Chapter 4. Priority Populations (continued, 3)

Recent Immigrants and Limited-English-Proficient Populations

Recent Immigrants

Immigrants often encounter barriers to high-quality health care. In 2003, about 11.7% (33.5 million of the 286 million people living in the United States) were born outside the United States, up from 7.9% (20 million) in 1990.²² Asians and Hispanics are much more likely to be foreign born than are Whites or Blacks. About 70% of Asians and 40% of Hispanics in the United States are foreign born, compared with about 4% of Whites and 6% of Blacks.²³

Certain diseases are concentrated among Americans born in other countries. For example, in 2006, 56.6% of tuberculosis cases in the Nation were among foreign-born individuals.²⁴ In addition, the case rate among foreign-born individuals is more than 10 times as high as the case rate among individuals born in the United States.²⁴ However, the case rates for tuberculosis among U.S.-born and foreign-born individuals are both decreasing.²⁴

Language Barriers

Quality health care requires that patients and providers communicate effectively. People who speak a language other than English at home may have less access to resources, such as health insurance, that facilitate getting needed health care. Providers' and patients' ability to communicate clearly with one another can be compromised if they do not speak the same language. Quality may suffer if patients with limited English proficiency cannot express their care needs to providers who speak English only and do not have an interpreter's assistance.

Communication problems between the patient and provider can lead to lower patient adherence to medication schedules and decreased participation in medical decisionmaking. These problems also can exacerbate cultural differences that impair the delivery of quality health care. Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, prohibits discrimination against patients based on their national origin by providers receiving Federal financial assistance.²⁵ Such providers are required to take reasonable steps to provide people with limited English proficiency with a meaningful opportunity to participate in programs funded by the U.S. Department of Health and Human Services.

Limited English proficiency is a barrier to quality health care for many Americans. About 52 million Americans, or 19.4% of the population, spoke a language other than English at home in 2000, up from 32 million in 1990. Of the 52 million, 32 million (about 12% of the population) spoke Spanish, 10 million (about 4% of the population) spoke another Indo-European language, 7.8 million (about 3% of the population) spoke an Asian or Pacific Islander language, and 2 million spoke other languages at home. Almost half of the people who spoke a foreign language at home reported not speaking English very well.²⁶ A study of health plan members and use of interpreters showed that the use of interpreters reduced disparities for Hispanic and Asian and Pacific Islander members (28% and 21%, respectively).²⁷

Measures

As in previous NHDRs, findings are presented below for several quality and access measures based on data from the National Tuberculosis Surveillance System and the Medical Expenditure Panel Survey (MEPS). These sources also are supplemented with data from the CHIS. Information on disparities in health care quality and access for Americans born outside the United States and for Americans with limited English-speaking skills are presented for tuberculosis therapy, poor communication with health care providers, and uninsurance.

Figure 4.25. Completion of therapy for tuberculosis within 1 year of being diagnosed, people born outside the United States, by race and ethnicity, 1999-2005

Key: API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1999-2005.
Denominator: Foreign-born U.S. resident population with verified tuberculosis, all ages.

• From 1999 to 2005, the percentage of people who completed therapy for tuberculosis within 1 year of being diagnosed improved for all groups, except for foreign-born non-Hispanic Whites (Figure 4.25).
• In 2005, the percentage of people who completed therapy for tuberculosis within 1 year of being diagnosed was significantly higher for foreign-born Blacks compared with foreign-born Whites (84.7% compared with 81.9%).
• There were no statistically significant differences between the percentage of foreign-born APIs and foreign-born Whites who completed therapy for tuberculosis within 1 year of being diagnosed (80.7% compared with 82.0%). Nor were there any statistically significant differences between foreign-born Hispanics and foreign-born non-Hispanic Whites (81.9% compared with 81.6%).

Figure 4.26. Composite measure: Adult ambulatory patients who reported poor communication with health providers, by race and ethnicity, stratified by language spoken at home, 2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Average percentage of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and were reported to have had poor communication with health providers (i.e., their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them). Data were insufficient for this analysis for Black non-English speakers.

• The overall percentage of adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with their health providers was significantly higher for individuals who speak a foreign language at home than for individuals who speak English at home (13.4% compared with 9.5%; Figure 4.26).
• The percentage of adults who reported poor communication with their health providers was significantly higher for Whites who speak some other language at home than for Whites who speak English at home (12.1% compared with 9.3%). The percentage also was higher for Asians who speak some other language at home than for Asians who speak English at home (17.4% compared with 9.3%).
• There were no statistically significant differences for other racial or ethnic groups due to small sample sizes.

Figure 4.27. Adults under age 65 who were uninsured all year, by race and ethnicity, stratified by language spoken at home, 2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.
Denominator: Civilian noninstitutionalized population ages 18-64.

• The overall percentage of adults under age 65 uninsured all year was almost three times as high for individuals who speak a foreign language at home as for individuals who speak English at home (33.5% compared with 11.5%; Figure 4.27).
• The percentage of people uninsured all year was significantly higher for Whites, Blacks, and Asians who speak some other language at home than for their counterparts who speak English at home (37.1% compared with 11.1% for Whites, 31.2% compared with 14.0% for Blacks, and 19.8% compared with 5.3% for Asians).
• The percentage of people uninsured all year was more than twice as high for Hispanics who speak some other language at home as for Hispanics who speak English at home (37.8% compared with 17.2%).

Language Assistance

Clear communication is an important component of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

For people with limited English proficiency, having language assistance is of particular importance. People with limited English proficiency may choose a usual source of care in part based on language concordance. Not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care.

The NHDR includes a noncore measure of access: provision of language assistance by the usual source of care. Language assistance includes bilingual clinicians, trained medical interpreters, and bilingual receptionists and other informal interpreters.

Figure 4.28. Adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, 2003-2006

Key: USC = usual source of care.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2006.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Language assistance includes bilingual clinicians, trained medical interpreters, and informal interpreters (e.g., bilingual receptionists).

• Half of individuals with limited English proficiency did not have a usual source of care in 2006 (Figure 4.28).
• In 2006, less than half (44%) of individuals with limited English proficiency had a usual source of care who offered language assistance.
• In 2006, only 6% of individuals with limited English proficiency had a usual source of care that did not offer language assistance.

Low-Income Groups

In this report, poor populations are defined as people living in families whose household income falls below specific poverty thresholds. These thresholds vary by family size and composition and are updated annually by the U.S. Bureau of the Census.^28,x After falling for nearly a decade (1990-2000), the number of poor people in America rose from 31.6 million in 2000 to 36.5 million in 2006, and the rate of poverty increased from 11.3% to 12.3% during the same period.²⁹

Poverty varies by race and ethnicity. In 2006, 24% of Blacks, 21% of Hispanics, 10% of Asians, and 8% of Whites were poor.²⁹ People with low incomes often experience worse health and are more likely to die prematurely.³⁰ In general, poor populations have reduced access to high-quality care. While people with low incomes are more likely to be uninsured, income-related differences in quality of care that are independent of health insurance coverage have also been demonstrated.³¹

Previous chapters of this report described health care differences by income. This section summarizes disparities in quality of and access to health care for poor^xi individuals compared with high-income^xii individuals. For each core report measure, poor people can have health care that is worse than, about the same as, or better than health care received by high-income people. Only relative differences of at least 10% that are statistically significant at alpha = 0.05 are discussed in this report. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

In addition, changes in differences related to income are examined over time. For each core report measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group at different times. Consistent with Healthy People 2010, disparities are measured in relative terms as the percentage difference between each group and a comparison group. Changes in disparity are measured by subtracting the percentage difference from the comparison group at the baseline year from the percentage difference from the comparison group at the most recent year. The change in each disparity is then divided by the number of years between the baseline and most recent estimate to calculate change in disparity per year.

Core report measures (refer to Table 1.2) for which the relative differences are changing less than 1% per year are identified as staying the same. Core report measures for which the relative differences are becoming smaller at a rate of more than 1% per year are identified as improving. Core report measures for which the relative differences are becoming larger at a rate of more than 1% per year are identified as worsening. Changes of greater than 5% per year are also differentiated from changes of between 1% and 5% per year in some figures.

Figure 4.29. Poor compared with high-income individuals on measures of quality and access

Better = Poor people receive better quality of care or have better access to care than high-income individuals.
Same = Poor and high-income individuals receive about the same quality of care or access to care.
Worse = Poor people receive poorer quality of care or have worse access to care than high-income individuals.
Key: CRM = core report measures (Table 1.2).
Note: Data presented are for the most recent data year available.

Table 4.11. Poor compared with high income on measures of quality and access for most current data year: Specific measures

Figure 4.30. Change in poor-high-income disparities over time

Improving >5% = Poor-high-income difference becoming smaller at an average annual rate greater than 5%.
Improving 1-5% = Poor-high-income difference becoming smaller at an average annual rate between 1% and 5%.
Same = Poor-high-income difference not changing.
Worsening 1-5% = Poor-high-income difference becoming larger at an average annual rate between 1% and 5%.
Worsening >5% = Poor-high-income difference becoming larger at an average annual rate greater than 5%.
Key: CRM = core report measures (Table 1.2).
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 24 core report measures of quality and access could be tracked over time for poor and high-income individuals.

Table 4.12. Change in poor-high-income disparities over time: Specific measures

Note: Measures in bold indicate improvement or worsening at a rate of greater than 5% per year.

Women

The U.S. Census Bureau estimated that there were 152 million females in the United States in 2006 (51% of the U.S. population)³²; of these, 47 million are members of racial or ethnic minority groups.³³ By 2050, it is projected that just under half of females in the United States will be members of racial or ethnic minority groups.³³ The ratio of males to females is highest at birth, when male infants outnumber female infants, and gradually declines with age due to higher male mortality rates. Among Americans age 85 and over, women outnumber men by more than 2 to 1.³⁴

Women in the United States have a life expectancy 5.2 years longer than men³⁵ and lower age-adjusted death rates than men for 12 of the 15 leading causes of death.³⁶ However, women are more likely than men to report conditions that affect daily function, such as arthritis and serious mental illness.³⁷ There is significant variation in health status and health-related behaviors for women of different races and ethnicities.³⁸ In general, gender differences in quality of care are small. Access may be affected by various factors, however. For example, poverty disproportionately affects women; in 2006, 14.1% of women lived in households with incomes below the Federal poverty level compared with 11.1% of men.³⁹

The NHDR tracks many measures of relevance to women. Findings presented here highlight four quality measures and one access measure of particular importance to women:

Quality of Health Care

Prevention: Adults With Obesity Given Advice About Healthy Eating

In 2005-2006, more than 35% of women age 20 and over in the United States were obese, compared with 33% of men,^40,xiii putting them at increased risk for many chronic, deadly conditions, such as hypertension, cancer, diabetes, and coronary heart disease.⁴¹ Reducing obesity is a major objective in preventing heart disease and stroke.⁴² Research shows large racial and ethnic differences in obesity rates among women. The prevalence of obesity is higher for Black and Mexican-American women compared with White women.⁴³ The health care system has a central role to play in helping people become aware of the risks of obesity when they are overweight and suggesting strategies for reducing these risks.

Figure 4.31. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by race and ethnicity, stratified by gender, 2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

• Obese women were more likely than men to receive advice about healthy eating (52.0% compared with 48.5%; Figure 4.31).
• Among obese women, Blacks were less likely than Whites to receive advice about healthy eating (46.0% compared with 54.0%), and Hispanics were less likely than non-Hispanic Whites to receive such advice (48.7% compared with 55.0%).

Outcome: Heart Attack Mortality

Cardiovascular disease is the number one killer among women.⁴⁴ While significant progress has been made in reducing mortality from heart disease over the past three decades, one woman in four still dies from this group of conditions. Women are generally older than men when diagnosed with heart disease (73 versus 65 years on average, according to one study⁴⁵). Therefore, treatment and outcomes may be compromised by the fact that women are more likely to have other chronic conditions when initially diagnosed.

Acute myocardial infarction (AMI) is one type of cardiovascular disease discussed in this report. Measuring processes of heart attack care can provide information about whether a patient received specific needed services, but these processes make up a very small proportion of all the care that a heart attack patient needs. Measuring outcomes of heart attack care, such as mortality, can provide a more global assessment of all the care a patient receives and usually is the aspect of quality that matters most to patients.

Figure 4.32. Deaths per 1,000 adult hospital admissions with acute myocardial infarction, by gender and race and ethnicity, 2006

Key: API = Asian or Pacific Islander. White, Black and API are non-Hispanic.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006.
Note: Rates are adjusted by age, gender, age-gender interactions, and all patient refined-diagnosis related group risk-of-mortality score. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.

• The death rate for hospital admissions with AMI was higher for females compared with males (86.6 per 1,000 compared with 61.7 per 1,000; Figure 4.32). Among females, rates were lower both for Blacks (61.5 per 1,000) and Hispanics (78.1 per 1,000) than for Whites (91.2 per 1,000).
• There were no statistically significant differences between API females and White females in the death rate for hospital admissions with AMI.

Outcome: New AIDS Cases

Early and appropriate treatment of HIV infection can delay progression to AIDS. Improved management of HIV infections has likely contributed to reduced transmission and an associated decline in new AIDS cases. But there are gender differences in sexual behavior patterns among men and women, leading to a higher prevalence of new AIDS cases in men. The higher rates of progression from HIV to AIDS in African Americans in general, and African-American women in particular, may be a function of poor medication self-management. Interventions to improve HIV medication self-management by addressing numeracy skills may help to narrow the gap in health disparities among African-American women with HIV and AIDS.⁴⁶

Figure 4.33. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, stratified by gender, 2007

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, HIV/AIDS Surveillance System, 2007.
Denominator: U.S. population age 13 and over.
Note: The source categorizes race/ethnicity as a single item. White = non-Hispanic White; Black = non-Hispanic Black. Data did not meet criteria for statistical reliability for AI/AN females.

• For the overall U.S. population, the rate of new AIDS cases for males was almost triple that for females (21.6 compared with 7.5 per 100,000 population; Figure 4.33).
• The rate was significantly higher for males than for females in all groups: Blacks (81.3 per 100,000 for males and 39.8 per 100,000 for females), Asians (7.3 per 100,000 for males and 1.6 per 100,000 for females), Hispanics (31.0 per 100,000 for males and 8.9 per 100,000 for females), and Whites (10.6 per 100,000 for males and 1.8 per 100,000 for females).
• Among females, Blacks and Hispanics had significantly higher rates of new AIDS cases than Whites (39.8 and 8.9 per 100,000, respectively, compared with 1.8 per 100,000). Asian women had lower rates than White women (1.6 per 100,000 compared with 1.8 per 100,000).
• No group has yet achieved the Healthy People 2010 target of 1.0 new AIDS case per 100,000 population.

^x For example, in 2008, the Federal poverty threshold for a family of two adults and two children was $21,834.
^xi Household income less than Federal poverty thresholds.
^xii Household income 400% of Federal poverty thresholds and higher.
^xiii Obesity is defined as having a body mass index (BMI) of 30 or higher. It is noteworthy that BMI incorporates both a person's weight and height in determining if he or she is overweight or obese.

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