Racial and ethnic differences in access to medical care in managed care plans

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.     

Health information Websites: characteristics of US users by race and ethnicity

We conducted a national public opinion survey of adults aged 18 years or older in the continental US to determine their use of health Websites. Of the 928 individuals contacted, 868 (94%) reported their race/ethnicity. More non-Hispanic Whites reported using the Internet (34%) than African Americans (31%) and Hispanics (20%). We used logistic regression to estimate adjusted odds ratios describing the relationship between Website usage and covariates across the racial/ethnic subgroups. Whereas better perceived health was associated with greater Website use among Hispanics and Whites, stronger health literacy was associated with greater use among Hispanics. No African American or Hispanic respondent aged 65 years or older reported going online. The relationship between education and use was more than twice as strong for African Americans and Hispanics than other groups. That some minority groups are less likely to use the World Wide Web for health information may further compound existing disparities. One place where this problem may be addressed is in the nation's schools.     

The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care

OBJECTIVE: To examine the extent to which health insurance coverage and available safety net resources reduced racial and ethnic disparities in access to care. DATA SOURCES: Nationally representative sample of 11,692 African American, 10,325 Hispanic, and 74,397 white persons. Nonelderly persons with public or private health insurance and those who were uninsured. STUDY DESIGN: Two cross-sectional surveys of households conducted during 1996-1997 and 1998-1999. DATA COLLECTION: Commonly used measures of access to and utilization of medical care were constructed for individuals. These measures include the following. (1) percent reporting unmet medical needs, (2) percent without a regular health care provider, and (3) no visit with a physician in the past year. FINDINGS: More than 6.5 percent of Hispanic and African Americans reported having unmet medical needs compared to less than 5.6 percent of white Americans. Hispanics were least likely to see the same doctor at their usual source of care (59 percent), compared to African Americans (66 percent) and whites (75 percent). Similarly, Hispanics were less likely than either African Americans or whites to have seen a doctor in the last year (65 percent compared to 76 percent or 79 percent). For Hispanics, more than 80 percent of the difference from whites was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services). Differences in measured characteristics between African Americans and whites explained less than 80 percent of the access disparities. CONCLUSION: Lack of health insurance was the single most important factor in white-Hispanic differences for all three measures and for two of the white-African American differences. Income differences were the second most important factor, with one exception. Community characteristics generally were much less important, with one exception. The positive effects of insurance coverage in reducing disparities outweigh benefits of increasing physician charity care or access to emergency rooms.     

Health care utilization and risk behaviors among HIV positive minority drug users

This study compared health care utilization and HIV-related risk behaviors between HIV-infected African American (n=123) and Hispanic (n=97) drug users recruited in New York City. African Americans were more likely to use crack, while Hispanics were more likely to use heroin and speedball. African Americans were more likely than Hispanics to report having traded sex for drugs or money. The two groups did not significantly differ in HIV care utilization (e.g., taking HIV medications). In multiple logistic regression analyses, for African Americans, taking HIV medications was significantly related to enrollment in HIV clinics and non-use of crack, while for Hispanics, being married and attending HIV support groups were significant factors. Drug treatment enrollment was significantly related to non-use of crack and injection drug use among African Americans, and a trend (p=.07) was found between injection drug use and drug treatment enrollment among Hispanics. The findings indicate the continuing need for harm reduction programs for HIV positive drug using populations. Programs for these populations should also take into account the different risk behaviors among different racial/ethnic groups, in order to tailor culturally sensitive programs for HIV care and intervention.     

Racial/ethnic differences in attitudes toward seeking professional mental health services

OBJECTIVES: This study examined racial/ethnic differences in attitudes toward seeking mental health services. METHODS: Data from the National Comorbidity Survey, which administered a structured diagnostic interview to a representative sample of the US population (N = 8098), were analyzed. Multiple logistic regression was used, and data were stratified by need for mental health services. RESULTS: African Americans with depression were more likely than Whites with depression to "definitely go" (odds ratio [OR] = 1.8, P < .001) seek mental health services. African Americans with severe psychiatric disorders were less likely to be "somewhat embarrassed if friends knew they sought care" (OR = 0.3, P < .001) than were their White counterparts. CONCLUSIONS: African Americans reported more positive attitudes toward seeking mental health services than did Whites.     

Race/Ethnicity, Parent-Identified Emotional Difficulties, and Mental Health Visits Among California Children

Variability in mental health services utilization by race/ethnicity was evaluated with a Behavioral Model approach. Subjects were 17,705 children 5 to 11 years of age in the 2005, 2007, and 2009 California Health Interview Surveys. Parents identified minor emotional difficulties in 18.7% of these children (ranging from 14.8% in Asians to 24.4% in African Americans) and definite or severe difficulties in 7.4% (5.5% in Asians to 9.7% in “other race”). Overall, 7.6% of children had at least one mental health visit in the prior year (2.3% in Asians to 11.2% in African Americans). Parent-identified need was the most salient predictor of mental health visits for all racial/ethnic groups. Beyond need, no consistent patterns could be determined across racial/ethnic groups with regard to the relationship between contextual, predisposing, and enabling measures and mental health service utilization. Different factors operated for each racial/ethnic group, suggesting the need for studies to examine mental health need, mental health service use, and determinants by racial/ethnic subgroup. These findings suggest that a “one-size-fits-all approach” with regard to policies and practices aimed at reducing mental health disparities will not be effective for all racial/ethnic groups.     

The influences of race, ethnicity, and poverty on the mental health of children

Sufficient evidence demonstrates that poverty has a negative effect on the psychological well-being of children, but most research has focused only on white populations. The purpose of this literature review is to gain a better understanding of the positive and negative influences of socioeconomic factors, cultural/ethnic characteristics, and racial differences on the mental health of children. A review of the literature on the influence of race, ethnicity, and poverty on the mental health of children found that (1) children whose parents are in poverty or who have experienced severe economic losses are more likely to report or be reported to have higher rates of depression, anxiety, and antisocial behaviors; and (2) after controlling for socioeconomic status, African Americans, Native Americans, and Hispanics are less likely to report or be reported to have such mental health problems. A theoretical construct for this protective effect is related to cultural factors, such as perceived social support, deep religiosity/spirituality, extended families, and maternal coping strategies as buffers against psychological distress.     

Variation in Older Americans Act Caregiver Service Use,Unmet Hours of Care,and Independence Among Hispanics,African Americans,and Whites

Home- and community-based services (HCBS) are underused by minority seniors and their caregivers, despite greater rates of disability. We examined racial/ethnic variation among 1,749 Hispanics, African Americans, and Whites receiving Older Americans Act Title III caregiver services in 2009. In addition, we identified the volume of services used by caregivers, their unmet hours of respite care, and the relationship between service use and seniors' ability to live independently. Minority caregivers cared for seniors in urban areas who had higher rates of disability, poverty, and Medicaid coverage. Hispanics had the highest rate of unmet hours of care, while caregiver services were less likely to help African Americans remain at home. Minorities sought services through community agencies and were more educated than demographically similar national cohorts. Greater efforts to reach minority caregivers of less educated, disabled seniors in urban areas and through community agencies may reduce unmet needs and support independent living.     

Health information seeking and use outside of the medical encounter: Is it associated with race and ethnicity?

Increasing numbers of adults in the United States of America (USA) are seeking and using health information within their medical encounters. The theory of uncertainty management suggests that patients reduce health care uncertainty by increasing their understanding of disease etiology or treatment options, improving patient–doctor communication, and enhancing knowledge of disease self-management through health information seeking. However, research shows racial and ethnic minorities are less likely than Whites to seek health information and use it in their physician visits. How racial and ethnic minorities use health information outside of their medical encounters is unknown. In this study we used data from the 2007 USA Health Tracking Household survey, a nationally-representative survey of civilian, non-institutionalized Americans (n = 12,549). Using logistic regression we found African Americans were no different from Whites in seeking health information and using it when they talked with their doctors. Latinos were significantly less likely than Whites to seek health information and less likely to use it when they talked with their doctors. But, among those who sought health information, African Americans and Latinos were significantly more likely than Whites to use health information to change their approach to maintaining their health and better understand how to treat illnesses. Also, education significantly moderated the relationship between race/ethnicity and health information seeking. However, results were mixed for education as a moderator in the relationship between race/ethnicity and health information use. Future research should focus on interventions to improve how African Americans and Latinos interface with providers and ensure that health information sought and used outside of their medical encounters augments treatment protocols.     

Awareness of racial and ethnic health disparities has improved only modestly over a decade

Documented disparities exist in the United States between the majority white population and various racial and ethnic minority populations on several health and health care indicators, including access to and quality of care, disease prevalence, infant mortality, and life expectancy. However, awareness of these disparities-a necessary first step toward changing behavior and compelling action-remains limited. Our survey of 3,159 adults age eighteen or older found that 59 percent of Americans in 2010 were aware of racial and ethnic disparities that disproportionately affect African Americans and Hispanics or Latinos. That number represents a modest increase over the 55 percent recorded in a 1999 survey. Meanwhile, in our survey, 89 percent of African American respondents were aware of African American and white disparities, versus 55 percent of whites. Yet the survey also revealed low levels of awareness among racial and ethnic minority groups about disparities that disproportionately affect their own communities. For example, only 54 percent of African Americans were aware of disparities in the rate of HIV/AIDS between African Americans and whites, and only 21 percent of Hispanics or Latinos were aware of those disparities between their group and whites. Policy makers must increase the availability and quality of data on racial and ethnic health disparities and create multisectoral partnerships to develop targeted educational campaigns to increase awareness of health disparities.     

Assessing the effects of race and ethnicity on use of complementary and alternative therapies in the USA

Objective To investigate the use of alternative therapies among different racial/ethnic groups in the USA. Specifically, we examined whether alternative medicine use differs for working aged whites, Asian Americans, African Americans, and Hispanics.

Design Using the 1996 Medical Expenditure Panel Survey, racial differences in utilization were investigated at two levels: (1) the bivariate level with no controls for other factors and (2) at the multivariate level with controls for age, sex, region, marital status, education, income, health status, satisfaction with conventional healthcare, and access measures.

Results Americans in this sample population used alternative and complementary therapies at a fairly low rate (6.5%). This 6.5%, however, was not consistent across all groups. African Americans and Hispanics were less likely than whites to utilize alternative therapies, whereas Asian Americans did not differ significantly from whites.

Conclusions The use of alternative and complementary therapies varied across racial/ethnic groups. Evidence showed that individuals who were dissatisfied with the availability of conventional healthcare, who were in poor health, but very satisfied with their conventional provider were more likely to use complementary and alternative medicine (CAM) therapies. The addition of these variables to a logistic regression model did not change the findings for differential use by ethnicity, the relative ranking of groups, or the overall strength of the relationship.     

Would safety-net expansions offset reduced access resulting from lost insurance coverage? Race/ethnicity differences

This study simulated whether increased community health center (CHC) funding under the Bush administration narrowed racial/ethnic gaps in access to care among low-income people. Expanded CHC funding resulted in small increases in access to care, more so for minorities than for whites. Spanish-speaking Hispanics had the largest improvements in access in the simulation. However, minorities experienced bigger drops in insurance coverage. The net result was no improvements in the access measures for Spanish-speaking Hispanics and slight decreases in access for whites, English-speaking Hispanics, and African Americans. Access gaps either remained the same or worsened slightly for English-speaking Hispanics and African Americans relative to whites.     

Do managed care plans reduce racial disparities in preventive care?

This study was designed to determine whether managed care plans reduce racial disparities in use of influenza vaccination, mammography, and prostate-specific antigen screening. The study analyzed the use of three types of preventive care in a population-based sample of adults who were 65 years or older and were enrolled in a Medicare managed care (MMC) or fee-for-service (FFS) plan in Allegheny County, Pennsylvania. The study sample included 463 African Americans and 592 whites. Fewer African Americans than whites reported having had an influenza vaccination (64.4% versus 76.5%; p < 0.01) or a prostate-specific antigen test (64% versus 71.2%; p = 0.09) during the previous year. Slightly more African Americans than white women reported having had a mammogram (66.1% versus 63.8%). Logistic regression showed that, regardless of health plan type, African Americans were significantly less likely than whites to have an influenza vaccination (p < 0.05). A MMC plan did not narrow racial differences in preventive care. Reducing disparities may require interventions developed for specific racial/ethnic groups.     

Perception of racial barriers to health care in the rural South

We assessed how commonly people in the rural South perceive racial barriers to care, the characteristics of the people among whom this perception is most common and whether this perception is associated with satisfaction with and use of health services. We analyzed telephone survey data collected in 2002-3, using weighted statistical techniques and multivariate logistic regression in analyses stratified by race. Fifty-four percent of African Americans and 23% of Whites reported that they perceive racial barriers to care in their communities. African Americans who were middle-aged or older, male, or who report being in good-to-excellent health were more likely to perceive racial barriers. Whites who were younger, less educated, and uninsured were more likely than other Whites to perceive racial barriers. For African Americans, perceptions of racial barriers were associated with lower likelihood of being satisfied with care, but not with use of preventive services. The perception of racial barriers to health care is prevalent in the rural South, especially among African Americans. The consequences of this perception may include mistrust and dissatisfaction with medical care.     

Achieving a credible health and safety approach to increasing seat belt use among African Americans

African American youth are 60 percent less likely than children from other racial or ethnic backgrounds to be buckled up. Seat belt use among African American males has largely remained stagnant while that for other groups has increased. Overall, African Americans buckle up less often than other racial or ethnic populations. Seat belt use is a preventive health care action within public health. Clearly, a credible health and safety message is not being communicated effectively to African American communities. This paper proposes a number of possible solutions, including: recognition of the role that health care providers play in shaping patient or consumer attitudes and subsequent behavior in terms of prevention of disease and injury, educating physicians and health care providers to routinely recommend seat belt use especially for children, culturally appropriate educational safety programs, an improved relationship between law enforcement and communities, and zero tolerance for nonuse of seat belts.     

Sociodemographic differences in depressed mood: results from a nationally representative sample of high school adolescents

BACKGROUND: Research on adolescent mental health suggests that prevalence rates for depressed mood are not uniformly distributed across all populations. This study examined demographic difference in depressed mood among a nationally representative sample of high school adolescents. METHODS: The 2003 National Youth Risk Behavior Survey was utilized to examine the association between depressed mood and demographic variables. To examine demographic associations, chi-square and follow-up logistic regression models were created for the sample of high school adolescents (N = 15,214). RESULTS: Caucasians and African Americans were significantly less likely to report depressed mood when compared to Hispanics and Others. Women were also more likely than men to report depressed mood. No significant differences were observed among levels of urbanicity and age. CONCLUSIONS: An understanding of the difference in the prevalence and correlates of depressed mood among adolescents of various ethnic/racial and gender groups deserves increased attention. Given the fact that challenges with depressed mood in adolescents can be substantial and relatively unrecognized, there is an increased need to identify these adolescents early and intervene with culturally appropriate interventions.     

Parenting,Family Processes,Relationships, and Parental Support in Multiracial and Multiethnic Families: An Exploratory Study of Youth Perceptions

Mixed‐race or multiethnic youth are at risk for mental and physical health problems. We used data from the National Longitudinal Study of Youth 1997 to compare family characteristics of adolescents of a mixed‐race or multiethnic background with those of a monoracial or monoethnic background. Mixed‐race or multiethnic youth reported feeling less supported by parents and reported less satisfactory parent‐adolescent relationships. Mixed‐race/multiethnic youth were more like monoracial White youth in terms of being independent but were more like racial or ethnic minorities (African Americans, Hispanics) in regard to family activities. Reasons for these findings are explored. We discuss the need for future research on the experiences of mixed‐race/multiethnic youth.     

Coercive and voluntary referrals: How ethnic minority adults get into mental health treatment

Two hypotheses are typically invoked to examine the referral of adults into mental health care. The first is the clinical behavior hypothesis that suggests the psychiatric problem defines people as dangerous and risky. Accordingly, people with severe mental disorders are more likely to be coercively placed into mental health facilities. The second hypothesis suggests that people with less power are more likely than the powerful to be coercively placed in psychiatric care. We examine the extent to which these hypotheses are supported in a large urban community by investigating referrals into community mental health clinics that serve predominantly poor populations. The data set is unique because it includes four ethnic categories, whites, African Americans, Asian Americans, and Mexican Americans. The findings indicate that the clinical behavior hypothesis is applicable to whites and the stratification hypothesis is consistent with the data for African American, particularly African American men. The referral pattern for Mexican Americans and Asian Americans do not conform to the findings for whites and African Americans. It is likely that other sociocultural factors influence the referrals of these ethnic categories.     

Disparities in access to care and satisfaction among U.S. children: the roles of race/ethnicity and poverty status

OBJECTIVES: The study assessed the progress made toward reducing racial and ethnic disparities in access to health care among U.S. children between 1996 and 2000. METHODS: Data are from the Household Component of the 1996 and 2000 Medical Expenditure Panel Survey. Bivariate associations of combinations of race/ethnicity and poverty status groups were examined with four measures of access to health care and a single measure of satisfaction. Logistic regression was used to examine the association of race/ethnicity with access, controlling for sociodemographic factors associated with access to care. To highlight the role of income, we present models with and without controlling for poverty status. RESULTS: Racial and ethnic minority children experience significant deficits in accessing medical care compared with whites. Asians, Hispanics, and blacks were less likely than whites to have a usual source of care, health professional or doctor visit, and dental visit in the past year. Asians were more likely than whites to be dissatisfied with the quality of medical care in 2000 (but not 1996), while blacks and Hispanics were more likely than whites to be dissatisfied with the quality of medical care in 1996 (but not in 2000). Both before and after controlling for health insurance coverage, poverty status, health status, and several other factors associated with access to care, these disparities in access to care persisted between 1996 and 2000. CONCLUSIONS: Continued monitoring of racial and ethnic differences is necessary in light of the persistence of racial/ethnic and socioeconomic disparities in access to care. Given national goals to achieve equity in health care and eliminate racial/ ethnic disparities in health, greater attention needs to be paid to the interplay of race/ethnicity factors and poverty status in influencing access.     

Racial/ethnic differences in rates of depression among preretirement adults

OBJECTIVES: We estimated racial/ethnic differences in rates of major depression and investigated possible mediators. METHODS: Depression prevalence rates among African American, Hispanic, and White adults were estimated from a population-based national sample and adjusted for potential confounders. RESULTS: African Americans (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 0.93, 1.44) and Hispanics (OR = 1.44, 95% CI = 1.02, 2.04) exhibited elevated rates of major depression relative to Whites. After control for confounders, Hispanics and Whites exhibited similar rates, and African Americans exhibited significantly lower rates than Whites. CONCLUSIONS: Major depression and factors associated with depression were more frequent among members of minority groups than among Whites. Elevated depression rates among minority individuals are largely associated with greater health burdens and lack of health insurance, factors amenable to public policy intervention.