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National Healthcare Disparities Report, 2003

Chapter 5. Priority Populations (continued)

Racial and Ethnic Subpopulations

Introduction

The U.S. population has become increasingly diverse in terms of national origin over the last three decades. In 2002, an estimated 28 million documented residents were foreign born;26 the actual number is undoubtedly higher, given the recent increase in illegal immigration. Although previous chapters of this report describe health care disparities by raciali and ethnicii categories (as defined by the Office of Management and Budget and used by the U.S. Census Bureau27), these aggregate figures fail to capture important variances among subsets of some primary groups. This section provides a look at health care disparities in subsets of three primary racial and/or ethnic groups: (1) the large and heterogeneous Hispanic population (based on place of origin); (2) the smaller but equally disparate Asian population; and (3) the approximately 60% of American Indian and Alaska Natives who receive care from Indian Health Services (IHS) facilities.

While disparities in health care for minority populations can be linked to levels of income and education, limited English proficiency (LEP) and cultural differences are important source of barriers. The 2000 census found that close to half of persons age 5 and over who speak a foreign language have difficulty communicating in English, and 4.7% of persons age 5 and over live in households where English is not routinely spoken.28

Numerous studies have shown the negative effect of LEP on health care. For example, non-English speaking patients are more likely than English-speaking consumers to rely on emergency rooms for primary care; non-English-speaking women who skipped the Pap test for cervical cancer said that educational materials on the procedure were unavailable or inadequate; and asthmatic patients with limited English skills are more likely than others to break appointments and stop taking their medication.29

Cultural differences are also significant causes of miscommunication.30 People in many parts of the world do not know of or accept the pathogen concept and choose to rely on folk remedies or herbs for treatment.31 Attitudes about the body and the role of the doctor can pose problems, as can ways of describing illnesses and needs.32 Proper treatment of behavioral anomalies such as phobias and visions may require understanding reported symptoms within the context of the patient's culture.33

These variables are reflected in the markedly higher proportions of Asian and Hispanic respondents who showed difficulty communicating at their last health visit, when stratified by income and education (go to Chapter 4). Only Asians in the highest income group reportedly approximated the communication skills of whites. Looking at these variables among subsets of the selected primary populations can shed light on the nature and dynamics of health care disparities in ethnic minorities.

Federal health care data collections often do not include information about ethnic subpopulations and, when they do, sample sizes tend to be small. In an attempt to help fill this gap, non-Federal data collections were examined; but none was identified that could provide reliable national estimates for subpopulations across a range of health care topics. As a result, and as noted below, findings are not nationally representative of racial and ethnic subpopulations.


i Races include: American Indian or Alaska Native, Asian, black or African American, Native Hawaiian or Other Pacific Islander, and white.
ii Ethnicity differentiates Hispanics and non-Hispanics. The NHDR also distinguishes non-Hispanic whites and non-Hispanic blacks.


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Quality and Access for Hispanic Subpopulations

Census 2000 counted over 35 million Hispanics, or 12.5% of the population in the United States, making Hispanics the largest minority group in America. An additional 3.8 million Hispanics live in the Commonwealth of Puerto Rico.34

The Hispanic population is highly heterogeneous. Mexicans are the largest Hispanic subpopulation in the United States, accounting for almost 60% of Hispanics, followed by Puerto Ricans, Central Americans and South Americans. Among Hispanics, variation in access to and quality of health care has been observed related to place of origin and degree of acculturation.35

To help tease apart these differences, AHRQ identified a State database, the 2001 California Health Interview Survey (CHIS), which includes large numbers of Hispanic subpopulations. California is home to more Hispanics (i.e., 11 million) than any other State; and CHIS included over 10,000 Hispanics in its sample design. In addition, CHIS was conducted in six languages, including Spanish, and collected information about languages spoken at home—which is used as a proxy for acculturation.i

This section identifies disparities in access to and, to a limited extent, quality of health care between Hispanics and non-Hispanic whites, among different Hispanic subpopulations related to place of origin, and among Hispanics related to language.


i Virtually no data sources routinely record language spoken at home, place or birth, or length of time in this country.


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Quality of Care

In California, the NHDR identifies disparities in quality of health care between Hispanics and non-Hispanic whites, among different Hispanic subpopulations related to place of origin, and among Hispanics related to language. For example, the percent of persons age 50 and over who ever had flexible sigmoidoscopy or colonoscopy is lower among Hispanic Californians (39%) compared with non-Hispanic white Californians (58%) (Figure 9). In addition, among Hispanics, this measure ranges from 32% for Central Americans to 51% for South Americans. This measure is also lower among Hispanics who speak Spanish only at home (29%) and Spanish and English at home (39%) compared with Hispanics who speak English only at home (50%).

Figure 9. Percent of Californians 50 and over who ever had flexible sigmoidoscopy or colonoscopy by ethnicity, place of origin, and language

Figure 9. Percent of Californians 50 and over who ever had flexible sigmoidoscopy or colonoscopy by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: California Health Interview Survey, 2001.

Similarly, the percent of persons age 65 and over that received influenza vaccination in the past 12 months is lower among Hispanic Californians (54%) than non-Hispanic white Californians (70%) (Figure 10). In addition, among Hispanics, influenza vaccination ranges from 41% for Central Americans to 58% of Mexicans. Hispanics who speak Spanish only at home (50%) and Spanish and English at home (54%) are less likely to receive the vaccination than Hispanics who speak English only at home (66%).

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Access to Care

Health insurance

The percent of persons with health insurance is lower among Hispanic Californians (74%) compared with non-Hispanic white Californians (93%) (Figure 11). In addition, among Hispanics, this measure ranges from 66% for Central Americans to 91% for Puerto Ricans. This measure is also lower among Hispanics who speak Spanish only at home (58%) and Spanish and English at home (76%) compared with Hispanics who speak English only at home (89%) (CHIS, 2001).

Figure 10. Percent of Californians 65 and over who received influenza vaccination in the past 12 months by ethnicity, place of origin, and language

Figure 10. Percent of Californians 65 and over who received influenza vaccination in the past 12 months by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: California Health Interview Survey, 2001.

Figure 11. Percent of Californians with health insurance by ethnicity, place of origin, and language

Figure 11. Percent of Californians with health insurance by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: California Health Interview Survey, 2001.

Usual source of care

Similarly, the percent of persons with a source of ongoing care is lower among Hispanic Californians (82%) compared with non-Hispanic white Californians (91%) (Figure 12). In addition, among Hispanics, this measure ranges from 78% for Central Americans to 89% of Puerto Ricans. This measure is also lower among Hispanics who speak Spanish only at home (73%) and Spanish and English at home (84%), compared with Hispanics who speak English only at home (88%).

Figure 12. Percent of Californians with source of ongoing care by ethnicity, place of origin, and language

Figure 12. Percent of Californians with source of ongoing care by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: California Health Interview Survey, 2001.

Patient perceptions of inadequate access and need

In contrast, the percent of persons who experience delays in medical care is lower among Hispanic Californians (15%) than among non-Hispanic white Californians (23%) (Figure 13). In addition, among Hispanics, this measure ranges from 13% for Mexicans to 24% for Puerto Ricans. This measure is also lower among Hispanics who speak Spanish only at home (11%) and Spanish and English at home (14%) compared with Hispanics who speak English only at home (20%).

Figure 13. Percent of Californians who experience delays in medical care by ethnicity, place of origin, and language

Figure 13. Percent of Californians who experience delays in medical care by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: California Health Interview Survey, 2001.

Because Federal health care data collections typically do not collect information on the patient-provider relationship, cultural competency, and health information, the NHDR uses the Commonwealth Fund Health Care Quality Survey to provide national estimates. In 2001, this survey included over 1,100 Hispanics and collected information about Hispanic subpopulations, and was conducted in five languages (including Spanish). The Commonwealth Fund survey included questions about languages spoken at home—which is used as a proxy for acculturation.

Patient-provider relationship

The percent of persons not treated with a great deal of dignity and respect, a measure of the patient-provider relationship, is not significantly different between Hispanics (24%) and non-Hispanic whites (23%) (Figure 14). However, among Hispanics, this measure ranges from 16% of Puerto Ricans to 34% of Central Americans. This problem is also reported less often by Hispanics who speak primarily Spanish at home (12%) than Hispanics who speak primarily English at home (31%).

Cultural competency

Similarly, the percent of persons who do not strongly agree that their doctor understands their background and values, a measure of cultural competency, is not significantly different between Hispanics (38%) and non-Hispanic whites (40%) (Figure 15). However, among Hispanics, this measure ranges from 34% of Central Americans to 41% of Mexicans. This problem is also reported less often by Hispanics who speak primarily Spanish at home (31%) than by Hispanics who speak primarily English at home (43%).

Figure 14. Percent of persons not treated with a great deal of dignity and respect by ethnicity, place of origin, and language

Figure 14. Percent of persons not treated with a great deal of dignity and respect by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: Commonwealth Fund Health Care Quality Survey, 2001.

Figure 15. Percent of persons who do not strongly agree that their doctor understands their background and values by ethnicity, place of origin, and language

Figure 15. Percent of persons who do not strongly agree that their doctor understands their background and values by ethnicity, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: Commonwealth Fund Health Care Quality Survey, 2001.

Health information

In contrast, the percent of persons who do not find it very easy to understand information from their doctor's office is higher among Hispanics (54%) than non-Hispanic whites (40%) (Figure 16). In addition, among Hispanics, this measure ranges from 40% of Puerto Ricans to 58% of Mexicans. This problem is also reported more often by Hispanics who speak primarily Spanish at home (63%) than Hispanics who speak primarily English at home (48%).

Figure 16. Percent of persons who do not find it very easy to understand information from their doctor's office by ethnicity, place of origin and language

Figure 16. Percent of persons who do not find it very easy to understand information from their doctor's office by ethnicity, place of origin and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Hispanics by place of origin.
Key: NHW=non-Hispanic white
Source: Commonwealth Fund Health Care Quality Survey, 2001.

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Quality and Access for Asian Subpopulations

Census 2000 counted almost 12 million Asians, or 4.2% of the population, in the United States. Asians are the fastest growing racial group in America.36 As with the Hispanic population, the Asian population is highly heterogeneous. Among Asians, differences in health care have been observed related to place of origin. Differences have also been observed related to degree of acculturation.37

No databases were identified that could provide reliable national estimates for Asian subpopulations for the topics covered in this report; but again the California Health Interview Survey, which includes large numbers of Asian subpopulations, was identified. California is the home to more Asians (i.e., 4.2 million) than any other State, and CHIS included almost 6,500 Asians in its sample design, including oversampling of Japanese, Vietnamese, South Asians, Koreans, and Cambodians. In addition, CHIS was conducted in six languages including Chinese, Vietnamese, Korean, and Khmer and collected information about languages spoken at home. Languages spoken at home are used as a proxy for acculturation and differentiate Asians who speak Asian languages only at home, Asian languages and English at home, and English only at home. This section presents data on access to care and quality of care among Asian subpopulations from CHIS in 2001.

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Quality of Care

In California, disparities exist in measures of quality of health care between Asians and whites, among different Asian subpopulations related to place of origin, and among Asians related to language. For example, the percent of persons age 50 and over who ever had flexible sigmoidoscopy or colonoscopy is lower among Asian Californians (44%) than white Californians (57%) (Figure 17), ranging from 36% of Vietnamese to 56% of Japanese. Asian Californians who only speak Asian languages at home (37%) and those who speak both Asian languages and English at home (42%) are less likely to have had flexible sigmoidoscopy or colonoscopy than Asians who speak English only at home (57%).

Figure 17. Percent of Californians 50 and over who ever had flexible sigmoidoscopy or colonoscopy by select race categories, place of origin, and language

Figure 17. Percent of Californians 50 and over who ever had flexible sigmoidoscopy or colonoscopy by select race categories, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: California Health Interview Survey, 2001.

Similarly, the percent of women age 18 and over who had a Pap smear in the past 3 years is lower among Asian Californians (72%) than white Californians (86%) (Figure 18), ranging from 63% of Vietnamese to 81% of Filipinos. Asian Californians who only speak Asian languages at home (56%) and those who speak both Asian languages and English at home (73%) are more likely to have had a Pap smear in the last 3 years compared with Asians who speak English only at home (81%).

Figure 18. Percent of Californian women 18 and over who had a Pap smear in the past 3 years by select race categories, place of origin, and language

Figure 18. Percent of Californian women 18 and over who had a Pap smear in the past 3 years by select race categories, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: California Health Interview Survey, 2001.

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Access to Care

Health insurance

In California, disparities in access to health care are noted between Asians and whites, among different Asian subpopulations related to place of origin, and among Asians related to language. For example, the percent of persons with health insurance is lower among Asian Californians (88%) compared with white Californians (90%) (Figure 19). In addition, health insurance coverage among California's Asian population ranges from 85% of Vietnamese to 94% of Japanese. Health insurance is less common among those who only speak Asian languages at home (78%) and those who speak both Asian languages and English at home (88%) compared with Asians who speak English only at home (92%).

Usual source of care

Similarly, Asian Californians are less likely than white Californians to have a source of ongoing care (Figure 20). Asians who only speak Asian languages than at home are less likely (80%) Asians who only speak English at home (90%) to have a source of ongoing care.

Figure 19. Percent of Californians with health insurance by select race categories, place of origin, and language

Figure 19. Percent of Californians with health insurance by select race categories, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: California Health Interview Survey, 2001.

Figure 20. Percent of Californians with source of ongoing care by select race categories, place of origin, and language

Figure 20. Percent of Californians with source of ongoing care by select race categories, place of origin, and language

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: California Health Interview Survey, 2001.

The NHDR uses the Commonwealth Fund Health Care Quality Survey to provide national estimates on measures of the patient-provider relationship, cultural competency, and health information among Asian subpopulations and identifies differences between Asians and whites and among different Asian subpopulations. In 2001, this survey included over 600 Asians and collected information about Asian subpopulations. In addition, it was conducted in five languages including Chinese, Korean, and Vietnamese.

Patient-provider relationship

The percent of persons not treated with a great deal of dignity and respect is higher among Asians (40%) than whites (23%) (Figure 21). Furthermore, not all Asians respond similarly: Filipinos are much less likely to report that they were treated with respect (27%) than Vietnamese respondents (47%).

Figure 21. Percent of persons not treated with a great deal of dignity and respect by select race categories and place of origin

Figure 21. Percent of persons not treated with a great deal of dignity and respect by select race categories and place of origin

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: Commonwealth Fund Health Care Quality Survey, 2001.

Cultural competency

Similarly, the percent of persons who do not strongly agree that their doctor understands their background and values is higher among Asians (51%) than with whites (40%) (Figure 22) and is reported differently by different subgroups—ranging from 39% of Filipinos to 55% of Chinese.

Figure 22. Percent of persons who do not strongly agree that their doctor understands their background and values by select race categories and place of origin

Figure 22. Percent of persons who do not strongly agree that their doctor understands their background and values by select race categories and place of origin

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: Commonwealth Fund Health Care Quality Survey, 2001.

Health information

Finally, the percent of persons who do not find it very easy to understand information from their doctor's office is higher among Asians (58%) than whites (42%) (Figure 23). In addition, among Asians, this problem ranges from 46% of Filipinos to 74% of Vietnamese.

Figure 23. Percent of persons who do not find it very easy to understand information from their doctor's office by select race categories and place of origin

Figure 23. Percent of persons who do not find it very easy to understand information from their doctor's office by select race categories and place of origin

Notes:
ˆ Indicates reference group.
* p<0.05 for comparison of group with reference group. Note that no comparisons are made among Asians by place of origin.
Source: Commonwealth Fund Health Care Quality Survey, 2001.

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Quality and Access for American Indians and Alaska Natives

There are slightly over 2 million self-identified American Indians and Alaska Natives in the United States, with only 38% that continue to reside on Federal trust lands.38 Over 30% of the AI/AN population falls below the poverty standard, experiencing unemployment rates that are 2.5 times that of the national average.39 Lower life expectancy and a disproportionate disease burden exist, perhaps due to inadequate education, disproportionate poverty, geographic isolation, service delivery problems, and cultural differences.40

Of all AI/ANs nationwide, approximately 60% rely on the Indian Health Service (IHS) to provide access to health care. The IHS serves populations in 35 States through a network of 12 areas that operate over 500 facilities.41 The IHS service population is predominantly rural. The disproportionate incidence of disease and conditions experienced by this population increases the costs of delivering care. Because life-threatening disease and injury get first priority, patients with less severe problems find their medical care may be postponed or simply never carried out.42 For example, cardiovascular disease has become a major source of disability, increasing hospitalizations and both inpatient and outpatient procedures, resulting in significantly increasing expenditures for IHS and Tribal Contract Health Service funds. A need for aggressive treatment and prevention activities has been recognized by Tribes as well as the IHS.43

Among persons with diabetes being served by IHS facilities, 93% had a hemoglobin A1c measurement done in the past year, and 53% received an annual flu vaccine, not unlike the rates experienced by the overall U.S. diabetic population. However only 53% received a retinal eye exam in the past year compared to 67% for the overall U.S. diabetic population, and only 55% received a foot examination in the past year, compared to the overall U.S. diabetic rate of 66%.44

The annual IHS per capita personal health care expenditure for AI/ANs in fiscal year 2001 was $1,730 compared with $4,392 for the overall U.S. population— a 39% lower per capita expenditure than that for the U.S. population as a whole. A study by managed care organizations showed the average cost of caring for a person with diabetes ranges from $5,000-$9,000 annually.45 More than $150 million is spent annually by the IHS on the treatment of injuries, may be reduced by implementation of effective injury prevention programs, in turn making additional resources potentially available for the treatment of other health conditions.46

Researchers examining medical care expenditures found only 1 in 3 AI/ANs has private health insurance, compared with 80% of U.S. whites.47 According to the 1999 Federal Employees Health Benefit Plan (FEHBP) Disparity Index study, IHS funding is only 60% of the funding provided by mainstream employer-provided plans. In trying to account for the disparities, health care experts, policymakers, and tribal leaders are looking into funding and other factors that affect health care delivery to AI/ANs.

There are significant disparities experienced by American Indians and Alaska Natives residing in areas served by the IHS — males can expect to live 6 years less than the average U.S. male and AI/AN females can expect to live 5 years less than the average U.S. female. Infant mortality rates among AI/ANs are 24% higher than the total U.S. population. Mortality rates experienced by AI/ANs are disparate with overall U.S. rates: mortality rates are 67% higher due to alcohol-related causes, 318% higher for diabetes, 180% higher mortality rates due to accidents, 92% higher due to suicide, and 110% higher due to homicide.48, 49

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Rural Populations

Introduction

According to the U.S. Bureau of the Census, more than 60 million people live in rural areasi, and roughly 55 million live in "non-metropolitan counties."ii Americans in these areas face specific challenges to accessing, utilizing, and paying for quality health care. Access to specialty care can be particularly difficult due to a limited (and diminishing) supply of health care delivery sites. Many facilities that rural residents have grown to rely upon, including small rural hospitals, have either closed or are in serious financial straits.50

Among these few delivery sites, the supply of health care providers in rural areas is smaller per capita than other areas. While 20% of Americans live in rural areas, only 9% of the Nation's physicians practice in rural areas.51 Loan forgiveness and other programs that seek to recruit and retain health care clinicians in shortage areas are facing difficult times, in part because funding sources for such initiatives have grown unstable.

Transit and transportation needs are also pronounced among rural populations, who face longer distances to reach health care delivery sites—particularly when seeking specialty or dental care. Usually, rural areas have no public transportation infrastructure. Residents of frontier counties, where there is a low population density, find it particularly difficult to access and receive health care where it is required that one travel over long distances or have long travel times to reach sources of care. Of the 940 frontier counties, most have few health care services and 78 do not have any at all.52

The unique demographics of rural areas augment the challenges of providing high-quality health care. Compared with their urban counterparts, rural populations are disproportionately elderly and less affluent, more likely to describe their health as poor or fair and to lack private health insurance, and receive care in a less timely fashion.53, 54, 8 Furthermore, low population density makes it difficult to deliver services that target persons with special health care needs. Groups at particular risk include: the elderly, the poor, those living with AIDS or HIV infection, the homeless, mothers with children and adolescents, racial and ethnic minorities, those living with disabilities,55 the uninsured, and agricultural workers.

Difficulties accessing and receiving health care may help explain some of the adverse health outcomes experienced by rural residents. Residents of the Nation's most rural counties experience the highest death rates for children and young adults, as well as the highest mortality for ischemic heart disease and suicide among men.56 Although inadequate controls in research on this topic make it difficult to argue that rurality alone significantly impacts health57, rural minorities appear to be particularly disadvantaged in cancer screening and management, cardiovascular disease, and diabetes as compared with their urban counterparts.58

This section applies the NHDR measure set to residents of rural, non-Metropolitan Statistical Area (MSA) counties. It is the first step to understanding disparities in quality and access to care among rural populations. Yet significant gaps exist. Many health care needs and services of importance to rural populations are not addressed. In addition, sample size limitations become a significant problem as the general population is subdivided into small groups. Hence, these findings should not be interpreted as a comprehensive assessment of disparities in health care among rural populations.


i For Census 2000, the Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urban areas (UAs) and urban clusters (UCs). The Census Bureau classified as "urban" all territory, population, and housing units located within:

  • Core census block groups or blocks that have a population density of at least 1,000 people per square mile, and
  • Surrounding census blocks that have an overall density of at least 500 people per square mile.

Go to www.census.gov/geo/www/ua/ua_2k.html for more detail.

ii The Office of Management and Budget (OMB) classifies metropolitan counties as having a population of at least 50,000, or a census-defined urbanized area and a total metropolitan area population of at least 100,000 (alternatively, it could reflect the economic activities of a location meeting this definition).


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Quality of Care

Effectiveness of Care

Most measures of effectiveness included in the quality of care measure set are applicable to the rural population, although small sample sizes become an analytic impediment. In addition, measures related to chronic kidney disease, HIV/AIDS, mental health, and long term care could not distinguish urban and rural residents. In general, disparities observed in the general population were also observed when examining rural residents; yet few differences were observed in the measure of effectiveness related to diabetes and heart disease. This section focuses on measures that demonstrate different disparities between rural and urban residents:

  • Cancer screening
  • Maternal and child health
  • Respiratory diseases

Cancer screening

As in the general population, minority and rural residents of lower socioeconomic position are less likely to receive many cancer screening services. Disparities in colorectal cancer screening may be particularly pronounced for some rural residents and reduced for others. Among urban residents, receipt of fecal occult blood testing within the past 2 years is reported at about the same rates by blacks (33%) and whites (34%). In contrast, among rural residents, colorectal screenings are reported less often by blacks (19%) than whites (32%). Among urban residents, receipt of fecal occult blood testing is reported less often by Hispanics (21%) than by non-Hispanic whites (36%). Rural residents, Hispanics (27%), and non-Hispanic whites (32%) have similar rates (NHIS, 2000).

Among rural populations, there do not appear to be any racial or ethnic differences for receipt of Pap screening. However, poor (70%) and near poor (77%) rural women are less likely than high income women (85%) to have received a Pap test within the last 3 years (NHIS, 2000.)

Maternal and child health

Rural maternal and child health data were insufficient to make statistically significant comparisons.

Respiratory diseases

Data on immunization in the general population indicate that blacks and persons of lower socioeconomic position tend to be less likely to receive influenza and pneumococcal immunization. Disparities in immunization may be particularly pronounced for some rural residents and reduced for others. Among urban residents, the percent of high risk persons ages 18 to 64 who received influenza vaccination in the past year is similar across income groups. However, among rural residents, poor (19%) and near poor (24%) persons had lower rates compared with high income persons (32%). On the other hand, urban blacks (25%) had lower rates than urban whites (29%), while rural blacks (26%) and whites (27%) had similar rates (NHIS, 2000).

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Patient Safety

Inpatient safety

When disparities among hospitalized rural residents are identified, they typically parallel disparities in the general population. However, there is an exception among all hospitalized patients and hospitalized urban residents, where rates of birth trauma are lower among non-Hispanic blacks compared with non-Hispanic whites. Among rural residents, this measure is higher among non-Hispanic blacks (7.5 per 1,000 live births) compared with non-Hispanic whites (6.2 per 1,000) (HCUP SID, 2000).

Medication safety

In the general population, the percentage of persons with a provider that does not usually ask about medications and treatments other doctors may give is higher among blacks compared with whites and among Hispanics compared with non-Hispanic whites (go to Chapter 4). Similarly, among rural residents, this measure is higher among blacks (87%) compared with whites (78%) and among Hispanics (88%) compared with non-Hispanic whites (77%) (MEPS, 1999).

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Timeliness and Patient Centeredness

Timeliness is the core need of the health care system to reduce waits and harmful delays for those who receive care. Health care cannot prevent death and disability if it is delivered too late and delays can lead to complications that ultimately increase health care costs. In general, rural residents wait longer periods of time to be seen in a doctor's office but shorter periods of time to be seen in emergency rooms. Disparities in most measures of timeliness are similar or slightly reduced among rural residents compared with urban residents. Measures of patient centeredness overlap with several concepts discussed in the access section below.

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Access to Care

Health insurance

Individuals living outside of MSAs are about as likely as those living inside MSAs to be uninsured. Blacks (35%) and APIs (46%) living in non-metropolitan areas are more likely than non-metropolitan whites (24%) to be uninsured for at least part of the year. Similar to the general population, Hispanics living in non-metropolitan areas (50%) are twice as likely to be uninsured as non-Hispanics (24%). As with the general population, poor, near poor, and middle income individuals (41%, 40%, and 22%, respectively) in non-MSAs are more likely than high income individuals (12%) to be uninsured for at least some period of time. Rural residents with less than a high school education are more likely than those with more than a high school education to be uninsured for at least part of the year (42% vs. 18%, respectively) (MEPS, 1999).

Individuals living in non-MSAs are somewhat more likely to have public insurance coverage than those living in MSAs. In non-metropolitan areas, blacks are more likely than whites (32% vs. 16%) and Hispanics are more likely than non-Hispanic whites (29% vs. 15%) to spend some time enrolled in a public insurance program during the year. As with the general population, rural residents who are poor (51%) or near poor (29%) are more likely to have any public coverage than those with high incomes (3%). Similarly, rural residents with fewer than 12 years of education are more likely to be publicly insured than those with more than 12 years of schooling (25% vs. 4%) (MEPS, 1999).

Usual source of care

Generally, rural and urban populations have similar access to sources of ongoing care, yet disparities observed in the general population typically persist among rural residents. Hispanics and lower income populations fare worse than non-Hispanic whites and high income persons across most "usual source of care" measures in both the general and rural populations. One exception may relate to rural blacks. Data indicate that in urban areas, blacks are more likely to identify a clinic, hospital outpatient department, or emergency room as their source of ongoing care compared with whites. In contrast, in rural areas, blacks and whites have similar rates (NHIS, 2000).

Patient perceptions of inadequate access and need

Generally, unmet needs in rural populations are similar to urban populations, yet disparities observed in the general population typically persist among rural residents. Data indicate that rural Hispanics and lower income individuals are more likely than rural non-Hispanic whites and wealthier populations to experience delays in care and be less satisfied that they can obtain health care should they need it. Also, blacks in rural areas are more likely to report that their families did not receive care or medications because the family needed the money compared with rural whites (MEPS, 1999).

Getting care

Rural and urban populations face similar barriers to getting care with one exception: rural residents report that their provider does not have office hours at night or on weekends more frequently than do urban residents. However, disparities observed in the general population typically persist among rural residents. Data indicate that reporting of problems in obtaining referrals to specialists is higher among rural Hispanics than rural non-Hispanic whites and by lower income rural residents compared with high income rural residents. One exception may relate to the ability of Hispanics to contact their providers to discuss health problems over the telephone. In urban areas, Hispanics are more likely to report problems than non-Hispanic whites, but in rural areas, this problem is experienced about equally by Hispanics and non-Hispanic whites (MEPS, 2000).

Waiting times

Rural residents tend to have longer waiting times to see their provider but shorter waiting times in emergency departments. However, racial/ethnic and socioeconomic disparities in waiting times are similar among rural and urban residents. Only about 16% of the overall population, compared with 21% of the rural population, report waiting more than 30 minutes to see their health care provider. This trend is reversed in hospital settings where 12% of the general population waits an hour or more for care in emergency departments, compared with only 7% of rural residents. Similarly, waiting times of an hour or more for semi-urgent/non-urgent emergency department care are more common among the population at large (26%) compared with the rural population (15%). Race, ethnicity, education, and income disparities in waiting times at doctor's offices appear to be less significant in the rural population than among the general population (MEPS, 1999).

Patient-provider communication

Patient-provider communication is comparable between urban and rural residents. Disparities in the general population typically persist among rural residents. Data indicate that rural residents with lower incomes and less education are more likely to report indicators of poor communication compared with more affluent rural residents (Commonwealth Fund Health Care Quality Survey, 2001).

Patient-provider relationship

Rural and urban populations have similar perceptions of their relationships with their health care providers. Disparities observed in the general population typically persist among rural residents. Data indicate that the percent of rural residents who rate satisfaction with health care lower (<= d 6 on 0-10 scale) is higher among blacks compared with whites and among lower income and less educated persons compared with more affluent persons (MEPS, 2000).

Cultural competency

Rural residents are more likely to report that their doctor understands their background and values compared with urban residents. Unfortunately, there is too little cultural competency data on rural priority populations to discern if and to what extent health care disparities exist.

Health information

Rural populations are more likely to have problems obtaining and understanding health information. Compared with urban respondents, rural respondents less frequently find information from their doctor's office that is easy to understand and experience greater difficulty in using the Internet to obtain health information. Disparities observed in the general population typically persist among rural residents: lower income and less educated rural residents have more difficulty finding easy to understand information from their doctor's office compared with more affluent rural residents.

Receipt of health care

In general, disparities in receipt of health care do not differ between rural and urban residents. In the general population, many racial/ethnic minorities as well as low income and less educated persons are less likely to receive office or outpatient visits, prescription medications, and dental visits. During the past year, office or outpatient visits were less likely to be received by blacks compared with whites, by Hispanics compared with non-Hispanic whites, by persons with lower family incomes compared with persons with higher family incomes, and by less educated persons compared with more educated persons (go to Chapter 4). Similarly, among rural residents, office or outpatient visits are less likely to be received by blacks (62%) compared with whites (74%) and by Hispanics (55%) compared with non-Hispanic whites (75%) (MEPS, 1999). The fundamental issue behind these disparities may be attributed to socioeconomic disparities, which are also present among rural residents but tend to be attenuated.

In the general population, rates of emergency department visits and hospitalization are higher among blacks than whites. Among rural residents, rates of emergency department visits are also higher among blacks (70 per 100 population) compared with whites (47 per 100) (NHAMCS-ED, 1999-2000).

Non-Hispanic blacks, Hispanics, and APIs typically have lower rates of utilization for high variation surgeries. For example, rates of PTCA are lower among non-Hispanic blacks (335 per 100,000 population), Hispanics (297 per 100,000), and APIs (195 per 100,000) compared with non-Hispanic whites (535 per 100,000). Also, compared with non-Hispanic whites, APIs have lower rates of Cesarean delivery and higher rates of vaginal birth after cesarean delivery; a disparity persists among rural residents (HCUP SID, 2000).

Mental health care and substance abuse treatment

Data on mental health care and substance abuse treatment come from the National Household Survey on Drug Abuse (NHSDA) where sample sizes do not allow assessment of disparities among rural residents, compounded by the paucity of mental health providers in rural areas.

Avoidable admissions

In the general population, non-Hispanic blacks typically have higher rates of avoidable admissions while APIs typically have lower rates than non-Hispanic whites. Among rural residents, these disparities typically persist. In terms of rates of admissions for chronic obstructive pulmonary disease for urban residents, rates are higher among non-Hispanic blacks (271 per 100,000 population 18 and over) than non-Hispanic whites (241 per 100,000); but overall rates in rural populations are higher: the rate for non-Hispanic blacks is 320 per 100,000 population 18 and over compared with a rate of 379 per 100,000 for non-Hispanic whites (HCUP SID, 2000).

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Individuals with Special Health Care Needs

Introduction

Persons with special health care needs may be particularly vulnerable to disparities in health care. Though somewhat constrained by the availability of data, four populations with special health care needs are examined:

  • Children with special health care needs
  • Persons with disabilities
  • Persons who utilize long term care
  • Persons at the end of life.

This section applies relevant NHDR measures to individuals with special health care needs. These findings are supplemented with some analyses from the Medicare Current Beneficiary Survey. The measures used include some measures specific to these individuals, but many health care needs and services of importance to each of these populations are not addressed. In addition, since sample size limitations are a significant problem among subgroups of the general population, these findings should not be interpreted as a comprehensive assessment of disparities in health care among the individuals with special health care needs.

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Children with Special Health Care Needs

Background

The term "children with special health care needs" (CSHCN) was first used in the Omnibus Budget Reconciliation Act of 1989, replacing earlier categories such as "crippled," "handicapped," "disabled" or "chronically ill." The broader classification provides a framework that focuses on common goals and needs, especially concerning services administered through the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration in States and territories. With the focus on prevention, functional limitations, and increased medical needs, the MCHB defines CSHCN as those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by most children.

The prevalence of CSHCN is estimated to fall between 10% and 20%59 of the nation's 72.5 million children. CSHCN often have a higher need for health and rehabilitative services, such as services from specialty physicians, mental health providers, or physical, speech, or occupational therapists; or personal assistance for developing children. As provision of health care services evolves, access to well-coordinated care that includes the development of relationships that support family caregivers is particularly important in providing effective care to this population.

Currently, parents of CSHCN report problems obtaining needed care for their children, including obtaining referrals, finding a provider with the needed skill and experience to provide care, and getting the number of visits needed for their child's care, as well as the family's out-of-pocket cost for services and poor coordination of the services.60 There are few studies addressing racial and ethnic disparities within CSHCN; however, racial/ethnic disparities in access to care, having a usual source of care, rates of unmet need, and dissatisfaction with services have been identified.2

Data on CSHCN are examined for access measures of patient perceptions of inadequate access and need, patient-provider communication, and the patient-provider relationship.

Patient perceptions of inadequate access and need

In general, CSHCN have greater unmet care needs than other children. However, among CSHCN, disparities in unmet need are noted. Among CSHCN, the percent of children who always can get appointments for routine care as soon as wanted is higher among blacks (55%) than whites (43%). Significant differences in the percent of children who always can get care for illness or injury as soon as wanted are not noted (MEPS, 2000).

Patient-provider communication

Disparities in patient-provider communication among CSHCN are also noted. Among CSHCN, the percent of children whose providers always listened carefully to them is higher among blacks (75%) than whites (60%) (MEPS, 2000).

Patient-provider relationship

Finally, disparities in patient-provider relationships among CSHCN are also noted. Among CSHCN, the percent of children who rate their health care 6 or worse on a scale from 0 to 10 is higher among children in poor households (32%) compared with children in high income households (12%) (MEPS, 2000).

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Persons with Disabilities

Background

There are multiple ways of defining and measuring disability. Two of the more common approaches are to identify functional activity limitations or to identify those meeting the criteria for eligibility for a program, such as Social Security Disability Insurance (SSDI), that addresses disability. A particular challenge in reporting on racial/ethnic and socioeconomic disparities related to disability is that many data collections do not capture disability and, when collected, do not have adequate sample sizes of the disabled to examine racial/ethnic and socioeconomic disparities.

Analyses of recent trends in disability and functioning among older adults have shown improvements in the last decade, with the prevalence of having any disability declining significantly during the 1990s. However, there are considerable gaps in availability of measures and understanding of trends in disparities across major racial and ethnic groups with respect to functional limitations in the elderly population.61 About 5.6 million beneficiaries under age 65 qualified for Medicare in 2001, and that number is expected to grow to more than 9 million by 2020.62 63 The non-elderly disabled beneficiaries are more likely to have lower income and difficulties accessing care than their elderly Medicare counterparts.5

Data on persons with disabilities are examined below in quality of care and access to care, including patient perceptions of inadequate access and need and utilization of care.

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Quality of Care

In general, MCBS findings indicate the presence of racial/ethnic and socioeconomic disparities in quality of health care among disabled persons. Among the disabled elderly, the percent of persons who report problems with quality of care is higher among APIs (11%) compared with whites (4%) and among persons in poor households (6%) compared with persons in high income households (3%). Small sample sizes preclude assessment of disparities in quality of health care among the disabled non-elderly.

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Access to Care

In general, data indicate the presence of racial, ethnic, and socioeconomic disparities in access to health care among disabled persons. For example, among the disabled elderly, the percent of persons with a problem getting to the doctor from home is higher among Hispanics (16%), compared with non-Hispanic whites (7%). In addition, there is an income gradient with this measure of physical access to a doctor: persons in poor (11%), near poor (9%), and middle income (7%) households experience more difficulty than persons in high income households (4%) (MCBS, 1999).

Among the disabled, blacks (12%) and Hispanics (12%) are less likely to report delayed care due to cost compared with whites (20%) and non-Hispanic whites (21%), respectively (MCBS, 1999).

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Persons Who Utilize Long-term Care

Background

Long-term care is the provision of personal, social, and medical services to persons who have functional or cognitive limitations in their ability to perform self-care and other activities necessary to live independently. It includes the provision of services at home, in the community, and in special facilities. As the number of elderly Americans increases from 35 million in 2000 to an estimated 71 million in 2030,64 long-term care is expected to increase.

Long-term care includes home health care that is available for those who can be managed at home. In 1996, about 12,000 home health care agencies provided care and 7.8 million persons completed episodes of care. About two-thirds of home health care discharges are elderly.65

For those with serious disabilities requiring 24-hour care and needs that can often be better met in a special facility, nursing homes are an option. In 1999, there were 1.6 million nursing home residents residing in 18,000 nursing homes.66 Just over half of nursing home residents are age 85 and over. Activities of daily living measure a person's ability to perform six basic self-care tasks: bathing, dressing, eating, transferring from a bed to a chair, toileting, and walking. On average, residents need help with 4.4 activities of daily living. Nursing home care costs $56,000 per year, and expenditures totaled almost $80 billion in 1998, about half of which were paid by Medicaid and Medicare. About 70% of nursing home residents are supported in part by Medicaid.67

In recent years, use of home health care and of nursing home care has declined. However, because growth in the elderly population has outpaced growth in the supply of nursing home beds, nursing homes are caring for older patients with more functional limitations.68 69

Racial, ethnic, and socioeconomic disparities in nursing home care have been documented.70 Differences in the management of pain71 and the receipt of rehabilitative services72 among nursing home residents have been demonstrated.

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Quality of Care

Disparities in quality of long-term care are present. Two types of care are examined: immunization of nursing home residents, which reflects medical care received by nursing home residents, and quality of nursing home care.

Immunization

Data on immunization of nursing home residents from the NNHS are sparse, allowing only comparison of blacks with whites. Significant disparities in influenza vaccination are not observed, but disparities in pneumococcal vaccination among some nursing home residents are present. Specifically receipt of influenza vaccination is significantly lower among black women (21%) compared with white women (36%) as well as lower among blacks than whites in two ages groups: 29% of blacks vs. 39% of whites ages 75 to 84 and 32% of blacks vs. 41% of whites ages 85 and over (NNHS, 1999).

Quality of nursing home care

Again, disparities are noted, and racial and ethnic minorities have more favorable care on some measures and less favorable care on others. The percent of nursing home residents with pain is lower among non-Hispanic blacks (7%), Hispanics (7%), and APIs (5) compared with non-Hispanic whites (10%). However, the percent of residents in physical restraints is higher among Hispanics (12%) and APIs (12%) compared with non-Hispanic whites (8%) (CMS's Nursing Home Resident Profile Table).

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Access to Care

Due to sample size constraints, the NHDR uses only black-white comparisons for these measures. Among persons ages 65 and over, rates of home health care discharge and nursing home discharge did not differ significantly between blacks and whites. Similarly, among persons ages 18 to 64, rates of home health care discharge did not differ significantly between blacks and whites. However, among persons ages 18 to 64, rates of nursing home discharge are higher among blacks (22 per 10,000 population) compared with whites (16 per 10,000). In addition, when discharged from a nursing home, the percent of persons who were stabilized or recovered is lower among blacks (22%) than to whites (34%) (NHHCS, 2000).

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Persons at the End of Life

Background

The quality of life and the quality of health care for individuals who are approaching the end of life is an integral and important part of the delivery of health care. As in other aspects of health care delivery, the social, cultural, and economic structure of the American health care system affects the experience of dying. Nationally, only 25% of deaths occur at home, although more than 70% of Americans say that this is where they prefer to die. About half of all deaths in the United States occur in hospitals, but less than 60% of hospitals in any given State offer end-of-life services.73 Evidence suggests persons living in wealthier areas are more likely to use hospice care.74

The Institute of Medicine's 1997 Approaching Death report emphasized that a significant number of people experience needless suffering, fear, and distress at the end of life. Research has found that many Americans are concerned that: (1) caregivers will overtreat, thereby protracting death by providing clinically inappropriate or care unwanted by the patient; (2) caregivers will underuse effective treatments to relieve pain or other physical or psychological symptoms; and (3) the quality of end-of-life care will not involve adequate pain and symptom management75 and lack access to supportive care.

End-of-life care includes the period of time during which an individual experiences declining health from an ultimately terminal illness or condition. For many, this period of time should include palliative care which focuses on addressing the control of pain and other symptoms (e.g., nausea, labored breathing, etc.), as well as psychological, social, and spiritual distress.

About one quarter of Medicare's dollars are spent on 5% of its beneficiaries in the last year of their life, half of which is spent in the last month of life.76 Racial/ethnic disparities in Medicare expenditures in the last year of life have been documented.77, 78 In addition, minority Medicare beneficiaries may be more likely to die suddenly with little or no interaction with the health care system before dying.79

While more research is needed to understand disparities in end-of-life care associated with age, gender, or income, access to appropriate end-of-life care with effective provider relationships continues to be of great concern. Today we are challenged by the affects of constraints within the health care system on patients, providers and institutions, and the need to address racial/ethnic disparities in end-of-life care, including palliative care.80

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Quality of Care

At the end of life, disparities in quality of health care are still present. Two measures of quality of palliative care for cancer were examined: (1) percent of people who died of cancer who received hospice care and (2) median length of stay for cancer patients who received hospice care. Low use of hospice and short lengths of stay in hospice among cancer patients would suggest suboptimal palliative care.

Data limitations only allow for black-white comparisons. While median lengths of stay for cancer patients in hospice were similar between blacks and whites, the percent of cancer patients who used hospice care prior to death was lower among elderly blacks (32%) than elderly whites (52%) (NNHS, 1999).

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Access to Care

Mean Medicare expenditures in the last year of life were higher among blacks ($31,759) compared with whites ($23,980). Since information on patient income or education is not available from this source, mean expenditures of Medicare beneficiaries who have both Medicare and Medicaid coverage (dual eligibles) was compared with all other Medicare beneficiaries as a crude proxy of socioeconomic position. Mean expenditures of dual eligibles are not significantly different from mean expenditures of other Medicare beneficiaries. These findings persist after stratification by age, gender, and comorbidities.

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