2012 National Healthcare Disparities Report

Chapter 10. Priority Populations

To examine the issue of disparities in health care, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report to track disparities related to "racial factors and socioeconomic factors in priority populations."i Although the emphasis is on disparities related to race, ethnicity, and socioeconomic status, this directive includes a charge to examine disparities in "priority populations," which are groups with unique health care needs or issues that require special attention.

Integrated throughout the Highlights in both the National Healthcare Disparities Report (NHDR) and the National Healthcare Quality Report (NHQR) and Chapters 2 through 9 of this report are racial, ethnic, socioeconomic, gender, geographic location, and age differences in quality of and access to health care in the general U.S. population. Subpopulation data for Asians and Hispanics are also integrated into these chapters where data are available.

Chapter 10 of the NHDR addresses the congressional directive on priority populations in addition to what is presented throughout the NHDR and in the NHQR this year.ii This chapter summarizes findings from data available on differences for racial, ethnic, and low-income populations, as well as for residents of rural areas and people with disabilities (activity limitations).

This year, the NHDR continues to feature health care data on lesbian, gay, bisexual, and transgender (LGBT) populations using data from the Medical Expenditure Panel Survey (MEPS). This section is intended to be an evolving part of the reports as the Department of Health and Human Services (HHS) and other organizations develop health care measures and data relevant to LGBT populations.

The approach taken in this chapter may help policymakers understand the impact of racial, ethnic, and socioeconomic differences on specific populations and target quality improvement programs toward groups in greatest need. The Data Tables appendix includes detailed tables that allow examination of racial, ethnic, and socioeconomic disparities both in the general population and across priority populations for most measures.

AHRQ's Priority Populations

AHRQ's priority populations, specified by Congress in the Healthcare Research and Quality Act of 1999 (Public Law 106-129), are:

  • Racial and ethnic minority groups.iii
  • Low-income groups.iv
  • Women.
  • Children (under age 18).
  • Older adults (age 65 and over).
  • Residents of rural areas.v
  • Individuals with special health care needs,vi including individuals with disabilities and individuals who need chronic care or end-of-life care.

Other populations, such as LGBT, are also included.

How This Chapter Is Organized

This chapter provides the most recent information available on racial, ethnic, and income differences in quality and access for priority populations. It is presented in the following order:

  • Racial and ethnic minorities.
  • Low-income groups.
  • Residents of rural areas.
  • Individuals with disabilities or special health care needs.
  • LGBT individuals.

Measures related to women, children, and older adults are integrated into other chapters of this report and the Data Tables appendix and include comparisons by sex and age. A list of where this information for these populations can be found in the reports is provided at the end of this chapter in the Priority Populations Appendix. We also include a list of figures that provide comparisons by income, education, insurance, and residence location.

This chapter does not provide a comprehensive assessment of health care differences in each priority population. In general, most of the measures tracked in the NHQR and NHDR were selected to be applicable across many population groups to fulfill the purpose of these reports, which is to track quality and disparities at the national level.

These general measures overlook some important health care problems specific to particular populations. For example, people with disabilities may face barriers in getting access to care and experience differences in quality of care that are not captured by data because of the limitations in the survey instruments and other data collection instruments. 

Racial and Ethnic Minorities

In 2010, more than one-third of the U.S. population identified themselves as members of racial or ethnic minority groups (U.S. Census Bureau, 2011a). By 2050, it is projected that these groups will account for almost half of the U.S. population. The U.S. Census Bureau estimated that the United States had about 39 million Blacks or African Americans in 2010 (12.6% of the U.S. population) (U.S. Census Bureau, 2011a); more than 50.5 million Hispanics or Latinos (16%) (Ennis, et al., 2010); almost 14.8 million Asians (4.8%); about 6.2 million NHOPIs (0.2%); and nearly 3 million AI/ANs (0.9%) (U.S. Census Bureau, 2011a), of whom 57% reside on Federal trust lands (Smedley, et al., 2003).

Racial and ethnic minorities are more likely than non-Hispanic Whites to be poor or near poor (Lillie-Blanton, et al., 2003). In addition, Hispanics, Blacks, and some Asian subgroups are less likely than non-Hispanic Whites to have a high school education (Collins, et al., 2002).

Previous chapters of the NHDR describe health care differences by racial and ethnic categories as defined by the Office of Management and Budget (OMB) and used by the U.S. Census Bureau (Executive Office of the President, 1997). In this section, quality of and access to health care for each minority group are summarized to the extent that statistically reliable data are available for each group.

Criteria for importance are that the difference be statistically significant at the alpha ≤0.05 level (two-tailed test) and that the relative difference from the reference group be at least 10% when framed positively as a favorable outcome or negatively as an adverse outcome. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

Changes Over Time

This section also examines changes over time in differences related to race and ethnicity. For each measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group. The time periods range from 2000-2003 to 2005-2011 depending on the data source. Consistent with Healthy People 2020, disparities are measured in relative terms as the percentage difference between each group and a comparison group. New this year is the use of a linear regression model to estimate the difference in the annual rate of change for the comparison group relative to the reference group.

The difference in annual rate of change for the comparison group relative to the reference group was estimated. Determinations of whether subgroup differences have grown, narrowed, or remained the same were based on estimated differences in annual rate of change as specified below:

  • Subgroup differences are deemed to be narrowing if the change in disparities is less than −1 and p <0.10.
  • Subgroup differences are deemed to be growing if the change in disparities is greater than 1 and p <0.10.
  • Subgroup differences are deemed to have remained the same if the change in disparities is between −1 and 1, or p >0.10.

Only those measures with 4 or more years of data were included in the trending analysis. Due to methodological changes in trending analysis, it is not appropriate to compare the annual change or rates of change for measure groups discussed in this year's report with those from prior years. More information regarding the methodology can be found in Chapter 1, Introduction and Methods.

Blacks or African Americans

Previous NHDRs showed that Blacks had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Among all measures of health care quality and access that are tracked in the reports and support trends over time, Blacks had worse care than Whites in the most recent year for 73 measures.

Most of these measures showed no significant change in disparities over time. These include preventive care measures for cancer, children's dental care, and flu vaccinations for adults over age 65; hospital admissions for diabetes complications; hospital admissions for asthma; hospital care for pneumonia; hospital care for heart attack; HIV infection deaths; infant mortality; patient safety events; patient-centered care; and access to care.

For 11 measures, the gap between Blacks and Whites grew smaller, indicating improvement:

  • Prostate cancer deaths per 100,000 male population per year.
  • Cancer deaths per 100,000 population per year.
  • Hospital admissions for congestive heart failure per 100,000 population.
  • Incidence of end stage renal disease (ESRD) due to diabetes per million population.
  • Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over.
  • New AIDS cases per 100,000 population age 13 and over.
  • Hospital patients with pneumonia who received influenza screening or vaccination.
  • Hospital patients with pneumonia who received pneumococcal screening or vaccination.
  • Long-stay nursing home residents who were assessed for pneumococcal vaccination.
  • Short-stay nursing home residents who were assessed for pneumococcal vaccination.
  • Short-stay nursing home residents who received influenza vaccination during the flu season.

For 2 measures, the gap grew larger, indicating worsening disparities:

  • Breast cancer diagnosed at advanced stage (regional, distant stage, or local stage with tumor greater than 2 cm) per 100,000 women age 40 and over.
  • Maternal deaths per 100,000 live births.

Asians

Previous NHDRs showed that Asians had similar or better quality of care than Whites but worse access to care than Whites for many measures that the report tracks. Among all measures of health care quality and access that are tracked in the reports and support trends over time, Asians or Asians and Pacific Islanders in aggregate had worse care than Whites in the most recent year for 37 measures.

Most of these measures showed no significant change in disparities over time. These include measures on preventive care for breast cancer, cervical cancer, and colorectal cancer; obstetric trauma; hospice care; timeliness of care; patient-centered care; and access to care.

For 4 measures, the gap between Asians and Whites grew smaller, indicating improvement:

  • Hospital patients with pneumonia who received influenza screening or vaccination.
  • Hospital patients with pneumonia who received pneumococcal screening or vaccination.
  • Adults age 65 and over who ever received pneumococcal vaccination.
  • Hospital admissions for asthma per 100,000 population, age 65 and over.

For 3 measures, the gap grew larger, indicating worsening disparities:

  • ESRD due to diabetes per million population.
  • Adults ages 18-64 at high risk (e.g., chronic obstructive pulmonary disease [COPD]) who ever received pneumococcal vaccination.
  • Hospice patients who received the right amount of help for feelings of anxiety or sadness.

On October 31, 2011, HHS published final standards for data collection on race, ethnicity, sex, primary language, and disability status, as required by Section 4302 of the Affordable Care Act. The law requires that data collection standards for these measures be used, to the extent practicable, in all national population health surveys. They will apply to self-reported information only.

The categories for HHS data standards for race and ethnicity are based on the disaggregation of the OMB standard used in the American Community Survey (ACS) and the 2000 and 2010 Decennial Census. Figure 10.1 is an example of how these final data standards can be used to report data on Asian subpopulations based on data from the National Survey on Drug Use and Health (NSDUH). Future national reports will include such disaggregated racial and ethnic categories from other data sources when data are available.

  Figure 10.1. Past month substance use among Asians age 18 and over, by Asian subgroup, 2004-2008

For Text Description, select the link below the image.

[D] Select for Text Description

Source: Reprinted from Office of Applied Studies. The NSDUH report: substance use among Asian adults. Rockville, MD: Substance Abuse and Mental Health Services Administration; May 20, 2010.
Denominator: Asian adults age 18 and over with substance use in the past month.

Substance use varied greatly among Asian subgroups:

  • Past month alcohol use ranged from 51.9% among Indian adults to 32.1% among Korean adults (Figure 10.1).
  • Past month binge alcohol use ranged from a high of 25.9% among Indian adults to a low of 8.4% among Vietnamese adults.
  • Illicit drug use ranged from 6.2% among Filipino adults to 2.1% among Vietnamese and Korean adults.

Native Hawaiians and Other Pacific Islanders

NHOPIs (alone or in combination with other races) are 0.4% of the U.S. population. From 2000 to 2010, the NHOPI population increased more than three times as fast as the total U.S. population (35% compared with 9.7% for the total U.S. population). More than half of the NHOPI population reported being of multiple race (56%). While three-fourths of the NHOPI population lived in the West, the South experienced the fastest growth in the NHOPI population (66%) (Hixson, et al., 2012).

The ability to assess disparities among NHOPIs for the NHDR has been a challenge for two main reasons. First, the NHOPI racial category is relatively new to Federal data collection. Before 1997, NHOPIs were classified as part of the Asian and Pacific Islander racial category and could not be identified separately in most Federal data.

In 1997, OMB promulgated new standards for Federal data on race and ethnicity and mandated that information about NHOPIs be collected separately from information about Asians (Executive Office of the President, 1997). However, these standards have not yet been incorporated into all databases. Second, when information about this population was collected, databases often included insufficient numbers of NHOPIs to allow reliable estimates to be made.

Due to these challenges, in previous NHDRs, estimates for the NHOPI population could be generated for only a handful of measures. A lack of quality data on this population prevents the NHDR from detailing disparities for this group. HHS is working to implement new data standards for analyzing data for minority populations, including NHOPIs.

Currently in the NHDR, some data on NHOPIs are available for some measures throughout the report, such as measures related to cancer treatment, heart disease, home health care, access to care, workforce diversity, patient centeredness, and timeliness. Data sources such as the Medical Expenditure Panel Survey, National Health Interview Survey, and Behavioral Risk Factor Surveillance System may have larger samples of NHOPIs due to efforts to improve sample sizes. However, these data are not necessarily a comprehensive survey of health and health care. Other surveys and data collection efforts, such as vital statistics and hospital administrative data, include more topics but do not identify NHOPIs or have large enough sample sizes to provide data for these populations.

For all national data sources, the relatively small population sizes of many Pacific Islander groups can cause these populations to be overlooked when categorized as NHOPIs. In addition, identifying individuals with chronic conditions or other health conditions within such small populations further reduces the sample sizes. However, as data become available, this information will be included in future reports.

American Indians and Alaska Natives

Previous NHDRs showed that AI/ANs had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Among all measures of health care quality and access that are tracked in the reports and support trends over time, AI/ANs had worse care than Whites in the most recent year for 36 measures.

Most of these measures showed no significant change in disparities over time. Such measures include measures for HIV/AIDS, preventive care for children, care for residents in nursing homes, home health care, hospice care, and access to care.

For one measure, the gap between AI/ANs and Whites grew smaller, indicating improvement:

  • Incidence of ESRD due to diabetes per million population.

For 3 measures, the gap grew larger, indicating worsening disparities:

  • Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy.
  • People with difficulty contacting their usual source of care over the telephone.
  • Hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at discharge.

Hispanics or Latinos

Previous NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures that the reports track. Among all measures of health care quality and access that are tracked in the reports and support trends over time, Hispanics had worse care than non-Hispanic Whites in the most recent year for 76 measures.

Most of these measures showed no significant change in disparities over time. Such measures include measures on preventive care for cervical cancer and colorectal cancer; diabetes care; HIV/AIDS; hospital admissions for asthma; quality of care for residents of nursing homes; home health care; timeliness of care; patient-centered care; and access to care.

For 4 measures, the gap between Hispanics and non-Hispanic Whites grew smaller, indicating improvement:

  • Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over.
  • Children ages 2-17 who had a dental visit in the calendar year.
  • Hospital patients with pneumonia who received influenza screening or vaccination.
  • Hospital patients with pneumonia who received pneumococcal screening or vaccination.

For 5 measures, the gap between Hispanics and non-Hispanic Whites grew larger, indicating worsening disparities:

  • Adults age 40 and over with diagnosed diabetes who received at least two hemoglobin A1c measurements in the calendar year.
  • Adult home health care patients whose ability to walk or move around improved.
  • Adult home health care patients whose shortness of breath decreased.
  • Hospital patients with heart attack who received fibrinolytic medication within 30 minutes of arrival.
  • People without a usual source of care who indicated a financial or insurance reason for not having a source of care.

Figure 10.2 is an example of how the final data standards described earlier can be used to report data for Hispanic subpopulations based on data from the NSDUH. Future national reports will include such disaggregated racial and ethnic categories from other data sources when data are available.

  Figure 10.2. Past month substance use among Hispanic adults, by origin of Hispanic subgroup, 2004-2008

For Text Description, select the link below the image.

[D] Select for Text Description

Source: Office of Applied Studies. The NSDUH report: substance use among Hispanic adults. Rockville, MD: Substance Abuse and Mental Health Services Administration; May 27, 2010.
Denominator: Hispanic adults age 18 and over with substance use in the past month.

  • Among Hispanic adults, substance use varied greatly by subgroup. Past month alcohol use ranged from 60.8% among adults of Spanish origin to 40.3% among adults of Dominican origin (Figure 10.2).
  • Past month binge alcohol use ranged from 28.7% among adults of Puerto Rican origin to 20.8% among those of Central or South American origin.
  • Illicit drug use ranged from 13.1% percent among adults of Spanish origin to 3.9% among those of Dominican origin.

i. For statutory requirements, refer to 42 U.S.C. 299a-1(a)(6).
ii. Populations of inner-city areas are also identified as one of AHRQ's priority populations pursuant to 42 U.S.C. 299(c)(1)(A). However, no data are available to support findings for this population.
iii. Racial groups are White, Black, Asian, Native Hawaiian or Other Pacific Islander (NHOPI), American Indian or Alaska Native (AI/AN), and more than one race. Ethnic groups are Hispanic or Latino, non-Hispanic White, and non-Hispanic Black.
iv. Thresholds for income categories—poor, low income, middle income, and high income—vary by family size and composition and are updated annually by the U.S. Bureau of the Census. For example, in 2012, the Federal poverty threshold for a family of two adults and two children was $23,050.
v. Rural areas can be defined differently depending on the data source. The NHDR uses Office of Management and Budget revised definitions of metropolitan and micropolitan statistical areas. Noncore areas are rural areas.
vi. Individuals with special health care needs include children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Disparities Report: Chapter 10. Priority Populations. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/chap10.html