Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, Editors Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care Board on Health Sciences Policy THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, D.C. 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Office of Minority Health, U.S. Department of Health and Human Services. Additional support for data collection activities was provided by The Commonwealth Fund and the Henry J. Kaiser Family Foundation. The views presented in this report are those of the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Unequal treatment : confronting racial and ethnic disparities in health care / Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, editors ; Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine. p. ; cm. Includes bibliographical references and index. ISBN 0-309-08265-X (hardcover with CD-ROM); ISBN 0-309-08532-2 (hardcover) 1. Discrimination in medical care. 2. Health services accessibility. 3. Minorities—Medical care. 4. Race discrimination. 5. Racism—Cross-cultural stdies. 6. Social medicine. {DNLM: 1. Health Services Accessibility—United States. 2. Ethnic Groups—United States. 3. Minority Groups—United States. 4. Quality of Health Care—United States. WA 300 U515 2002] I. Smedley, Brian D. II. Stith, Adrienne Y. III. Nelson, Alan R. (Alan Ray) IV. Institute of Medicine (U.S.). Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. RA563.M56 U53 2002 352.1′089—dc 21 2002007492 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. 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The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal govern- ment. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering commu- nities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org COMMITTEE ON UNDERSTANDING AND ELIMINATING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE ALAN R. NELSON, M.D., (Chair), retired physician and current Special Advisor to the Chief Executive Officer, American College of Physicians–American Society of Internal Medicine, Washington, DC MARTHA N. HILL, Ph.D., R.N., (Co-Vice Chair), Interim Dean, Professor and Director, Center for Nursing Research, Johns Hopkins University School of Nursing, Baltimore, MD RISA LAVIZZO-MOUREY, M.D., M.B.A., (Co-Vice Chair), Senior Vice President, Health Care Group, Robert Wood Johnson Foundation, Princeton, NJ JOSEPH R. BETANCOURT, M.D., M.P.H., Senior Scientist, Institute for Health Policy, Director for Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital, Partners HealthCare System, Boston, MA M. GREGG BLOCHE, J.D., M.D., Professor of Law, Georgetown University and Co-Director, Georgetown-Johns Hopkins Joint Program in Law and Public Health, Washington, DC W. MICHAEL BYRD, M.D., M.P.H., Instructor and Senior Research Scientist, Harvard School of Public Health, and Instructor/Staff Physician, Beth Israel Deaconess Hospital, Boston, MA JOHN F. DOVIDIO, Ph.D., Charles A. Dana Professor of Psychology and Interim Provost and Dean of Faculty, Colgate University, Hamilton, NY JOSE ESCARCE, M.D., Ph.D., Senior Natural Scientist, RAND and Adjunct Professor, UCLA School of Public Health, Los Angeles, CA SANDRA ADAMSON FRYHOFER, M.D., M.A.C.P., practicing internist and Clinical Associate Professor of Medicine, Emory University School of Medicine, Atlanta, GA THOMAS INUI, Sc.M., M.D., Senior Scholar, Fetzer Institute, Kalamazoo and Petersdorf Scholar-in-Residence, Association of American Medical Colleges, Washington, DC JENNIE R. JOE, Ph.D., M.P.H., Professor of Family and Community Medicine, and Director of the Native American Research and Training Center, University of Arizona, Tucson, AZ THOMAS McGUIRE, Ph.D., Professor of Health Economics, Department of Health Care Policy, Harvard Medical School, Boston, MA CAROLINA REYES, M.D., Vice President, Planning and Evaluation, The California Endowment, Woodland Hills, CA, and Associate Clinical Professor, UCLA School of Medicine, Los Angeles, CA DONALD STEINWACHS, Ph.D., Chair and Professor of the Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, and Director, Johns Hopkins University Health Services Research and Development Center, Baltimore, MD DAVID R. WILLIAMS, Ph.D., M.P.H., Professor of Sociology and Research Scientist, Institute for Social Research, University of Michigan, Ann Arbor, MI HEALTH SCIENCES POLICY BOARD LIAISON GLORIA E. SARTO, M.D., Ph.D., Professor, University of Wisconsin Health, Department of Obstetrics and Gynecology, Madison, WI IOM PROJECT STAFF BRIAN D. SMEDLEY, Study Director ADRIENNE Y. STITH, Program Officer DANIEL J. WOOTEN, Scholar-in-Residence THELMA L. COX, Senior Project Assistant SYLVIA I. SALAZAR, Edward Roybal Public Health Fellow, Congressional Hispanic Caucus Institute IOM STAFF ANDREW M. POPE, Director, Board on Health Sciences Policy ALDEN CHANG, Administrative Assistant CARLOS GABRIEL, Financial Associate PAIGE BALDWIN, Managing Editor COPY EDITOR JILL SHUMAN vi REVIEWERS This report has been reviewed in draft form by individuals chosen for their di- verse perspectives and technical expertise, in accordance with procedures ap- proved by the NRC’s Report Review Committee. The purpose of this indepen- dent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsive- ness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: LU ANN ADAY, Professor of Behavioral Sciences, University of Texas-Houston Science Center, TX JOHN F. ALDERETE, Professor of Microbiology, University of Texas Health Science Center at San Antonio, TX NAIHUA DUAN, Professor-in-Residence, Center for Community Health, UCLA Wilshire Center, Los Angeles, CA DEAN M. HASHIMOTO, Associate Professor, Boston College Law School, Newton, MA SHERMAN A. JAMES, Director, Center for Research on Ethnicity Culture & Health, School of Public Health, University of Michigan, Ann Arbor, MI JEROME P. KASSIRER, Yale University School of Medicine, New Haven, CT WOODROW A. MYERS, Executive Vice President, Wellpoint Health Net- works, Thousand Oaks, CA FRANK A. SLOAN, Director, Center for Health Policy, Law & Management, Duke University, Durham, NC KNOX H. TODD, Adjunct Associate Professor, The Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA WILLIAM A. VEGA, Director, Behavioral and Research Training Institute, Universit of Medicine and Dentistry of New Jersey, New Brunswick, NJ EUGENE WASHINGTON, Professor and Chair, Department of Ob/Gyn & Reproductive Sciences, University of California, San Francisco, CA Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda- tions nor did they see the final draft of the report before its release. The review of this report was overseen by HAROLD C. SOX, Editor, Annals of Internal Medicine, Philadelphia, PA, appointed by the Institute of Medicine, and ELAINE L. LARSON, Professor of Pharmaceutical & Therapeutic Research, Columbia Uni- versity School of Nursing, New York, NY. Appointed by the NRC’s Report Re- view Committee, these individuals were responsible for making certain that an independent examination of this report was carried out in accordance with insti- tutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. vii Acknowledgments Many individuals and groups made important contributions to the study committee’s process and to this report. The committee wishes to thank all of these individuals and organizations, but recognizes that at- tempts to identify all and acknowledge their contributions would require more space than is available in this brief section. To begin, the committee would like to thank the sponsors of this report. Core funds for the committee’s work were provided by the Office of Minority Health, U.S. Department of Health and Human Services, in response to a Congressional request. The committee thanks Joan Jacobs and Olivia Carter-Pokras of this office, who served as the Task Order Officers on this grant. Additional funding for data collection efforts was provided by the Henry J. Kaiser Family Foundation of Menlo Park, Cali- fornia, and The Commonwealth Fund, a New York City-based private, independent foundation. The committee thanks Marsha Lillie-Blanton of the Henry J. Kaiser Family Foundation, and Karen Scott Collins and Dora L. Hughes of The Commonwealth Fund for their support. The committee found the perspectives of many individuals and or- ganizations to be valuable in understanding the complex problem of racial and ethnic disparities in healthcare. Several individuals and orga- nizations provided important information at open workshops of the committee. These include, in order of appearance, Nathan Stinson, Ph.D., M.D., M.P.H., Deputy Assistant Secretary for Minority Health, U.S. Department of Health and Human Services; Charles Dujon, Legis- lative Assistant, Office of the Honorable Jessie Jackson, Jr., U.S. House ix