicity categories. As a result, the data are often incomplete.64
At the hospital level, research suggests that there are gaps in the collection and standardization of race and ethnicity data across hospitals.65 Health information technology may be one avenue for improving the standardization of data on race, ethnicity and language data. Standardized use of electronic health records systems to capture patient data related to race, ethnicity and language could dramatically enhance the ability to identify and monitor care disparities.
The American Recovery and Reinvestment Act signed into law by President Obama in February 2009 ensures that data are collected on race, ethnicity and primary language.66 As noted above, the ACA goes farther. It requires collection and reporting of data on race, ethnicity, sex, primary language and disability status. It also requires collection of data on access to care and treatment for people with disabilities.67
By disaggregating data, the hope is to enhance efforts in reducing health disparities. But questions remain. Will the new data collection requirements be followed? What will government and public sector entities do with the data? Will the enhanced data collection make a difference in reducing disparities?
1 Hope Yen, Associated Press (2010). “U.S. Minority Population Could Be Majority By Mid-Century, Census Shows.” June 10, 2010. http://goo.gl/wVVd4
2 U.S. Department of Health and Human Services (2012). “Improving Data Collection to Reduce Health Disparities.” January 23, 2012, http://www.healthcare.gov/news/factsheets/2011/06/disparities06292011a.html
3 U.S. Census Bureau (2012) “Income, Poverty, and Health Insurance Coverage in the United States: 2011.”
4 U.S. Department of Health and Human Services, Department of Minority Health. “Ensuring that Health Care Reform Will Meet the Health Care Needs of Minority Communities and Eliminate Health Disparities, A Statement of Principles in Recommendations, July 2009.” http://goo.gl/b7w7V
5 Agency for Healthcare Research and Quality (2012). “2011 National Health Care Disparities Report.” http://www.ahrq.gov/qual/nhqr11/key.htm
6U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. “Being foreign-born affects access to care.” http://www.ahrq.gov/research/feb12/0212RA17.htm
7 National Conference of State Legislatures (2012). “Disparities in Health.” January 2012, http://www.ncsl.org/issues-research/health/health-disparities-overview.aspx
8 Centers for Disease Control and Prevention (2011). “CDC Health Disparities and Inequalities Report – United States, 2011.” January 14, p. 1. http://goo.gl/uAgXa
9 HealthCare.gov. “Health Disparities and the Affordable Care Act.” http://goo.gl/g1oKH
10 HealthyPeople.gov (2011). “Access to Health Services, Objectives.” http://goo.gl/1jBl5
11 Department of Health and Human Services (2012). “Improving Data Collection to Reduce Health Disparities.” January 23, 2012, http://www.healthcare.gov/news/factsheets/2011/06/disparities06292011a.html
12 U.S. Census Bureau (2008). “An Older and More Diverse Nation by Midcentury.” News release, Aug. 14. http://goo.gl/1Cxo4)
13 Agency for Healthcare Research and Quality (2012). “2011 National Health Care Disparities Report.” Highlights – Figure H.1 http://www.ahrq.gov/qual/nhqr11/key.htm
14 Agency for Healthcare Research and Quality (2012). “2011 National Health Care Disparities Report.” Highlights – Figure H.3 http://www.ahrq.gov/qual/nhqr11/key.htm
15 Agency for Healthcare Research and Quality (2012). “2011 National Health Care Disparities Report.” Highlights – Figure H.4 http://www.ahrq.gov/qual/nhqr11/key.htm
16 NIH News (2010). “NIH Announces Institute on Minority Health and Health Disparities.” News release, September 27. http://goo.gl/7K5VI)
17 Romana Hasnain-Wynia,David W. Baker, David Nerenzet al. (2007). “Disparities in Health Care Are Driven by Where Minority Patients Seek Care.” Archives of Internal Medicine, Vol. 167, June 25, p. 1237. http://goo.gl/FpL5T
18 Jerome H. Liu, David S. Zingmond, Marcia L. McGory et al. (2011). “Disparities in the Utilization of High-Volume Hospitals for Complex Surgery.” JAMA, Vol. 305, No. 3, pp. 223-319, July 19, abstract. http://goo.gl/0cDbh )
19 John Gever (2010). “Racial Differences in CABG Socioeconomic, Too.” MedPage Today, July 27. http://goo.gl/8Hrql and Ioana Popescu, Brahmajee K. Nallamothu, Mary S. Vaughan-Sarrazin and Peter Cram (2010). “Racial Differences in Admissions to High-Quality Hospitals for Coronary Heart Disease.” Archives of Internal Medicine, Vol. 170, No. 14, July 26 (abstract). http://goo.gl/CM2Tt
20 Darrell Gaskin, Christine S. Spencer, Patrick Richard et al. (2008). “Do Hospitals Provide Lower-Quality Care to Minorities than to Whites?” Health Affairs, March/April, p. 518, 523. (www.healthaffairs.org).
21 John Gever (2010). “Racial Differences in CABG Socioeconomic, Too.” MedPage Today, July 28. http://goo.gl/aWgAK
22 Agency for Healthcare Research and Quality (2012). “2011 National Health Care Disparities Report.” http://www.ahrq.gov/qual/nhqr11/key.htm
23 U.S. Census Bureau (2012). “Income, Poverty and Health Insurance Coverage in the United States: 2011” Table C-2: Health Insurance Coverage by Race and Hispanic Origin, page 67-69 http://www.census.gov/prod/2012pubs/p60-243.pdf
24 U.S. Census Bureau (2012). “Income, Poverty and Health Insurance Coverage in the United States: 2011” Table 7: People Without Health Insurance Coverage by Selected Characteristics: 2010 and 2011, page 22 http://www.census.gov/prod/2012pubs/p60-243.pdf
25 Congressional Budget Office (2012). “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision.” July 2012 http://www.cbo.gov/publication/43472
26 Congressional Budget Office (2012). “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision.” July 2012 http://www.cbo.gov/publication/43472
27 HealthyPeople.gov (2011). “Access to Care, Objectives.” http://goo.gl/UJx52
28 Healthy People.gov(2011), “Disparities.” http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx
29 U.S. Census Bureau (2010). “Language Use.” Table 1, Detailed Languages Spoken at Home and Ability to Speak English for the Population 5 Years and Over for the United States.” http://goo.gl/pZSqC
30 Melanie Au, Erin Fries Taylor and Marsha Gold (2009). “Improving Access to Language Services in Health Care: A Look at National and State Efforts.” http://goo.gl/Zf4ej
31Melanie Au, Erin Fries Taylor and Marsha Gold (2009). “Improving Access to Language Services in Health Care: A Look at National and State Efforts.” April, p. 1. http://goo.gl/Zf4ej
32 Department of Health and Human Services, Office of Civil Rights. “Your Rights Under the Community Service Assurance of the Hill – Burton Act.” http://goo.gl/rsQLL
33 HHS Office of Minority Health. “National Standards on Culturally and Linguistically Appropriate Services.” http://goo.gl/qc4H8
34 Jane Perkins and Mara Youdelman (2008). “Summary of State Law Requirements Addressing Language Needs in Health Care.” National Health Law Program, January. http://goo.gl/ZtLDz
35 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://goo.gl/ZumOo
36 Rachel Tolbert Kimbro, Sharon Bzostek, Noreen Goldman and Germán Rodríguez (2008). “Race, Ethnicity, and the Education Gradient in Health.” Health Affairs, March/April, p. 361. (www.healthaffairs.org).
37 The Commonwealth Fund, Racial and Ethnic Disparities in U.S. Health Care: A Chartbook, charts 2-3, 2-4 and 2-6. http://goo.gl/NoBMz
38 Centers for Disease Control and Prevention (2011). , “CDC Health Disparities and Inequalities Report – United States, 2011.” January 14, p. 1. http://goo.gl/RZ1H7
39 Camara Phyllis Jones. “Social Determinants of Health and Social Determinants of Equity.” PowerPoint presentation. http://goo.gl/uNqEf
40 The Commonwealth Fund (2007). “Closing the Divide: How Medical Homes Promote Equity in Health Care: Results from The Commonwealth Fund 2006 Health Quality Survey.” June. http://goo.gl/bW5ei
41 H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 3502. http://goo.gl/jHuy7
42 H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 1311. http://goo.gl/jHuy7
43 Michelle van Rhyn (2003). “Paved With Good Intentions: Do Public Health and Human Services Providers Contribute to Racial/Ethnic Disparities in Health?” American Journal of Public Health, Feb., p. 248.
44 Schulman, Kevin and others (1999). “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization.” New England Journal of Medicine, Feb. 25, p. 618. In addition, see earlier studies cited herein. http://goo.gl/WVEJB
45 Contessa Fincher, Joyce E. Williams, Vicky MacLean and others (2004). "Racial disparities in coronary heart disease: a sociological view of the medical literature on physician bias" Ethnicity and disease 14.3. Available at: http://works.bepress.com/jeroan_allison/122
46 C.W. Cené, D. Roter, K.A. Carson et al. (2009). “The effect of patient race and blood pressure control on patient-physician communication.” Journal of Internal Medicine, Sep., 24(9): 1057-64. http://goo.gl/xO5V4
47 Preidt, Robert (2012). “Discrimination Seems to Harm Health Regardless of Race.” Medline Plus. http://www.nlm.nih.gov/medlineplus/news/fullstory_121291.html
48 Acevedo-Garcia, Dolores; Osypuk, Theresa L.; McArdle, Nancy;Williams, David R. (2008). “Toward a Policy-Relevant Analysis of Geographic and Racial/Ethnic Disparities in Child Health.” Health Affairs, March/April, p. 323-324. www.healthaffairs.org
49 S.V. Subramanian, Dolores Acevedo-Garcia and Theresa L. Osypuk (2005). “Racial residential segregation and geographic heterogeneity in black/white disparity in poor self-rated health in the U.S.: a multilevel statistical analysis.” Social Science & Medicine, Volume 60, Issue 8, April, pp 1667-1679 http://goo.gl/XaeaX
50 David R. Williams. “A Time For Action: the Enigma of Social Disparities in Health and How to Effectively Address Them.” PowerPoint presentation. http://goo.gl/xLubu
51 David Barton Smith, Zhanlian Feng, Mary L. Fennell and others (2007). “Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes.” Health Affairs, September/October, pp. 1448-1458. www.healthaffairs.org and The Commonwealth Fund (2007). “New Study: In Many U.S. Cities, Blacks More Likely Than Whites to Live in Poor Quality Nursing Homes.” News release, September 11. http://goo.gl/DcYFB )
52 The Alliance for Quality Nursing Home Care (2010). “With FMAP Delay, Recession, Pressure on State Medicaid Programs, African-American and Hispanic Seniors More Likely to Face Problems Accessing Quality Nursing Home Care.” News release, June 10. http://goo.gl/68Ar1 )
53 HealthCare.gov. “Health Disparities and the Affordable Care Act.” http://goo.gl/tjv2u
54 Kaiser Family Foundation. “Summary of New Health Reform Law.” P. 10. http://goo.gl/1J2kB
55 Kaiser Permanente. Centers of Excellence in Culturally Competent Care. Brochure. http://goo.gl/3Xmdl
56 “About Genesee County REACH U.S.” Genesee County Health Department, September 2010. http://www.gchd.us/Services/PersonalHealth/REACH/about.asp
57 Nicole Lurie, Allen Fremont, Stephen A. Somers and others (2008). “The National Health Plan Collaborative to Reduce Disparities and Improve Quality.” The Joint Commission Journal on Quality and Patient Safety.” March, pp. 256 – 265. http://goo.gl/5xCwx
58 Theresa M. Wizemann and Karen M. Anderson, Rapporteurs (2009). “Focusing on Children’s Health: Community Approaches to Addressing Health Disparities: Workshop Summary.” Institute of Medicine and National Research Council, pp. 20-23. http://goo.gl/zTk6F
59 Casalino, Lawrence P.; Elster, Arthur; Eisenberg, Andy, and others (2007). “Will Pay-For-Performance and Quality Reporting Affect Health Care Disparities?” Health Affairs Web Exclusive, May/June. www.healthaffairs.org
60 Centers for Medicare and Medicaid Services. “Physician Quality Reporting Initiative.” www.cms.gov/pqri/
61 Kaiser Family Foundation. “Summary of New Health Reform Law.” Pp. 8,9. http://goo.gl/lkc40
62 “The Moment of Truth: Report of the National Commission on Fiscal Responsibility and Reform.” P. 37 http://goo.gl/YMJg8
63 Office of Management and Budget and Office of Management and Budget (1997). “Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity.” Federal Register Notice, October 30. http://goo.gl/Z4xar
64 Karen Lamos and Lindsay Palmer (2006). “Using Data on Race and Ethnicity to Improve Health Care Quality for Medicaid Beneficiaries.” Center for Health Care Strategies June, p. 1. http://goo.gl/kNQR2
65 Siegel, Bruce; Regenstein, Marsha; Jones, Karen (2007). “Enhancing Public Hospitals’ Reporting of Data on Racial and Ethnic Disparities in Care.”January. http://goo.gl/AtnlB See also: Lin C.J.; Musa, D.; Silverman, M. (2003).“Is Managed Care a Potential Source of Racial Disparities in the Use of Preventive Care?” http://goo.gl/FvDD0
66 American Recovery Act of 2009, Title XIII, §3002(b)(2)(B)(vii).
67 Kaiser Family Foundation. “Summary of New Health Reform Law.” Pp. 8,9. http://goo.gl/fJOu8