Over the course of its history, the United States has experienced dramatic improvements in overall health and life expectancy due largely to initiatives in public health, health promotion, disease prevention, and chronic care management. Our ability to prevent, detect, and treat diseases in their early stages has allowed us to target and reduce morbidity and mortality. Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities (blacks, Hispanics/Latinos, Native Americans/Alaskan Natives, Asian/Pacific Islanders) have benefited less from these advances and suffer poorer health outcomes than whites from many major diseases (e.g., cardiovascular disease, cancer, diabetes) in the United States. Research has highlighted that minorities may receive less care and lower quality care than whites, even when confounders such as stage of presentation, comorbidities, and health insurance are controlled. These differences in quality are called racial and ethnic disparities in health care. This chapter will provide an overview of racial and ethnic disparities in health and health care, identify root causes, and provide key recommendations to address them at both the clinical and health system levels.
Nature and Extent of Racial and Ethnic Disparities in Health and Health Care
Minority Americans have poorer health outcomes (compared with whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others (Fig. e4-1). Multiple factors contribute to these racial and ethnic disparities in health. First and foremost, there is little doubt that social determinants—such as lower levels of education, lower socioeconomic status, inadequate and unsafe housing, racism, and living in close proximity to environmental hazards—disproportionately impact minority populations and thus contribute to poorer health outcomes. For example, three of the five largest landfills in the country are found in black and Latino communities; these environmental hazards have contributed to some of the highest rates of pediatric asthma among these populations. Second, lack of access to care also takes a significant toll, as uninsured individuals are less likely to have a regular source of care, and are more likely to delay seeking care and go without needed care—all resulting in avoidable hospitalizations, emergency hospital care, and adverse health outcomes.
Age-adjusted death rates for selected causes by race and Hispanic origin, 2005. (From U.S. Census Bureau, 2009.)
In addition to the existence of racial and ethnic disparities in health, there are racial/ethnic disparities in the quality of care for those with access to the health care system. For instance, disparities have been found in the treatment of pneumonia (Fig. e4-2) and congestive heart failure (blacks receiving less optimal care than whites when hospitalized for these conditions) and referral to renal transplantation (blacks with end-stage renal disease being referred less often to the transplant list than whites) (Fig. e4-3). Disparities have also ...