1. ELIMINATING HEALTH DISPARITIES IN AN URBAN AREA VIRGINIA A. CAINE, M.D., DIRECTOR MARION COUNTY HEALTH DEPARTMENT INDIANAPOLIS, INDIANA May 1, 2002

2. “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 Clinton February 21, 1998

3. President’s Initiative to Eliminate Racial and Ethnic Disparities in Health Target conditions Infant mortality Cancer screening and management Cardiovascular disease Diabetes HIV infection/AIDS Immunizations

4. Healthy People 2010 Two Overarching Goals: Increase Quality and Years of Healthy Life Eliminate Health Disparities

5. 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?

6. 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

7. Percent Distribution of U.S. Population by Race and Ethnicity, 2000 Source: U.S. Census Bureau, 2000

8. Percent of the Population by Race and Hispanic Origin, 2000 and 2050 71.8% 52.8% 11.4% 24.5% 12.2% 13.6% American Indian/Alaska Native Asian/Pacific Islander Black/African American Hispanic/Latino White, not Hispanic/Latino 20002050 8.2% 3.9% Source: U.S. Bureau of the Census 2000

9. Minority people are the majority in three states California (50.1%) Hawaii(71%) New Mexico (53%) District of Columbia (71%) Emerging Majorities

10. 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

11. Percent of the Population by Race and Hispanic Origin, Indiana 1990 White, not Hispanic: 90.1% Black/African American: 7.8% Asian/Pacific Islander: 0.2% Hispanic/Latino: 1.7% American Indian/Alaska Native: 0.3% 2000 White, not Hispanic: 86.5% Black/African American: 8.3% Asian/Pacific Islander: 1.0% Hispanic/Latino: 3.6% American Indian/Alaska Native: 0.7%

13. Life Expectancy at Birth, 1900-1998 Years White Black 0 SOURCE: CDC/NCHS, National Vital Statistics Systems, 1900-98 1998 1900 1950 47.6 33.0 71.3 77.3

14. Infant Mortality Rates, 1980- 1998 Deaths <1 year/1000 live births 10.9 6.0 22.2 14.3 SOURCE: CDC/NCHS, National Vital Statistics System, 1980-1998

15. Infant mortality rates by race and Hispanic origin of mother Total Hispanic Non-Hispanic white Non-Hispanic black Asian/Pacific Islander Deaths <1 year per 1000 live births SOURCE: CDC/NCHS, National Vital Statistics System, 1995

16. Infant mortality rates by Hispanic origin of mother Total Hispanic Mexican Puerto Rican Cuban Central/South American Deaths <1 year per 1000 live births SOURCE: CDC/NCHS, National Vital Statistics Systems, 1995

17. Infant mortality rates by Asian/Pacific Islander subgroup Asian/Pacific Islander Chinese Japanese Hawaiian Filipino Deaths <1 year per 1000 live births SOURCE: CDC/NCHS, National Vital Statistics Systems, 1995

18. Coronary heart disease death rates 1990 1996 Per 100,000 population NOTE: 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

20. 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

21. 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

22. How Do We Explain Racial And Ethnic Disparities In Health?

23. Several Causal Factors Socioeconomic status (SES) Health risk behaviors Psycho-social factors Acculturation Biologic/Genetic factors Health care

24. Socioeconomic Status Education Occupation Income Environment Culture

27. Infant Mortality Rates in the United States Deaths/1000 Live births SOURCE: CDC/NCHS/NVSS Education in years

28. Health Risk Behaviors

29. >1 oz. alcohol per day Current smokers Regular exercise or sports SOURCE: CDC/NCHS, National Health Interview Survey, 1990 White Black Hispanic Female Health Risk Behaviors percentage engaging in activity

30. Health Risk Behaviors Male Current smokers >1 oz. alcohol per day Regular exercise or sports White Black Hispanic percentage engaging in activity SOURCE: CDC/NCHS, National Health Interview Survey, 1990

31. Age-adjusted Prevalence of Obesity (BMI 30.0) 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 >

32. Age-Adjusted Prevalence of Obesity (BMI 30.0) Male Non-Hispanic Whites Non-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 >

33. Psychosocial Factors

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

35. Acculturation

36. Some health behaviors “worsen” with acculturation

37. Biological and Genetic Factors

38. Health Care

39. Percentage Uninsured Under Age 18 United States Percent of Population Source: CPS, USCB

40. Health Care Coverage of Persons Under 65 (Age-adjusted) NH White All Hispanic NH Black SOURCE: CDC/NCHS, National Health Interview Survey, 1996 Private Medicaid/ Public Assistance Not covered Percent Asian/PI

42. Health Care Extensive evidence of racial and/or ethnic Differences in utilization of health care Diagnostic tests and procedures Therapeutic procedures Intensity of care Pain control Transplants Preventive services

43. Possible Explanations for the Racial and Ethnic Differences in Utilization Socioeconomic status Language Insurance status Severity of illness Patient health behaviors Provider bias

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

58. 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 Report Findings

59. IOM Report Recommendations Increase awareness of racial and ethnic disparities among the general public, key stakeholders, and healthcare providers Legal, regulatory, and policy interventions Health systems interventions

60. 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

61. Of all the forms of inequality, injustice in health is the most shocking and the most inhumane. -- Dr. Martin Luther King, Jr.