The Health Care Home Model: Primary Health Care Meeting Public Health Goals

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.THE AMERICAN PUBLIC HEALTH Association (APHA) has 3 overarching policy priorities: rebuild the public health infrastructure, ensure access to care, and reduce health disparities.1,2 The health care home model contributes to these goals by improving health care delivery at the patient level through redesigning and expanding the scope of primary health care services and improving the interface between primary care practices and public health agencies.In November 2010, APHA endorsed the health care home model of primary care for its public health value. Health care home, a term used by the National Association of Community Health Centers, is a model also referred to as the medical home.3,4 The health care home is a vehicle by which patient- and family-level care at the point of delivery may contribute to meeting population-level goals of improving access to care, reducing health disparities, increasing preventive service delivery, and improving chronic disease management.5 Here we summarize the APHA health care home policy statement and suggest next steps for moving the model forward.     

Health and Health Care Disparities Among Homeless Women

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.     

Latina Self-Reported Mental Health and Delay in Health Care in a New Latino Destination

Understanding how depression and/or anxiety affects use of health care among Latinas in rapidly growing new Latino destinations, population where the growth rate of the Latino population exceeds the national average, may enhance community engagement efforts. Using community-based participatory research, a questionnaire assessing health care use was administered to 289 Latinas. Most (70%) reported delaying healthcare, and self-reported depression/anxiety was associated with a 3.1 fold (95% CI: 1.6–5.9) increase in delay, after adjusting for current health status, acculturation, age, education, and place of birth. Mental health disparities exist among Latinas, which are related to delays in use of health care. A gap exists regarding health education interventions for Latinas. More research is needed to identify successful models, especially in new Latino destinations as they may be particularly vulnerable to delay care.     

Managed Care and Gender Disparities in Problematic Health Care Experiences

Objective. To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care.
Data Sources. The 2002 Yale Consumer Experiences Survey ( N =5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002.
Study Design. Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression.
Principal Findings. Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans.
Conclusions. There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.     

Future Trends in Health and Health Care: Implications for Social Work Practice in an Aging Society

Major economic, political, demographic, social, and operational system factors are prompting evolutionary changes in health care delivery. Of particular significance, the “graying of America” promises new challenges and opportunities for health care social work. At the same time, the Patient Protection and Affordable Care Act of 2010, evolution of Accountable Care Organizations, and an emphasis on integrated, transdisciplinary, person-centered care represent fundamental shifts in service delivery with implications for social work practice and education. This article identifies the aging shift in American demography, its impact on health policy legislation, factors influencing fundamentally new service delivery paradigms, and opportunities of the profession to address the health disparities and care needs of an aging population. It underscores the importance of social work inclusion in integrated health care delivery and offers recommendations for practice education.     

Successful Reentry: The Perspective of Private Correctional Health Care Providers

Due to public health and safety concerns, discharge planning is increasingly prioritized by correctional systems when preparing prisoners for their reintegration into the community. Annually, private correctional health care vendors provide $3 billion of health care services to inmates in correctional facilities throughout the U.S., but rarely are contracted to provide transitional health care. A discussion with 12 people representing five private nationwide correctional health care providers highlighted the barriers they face when implementing transitional health care and what templates of services health care companies could provide to state and counties to enhance the reentry process.     

Racial/Ethnic Disparity Trends in Children's Mental Health Care Access and Expenditures from 2002 to 2007

Objective

To examine trends in disparities in children''s mental health care.

Data

2002–2007 Medical Expenditure Panel Survey.

Study Design

We used the Institute of Medicine (IOM) definition of health care disparities and estimated two-part expenditure models to examine disparity trends in any mental health care use, any outpatient care, and psychotropic drug use, as well as expenditures in these three categories, conditional on use. We used 2-year longitudinal panel data to determine disparities in care initiation among children with unmet need.

Principal Findings

Assessing trends over time between 2002 and 2007, we identified that disparities persist for blacks and Latinos in receipt of any mental health care, any outpatient care, and any psychotropic drug use. Among those with positive mental health care expenditures, Latino–white disparities in overall mental health care expenditures increased over time. Among children with unmet need, significant disparities in initiation of an episode of mental health care were found, with whites approximately twice as likely as blacks and Latinos to initiate care.

Conclusions

Disparities in children''s mental health care use are persistent and driven by disparities in initiation, suggesting policies to improve detection or increase initial access to care may be critical to reducing disparities.     

Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review

Background. In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition.Objectives. We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals’ implicit attitudes about racial/ethnic groups and health care outcomes.Search Methods. To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique.Selection Criteria. We assessed eligibility using double independent screening based on a priori inclusion criteria. We included studies if they sampled existing health care providers or those in training to become health care providers, measured and reported results on implicit racial/ethnic bias, and were written in English.Data Collection and Analysis. We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings.Main Results. Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient–provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient–provider interactions and health outcomes than treatment processes.Conclusions. Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color.PLAIN-LANGUAGE SUMMARY: Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. Negative implicit attitudes about people of color may contribute to racial/ethnic disparities in health and health care. We systematically reviewed evidence on implicit racial/ethnic bias among health care professionals and on the relationships between health care professionals’ implicit attitudes about racial/ethnic groups and health care outcomes. Fifteen relevant studies were identified through searches of bibliographic databases and reference lists of studies that met inclusion criteria. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient–provider interactions, treatment decisions, treatment adherence, and patient health outcomes.In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes.1–3 Compared with Whites, people of color face more barriers to accessing care, which includes preventive services, acute treatment, and chronic disease management.4 People of color are also generally less satisfied with their interactions with health care providers. The National Healthcare Disparities Report showed that White patients received better quality of care than Black American, Hispanic, American Indian, and Asian patients.4 Dominant communication styles, fewer demonstrated positive emotions, infrequent requests for input about treatment decisions, and less patient-centered care seem to characterize patient–provider interactions involving people of color.4–6People of color also face disparities in terms of morbidity, mortality, and health status. Black Americans, Hispanic Americans, and American Indians have higher infant mortality rates than White and Asian Americans.1 The premature death rate from heart disease and stroke is highest among Black Americans. In addition, numerous disparities in health conditions and risk behaviors exist among people of color, including asthma, cigarette smoking, diabetes, early childbearing, HIV/AIDS, hypertension, low birth weight, obesity, periodontitis, preterm births, and tuberculosis.1,4 Black Americans, Hispanic Americans, and American Indians were more likely to rate their health as fair or poor, and reported more days of feeling unwell in the past month, compared with White and Asian Americans.1 Despite all of the advancements in health care in the past century, disparities based on race and ethnicity persist in access to health care, quality of care received, disease incidence and prevalence, life expectancy, and mortality.     

Health Care Coverage and the Health Care Industry

Objectives. We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category.Methods. We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype.Results. Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI] = 2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI = 3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR] = 1.5; 95% CI = 1.0, 2.4).Conclusions. Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern.For complex socioeconomic reasons, private health insurance, typically provided by an employer, is “the dominant mechanism for paying for health services” in the United States.^1(p79) According to the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, analyses of data from the Current Population Survey (CPS) show that, in 2006, 54% of the US civilian, noninstitutionalized population had employer-sponsored health insurance; 5% had private, nongroup health insurance; and 26% had public health insurance coverage. Approximately 46 million US residents (16% of the population) are currently uninsured.² Numerous studies have shown that, relative to people with health insurance, uninsured people receive less preventive care, are diagnosed at more advanced disease stages, and, once diagnosed, tend to receive less therapeutic care and have higher mortality rates.^3–8Although national uninsurance trends are well-documented, the rate of uninsurance within the health care workforce has received scant attention. Given that health care employment rates are increasing at a more rapid pace than overall employment rates, this lack of attention is especially worrisome. According to the Bureau of Labor Statistics, nearly half of the 30 occupations in which employment opportunities are growing fastest are health care occupations. For example, whereas the Bureau of Labor Statistics projects that overall employment will increase about 10% from 2006 to 2016, employment opportunities for personal and home care aides are projected to increase nearly 51%, and opportunities for physical therapist assistants are expected to increase by a third. The Bureau of Labor Statistics also projects that, by 2016, new job opportunities for registered nurses will increase by approximately 24% (approximately 587 000 new jobs).⁹Although the overall employment outlook for health care workers is promising, what is less clear is to what degree employment in health care is associated with health insurance coverage. A 2001 General Accounting Office report suggested that one fourth of nursing home aides and one third of home health care aides were uninsured.¹⁰ The Kaiser Family Foundation reported that the uninsured rate among workers in the health and social services industry was 23% in 2007.¹¹ On the basis of a review of the literature in the health and human services occupations, Ebenstein concluded that the health insurance plans offered to direct care workers in the developmental disabilities field are “inferior … with less coverage and more out-of-pocket expenses” and that fewer direct care workers “are able to afford health coverage even if they are eligible.”^12(p132)Taking a more comprehensive look at the US health care workforce, Himmelstein and Woolhandler¹³ used 1991 CPS data to estimate uninsurance rates among physicians and other health care personnel. They reported that, overall, 9% of health care workers were uninsured, along with more than 20% of nursing home workers. Examining CPS data from 1988 to 1998, Case et al. found that uninsurance rates among all health care workers rose from 8% to 12%, that rates increased more for health care workers than for workers in other industries, and that rates differed according to occupation and place of employment.¹⁴ For example, occupation-specific uninsurance rates were 23.8% among health aides, 14.5% among licensed practical nurses, and 5% among registered nurses, whereas place-specific rates were 20% among nursing home workers, 8.7% among medical office workers, and 8.2% among hospital workers.¹⁵In their studies, Himmelstein and Woolhandler¹³ and Case et al.¹⁴ used national-level data to estimate uninsurance trends among health care workers. However, these trends were not adjusted for health care workers'' social, demographic, or economic characteristics, which would have helped explain variation across categories or over time. Moreover, with the growth of the health care workforce, estimates from these older studies probably do not reflect the current situation. As a result, the picture of uninsurance as it pertains to the health care workforce lacks the precision and currentness necessary for sound policy decisions. In an effort to expand knowledge in this area, produce more up-to-date estimates, and provide support for possible policy decisions, we used data from the National Health Interview Survey (NHIS) to examine uninsurance among workers in the health care industry.     

Evaluating Area-Based Socioeconomic Status Indicators for Monitoring Disparities within Health Care Systems: Results from a Primary Care Network

ObjectiveTo determine which area-based socioeconomic status (SES) indicator is best suited to monitor health care disparities from a delivery system perspective.ConclusionsArea-based SES indicators detected health outcome differences well and may be useful for monitoring disparities within health care systems. Our preferred indicator was ZIP-level median household income or percent poverty, using cut points.     

An Experimental Investigation of Possible Memory Biases Affecting Support for Racial Health Care Policy

Objectives. We aimed to test the theory that estimates of racial disparities may be based on small recalled samples of specific individuals (Black vs White), a strategy likely to lead to underestimates of true racial disparities and a corresponding opposition to race-focused health care policies.Methods. We asked a sample of White adults to list the first 5 Black and White individuals who came to mind, and then measured support for various race-focused health care policies.Results. Analyses indicated that the Black individuals recalled by participants tended to be more famous and wealthy than their White counterparts. Furthermore, the tendency to list wealthier Black individuals predicted opposition to progressive racial health care programs. A follow-up study demonstrated that support for certain race-focused health care policies could be increased by informing Whites of potential memory biases.Conclusions. The survival and success of minority health care policies depend partially on public acceptance. Education regarding continuing racial disparities may help to increase support for race-focused health care policies.Racial disparities in the health care domain have been well documented1 and would seem to justify proactive remedial policies (i.e., race-focused health care policies). Public opposition to race-focused policies, however, can threaten the existence of racial health care initiatives by swaying the actions of health care providers, insurers, and lawmakers. We theorized that opposition to race-focused health care policies may reflect, in part, the operation and existence of basic cognitive and belief-based mechanisms.Generally speaking, race-focused policies are more likely to be deemed unnecessary to the extent that racial disparities are perceived to be minimal.2–5 Recent studies have confirmed that many Whites tend to perceive racial disparities as trivial,6 especially compared with the typical views of racial minorities.7Clearly, most individuals do not possess encyclopedic knowledge regarding the true statistical nature of racial disparities. Instead, people may seek to generalize from available individual examples to form estimates of racial disparities. Such a strategy is hypothesized to take place in 3 steps. The first step involves the generation of a short list of example individuals for each race being considered (e.g., Blacks vs Whites). In the second step, individuals are thought to form a basic impression of the general levels of wealth and opportunity of the recalled individuals. Finally, in the third step, these impressions would be used to form a view of racial disparities in general.We attempted to examine the operation of this strategy among a sample of White adults. We predicted that because of continuing racial separation, the average White person would be less likely to have available examples of personally known Black individuals. Instead, we predicted that famous and wealthy Black individuals such as Barack Obama and Oprah Winfrey would be more likely to come to mind. By contrast, we predicted that when a White person generated an analogous list of White individuals, relatively less-privileged, personally known individuals such as friends, family members, neighbors, and coworkers would be more likely to be recalled.In general, the influence of recalled examples on estimates of more general rates or frequencies is consistent with classic research on the availability heuristic, in which the ease or difficulty of recall is used to make inferences about likelihoods.8,9 Work on the availability heuristic applies to situations in which processors attempt to make likelihood judgments based on a simple memory search. When information relating to a particular category or outcome is easy to generate, this will result in perceptions of increased likelihoods. By contrast, when information relating to a particular category or outcome is difficult to generate, this will result in perceptions of decreased likelihood. In the present scenario, if it is perceived to be either difficult to generate specific examples of poor Blacks or easy to generate specific examples of wealthy Blacks (or both), this should result in a correspondingly biased perception of Blacks’ levels of wealth and privilege in general.Of course, the typical person is presumably aware that a small, idiosyncratic sample of recalled individuals may not adequately represent the respective populations from which they were drawn. Hence, the generalization step of the estimation strategy would likely be accompanied by some form of adjustment—yet another process that is likely to be biased by a common cognitive tendency. When individuals attempt to generalize estimates based on small idiosyncratic samples to a larger population, they often make use of the anchor-and-adjust heuristic.10 This heuristic involves beginning with a given reference value (the anchor) and then attempting to adjust up or down to a more appropriate estimate. For example, when asked to guess the number of nations on Earth, a given individual may begin by reckoning that the number has to be larger than 100. That person would then adjust upward to arrive at a final guess. Previous research has demonstrated that adjustment is typically insufficient, leading to final estimations or judgments that are biased in the direction of the chosen anchor.11 In the present context, we hypothesized that Whites would use their generated list of highly privileged Blacks as an initial anchor, and then to adjust insufficiently when trying to estimate the actual level of racial disparities in present-day America.As a final note, it is possible that individuals may make a simple inference about race and opportunity when considering wealthy or privileged Black Americans. Namely, these examples may be taken as living proof that it is at least possible to overcome lingering prejudice and discrimination. This belief, in turn, would likely lend credence to the conviction that Blacks no longer require special consideration in terms of remedial policies. In fact, Kaiser et al.12 reported that Barack Obama’s 2008 election was associated with perceptions of increased racial equality since the 1960s, and with decreases in support for affirmative action among White college students.We conducted 2 studies to examine the relationship between racial disparity perceptions and racial health policy attitudes. In study 1, we tested the hypothesis that Whites who use famous and wealthy Black Americans as reference points would be less likely to support race-focused health care policies. In study 2, we attempted to increase support for race-focused health care policies by informing participants of the potential effect of the heuristic-based recall strategy.     

Adding Home Health Care to the Discussion on Health Information Technology Policy

The potential for health information technology to improve the efficiency and effectiveness of health care has resulted in several U.S. policy initiatives aimed at integrating health information technology into health care systems. However, home health care agencies have been excluded from incentive programs established through policies, raising concerns on the extent to which health information technology may be used to improve the quality of care for older adults with chronic illness and disabilities. This analysis examines the potential issues stemming from this exclusion and explores potential opportunities of integrating home health care into larger initiatives aimed at establishing health information technology systems for meaningful use.     

The Relation Between Health Insurance and Health Care Disparities Among Adults With Disabilities

Objectives. We examined disparities among US adults with disabilities and the degree to which health insurance attenuates disparities by race, ethnicity, and socioeconomic status (SES).Methods. We pooled data from the 2001–2007 Medical Expenditure Panel Survey on individuals with disabilities aged 18 to 64 years. We modeled measures of access and use as functions of predisposing, enabling, need, and contextual factors. We then included health insurance and examined the extent to which it reduced observed differences by race, ethnicity, and SES.Results. We found evidence of disparities in access and use among adults with disabilities. Adjusting for health insurance reduced these disparities most consistently for emergency department use. Uninsured individuals experienced substantially poorer access across most measures, including reporting a usual source of care and experiencing delays in or being unable to obtain care.Conclusions. Although health insurance is an important enabling resource among adults with disabilities, its effect on reducing differences by race, ethnicity, and SES on health care access and use was limited. Research exploring the effects of factors such as patient–provider interactions is warranted.Continuing its emphasis on reductions in health care disparities, Healthy People 2020 identifies the elimination of health disparities as 1 of 4 overarching goals.1 Congress has charged the Agency for Healthcare Research and Quality (AHRQ) with tracking disparities in health care access and quality among racial, ethnic, and socioeconomic groups, as well as for priority populations. In April 2012, AHRQ released its ninth report, finding that, although there was evidence of improvements in quality of care, health care access and quality are suboptimal, particularly for individuals who are racial/ethnic minorities or of lower socioeconomic status (SES).2An estimated 1 in 5 noninstitutionalized individuals in the United States experiences a disability.3 Although individuals with disabilities have been identified as a priority population by Congress,2 examining disparities among those with disabilities has garnered less attention. There is evidence that individuals with disabilities receive fewer preventive and treatment services than individuals without disabilities.4–7 Individuals with disabilities are more likely to report cost as a barrier to care,4,8 to report higher out-of-pocket costs,9 and to report unmet need for medical care.8Individuals with disabilities are disproportionately racial/ethnic minority and of lower SES. Rates of disability are higher for Blacks (22.2%) than for Hispanics (17.8%) and Whites (17.4%).3 Using data from the American Community Survey, Erickson and Lee10 found prevalence of disability to decline with increasing income. Disability is also associated with educational attainment. Substantially more people without a disability (30.8%) had a bachelor’s degree or higher than people with a disability (12.5%). Limited work has focused on disparities by race and SES on health care access and use among individuals with disabilities.11Health insurance provides an essential link to health services and outcomes,12,13 attenuating but not eliminating disparities by race and SES in the general population.14 Data from the 2010 American Community Survey indicate that, nationally, 82.1% of working-age individuals with disabilities had health insurance, compared with 78.2% among working-age individuals without disabilities.15 Nationally, 17.9% of working-age adults with disabilities were uninsured, but there was substantial state variability. Adults with disabilities are much more likely to have public, relative to private, coverage—50.5% public and 43% private coverage nationally in 2010 (some individuals have both public and private coverage). Research has rarely examined the extent to which health insurance coverage reduces potential disparities by race, ethnicity, and SES among individuals with disabilities. Thus, we extended the research on disparities among individuals with disabilities by examining whether minority and lower-SES adults with disabilities experience disparate access to and use of health care services.     

Racial/Ethnic Disparities in Health and Health Care among U.S. Adolescents

Objective

To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.

Data Source

Secondary data analysis of the 2003 National Survey of Children''s Health. The survey focus was children 0–17 years old.

Study Design

Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.

Principal Findings

Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.

Conclusions

U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Children with Special Health Care Needs: How Immigrant Status is Related to Health Care Access,Health Care Utilization,and Health Status

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0–11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent’s language, parental education, ethnicity, and children’s insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.     

Childbearing, Stress and Obesity Disparities in Women: A Public Health Perspective

The perinatal period, from early in the first trimester to 1 year postpartum, provides opportunities for novel public health interventions to reduce obesity disparities. We present a unifying socio-biological framework to suggest opportunities for multidisciplinary research and public health approaches to elucidate and target the mechanisms for the development of maternal obesity and related disparities. The framework illustrates the interplay of the social, cultural and physical environment; stress appraisal and response; and coping behaviors on short-term outcomes (e.g. allostatic load and gestational weight gain), the intermediate outcomes of persistent insulin resistance and post-partum weight retention, and longer term outcomes of obesity and its disease consequences. Testing the proposed relationships may provide insights into how childbearing risk factors such as gestational weight gain, postpartum weight retention and parity contribute to obesity, which are needed to inform public health policies and clinical care guidelines aimed at reducing obesity and improving the health of women.     

The Neglect of Racism as an Ethical Issue in Health Care

Race and racism has been increasingly implicated in known disparities in the health and health care of racial, ethnic and cultural minorities groups. Despite the obvious ethical implications of this observation, racism as an ethical issue per se has been relatively neglected in health care ethics discourse. In this paper consideration is given to addressing the following questions: What is it about racism and racial disparities in health and health care that these command our special moral scrutiny? Why has racism per se tended to be poorly addressed as an ethical issue in health care ethics discourse? And why, if at all, must racism be addressed as an ethical issue in addition to its positioning as a social, political, cultural and legal issue? It is suggested that unless racism is reframed and redressed as a pre-eminent ethical issue by health service providers, its otherwise preventable harmful consequences will remain difficult to identify, anticipate, prevent, manage, and remedy.     

Violence Against Women and Reproductive Health: Toward Defining a Role for Reproductive Health Care Services

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.