1. Racial and Ethnic Disparities in Health and Health Care: Why the Gaps? Brian D. Smedley, Ph.D. The Opportunity Agenda

2. Age-Adjusted Death Rates by Sex, Race, and Hispanic Origin, 2002 Per 100,000 resident population Source: Health, United States, 2004

3. Age-Adjusted Death Rates per 100,000 for Selected Causes of Death by Race and Ethnicity, 2002 Source: Health, United States, 2004

4. Low birthweight by education and race or ethnicity, United States, 2002 Source: Health, United States, 2004

5. What Factors Contribute to Racial and Ethnic Health Disparities? Socioeconomic inequality Socioeconomic inequality Residential segregation and environmental living conditions Residential segregation and environmental living conditions Stress, coping, health risk and health- seeking behaviors Stress, coping, health risk and health- seeking behaviors Differences in access to health care Differences in access to health care Differences in health care quality, even at equal levels of access Differences in health care quality, even at equal levels of access

6. Racial and Ethnic Differences in Access to Care and Quality of Care Minorities are more likely to be un- or underinsured Minorities are more likely to be un- or underinsured Minorities are more likely to live in medically underserved communities Minorities are more likely to live in medically underserved communities Minorities are more likely to experience cultural and linguistic barriers to care Minorities are more likely to experience cultural and linguistic barriers to care

7. Evidence of Racial and Ethnic Disparities in Healthcare, Even When Access is Similar Cardiovascular Disease – African Americans are less likely to receive appropriate diagnostic tests, medications, or to undergo bypass surgery Cardiovascular Disease – African Americans are less likely to receive appropriate diagnostic tests, medications, or to undergo bypass surgery Cancer – African Americans receive less aggressive treatments Cancer – African Americans receive less aggressive treatments Kidney Disease – African Americans less likely to be told about, evaluated for, or to receive kidney transplantation Kidney Disease – African Americans less likely to be told about, evaluated for, or to receive kidney transplantation HIV/AIDS – Minorities less likely to receive antiretroviral or other state-of-the-art treatments HIV/AIDS – Minorities less likely to receive antiretroviral or other state-of-the-art treatments

8. What are potential sources of disparities in care? Health systems-level factors – financing, structure of care; cultural and linguistic barriers; and the inequitable distribution of health care resources Health systems-level factors – financing, structure of care; cultural and linguistic barriers; and the inequitable distribution of health care resources Patient-level factors – including patient preferences, refusal of treatment, poor adherence Patient-level factors – including patient preferences, refusal of treatment, poor adherence Disparities arising from the clinical encounter – biases and stereotyping Disparities arising from the clinical encounter – biases and stereotyping

9. Health Care – Still Separate and Unequal in Some Areas? Nationwide, 40% of African American nursing home residents live in lower-tier facilities compared to 9% of white nursing home residents Lower-tier nursing homes have a high concentration of Medicaid residents, very limited resources, inadequate staffing, and lower quality scores CMS provides performance bonuses for top-performing nursing homes, but does not provide additional resources to assist lower- tier facilities

10. Patients experiencing symptoms of heart disease, from Schulman et al. (1999)

12. Conclusions Racial and ethnic disparities in health status are persistent, and are caused by multiple factors that have roots in historic and contemporary disadvantage Racial and ethnic disparities in health status are persistent, and are caused by multiple factors that have roots in historic and contemporary disadvantage Health care access and quality for many communities of color is poorer than should be tolerated Health care access and quality for many communities of color is poorer than should be tolerated Health care services remain separate and unequal in many areas Health care services remain separate and unequal in many areas Evidence of racial disparities in many clinical services persists, even when insurance and other factors are equal Evidence of racial disparities in many clinical services persists, even when insurance and other factors are equal