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Causes of Health Disparities

Socioeconomic Status

Socioeconomic Status

Income and educational attainment on average are lower for ethnic/racial minority groups.

Poverty Rates

  • In 2008, about 29 percent of U.S. adults (25 years of age or older) had at least a bachelor's degree, including 52 percent of Asian/Pacific Islander adults, 33 percent of White adults, 20 percent of Black adults, 13 percent of Hispanic adults, and 15 percent of American Indian/Alaska Native adults.21
  • Hispanic adults in the United States had lower rates of high school attainment than adults of other racial/ethnic groups. In 2008, about 62 percent of Hispanic adults over the age of 25 had completed at least high school or the equivalent, while 92 percent of Whites, 89 percent of Asians/ Pacific Islanders, 83 percent of Blacks, and 78 percent of American Indians/Alaska Natives had done so.21
  • Black children and adolescents under age 18, experience poverty more than their same- age peers in other racial/ethnic groups. Hispanic youths had the second highest poverty rate, followed by White and A/PI youth.22

 

A link between poverty, low educational attainment and poorer health outcomes with increased morbidity and mortality is well established. Heart disease, diabetes, obesity, elevated blood lead level, and low birth weight are more prevalent among individuals with low income and low educational attainment.

Additionally, higher socioeconomic groups have recently achieved greater improvements in health status than lower socioeconomic groups.23

Federal initiatives have acknowledged the importance of the relationship of socioeconomic inequalities to health.

The percentages of children who were living in poverty were higher for Blacks (34 percent), American Indians/Alaska Natives (33 percent), Hispanics (27 percent), and Native Hawaiians or Other Pacific Islanders (26 percent), than for children of two or more races (18 percent), Asians (11 percent), and Whites (10 percent).21

Culture

Culture plays an important role in determining health related beliefs and practices.

Effective health care delivery requires the application of knowledge of cultural health related beliefs, practices and health risks.

For example, individuals from specific cultures may require screening for diseases that are more prevalent in that culture, react differently to a medication, or use traditional healing practices. Health care delivery organizations are legally required to respond to the language and cultural needs of their service area by becoming "linguistically and culturally competent.

Cultural competence is defined as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.24

Thus, cultural competence goes beyond awareness and sensitivity by requiring that health care providers apply an understanding and respect for different cultures when working with clients from cultures different from their own. Culturally competent health providers could help reduce disparities.24

Techniques that health care agencies could use to become more culturally competent include:24

  • Interpreter services
  • Recruitment and retention of minority staff
  • Training programs to increase cultural awareness, knowledge, and skills, leading to changes in staff behavior and patient-staff interactions
  • Coordination with traditional healers
  • Use of community health workers
  • Including family and/or community members
  • Immersion in another culture
  • Administrative and organizational accommodations

 

African American Culture and Health

In a study of African American health attitudes, beliefs, and behaviors, 30% believed that their health was dependent upon fate or destiny and only about 50% felt health was a high priority in their life. Participants in this study also stated that they believed health talks and other health information were helpful in preventing disease.25

In another study, caregivers of obese or super-obese children do not always believe the child's weight is a potential health problem. Reasons for lack of concern include a culturally based greater acceptance of a large body size, lack of knowledge about the connection between childhood obesity and future health risk, and feeling invulnerable.26

Hispanic Culture and Health

Some common cultural-based Hispanic health beliefs and practices include:27

  • Placing little value on early detection and preventative health care
  • Lack of knowledge of the benefits of early detection and prevention
  • Infrequent medical visits and delayed treatment when symptoms occur
  • Fatalisimo, a cultural norm that combines negative expectations with a relinquishment of power to God
  • A need for confianza (trust) and personalismo (personalized caring) in medical interactions

 

Access to and Utilization of Health Care

Several different factors both nonfinancial and financial impact minority children's access to and utilization of health care services.27,28

Inequalities in use of preventive and primary care services have been documented with respect to vision screening, prescription medicines, equipment for the management of asthma, and access to and use of mental health services.28 The result places these children at risk for inadequate preventive care, more lost school days and health problems as adults.28

Nonfinancial utilization factors may include:

  • Caregivers are unaware of services
  • Caregivers feel uncomfortable with providers
  • Health provider attitudes
  • Unavailability of translators
  • Long waiting times
  • Inconvenient location 25,28

 

Health Insurance

Minorities are far less likely than Whites to have private coverage and far more likely to be uninsured. Uninsured rates for Hispanics (30.7%) and blacks (20.8%) are higher than for non-Hispanic whites (11.7%).29

When racial and ethnic minorities had insurance, they were more likely to be covered by public rather than private insurance. Hispanics were most likely to be uninsured (35.4%), followed by

American Indians (27.3%), Blacks (25.6%) and Asians (21.2%).30

Among adults 18–44 years of age, the percentage with private coverage declined from 72% in 1999 to 62% in 2009, while Medicaid coverage increased from 6% to 10%, resulting in an increase in the percentage of persons 18–44 years of age who were uninsured. The uninsured and the difference health insurance makes [online].31

Health insurance coverage has declined over the past decade due to fewer employers offering health insurance and increasing health premiums.27,30

Minorities face more difficulties obtaining health insurance coverage, especially through employers, than White Americans. Minorities also are less likely to accept offers of health insurance from their employers. Public insurance does not close the insurance gap between minorities and White Americans.27

Individuals with low income and educational attainment are less likely to have health insurance. Individuals with low education were less likely to enroll in a health insurance program even if eligible.32

Coverage has an impact on whether people have a usual source of care. People with health insurance coverage—private or public—are much more likely to have a usual source of care than people without coverage.32

The perceived need for a usual source of care may be low among people who say they seldom or never get sick. Some people do not feel the need for a usual source of care. Yet, because they lack a usual source of care, these people may be at risk for missing preventive care and early diagnosis and treatment of serious diseases. 32

Disparities for health insurance coverage exist for children as well:

Uninsurance rates for children were:33

  • 6% for whites
  • 21% for Latinos
  • 15% for Native Americans
  • 7% for African Americans
  • 4% for Asians or Pacific Islanders

 

The proportions with a usual source of care were as follows:

  • Whites, 90%
  • Native Americans, 61%
  • Latinos, 68%
  • African Americans, 77%
  • Asians or Pacific Islanders, 87%.

 

Between 1999 and 2009, the percentage of children under 18 years of age with private health insurance declined from 69% to 56%. During this period, Medicaid coverage (which includes the CHIP category) increased from 18% to 35%. This led to a decline in the percentage of children who were uninsured, from 12% in 1999 to 8% in 2009.34

In 2009, children 6–17 years of age were more likely to be uninsured than younger children, and children with a family income below 200% of the poverty level were more likely to be uninsured than children in higher-income families. 34

Hispanic children are more likely than any other racial/ethnic group to be uninsured, with the Mexican American subgroup most likely to be uninsured.28,30,35

Contributing factors include parents working in economic sectors that lack employment linked health benefits and multiple and persistent barriers experienced by Latinos in accessing health care.

The older the Latino child, the more likely he or she is to have no medical contact compared to his or her African American and non-Hispanic White peers.28

  • African American children are most likely to be covered by Medicaid.
  • Children under six years of age are more likely to be covered than children age 6-17 years.

 

Other factors impacting health insurance coverage are:

  • Parental education: Children of parents with a higher level of education are most likely to privately insured and least likely to be uninsured.
  • Employment of parents: children living with two employed parents are most likely to be privately insured and least likely to be uninsured.
  • Residence: Children living in metropolitan statistical areas are more likely to privately insured and least likely to be uninsured.35

 

Federal regulations require that states provide health care coverage for:

  • children through age 5 in families who live with incomes below 133% of the federal poverty level
  • children ages 6-13 in families with incomes at or below the federal poverty level
  • children ages 14-18 only if they would have been eligible under the Aid to Families with Dependent children program rules

 

Many states have expanded health care coverage beyond the federal requirements.

There are 9,069,000 uninsured children in the United States.

Of these children, more than 60 percent are racial or ethnic minorities.36

The Children's Health Insurance Program (CHIP) provides coverage to eligible low-income, uninsured children who do not qualify for Medicaid. CHIP was originally enacted by the Balanced Budget Act of 1997 (BBA) (1). The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA, P.L. 111–3) reauthorized CHIP through fiscal year 2013. CHIP is jointly financed by federal and state governments and is administered by the states.34

The Affordable Care Act of 2010 maintains CHIP eligibility standards in place as of enactment through 2019. This legislation extends CHIP funding to October 1, 2015, when the already enhanced CHIP federal matching rate will be increased be 23 percent, brining the average federal matching rate for CHIP to 93%. This act also provided an additional $40 million in federal funding to continue effort to promote enrollment in Medicaid and CHIP.34

Utilization of Preventive Care

Uninsured children are significantly less likely to have a personal doctor or nurse than insured children regardless of race, yet the disparity is larger for black and Hispanic children. Uninsured black children in 2003 were 35 percent less likely to have a usual source of care than insured black children, and uninsured Hispanic children have an even larger disparity; they are more than 45 percent less likely to have a personal doctor or nurse than insured Hispanic children. But uninsured white children were only 18 percent less likely to have a usual source of care than insured white children. (Figure 2).23

Having a usual source of care increases the chance that people receive adequate health services, such as preventive care. With adequate health care, health status disparities can be addressed.36

Additionally, for Hispanic children, limited knowledge of English can make it difficult for parents to find a provider with whom they can clearly and comfortably communicate and who understands their knowledge and beliefs about health care.

  • About 30 percent of Hispanic and 20 percent of black Americans lack a usual source of health care compared with less than 16 percent of whites.
  • Hispanic children are nearly three times as likely as non-Hispanic white children to have no usual source of health care.
  • African Americans and Hispanic Americans are far more likely to rely on hospitals or clinics for their usual source of care than are white Americans (16 and 13 percent, respectively, v. 8 percent).37

 

The children least likely to have a usual source of health are

  • Hispanic or Black youth
  • Teenagers living with parents who have less than a high school education
  • Live in the South (10.5%) and West (12.4%) rather than the Northeast (5.8%) and Midwest (4.9%)35

 

Racial and ethnic disparities are still present after adjusting for differences in health insurance, income, and other individual characteristics. Equalizing the income and health insurance status of African Americans and Hispanics to that of whites eliminates 33% to 45% of the disparities in usual source of care and use of ambulatory care.38

Children with a usual source of health care often face other barriers to receiving needed health care.

Access to Dental Care

Millions of children have little to smile about. For them the daily reality is persistent dental pain, endurance of dental abscesses, inability to eat comfortably or chew well, embarrassment at discolored and damaged teeth, and distraction from play and learning.39

Extent of the Problem

  • Four to five million children experience untreated dental disease sufficiently extensive and severe enough to cause chronic dental pain.
  • Nearly 1 in 5 preschoolers have experienced some visually evident tooth decay increasing to more than 50% by middle childhood and 80% by late adolescence
  • Once dental caries have been established, future decay is likely, as the process stabilizes within the oral cavity
  • Certain children are more vulnerable; In permanent teeth, 80% of all cavities occur in 25% of children.
  • Decayed teeth in youth from lower-income households are more likely to remain untreated at all ages.40,41
  • That report also estimates that poor children suffer nearly 12 times more restricted-activity days, such as missing school, as a result of dental problems, than higher-income children.31

 

Substantial disparities in the prevalence, severity, and consequence of oral health problems exist among American youth. Children from low-income families, who are a racial or ethnic minority, and whose parents have limited education experience higher caries rates.41

  • Preschoolers living in poverty have twice the odds of having decayed teeth, twice the extent of decay when they have disease, and twice the pain experience of their more affluent peers.
  • Additionally, they are half as likely to have a dental visit. This occurs despite the fact that low-income children are eligible for comprehensive dental coverage through Medicaid.41
  • Poor adolescents were less likely to have had a dental visit in the past year than near-poor and non-poor adolescents (64% vs. 80%)42
  • Low-income adolescents, particularly those living near poverty are less likely to have dental insurance (51%) than adolescents with higher family incomes (65%) or those living below the poverty level (60%)42
  • 2-4 times as many Black and Mexican American children and adolescents and Asian/Pacific Islander children have untreated dental caries as white children and adolescents.23

 

In 2006, nearly a quarter of all children age 2-17 had not had a dental visit in the past year, but poor and low-income children were more likely to lack a recent visit than higher-income children (31% and 33% versus 18%).43

Reasons for Disparities:

Practitioner Supply

The supply of dentists available to treat young children is inadequate and decreasing; There are only 3500 pediatric dentists nationwide

Inadequate numbers of dentists treat Medicaid eligible children (only 10% of dentists participate nationwide). Most dental care is provided in practices with only 1 to 2 dentists who have limited ability to offset low Medicaid fees or costs of missed appointments

Public Health Infrastructure

The number and distribution of providers participating in programs to reach underserved children is inadequate to meet the need. Only 58% of federally qualified health center grantees provide dental services. Thus, nearly half of the 4 million children who obtain their routine health care in community health care centers have no access to dental care in their health center. 41,42

Water fluoridation is the most cost effective measure for preventing caries, yet only 62% of community water supplies are fluoridated.41

Insurance Coverage

Insurance coverage can facilitate provision of care. Children who have no dental coverage are three-fold more likely to have an unmet dental need than are children with dental coverage. 42

Inadequate reimbursement rates that often do not cover costs

Burdensome provider and administrative barriers to enrollment, procedure prior-authorization and claims filing requirements

Behavioral and cultural disjunctions between dentists and patients' knowledge and expectations that are expressed as missed appointments or lack of compliance.

Transportation

Language barriers 41,42

Racism

Racism provides another reason for the health disparities of minorities. In fact, negative stereotypes of minority racial/ethnic groups are common.

According to national data 45% of Whites believe that most Blacks are lazy, 51% that most Blacks are prone to violence, 29% that most Blacks are not intelligent, and 56% that Blacks prefer to live off welfare.

Whites also are reluctant to acknowledge positive stereotypes of Blacks.

Only 17% of Whites indicated that most Blacks are hard-working, 15% that most Blacks are not prone to violence, 21% that most Blacks are intelligent and 12% that most Blacks prefer to be self-supporting.

Whites possess negative views of all minority racial groups, with Blacks being viewed more negatively than any other group.44

Racism provides one explanation for the low socioeconomic attainment of minorities. Minorities live in areas of concentrated poverty with poor schools that limit educational and employment opportunities. High paying low skill jobs have followed Whites migration from cities to suburbs resulting in higher rates of job losses for African Americans. In addition, impoverished segregated communities contain many barriers that impact employment and socioeconomic status.44

Individuals who perceive themselves experiencing racism are more likely to suffer psychological distress, depressive symptoms, substance use, and physical health problems. 44

The high rates of hypertension among African Americans may be explained in part by exposure to chronic stressors such as perceived racism.45 Dark-skinned Blacks have significantly higher rates of hypertension than their lighter-skinned counterparts and are 11 times more likely to experience frequent racial discrimination when compared to their light-skinned counterparts.46 African American youth exhibit greater cardiovascular reactivity to various stressors compared with Whites.47 This effect was buffered by family socioeconomic status.48

Conclusion

In summary, the problem of racial disparities is complex and no one causative factor or magic bullet to resolve the problem can be identified.

Reducing racial disparities will require addressing nonfinancial barriers to accessing health care such as the cultural and linguistic competency of health providers and institutions, the lack of health care providers where minority groups reside, both intentional and unintentional discrimination within the health care system, and perception of discrimination on the part of members of various racial and ethnic groups.19

References

  1. Aud, S., Fox, M., and Kewal Ramani, A. (2010). Status and Trends in the Education of Racial and Ethnic Groups (NCES 2010-015). U.S. Department of Education, National Center for Education Statistics. Washington, DC: U.S. Government Printing Office.
  2. National Adolescent Health Information Center. (2003). Fact Sheet on Demographics: Adolescents. San Francisco, CA: Author, University of California, San Francisco.
  3. U.S. Department of Health and Human Services. (2000) Healthy People 2010 (Conference Edition, in Two Volumes). Washington, DC: January 2000.
  4. Brach C & Fraser I. (2000) Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model. Medical Care Research and Review 57(Suppl 1): 181-217.
  5. Lewis RK & Green BL. (2000) Assessing the health attitudes, beliefs, and behaviors of African Americans attending church: a comparison from two communities. J Community Health 25: 211-224.
  6. Young-Hyman D, Herman LJ, Scott DL, & Schlundt DG. (2000) Care giver perception of children's obesity-related health risk: a study of African American families. Obes Res 8: 241-248.
  7. Monheit AC & Vistnes JP (2000) Race/Ethnicity and Health Insurance Status: 1987 and 1996. Medical Care Research and Review 57(Suppl 1): 11-35.
  8. Zambrana RE & Logie LA (2000). Latino child health: need for inclusion in the US national discourse. Am J Public Health 90:1827-1833.
  9. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (2011). Overview of the Uninsured In the United States: A Summary of the 2011 Current Population Survey. Retrieved from website: http://aspe.hhs.gov/health/reports/2011/CPSHealthIns2011/ib.pdf
  10. Shi L. (2000) Vulnerable Populations and Health Insurance. Medical Care Research and Review 57: 110-134. http://www.kff.org/uninsured/upload/1420-12.pdf.
  11. The Henry J Kaiser Family Foundation. (2010). The Uninsured and the Difference Health Insurance Makes. Kaiser Commission on Key Facts #1420-12.
  12. Williams, C. (2002). From Coverage to Care: Exploring Links Between Health Insurance, A Usual Source of Care, and Access. (Policy Brief 1 ed.). Retrieved from http://www.rwjf.org/pr/synthesis/reports_and_briefs/pdf/no1_policybrief.pdf
  13. Glenn Flores, MD, Sandra C. Tomany-Korman, MS. (2008). Racial and Ethnic Disparities in Medical and Dental Health, Access to Care, and Use of Services in US Children. PEDIATRICS Vol. 121 No. 2. pp. e286 -e298.
  14. Sommers, B. (2011). 1.2 Million Children Gain Insurance Since Reauthorization of Children's Health Insurance Program. Centers for Medicare and Medicaid Services. Retrieved from http://aspe.hhs.gov/health/reports/2011/CHIPRA/ib.shtml
  15. Weinick RM, Weigers RE & Cohen JW. (1998). Children's Health Insurance, Access to Care, and Health Status: New Findings. Health Affairs 12: 127-136.
  16. Families USA for the Campaign for Children's Health Care. (2006). America's Uninsured Children: Minority Children at Greater Risk. Washington, DC: Retrieved from www.childrenshealthcampaign.org/assets/pdf/Uninsured-Minority-Kids-at-Risk.pdf
  17. Addressing Racial and Ethnic Disparities in Health Care" Fact Sheet. AHRQ Publication No. 00-PO41, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/disparit.htm
  18. Weinick RM & Krauss NA (2000) Racial/Ethnic Differences In Children's Access to Care. American Journal of Public Health 90: 1171-1174.
  19. The National Institute of Dental and Craniofacial Research of the National Institutes of Health A Plan to Eliminate Craniofacial, Oral, and Dental Health Disparities http://www.nidcr.nih.gov/research/healthdisp/hdplan.pdf
  20. Mouradian WE, Wehr E, & Crall JJ. (2000) Disparities In Children's Oral Health and Access to Dental Care. Journal of the American Medical Association. 284: 2625-2631.
  21. Edelstein BL. (2000) Public and Clinical Policy Considerations In Maximizing Children's Oral Health. Pediatric Clinics of Northern America. 47(5): 1177-1189.
  22. MacKay AP, Fingerhut LA, & Duran CR. (2000) Adolescent Health Chartbook. Health, United States, 2000, Hyattsville, Maryland: National Center for Health Statistics.
  23. Gehshan, S., Snyder, A., & Paradise, J. (2008). Filling An Urgent Need: Improving Children's Access to Dental Care in Medicaid and SCHIP. The Kaiser Commission on Medicaid and the Uninsured, Retrieved from http://www.kff.org/medicaid/upload/7792.pdf
  24. Williams DR. (1999) Race, Socioeconomic Status, and Health. Annals New York Academy of Science 896: 173-188.
  25. Clark R. (2000) Perceptions of Interethnic Group Racism Predict Increased Vascular Reactivity to a Laboratory Challenge in CollegeWomen. Annals of Behavioral Medicine 22: 214-222.
  26. Klonoff KA & Landrine H. (2000) Is Skin Color a Marker For Racial Discrimination? Explaining the Skin Color-Hypertension Relationship. Journal of Behavioral Medicine 23: 329-338.
  27. Barnes VA, Treiber FA, Musante L, Turner JR, Davis H, & Strong WB. (2000) Ethnicity and Disease 10: 4-16.
  28. Wilson DK, Kliewer W, Plybon L, & Sica DA. (2000) Socioeconomic Status and Blood Pressure Reactivity in Healthy Black Adolescents. Hypertension 35(part 2): 496-500.

Health Disparities

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