Ethnic and racial minorities manifest significantly poorer health status than their white counterparts. Health disparities are defined by the National Institutes of Health as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” Although these disparities have existed for more than two centuries, defining and characterizing disparities in health and health care are necessary beginnings to understanding the problem and seeking effective solutions to inequities in health status. Cardiovascular disease, cancer, and diabetes mellitus are the most commonly reported health disparities followed by cerebrovascular diseases, unintentional injuries, and HIV/AIDS. Assessing these differences requires that a variety of factors including age, gender, nationality, family of origin, religiosity, education, income, geographic location, race or ethnicity, sexual orientation, and disability be considered.

Health care disparities are defined by the Institute of Medicine (IOM) as “differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.” Causes of health care disparities most often relate to quality and include provider-patient relationships, provider bias and discrimination, and patient variables such as mistrust of the health care system and refusal of treatment. Although disparities in health and health care can be inextricably tied to one another, distinguishing between them increases our understanding of the complexity of the problem.

One of the most significant efforts to address disparities has been the introduction of the Healthy People goals in the late 1990s. Foundational principles of the federal Healthy People initiatives are (1) that all people are valued equally, (2) health is valued for everyone, (3) everyone should be able to achieve the highest level of health possible, and (4) the resources needed for health should be distributed fairly (http://www.healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pd). The disparities evident in the health and/or health care of the US population reflect inconsistencies in implementing these principles.

Concerns regarding health and health care disparities are amplified when the dramatic changes in the population served during the last two decades of the twentieth century are considered. Between 1980 and 2000 the white non-Hispanic population of the United States increased 7.9% compared with an 88% increase in the aggregated minority (people of races other than white or of Hispanic ethnicity) population. An estimated 1 in 4 Americans (almost 70 million persons) is classified as a member of one of the four major racial or ethnic minority groups: African American, Latino/Hispanic, Native American, and Asian/Pacific Islander. By the year 2050, the US census estimates that people of color will represent 1 in 3 Americans. These populations bear a disproportionate burden of illness and disease relative to their percentage distribution in the population. Understanding the factors that contribute to inequities in health among these populations and the strategies that have resulted in improved health can inform and promote the delivery of quality health care.

Institute of Medicine Reports

In 1999, a report from the IOM entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care was written in response to a request from Congress to the IOM to address the extent of racial and ethnic disparities in health care. Following review of more than 100 publications, the IOM study committee concluded that research findings consistently indicated that minorities were less likely than whites to receive needed services, including lifesaving procedures. The most commonly reported health care disparities were seen in cardiovascular disease, cancer, and diabetes. Other illnesses included cerebrovascular diseases, mental illness, and HIV/AIDS.

The IOM committee outlined three sets of factors that likely contributed to the complex problem of health care disparities. The first set of factors relates to minority patients’ attitudes toward health care, preferences for treatment and subtle differences in the ways that racial and ethnic groups respond to treatment, particularly pharmaceutical interventions. The second group relates to the operation of health care systems and the legal and regulatory environment in which they function. These factors include lack of interpretation services for those with limited English proficiency, lack of resources for those with limited health literacy, where care is received, and how it is delivered. The third set of factors is derived from the clinical encounter. The committee’s review suggested that provider bias, clinical uncertainty, and stereotyping or beliefs about the behavior of minorities may have a negative impact on the health outcomes of minorities. On the other side of the clinical encounter is the patient; his or her reaction to the provider’s biased or stereotyped behaviors may also contribute to disparities.

National Healthcare Disparities Report

With a directive from the Healthcare Research and Quality Act of 1999 (Public Law 106-129) and guidance from the IOM, the Agency for Healthcare Research and Quality (AHRQ) developed and produced two reports. The first of these, the National Healthcare Disparities Report (NHDR), was the first national comprehensive effort to measure differences in access and use of health care services by various populations. It incorporated a broad set of performance measures through which the data on differences in the use of services, access to health care, differences in use of services by priority populations, and impressions of quality for seven clinical conditions could be viewed and assessed. The second report, the National Healthcare Quality Report (NHQR), focused on safety, effectiveness, patient centeredness, and timeliness, with equity as a cross-cutting dimension. The two reports were released simultaneously in 2003 to provide a more comprehensive view of the performance of the health care system, its strengths, and areas that should serve as a focal point for future improvement. The performance measures underlying the two reports will be used to monitor the nation’s progress toward improved health care delivery. Reports have been issued annually since 2003.

The NHQR sought to analyze national disparities as both a function of health care access and quality. Disparities were related to socioeconomic position as well as to race and ethnicity. The NHQR’s key findings were that inequality in quality persists, disparities come at a personal and societal price, differential access may lead to disparities in quality, opportunities to provide preventive care are frequently missed, knowledge of why disparities exist is limited, improvement is possible, and data limitations hinder targeted efforts to provide the level necessary to measure the effect of national initiatives to reduce disparities.

In 2005, a third NHQR highlighted four key themes: disparities are pervasive and still exist, some disparities are diminishing, opportunities for improvement remain, and information regarding disparities is improving. New databases and measures were added to provide a more comprehensive assessment of disparities and new methods for tracking changes in disparities in a standardized fashion have been implemented. This allows for the identification of specific disparities that are improving and disparities that are worsening.

Agency for Healthcare Research and Quality, March 2009 report focused on quality of care and disparities in health care in America overall and AHRQ’s priority populations in particular. The 2008 National Healthcare Disparities Report found that although some of the biggest disparities in quality remain, progress has been made in reducing disparities in areas, such as dialysis, hospital admissions for perforated appendix, and childhood vaccinations. Most recently, the NHDR also reportd that there are significant disparities in quality documented over the years where there has not been improvement, such as new AIDS cases (AHRQ 09-0002) (http://www.ahrq.gov/news/pubcat/c_quca.htm).

Healthy People 2010

Healthy People 2010 was launched in January of 2000. The program is a set of comprehensive health objectives for the nation that can be used by many different people, states, communities, professional organizations, and others to help them develop programs to improve health. The Healthy People 2010 objectives build on the 1979 Surgeon General’s report, Healthy People, and Healthy People 2000. All three initiatives were developed through broad consultation, backed by the best scientific knowledge available, and were designed to measure programs over time.

The two overarching goals of Healthy People 2010—to increase quality and years of healthy life and eliminate health disparities—served as a guide for developing the 467 objectives, designed to serve as a roadmap to measure progress. The achievement of these national objectives is dependent in part on the ability of health agencies at all levels of government and on nongovernmental organizations to assess their progress.

Original American citizens of color bear a historical legacy that affects all aspects of their integration into society today. American Indians make up a fraction of today’s citizens (0.7% in the 2000 census) but have significant health disparities. The prevalence of diabetes mellitus, obesity, alcoholism, and suicide is substantially greater in this population than in other US population groups. They are the one population with a health system that was established to help meet their medical needs. The availability of these services, however, is limited by distance for the many American Indians living in rural areas, and they may be completely inaccessible to those living in urban areas.

African Americans encompass several groups who came to the United States at different times. The impact of slavery on the original Africans cannot be minimized. Residual effects of this historical tragedy have been associated with discriminatory residential practices, educational disadvantages, and treatment practices in separate but unequal health care facilities. Later immigrants of African origin came to the United States from the West Indies where slavery was abolished well before the Emancipation Proclamation in the United States. These differing experiences have influenced the views of Caribbean Americans and result in differences between them and African Americans who descended directly from slaves on the North American continent. The final group of immigrants from African countries chose to come to the United States in recent years for both educational, economic, and political reasons. Cultural differences often exist among these three groups and include differences in customs, family roles, religious preferences, and their definition and experience of illness and disease.

Despite the fact that the foundation of the United States was a union of indigenous groups and immigrants, the preceding groups along with new immigrants bear much of the burden of disease in the nation today. The number of immigrants entering the United States during the past 15 years has increased dramatically compared with the numbers seen in the previous four decades. Political crises, natural disasters, poverty, and hunger have forced population groups of significant size to leave their homes. These migrations have resulted in loss of homes and support systems, overcrowding and overexposure, decreased access to food and medical services, and contact with new infectious agents and other toxins.

The term immigrant has been applied to legal and illegal (undocumented) refugees and children adopted from other countries. Most immigrants reside in linguistically isolated households (those in which no one >14 years speaks English), which were identified for the first time in the 1990 census). Four percent of US households are in this category. This figure includes 30% of Asian households, 23% of Hispanic households, and 28% of all immigrant households with school-age children.

Immigrants enter the United States from many countries, but those coming from Mexico represent the largest group. Many Mexican immigrants arrive in the United States healthier than their white counterparts. However, their health deteriorates the longer they live here, possibly as a result of lifestyle changes (years of difficult labor, poverty, smoking, poor diet, and lack of attention to prevention) and a lack of health insurance. One study found that 2.6% of recent Mexican immigrants had diabetes mellitus, compared with 7.7% of Mexican immigrants who had lived in the United States for 15 years. More than two-thirds of recent Mexican immigrants and 44.8% of “long-term immigrants” have no health insurance, compared with 22.5% of Mexican-born Americans and 12.3% of US-born whites. Fewer than 10% of recent Mexican immigrants reported using emergency departments in 2000. Furthermore, more than 33% of Mexican women aged 18-64 years who were recent immigrants had not had a Pap smear in 3 years. About 37% of recent Mexican immigrants visited a health clinic instead of a physician for health care, compared with about 15% of US-born whites.

Pregnant women are of major concern because of risk for poor pregnancy outcomes. In spite of these concerns, evidence suggests that infants of Mexican immigrants have favorable birth outcomes despite their high socioeconomic risks. These favorable outcomes have been associated with a protective sociocultural orientation among this immigrant group, including a strong family unit. Yet, one-fourth of infants of immigrants in predominantly Spanish-speaking households are at high risk for serious infectious disease despite using preventive care. As these children mature beyond the neonatal period, factors predisposing to illness are large households, poor access to care, and maternal characteristics, including smoking, pregnancy complications, and employment.

Lack of understanding by health care providers of traditional remedies for common ailments can result in negative interactions between patients and clinicians, misdiagnosis, and poor health outcomes. In one study, health care providers and the population of Vietnamese immigrants for whom they cared both identified misinterpretation of patient symptoms and health care provider recommendations as major issues. The special problems of unemployment, depression, surviving torture, and obtaining assistance are all made more difficult for refugees living in small communities that lack sufficiently large ethnic populations to facilitate culturally sensitive provision of health care.

With the exception of Southeast Asian refugees, there are few clinical studies on the health problems of refugees after arrival in the United States. Tuberculosis, nutritional deficiencies, intestinal parasites, chronic hepatitis B infection, lack of immunization, and depression are major problems in many groups. The great variation in health and psychosocial issues, as well as cultural beliefs, among refugees requires careful attention during the medical encounter. In addition to a complete history and physical examination, tests for tuberculosis, hepatitis B surface antigen, ova and parasites, as well as hemoglobin measurement, are advised for most groups.

A greater percentage of African Americans (53%) and Latinos (59%) have incomes that are below 200% of the federal poverty line than non-Hispanic white Americans (25%) across their lifespans. Financial disadvantage has an impact on health in that mortality rates around the world decline with increasing social class, a concept most easily associated with access to financial resources.