Chapter 4. Access to Health Care (continued)

Tables

Table 1. Racial and Ethnic Differences in Entry into the Health Care System

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Health Insurance Coverage
% of persons, ages <65, with health insurance3
% of persons, ages <65, with public health insurance only3
% of persons, ages <65, with any private health insurance3
% of persons, ages 65+, with any private health insurance3
% of persons uninsured all year4		4
% of persons uninsured all year4		4
% of persons uninsured all year4		4
Usual Source of Care
% of persons who have a specific source of ongoing care3
% of persons in fair or poor health who have a specific source of ongoing care3
% of persons with a hospital, emergency room, or clinic as source of ongoing care3
% of persons with a community health center as source of ongoing care3
% of persons without a usual source of care who indicate a financial or insurance reason for not having a source of care4		4
% of persons who have a usual primary care provider 4		4
% of adults who report very little or no choice in source of care5
% of adults who have had a regular doctor for more than 5 years5

¹Compared with whites.
² Compared with non-Hispanic whites.
³ Source: National Center for Health Statistics, National Health Interview Survey, 2000.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race.
⁵ Source: The Commonwealth Fund Health Care Quality Survey, 2001. This source did not collect information for >1 race separately.

Table 1. Racial and Ethnic Differences in Entry into the Health Care System (continued)

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Patient Perceptions of Need
% of families that experience difficulties or delays in obtaining health care or do not receive needed care3		3
% of families that experience difficulties or delays in obtaining health care due to financial or insurance reasons3		3
% of families that did not receive a doctor's care or prescription medications because the family needed the money3		3
% of families not very satisfied that they can get health care if they need it3		3
% of persons who can always get appointments for routine care as soon as wanted4		4
% of persons who can always get care for illness or injury as soon as wanted4		4

¹Compared with whites.
² Compared with non-Hispanic whites.
³ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race.

Key to Access to Health Care Tables:

: Selected population and comparison population receive about same quality of health care

: Selected population receives better quality care than the comparison population

: Selected population receives worse quality care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native; NHB=non-Hispanic black

Table 2. Socioeconomic Differences in Entry into the Health Care System

Measure	Income Difference1			Educational Difference2		Insurance Difference3
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Health Insurance Coverage
% of persons, ages <65, with health insurance4
% of persons, ages <65, with public health insurance only4
% of persons, ages <65, with any private health insurance4
% of persons, ages 65+, with any private health insurance4
% of persons uninsured all year5
% of persons with any period of uninsurance during the year5
% of persons with any period of public insurance during the year5
Usual Source of Care
% of persons who have a specific source of ongoing care4
% of persons in fair or poor health who have a specific source of ongoing care4
% of persons with a hospital, emergency room, or clinic as source of ongoing care4
% of persons with a community health center as source of ongoing care6
% of persons without a usual source of care who indicate a financial or insurance reason for not having a source of care5
% of persons who have a usual primary care provider5
% of adults who report very little or no choice in source of care6
% of adults who have had a regular doctor for more than five years6

¹ Compared with persons with family incomes 400% of Federal poverty threshold or above.
² Compared with persons with any college education.
³ Compared with persons under 65 with any private health insurance.
⁴ Source: National Center for Health Statistics, National Health Interview Survey, 2000.
⁵ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999.
⁶ Source: The Commonwealth Fund Health Care Quality Survey, 2001.

Table 2. Socioeconomic Differences in Entry into the Health Care System (continued)

Measure	Income Difference1			Educational Difference2		Insurance Difference3
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Patient Perceptions of Need
% of families that experience difficulties or delays in obtaining health care or do not receive needed care4
% of families that experience difficulties or delays due to financial or insurance reasons4
% of families that did not receive a doctor's care or prescription medications because the family needed the money4
% of families not very satisfied that they can get health care if they need it4
% of persons who can always get appointments for routine care as soon as wanted5
% of persons who can always get care for illness or injury as soon as wanted5

¹ Compared with persons with family incomes 400% of Federal poverty threshold or above.
² Compared with persons with any college education.
³ Compared with persons under 65 with any private health insurance.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999.
⁵ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000.

Key to Access to Health Care Tables:

: Selected population and comparison population receive about same quality of health care

: Selected population receives better quality care than the comparison population

: Selected population receives worse quality care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

HS=high school

Table 3. Racial and Ethnic Differences in Structural Barriers within the Health Care System

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Barriers to Getting Care
% of persons with provider who has office hours nights or weekends3		3
% of persons with difficulty getting appointments on short notice3		3
% of persons with difficulty contacting provider over the telephone3		3
% of adults without problems getting referral to a specialist in past year3		4
% of persons not very satisfied with professional staff at provider's office3		3
Waiting Times
% of persons who usually wait >30 minutes before seeing provider3		3
% of emergent/urgent emergency department visits with wait ≥ 1 hour4		4
% of semi-urgent/non-urgent emergency department visits with wait ≥ 1 hour4		4
% of emergency department visits in which the patient left without being seen4		4

¹ Compared with whites.
² Compared with non-Hispanic whites.
³ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race.
⁴ Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey-Emergency Department, 2000. This source did not collect information on Asians and NHOPIs separately. This source did not collect information for >1 race. Missing rates preclude analysis by ethnicity.

Key to Access to Health Care Tables:

: Selected population and comparison population receive about same quality of health care

: Selected population receives better quality care than the comparison population

: Selected population receives worse quality care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native; NHB=non-Hispanic black

Table 4. Socioeconomic Differences in Structural Barriers within the Health Care System

Measure	Income Difference1			Educational Difference2		Insurance Difference3
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Barriers to Getting Care
% of persons with provider who has office hours nights or weekends4
% of persons with difficulty getting appointments on short notice4
% of persons with difficulty contacting provider over the telephone4
% of adults without problems getting referral to a specialist in past year4
% of persons not very satisfied with professional staff at provider's office4
Waiting Times
% of persons who usually wait >30 minutes before seeing provider4
% of emergent/urgent emergency department visits with wait >=1 hour5
% of semi-urgent/non-urgent emergency department visits with wait >=1 hour5
% of emergency department visits in which the patient left without being seen5

¹ Compared with persons with family incomes 400% of Federal poverty threshold or above.
² Compared with persons with any college education.
³ Compared with persons under 65 with any private health insurance.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000.
⁵ Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey-Emergency Department, 2000. This source did not collect information about income or education. Insurance contrast compares uninsured with persons with any private insurance including all ages.

Key to Access to Health Care Tables:

: Selected population and comparison population receive about same quality of health care

: Selected population receives better quality care than the comparison population

: Selected population receives worse quality care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

HS=high school

Table 5. Racial and Ethnic Differences in Ability of Provider to Address Patient Needs

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Patient-Provider Communication
% of persons with provider who generally listens and gives needed information about health/health care3		3
% of persons with provider who usually asks about medications and treatments other doctors may give3		3
% of adults whose providers always listened carefully to them4		4
% of adults whose providers always explained things in a way they could understand4		4
% of adults whose providers always showed respect for what they had to say4		4
% of adults with one or more indicators of poor communication at their last visit5
Patient-Provider Relationship
% of persons not satisfied with quality of care received from provider3		3
% of persons not confident in provider's help when they have a medical problem3		3
% of adults whose providers always spent enough time with them4		4
% of adults who rate their health care in the past year <6 on a scale from 0 to 104		4
% of adults not treated with a great deal of dignity and respect5
% of adults not involved as much as wanted in decision-making5
% of adults not with as much time as wanted with doctor5
% of adults with incident in past two years when they did not follow doctor's advice5
% of adults with family member who got sick due to doctor or hospital mistake5
Cultural Competency5
% of adults who believe they would have gotten better care if different race/ethnicity
% of adults who felt treated with disrespect because of race/ethnicity
% of adults who do not strongly agree that doctor understands background and values

¹ Compared with whites.
² Compared with non-Hispanic whites.
³ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian or Pacific Islander. This source did not collect information for >1 race.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian or Pacific Islander. This source did not collect information for >1 race.
⁵ Source: The Commonwealth Fund Health Care Quality Survey, 2001. This source did not collect information for >1 race separately

Table 5. Racial and Ethnic Differences in Ability of Provider to Address Patient Needs (continued)

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Health Information3
% of adults who did not find prescription bottle very easy to understand
% of adults who did not find information from doctor's office very easy to understand
% of adults who do not use web for health information
% of adults who do not use printed material for health information
% of adults who do not call their doctor for health information

¹Compared with whites.
²Compared with non-Hispanic whites.
³Source: The Commonwealth Fund Health Care Quality Survey, 2001. This source did not collect information for >1 race separately

Key to Access to Health Care Tables:

: Selected population and comparison population receive about same quality of health care

: Selected population receives better quality care than the comparison population

: Selected population receives worse quality care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native; NHB=non-Hispanic black

Table 6. Socioeconomic Differences in Ability of Provider to Address Patient Needs

Measure	Income Difference4			Educational Difference5		Insurance Difference6
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Patient-Provider Communication
% of persons with provider who generally listens and gives needed information about health/health care7
% of persons with provider who usually asks about medications and treatments other doctors may give7
% of adults whose providers always listened carefully8
% of adults whose providers always explained things in a way they could understand8
% of adults whose providers always showed respect for what they had to say8
% of adults with one or more indicators of poor communication at their last visit9

⁴ Compared with persons with family incomes 400% of Federal poverty threshold or above.
⁵ Compared with persons with any college education.
⁶ Compared with persons under 65 with any private health insurance.
⁷ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999.
⁸ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000.
⁹ Source: The Commonwealth Fund Health Care Quality Survey, 2001.

Table 6. Socioeconomic Differences in Ability of Provider to Address Patient Needs (continued)

Measure	Income Difference1			Educational Difference2		Insurance Difference3
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Patient-Provider Relationship
% of persons not satisfied with quality of care from provider4
% of persons not confident in provider's help when they have a medical problem4
% of adults whose providers always spent enough time5
% of adults who rate their health care in the past year <6 on a scale from 0 to 105
% of adults not treated with a great deal of dignity and respect6
% of adults not involved as much as wanted in decisionmaking6
% of adults who did not have as much time as wanted with doctor6
% of adults with incident in past 2 years when they did not follow doctor's advice6
% of adults with family member who got sick due to doctor or hospital mistake6
Cultural Competency6
% of adults who believe would have gotten better care if different race/ethnicity
% of adults who felt treated with disrespect because of race/ethnicity
% of adults who do not strongly agree that doctor understands background and values
Health Information6
% of adults who do not find prescription bottle very easy to understand
% of adults who do not find information from doctor's office very easy to understand
% of adults who do not use web for health information
% of adults who do not use printed material for health information
% of adults who do not call doctor for health information

Key to Access to Health Care Tables:

: Selected population and comparison population receive about same quality of health care

: Selected population receives better quality care than the comparison population

: Selected population receives worse quality care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

HS=high school

¹ Compared with persons with family incomes 400% of Federal poverty threshold or above.
² Compared with persons with any college education.
³ Compared with persons under 65 with any private health insurance.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999.
⁵ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000.
⁶ Source: The Commonwealth Fund Health Care Quality Survey, 2001.

Table 7. Racial and Ethnic Differences in Health Care Utilization

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Routine Health Care
% of persons with office or outpatient visit3		3
% of persons with prescription medications3		3
% of persons with dental visit3		3
Outpatient visits per population4		4
Acute Care
% of persons with emergency room visit3		3
% of persons with inpatient discharge3		3
Emergency department visits per population4		4
Total hospitalizations per population5
Chronic Care
% of persons with home health visit3		3
Home health care discharges per population 18-646	6
Home health care discharges per population 65 and older6	6
Nursing home discharges per population 18-647	7
Nursing home discharges per population 65 and older7	7
Hospice discharges per population 18-646	6
Hospice discharges per population 65 and older6	6
Avoidable Admissions8
Avoidable admissions for hypertension per population 18 and older	*8	8
Avoidable admissions for angina per population 18 and older	*8	8
Avoidable admissions for chronic obstructive pulmonary disease per population 18 and older	*8	8
Avoidable admissions for bacterial pneumonia per population	*8	8

¹ Compared with whites.
² Compared with non-Hispanic whites.
³ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race.
⁴ Source: National Center for Health Statistics, National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 1999-2000. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race. Missing rates preclude analysis by ethnicity.
⁵ Source: National Center for Health Statistics National Hospital Discharge Survey, 2000. This source did not collect information for >1 race separately. Missing rates preclude analysis by ethnicity.
⁶ Source: National Center for Health Statistics, National Home and Hospice Care Survey, 2000. Sample size constraints permit black-white comparisons only.
⁷ Source: National Center for Health Statistics, National Nursing Home Survey, 1999. Sample size constraints permit black-white comparisons only
⁸ Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project State Inpatient Databases, 16-State database, 2000. This source categorizes race/ethnicity very differently from other sources. Race/ethnicity information is categorized as a single item: non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander. These contrasts compare each group with non-Hispanic whites. An * is inserted in the black column to indicate that estimates for this group could not be produced.

Table 7. Racial and Ethnic Differences in Health Care Utilization (continued)

Measure	Racial Difference1					Ethnic Difference2
	Black	Asian	NHOPI	AI/AN	>1 Race	NHB	Hispanic
Mental Health Care and Substance Abuse Treatment
% of adults who received mental health treatment or counseling in the past year3
% of adults who received outpatient mental health treatment or counseling3
% of adults who received prescription medications for mental health treatment3
% of adults who received inpatient mental health treatment or counseling3
% of adults with serious mental illness who received mental health treatment or counseling3
% of persons 12 and older who received illicit drug or alcohol abuse treatment in the past year3
% of persons 12 and older who needed treatment for illicit drug use and who received such treatment in the past year3
Inpatient admissions to specialty mental health organizations per population4		4
Residential care admissions to specialty mental health organizations per population4		4
<24 hour admissions to specialty mental health organizations per population4		4
HIV Care
Hospitalizations for HIV per population5
% of HIV patients with 4+ ambulatory visits in the past year6	*6	6
% of HIV patients with CD4 <50 with 4+ ambulatory visits in the past year6	*6	6
% of HIV patients with inpatient hospitalization in the past year6	*6	6
% of HIV patients with CD4 <50 with inpatient hospitalization in the past year6	*6	6

Key to Health Care Utilization Tables:

: Selected population and comparison population receive about same amount of health care

: Selected population receives more care than the comparison population

: Selected population receives less care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native; NHB=non-Hispanic black

¹ Compared with whites.
² Compared with non-Hispanic whites.
³ Source: Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse, 2001.
⁴ Source: Substance Abuse and Mental Health Services Administration, Client/Patient Survey Sample, 1997. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asians or Pacific Islanders. This source did not collect information for >1 race.
⁵ Source: National Center for Health Statistics, National Hospital Discharge Survey, 2000. This source did not collect information for >1 race separately. Missing rates preclude analysis by ethnicity.
⁶ Source: HIV Research Network, 2000. This source categorizes race/ethnicity very differently from other sources. Race/ethnicity information is categorized as a single item: non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander American Indian or Alaska Native. These contrasts compare each group with non-Hispanic whites. An * is inserted in the black column to indicate that estimates for this group could not be produced.

Table 8. Socioeconomic Differences in Health Care Utilization

Measure	Income Difference1			Educational Difference2		Insurance Difference3
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Routine Health Care4
% of persons with office or outpatient visit
% of persons with prescription medications
% of persons with dental visit
Acute Care4
% of persons with emergency room visit
% of persons with inpatient discharge
Chronic Care4
% of persons with home health visit
Mental Health Care and Substance Abuse Treatment5
% of adults who received mental health treatment or counseling in the past year
% of adults who received outpatient mental health treatment or counseling
% of adults who received prescription medications for mental health treatment
% of adults who received inpatient mental health treatment or counseling
% of adults with serious mental illness who received mental health treatment or counseling
% of persons age 12 and older who received illicit drug or alcohol abuse treatment in the past year
% of persons age 12 and older who needed treatment for illicit drug use and who received such treatment in the past year
HIV Care6
% of HIV patients with 4+ ambulatory visits in the past year						6
% of HIV patients with CD4 <50 with 4+ ambulatory visits in the past year						6
% of HIV patients with inpatient hospitalization in the past year						6
% of HIV patients with CD4 <50 with inpatient hospitalization in the past year						6

Key to Health Care Utilization Tables:

: Selected population and comparison population receive about same amount of health care

: Selected population receives more care than the comparison population

: Selected population receives less care than the comparison population

: Data are collected but do not meet criteria for statistical reliability

¹ Compared with persons with family incomes 400% of Federal poverty threshold or above.
² Compared with persons with any college education.
³ Compared with persons under 65 with any private health insurance.
⁴ Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1999.
⁵ Source: Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse, 2001. Income and insurance disparities were not analyzed.
⁶ Source: HIV Research Network, 2000. This source did not collect information about income or education. Because Ryan White covers HIV patients who otherwise would be uninsured, this insurance contrast compares HIV patients who are uninsured or have no coverage other than Ryan White with patients with private health insurance.

References

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2. Millman, Michal (ed.) Access to Health Care in America. Washington, DC: National Academy Press, 1993.

3. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, p. 33.

4. Trevino, F. M., Moss, A. J. Health Indicators for Hispanic, Black and White Americans. September 1984. 88pp. (PHS) 84-1576. PB87-156956. PC A05 MF A02.

5. U.S. Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, D.C.: DHHS, 1985.

6. Institute of Medicine. Access to Health Care in America. Washington, D.C.: National Academy Press, 1993.

7. "Care Without Coverage: Too Little, Too Late," by the Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine. National Academy Press, Washington, DC, 2002. p. 5.

8. Sicker and Poorer: The Consequences of Being Uninsured, prepared for the Kaiser Commission on Medicaid and the Uninsured by Jack Hadley, Ph.D., The Urban Institute, in May 2002 (updated in February 2003). Executive summary can be accessed at: http://www.kff.org/uninsured/index.cfm.

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10. Centers for Disease Control. Self-Assessed Health Status and Selected Behavioral Risk Factors Among Persons With and Without Health-Care Coverage, U.S., 1994-1995. MMWR 1998; 47:176-180.

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14. "The Importance of Having a Usual Source of Care," One Pager Number 3, January 2000; The Robert Graham Center for Policy Studies in Family Practice and Primary Care.

15. The importance of having a usual source of health care; American Family Physician; Kansas City; Aug 1, 2000.

16. Lou Ann Hartley, "Examination of primary care characteristics in a community-based clinic Journal of Nursing Scholarship"; Indianapolis; Fourth Quarter 2002; Volume 34, Issue 4, pp. 377.

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20. Millman, Michal (ed.) Access to Health Care in America. Washington, DC: National Academy Press, 1993.

21. Grumbach K, Selby JV, Damberg C, Bindman AB, Quesenberry C Jr, Truman A, Uratsu C. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282(3):261-6.

22. Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians' experience of financial incentives in managed-care systems. N Engl J Med 1998; 339(21):1516-21.

23. Healthy People 2010, p. 11-3.

24. Healthy People 2010, p. 11-8; also, Roter, D.L., and Hall, J.A. Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits. Westport, CT: Auburn House, 1992.

25.Collins, Karen Scott, Hughes, Dora L., Doty, Michelle M., Ives, Brett L., Edwards, Jennifer N., Tenney, Katie. "Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans." The Commonwealth Fund, New York: March 2002, p. 9.

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28. Risa Lavizzo-Mourey and Elizabeth R. Mackenzie, "Cultural Competence: Essential Measurements of Quality for Managed Care Organizations," Annals of Internal Medicine, 124 (May 15, 1996), 919-21.

29. Healthy People 2010, p. 11-20.

30. Joseph R. Betancourt, Alexander R. Green, and J. Emilio Carrillo. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Field Report for the Commonwealth Fund, October 2002. http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf?section=4039. Accessed August 17, 2007.

31. Cindy Brach and Irene Fraser. "Reducing disparities through culturally competent health care: An analysis of the business case." Quality Management in Health Care 10(4), pp. 15-28, 2002.

32. Betencourt, et al, 2002; refer also to Cindy Brach and Irene Fraser. "Reducing disparities through culturally competent health care: An analysis of the business case." Quality Management in Health Care 10(4), pp. 15-28, 2002; and Elena Cohen and Tawara D. Goode, "National Center for Cultural Competence," Policy Brief 1, Rationale for Cultural Competence in Primary Health Care. Winter 1999. http://www11.georgetown.edu/research/gucchd/nccc/documents/Policy_Brief_1_2003.pdf [PDF Help]. Accessed 8/17/2007.

33. Jay Greene. "Teaching Cultural Competence." American Medical News, Chicago, October 25, 1999.

34. Go to Healthy People 2010, p. 11-20; also, HHS, National Institutes of Health, National Library of Medicine (NLM). In: Seiden, C.R.; Zorn, M; Ratzan, S; et al.; eds. Health Literacy, January 1990-1999. NLM Pub. No. CBM 2000-1. Bethesda, MD: NLM, February 2000, vi.

35. Healthy People 2010, p. 11-9; also, Weiss, B.D., Blanchard, J.S.; McGee, D.L.; et al. "Illiteracy among Medicaid recipients and its relationship to health care costs." Journal of Health Care for the Poor and Underserved 5:99-111, 1994.

36. Healthy People 2010, p. 11-9; also, Baker, D.W.; Parker, R.M.; Williams, M.V.; et al. "The relationship of patient reading ability to self-reported health and use of health services." American Journal of Public Health 87:1027-1030, 1997.

37. Williams, M.V., Baker, D.W., Parker, R.M., et al. "Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes." Archives of Internal Medicine 158:166-172, 1998.

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