ELIMINATING HEALTH DISPARITIES IN AN URBAN

AREA

VIRGINIA A. CAINE, M.D., DIRECTORMARION COUNTY HEALTH DEPARTMENT

INDIANAPOLIS, INDIANAMay 1, 2002

“Racial and ethnic disparities in health care are unacceptable in a country that values equality and equal opportunity for all. And that is why we must act now with a comprehensive initiative that focuses on health care and prevention for racial and ethnic minorities.”

President Bill ClintonFebruary 21, 1998

President’s Initiative to Eliminate Racial and Ethnic Disparities in

HealthTarget conditions

• Infant mortality

• Cancer screening and management

• Cardiovascular disease

• Diabetes

• HIV infection/AIDS

• Immunizations

Healthy People 2010

Two Overarching Goals:

• Increase Quality and Years of Healthy Life

• Eliminate Health Disparities

Differences in the incidence, prevalence,mortality, and burden of diseases and other adverse health conditions that exist among specific

population groups in the United States.

What Are Health Disparities?

Why The Interest In Disparities?

• The changing demography of the American population

• The persistence of disparities in the health status of racial and ethnic minorities

Percent Distribution of U.S. Population by Race and Ethnicity, 2000

African American/Black12.2%

Asian/Pacific Islander3.8%

Hispanic/Latino11.9%

American Indian/Alaska Native0.7%

White, not Hispanic/Latino71.4%

Source: U.S. Census Bureau, 2000

Percent of the Population by Race and Hispanic Origin, 2000 and 2050

71.8%

52.8%

11.4%

24.5%

12.2%13.6%

AmericanIndian/Alaska Native

Asian/Pacific Islander

Black/African American

Hispanic/Latino

White, not Hispanic/Latino

2000 2050

8.2%3.9%

Source: U.S. Bureau of the Census 2000

Minority people are the majority in three states

• California (50.1%)

• Hawaii (71%)

• New Mexico (53%)

• District of Columbia (71%)

Emerging Majorities

Minority people are now at least 30% of the population in ten states:

• Texas (45%)

• Mississippi (38%)

• Maryland (36%)

• New York (35%)

• Georgia (34%)

• Arizona (32%)

• Florida (32%)

• New Jersey (32%)

• South Carolina (32%)

• Nevada (30%)

Emerging Majorities

Percent of the Population by Race and Hispanic Origin, Indiana

1990White, not Hispanic: 90.1%

Black/African American: 7.8%

Asian/Pacific Islander: 0.2%

Hispanic/Latino: 1.7%

American Indian/Alaska

Native: 0.3%

2000White, not Hispanic: 86.5%

Black/African American: 8.3%

Asian/Pacific Islander: 1.0%

Hispanic/Latino: 3.6%

American Indian/Alaska

Native: 0.7%

Life Expectancy at Birth, 1900-1998

20

30

40

50

60

70

80

1980

YearsWhite

Black

0

SOURCE: CDC/NCHS, National Vital Statistics Systems, 1900-98

19981900 1950

47.6

33.0

71.3

77.3

Infant Mortality Rates, 1980-1998

0

5

10

15

20

25

1980 1985 1990 1995 1998

White

Black

Deaths <1 year/1000 live births

10.9

6.0

22.2

14.3

SOURCE: CDC/NCHS, National Vital Statistics System, 1980-1998

Infant mortality rates by race and Hispanic origin of mother

5.3

14.3

6.3

6.3

0 4 8 12 16

Total Hispanic

Non-Hispanic white

Non-HispanicblackAsian/Pacific Islander

Deaths <1 year per 1000 live birthsSOURCE: CDC/NCHS, National Vital

Statistics System, 1995

Infant mortality rates by Hispanic origin of mother

5.3

5.3

8.9

6.0

6.3

0 2 4 6 8 10

Total HispanicMexican

Puerto Rican

Cuban

Central/South

American

Deaths <1 year per 1000 live births

SOURCE: CDC/NCHS, National Vital Statistics Systems, 1995

Infant mortality rates by Asian/PacificIslander subgroup

5.6

6.6

5.3

3.8

5.3

0 1 2 3 4 5 6 7

Asian/Pacific Islander

Chinese

Japanese

Hawaiian

Filipino

Deaths <1 year per 1000 live birthsSOURCE: CDC/NCHS, National Vital Statistics Systems, 1995

Coronary heart disease death rates

78.1

81.2

63.1

151.3

111.4

72.7

74.5

56.7

102.1

140.4

0 50 100 150 200

1990

1996

Per 100,000 populationNOTE: Death rates are age-adjusted to 1940 standard million age distribution. A/PI is Asian American or Pacific Islander; AI/AN is American Indian or Alaska Native. SOURCE: CDC/NCHS, National Vital Statistics System, 1990 and 1996

White

Black

A/PI

AI/AN

Hispanic

Racial and Ethnic Disparities: Morbidity and Mortality

• African American men have a 40 percent higher heart disease rate than White men

• Women of Vietnamese origin in the United States suffer from cervical cancer at nearly five times the rate than White women

• Native Americans have a diabetes rate that is nearly three times the rate of Whites. The Hispanic rate is nearly double that of Whites

• African American women are 28% more likely to die from breast cancer, although the incidence is greater in White women

Racial and Ethnic Disparities: Morbidity and Mortality

How Do We Explain Racial And Ethnic

Disparities In Health?

Several Causal Factors

• Socioeconomic status (SES)

• Health risk behaviors

• Psycho-social factors

• Acculturation

• Biologic/Genetic factors

• Health care

Socioeconomic Status

•Education

•Occupation

•Income

•Environment

•Culture

14.8

10.0

6.5

13.9

11.6

5.0

10.4

4.1

0

5

10

15

NHW=Non-Hispanic White NHB=Non-Hispanic Black

<12 12 13-15 16+

Infant Mortality Rates in the United States

Deaths/1000 Live births

SOURCE: CDC/NCHS/NVSS

Education in years

Health Risk Behaviors

31.9

1.7

16.3

27.9

1.2

21.2

39.1

1.8

23.4

0 10 20 30 40 50

>1 oz. alcoholper day

Current smokers

Regular exercise

or sports

SOURCE: CDC/NCHS, National Health Interview Survey, 1990

White

BlackHispanic

FemaleHealth Risk Behaviors

percentage engaging in activity

Health Risk BehaviorsMale

38.4

8.8

30.9

42.2

8.2

32.5

44.1

10.1

28.0

0 10 20 30 40 50

Current smokers

>1 oz. alcoholper dayRegular

exercise or sports

White

BlackHispanic

percentage engaging in activity

SOURCE: CDC/NCHS, National Health Interview Survey, 1990

Age-adjusted Prevalence of Obesity (BMI 30.0)

25.4

30.0

14.8

43.2

37.4

22.4

0 10 20 30 40 50

Non-Hispanic

Blacks

Non-Hispanic

Whites

Mexican Americans

SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80 Third National Health and Nutrition Examination Survey, 1988-94

Percent

Female

NHANES III

NHANES II

>

Age-Adjusted Prevalence of Obesity (BMI 30.0)

Male

23.1

21.3

20.0

15.4

15.0

12.0

0 5 10 15 20 25

Non-Hispanic

WhitesNon-

Hispanic Blacks

Mexican Americans

SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80 Third National Health and Nutrition Examination Survey, 1988-94

NHANES II NHANES

III

Percent

>

Psychosocial Factors

Psychosocial Factors

• Large complex literature relating factors such as stress and discrimination with racial/ethnic differences in hypertension

Acculturation

Acculturation

Some health behaviors “worsen” with acculturation

Biological and Genetic Factors

Health Care

Percentage Uninsured Under Age 18United States

21.0 20.0

30.0

05

10

1520253035

404550

White Black Hispanic

Per

cen

t o

f P

op

ula

tio

n

Source: CPS, USCB

Health Care Coverage of Persons Under 65 (Age-adjusted)

18.05

19

15

35

15.0

25.0

5.0

65.4

55

80

25.055

0 20 40 60 80

NH White

All Hispanic

NH Black

SOURCE: CDC/NCHS, National Health Interview Survey, 1996

PrivateMedicaid/Public Assistance

Not covered

Percent

Asian/PI

Health CareExtensive evidence of racial and/or ethnicDifferences in utilization of health care

• Diagnostic tests and procedures• Therapeutic procedures• Intensity of care• Pain control• Transplants• Preventive services

Possible Explanations for the Racial and Ethnic Differences in Utilization

• Socioeconomic status

• Language

• Insurance status

• Severity of illness

• Patient health behaviors

• Provider bias

IOM Report Findings

Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.

Factors contributing to racial and

ethnic disparities in healthcare:• Health systems• Healthcare providers• Patients and utilization managers• Bias, stereotyping, prejudices• Clinical uncertainty on the health of

care providers

IOM ReportFindings

IOM ReportRecommendations

• Increase awareness of racial and ethnic disparities among the general public, key stakeholders, and healthcare providers

• Legal, regulatory, and policy interventions

• Health systems interventions

Factors Influencing Optimal Medical Care

• Effective patient-physician communication• Overcoming cultural and linguistic barriers• Access to affordable health insurance• Alternatives to hospital emergency rooms• Improvement in continuity of care• Improving information for patients• Participate in the latest quality

improvement innovations

Of all the forms of inequality, injustice in health is the most shocking and the most inhumane.

-- Dr. Martin Luther King, Jr.