public administration
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ÂTRANSCRIPT
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Memorandum
To: TBD From: Jetmir Troshani Date: Date goes here
Re: Public Administration
Outline
- Background of the problem - Significance of the problem - Problem statement - Analysis of alternatives - Conclusion
Background of the problem
“Overwhelming facts reveal that racial and cultural minority groups are more
likely to receive poorer quality health care than white Americans, even when factors
such as insurance status are controlled” (American College of Physicians 2010). As
the country’s population continues to grow and diversify, the health care system will
have to change and adjust to meet the needs of an increasingly multicultural patient
base. The statistical and anecdotal facts of racial injustice in American healthcare
are undeniable. Studies done since 2003 by ACP show systemic in addition to
clinical discrimination. Health practitioners, legislators, and citizens at large can no
longer ignore the fact that America’s focus on the color of one’s skin and the national
origin of one’s ancestors still largely determines the quality of health care a
consumer receives (American College of Physicians 2008; Urban Institute (2005).
America thought that the issue of racial injustice and inequity was long gone,
but it is shocking that the vice still endures largely, not only in the common platforms,
politics and socials, but in a more critical issue like health care. After controlling the
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differences among the races in socioeconomic status, health insurance, access to
health care and geographic differences, the statistical facts still demonstrates that
Blacks and Latinos still get lesser and substandard medical attention than their
counterparts, the whites, irrespective of whether those services are for treatment of
cardiovascular disease, chronic diseases, mental illness, child medical care or
HIV/AIDS.
Comparing these minority groupings (African Americans, Native Americans,
Asian Americans, and Latinos) with the white Americans, they are more vulnerable
to chronic illnesses, higher mortality rates, and worst health effects (Bardach 2009).
Among the disease-specific examples of racial and ethnic disparities in the U.S. is
the cancer incidence rate among Blacks that is 10 percent more than among the
white Americans (Barrett, Dyer and Westpheling 2008; Kettl 2007). Also, adult
Blacks and Latinos are almost twice more than Whites prone to diabetic
complications. Although African Americans, Latinos and Native Americans suffer and
succumb to diabetes more often than then whites, research show the disease is not
well handled among minorities.
Ironically, Black, Native and Hispanic Americans have more medical attention
services than whites do for those undesirable medical attentions, for instance
amputations, and cesarean section among others. Although these are necessary
attentions, they are considered undesirable because a patient would rather avoid
them if at all they had an option, for instance many patients would prefer to keep a
leg if it could be made healthy, rather than going for an amputation. Undisputedly,
ignoring these injustices would take the efforts of social scientists, researchers,
health care providers, legislators, environmentalists, clergy, and patients among
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others to adequately attend to the matter (Lurie and Dubowitz 2007; Schlotthauer et
al. 2008; Zuckerman et al. 2008). Although the issue is multi-sided, this paper looks
at the policy solutions available.
Significance of the problem
Lexically, health inequalities refer to the gap in the quality and accessibility of
medical attention among racial, ethnic, socio-economic groupings. Almost as long as
there have been hospitals in America, there have been racial disparities in the health
care system. The first hospital founded in the U.S. was the Pennsylvania General
Hospital, established in Philadelphia in 1751 from private funds, donated for the care
of the less-fortunate and the mentally unstable. In the beginning of its operations,
records from Pennsylvania General did not show that any patients other than whites
were admitted for care. The institution was, in fact called the “First Anglo Hospital”1
in the U.S. nevertheless, historical records reveals that the institution eventually
began to admit non-Caucasian patients. Beginning in 1825 and 1829 respectively,
Pennsylvania General began to record the “color” and “national origin” of admitted
patients, confirming that the hospital at some point began offering services to both
Black and white patients (Baker et al. 1996).
In fact, before end of slavery in America, the judicial record reveals that
African-Americans got a significant healthcare whenever need be; their health
influenced their monetary value as property of slave-owners. After the Civil War,
giving access to African Americans took on a different dimension. Waves of Blacks
migrating from the south began to mount pressure on health care amenities to serve
Black and white patients the same. During the Reconstruction, racial segregation,
1 More reading from Grumbach, K. and Mendoza, R. (2008) and American College of Physicians. (2006).
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surfaced both within healthcare institution used by both the non-native American and
white patients, professional, and physicians, and in the structure of the hospital
industry itself. Martin Luther King, Jr. quotes that “Of all the forms of inequality,
injustice in healthcare is the most shocking and inhumane” (as cited in ACP 2004).
Ever since overt racial disparities has grown and still looms.
Arguably, health disparity starts shortly after conception. One pointer of a
child's healthy birth, making other lifetime outcomes more probable to be successful,
is whether mothers get early medical care at pregnancy. 25% of African-American
women do not receive prenatal attention at the first trimester, while 11% of white
women get none (American College of Physicians 2007; Bach et al. 2004; Dorn et al.
2008). For African-American women, 6% do not receive prenatal attention, but only
2% of white women, one third the number of 27 blacks, get no or too-late care.
Considering infant mortality during the first year of life, there are 14 deaths for
African-American and six for Native Americans out of 1,000 live births. However,
proper prenatal care likely could have prevented some of these deaths. Infant
mortality and morbidity are enduring, thus the high rate of African-American infant
mortality shows the probability of a similarly higher rate of black infants who survive
with unhealthy conditions that make school and lifetime success more difficult. It is
these disparities in pregnancy and childbirth, which are eventually reflected in racial
inequality (Winkleby et al. 1992).
Problem statement
Inequality of access to health care in the adequacy of care to different cultural
and racial groups get can include:
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Difficulties with patient-practitioner communication. In delivering medical care,
communication is essential so as to administer proper and effectual treatment
and attention in disregard to racial group. As miscommunication could lead to
inaccurate analysis, wrong medication, and failure to get a follow-up attention.
As Flores (2007) describes, “Cross-cultural differences in information-seeking
patterns, communication styles, perceptions of health risk, and ideas about
prevention of disease [have] an impact on health.” In the US, language barrier
is even worse, especially among the non-natives groups. Statistically, “less
than half of non-English speakers who say they need an interpreter during
health care visits report having one. In addition, communication barriers crop
up from the lack of cultural understanding on the part of white providers for
their minority patients” (Halbert et al. 2006).
Practitioner inequity. In some cases the medical care practitioners either
unconsciously or consciously attends to some racial patients in a different way
than other patients. Some studies show that racial minority patients are “less
likely than whites to receive a kidney transplant once on dialysis. Critics argue
that certain diseases cluster by ethnicity and that clinical decision making
does not always reflect these differences” (Institute of Medicine 2004).
Lack of preventive care. According to the 2009 National Healthcare
Disparities Report, “uninsured Americans are less likely to receive preventive
services in health care, for instance racial minorities are not regularly
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screened for colon cancer and the death rate for colon cancer has increased
among African Americans and Hispanic people”2.
“Many people of colored skin are facing poor health care than whites from the
cradle to the grave, in terms of greater rates of infant mortality, chronic diseases and
disability, and pre-mature death” (Peterson and Yancy 2009). These health
disparities take a significant human toll, but in addition inflict a huge economic weight
on America. A recent research conducted shows that the direct health costs, that is,
related with health inequalities, extra costs of medical services incurred due to the
greater burden of diseases suffered by the minority groups-was more than US$250B
in the period between 2003 and 2006. Aggregating the indirect costs related with
health inequalities, for instance foregone salaries and yield and foregone tax
revenue, the total costs of health inequalities for the country was US$1.24B in the
same duration (Kettl and Fesler, 2009).
With the inception of Obama administration, things are looking bright. With the
enactment of the Health Reform Law, this will see more than 32 million uninsured
Americans, the majority being the minorities get insurance coverage. These laws will
avert insurance companies from exploiting new enrollees and rejecting claims due to
the earlier conditions and more medical care providers will get more incentives to
work in “medically underserved communities, among other expected benefits. These
legislations will improve the current state of health care for people of color, who are
disproportionately un- and under-insured and who face greater barriers than whites
to receiving high-quality care, even when insured” (Herbert et al. 2008). A research
2 As cited in U.S. Department of Health and Human Services Office of Disease Prevention and Health
Promotion (2007).
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commissioned by the Institute of Medicine (2002) estimated that: “over 886,000
deaths could have been prevented from 1991 to 2000 if African Americans had
received the same care as whites. The main differences were due to lack of
insurance, inadequate insurance and poor service for the minority patients.”
Analysis of alternatives
Youdelman (2007) and Smedley (2008) argue that “The correlation between
socioeconomic position and health, is a pervasive correlation, which is seen across
periods of time, across places in the world, and across groups… and it is almost
invariably in the same direction,” as socioeconomic position increases, health
improves. Youdelman opines that although there are various means to explain health
inequalities (from a racial and ethnical dimension, socio-economics, and geography)
socioeconomic inequalities should take center stage in the health policy talk,
because application of some policy functions can worsen this issue.
However, according to Schillinger et al. (2003) ‘race is not an issue’ when it
comes to matters of health inequity. He notes that the income differences across
racial groups, exposure to social and economic adversity over the time and
subjection to prejudice and institutional bigotry can influence the health of the
minorities in several ways. Schillinger et al. (2003) “underscores this by revealing
that majority of the socio-economic group of black women have almost or even
higher rates of infant mortality, low birth-weight, hypertension and obesity than the
lowest socioeconomic group of white women.” Blendon et al. (2008) emphasize on
the use of specific approaches to contain racial disparities and urges that the health
policy should be redefined so as to take account other sectors of the community,
which have health impacts.
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It is noticeable that the minority groups face distinctive and intricate
challenges in modern policy environment, from crisis alertness and response to
equal access to proper medical attention. Recognizing the situation, those
representing these groups should join forces and put forward a strong voice in
addressing these intricate (Williams and Jackson 2005).
To reduce the health inequalities, more emphasis should be made on
evidence-based techniques modeled to overcome the groups struggle against
medical and public health research, together with:
Result-orientation: research entrenched in a community background modeled
to achieve substantial outcomes and attain the optimal performance.
Community collaboration: partnering “with” the groups, instead of giving things
“to” them;
Ethnical tolerance: models custom-made for community demands and
reaches;
Notably, equity of access to quality health care cannot be guaranteed through
uniformity in a multicultural community, but through cultural sensitivity in delivery of
medical care is equally necessary in achieving this equality. In ascertaining cultural
tolerance, we should find if the current delivery of health care is impartial, and if it is
as it is, then know how to reverse the situation. A more practically approach in
dealing with this is “ethnic match”3 which seems to have a remarkable effect on the
patients and providers in terms of access and utilization of health care services. In
America, Barrett, Dyer and Westpheling (2008) observe that the more the minorities’
3 See more discussion on “ethnic match” by Barret, S. R. et al. (2008). Health Literacy Practices in Primary Care Settings: Examples from the Field. Washington, DC: The Commonwealth Fund.
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workers working in a mental institution, the higher the utilization rate by the
minorities.
Moreover, many surveys have revealed that an “ethnic match” between
patient and the practitioner normally increase utilization rate while reducing the
dropout rate. However, in addressing such inequalities numerous viable options
have been raised. These options range from simple and realistic to involving a whole
change to the system. Blanton et al (2002) notes “improvements in quality of care
can simply begin with multilingual information, link workers, appropriate diets to a
multi-faith approach in hospital.” While on the other hand, U.S. Department of Health
and Human Services Office of Disease Prevention and Health Promotion (2008)
advocates for “anti-racism service delivery” which involves “ensuring that providers
are reflective of ethno-racial communities and knowledgeable about issues of race,
gender, power and privilege, that people of color are involved in planning,
implementing and evaluating these services and that services are appropriate to the
needs of communities of color”4.
However, the provisions made on the health reform law do not assure an
answer to the health care inequalities issue; according to studies having health
insurance does not assure access to quality medical services neither does it
considerably better health services. Instead, it is notable that health disparities
continue due to differences in the neighbourhoods of the minority and non-minority
groups. Racial and cultural minority groups are more probable than white Americans
to live in segregated, poverty-ridden populations, people who have ever since
experienced lack of health care resources (Zuvekas and Taliaferro, 2003). Even
4 Also cited by Kaiser Family Foundation (2006).
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worse, majority of these people stare at a host of health dangers, for instance a lot of
environmental stressors, and an influx fast food outlets and liquor shops and should
have rather countable health-conscious investments such as grocery outlets.
One’s environment has a considerable effect on his/her general health status.
25% of preventable diseases globally are associated to poor environmental quality.
Reschovsky and O’Malley (2008) recommend that “The government at all levels can
improve health opportunities by stimulating public and private investment to help
make all communities healthier. It can achieve this by providing incentives to
improve neighbourhood food options, by aggressively addressing environmental
degradation, and by de-concentrating poverty from inner-cities and rural areas
through smart housing and transportation policy.” Many of these strategies are highly
cost-effective; however addressing health inequities that are the outcome of
environmental stressors can be a complex and challenging task. Moreover,
policymakers should come up with a set of measures to track environmental
stressors and how they cause impacts on the health inequities of racial and cultural
minority groups (Gaskin et al. (2007).
According to the American College of Physicians, although America has made
some tremendous advances towards achieving health care equality, a lot still needs
to be done. "Closing the disparity gap is not only morally and professional
imperative, it remains a glaring civil rights injustice that must be addressed," the ACP
(2010) says. Improved communication is one of the core issues in bridging the
inequality gulf in a country where approximately a quarter of the inhabitants are not
native English speakers. Also, given that by the year 2042, according to the U.S.
Census Bureau, “half of America’s population will be people of colour, it is imperative
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that we be prepared to address the health needs of an increasingly diverse
population”5. It is also recommended that all third‐party payers, such as Medicare,
pay for the services of interpreters, and “language services”. In addition, medical
professionals should be trained to have racial and ethnical tolerance so they
appreciate the medical care practices and misunderstandings harboured by racial
and ethnic minority groups (Hoffman and Tolbert 2006).
“Organizations that set standards for medical education”, the ACP (2010)
reports, “are becoming believers in this kind of training — an encouraging sign of
progress. To create a more diverse physician workforce, we should strengthen the
education of minority students, especially in math and science, at all levels to create
a larger pool of qualified minority applicants for medical school.” Similarly, medical
schools should enrol and retain more minority faculty. One nagging societal ills
highlighted in the ACP report is the advertisement of tobacco and alcoholic products,
and fast foods to minority groups.
Conclusion
Racial and cultural inequities in health care emerge from the interaction of
many intricate factors, including past and current discrimination in health care,
genetics, unequal educational opportunity, income and health care access
disparities, cultural beliefs, and community systems. Bridging the disparity gulf is not
easy, but it is a moral imperative that appropriate resources should be made to
address these differences.
5 Cited by James, C. et al. (2009). Putting Women’s Health Care Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level. Kaiser Family Foundation. Retrieved from http://www.kff.org/minorityhealth/upload/7886.pdf
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