Which Of The Following Is One Of The Reasons Why Women Tend To Use Health Care Services More Often?

Racial and indigenous minorities may face challenges in having access to medical care in the United states of america. When they receive it, their care may not be equivalent to that for other groups. Why this is so, however, is a complex effect involving non just possible differences in ability to pay and provider behavior, but also in such factors as patient preferences, differential handling past providers, and geographical variability.

INSURANCE COVERAGE

Blacks, Hispanics, and some Asian populations, when compared with whites, appear to have lower levels of health insurance coverage, with Hispanics facing greater barriers to health insurance than whatever other group (Institute of Medicine, 2002). However, Hispanics and Asians are considerably heterogeneous in insurance coverage, as Table ten-ane shows for the adult population nether 65 (Collins et al., 2002; Doty and Ives, 2002; Hughes 2002). Uninsured rates are much college for Mexicans and Central Americans than for Puerto Ricans. Among Asians, Chinese, Japanese, Filipinos, and Indians take uninsured rates that are comparable to or lower than those of whites, while Koreans and Vietnamese have college uninsured rates than blacks.

TABLE 10-1

Health Insurance Coverage for U.S. Adults Aged eighteen-64, 2001.

Blacks and Hispanics are less probable to have insurance coverage from a private employer, whether directly or through a spouse, and more likely to accept public health insurance coverage than whites (Blendon et al., 1989; Hogue et al., 2000; National Institutes of Health, 1998). Blacks and Hispanics are also more probable than whites to receive intendance in nonoptimal organizational settings (such as emergency rooms) and to lack continuity in health care. Analyses of racial and ethnic differences in access to and the use of health services between 1977 and 1996 bear witness that the black-white gap has not narrowed over time, and the gap betwixt Hispanics and whites has widened (Weinick et al., 2000). Moreover, this report establish that, even if income and health insurance coverage were equal, racial and ethnic differences in having a usual source of care and in receiving ambulatory care in the previous twelvemonth would not have been eliminated, because one-half to 3-quarters of the differences on these indicators were not accounted for by income and insurance coverage.

In 1965, the Medicare program was established to reduce financial barriers to hospital and physician services for persons anile 65 and older. To participate in this program, hospitals had to comply with Championship 6 of the Civil Rights Human action of 1964, which requires that no one be excluded from federal benefits based on race, colour, or national origin. This requirement played a large role in desegregating hospitals (Quadagno, 2000).

Medicare has indeed improved the state of affairs for older adults. For example, Decker and Rapaport (2002) show that turning 65 increases the chances of having a mammogram among blackness women, particularly uneducated black women. Yet, there is also prove that racial differences remain amongst older adults in access to health services (Gornick, 2000). Tabular array x-2 shows the level of wellness care coverage for black, white, and Hispanic older adults (National Centre for Wellness Statistics, 2001). Nigh all of these persons accept Medicare. Even so, in comparing with whites, blackness and Hispanic older adults are considerably less probable to accept private insurance and more likely to receive Medicaid or to have Medicare as their only insurance.

TABLE 10-two

Health Care Coverage for Persons 65 Years of Age and Over, 1998 (in percent).

The limitations of Medicare create economic challenges for blacks and Hispanics. Medicare does not cover such medical needs equally prescription drugs, dental care, and long-term care, and it imposes various out-of-pocket medical expenses: an annual deductible for some care, copayments on physician charges, and payment for one twenty-four hour period of inpatient care. These expenses may represent a substantial burden for low-income older adults, and minorities are more affected because of lower household incomes. In 1996, two-thirds of white Medicare beneficiaries had incomes of less than $25,000; 90 percent of black and Hispanic beneficiaries had incomes this low (Gornick, 2000). Other data show that black and Hispanic older adults have higher rates of poverty than their white counterparts, as do Asians and American Indians and Alaska Natives (Williams and Wilson, 2001).

Many older adults reduce their out-of-pocket expenses by purchasing supplemental individual insurance, merely black and Hispanic older adults are a little more than twice equally likely every bit whites non to do so (Wallace et al., 1998). Not surprisingly, although blackness Medicare beneficiaries report higher levels of morbidity than their white counterparts, they report lower levels of office visits and more than inpatient, emergency room, and nursing home visits (Gornick, 2000). In comparison with whites, black beneficiaries also have markedly fewer visits to specialists, and they receive such diagnostic services as mammography and sigmoidoscopy much less often (Gornick, 2000). For some older persons with low incomes and limited assets, Medicaid can cover much of their out-of-pocket medical expenses. However, only about 11 percent of older Medicare beneficiaries also receive Medicaid; these dual eligibles are more likely to be in poor health and over age 85 than other Medicare beneficiaries (Feder et al., 2001).

The situation with regards to American Indians and Alaska Natives is somewhat unique because of the being of the Indian Wellness Service (IHS), which operates its ain network of inpatient and ambulatory care facilities. While insurance coverage is an issue—24 percent of American Indians practice not have health insurance (Brown et al., 2000)—information technology does not factor into matters of admission to care in the same manner every bit for other subpopulations. The tripartite organization of the IHS, tribally operated clinics, and urban Indian clinics stand for a unique ecology inside which American Indians seek help for physical, mental, alcohol, and drug problems. This is peculiarly relevant when discussing health care challenges for American Indian elderly since the emphasis of the IHS system is on astute rather than chronic health problems (Baldridge, 2001). Although the IHS is intended, legally, to be a residual provider, a large fraction of the IHS-eligible population depends on it (Cunningham, 1996).

QUALITY OF Care

Research reveals systematic racial differences in the kind and quality of medical care received by Medicare beneficiaries (Escarce et al., 1993; McBean and Gornick, 1994). In 1992, blackness Medicare beneficiaries were less probable than their white counterparts to receive any of the 16 virtually unremarkably performed hospital procedures (McBean and Gornick, 1994). The differences were largest for referral-sensitive procedures. The Medicare files showed only four nonelective procedures that black Medicare beneficiaries received more frequently than whites—all procedures (such as the amputation of a lower limb and the removal of both testes) that reflect delayed diagnosis or initial failure in the direction of chronic illness. Since a greater pct of black than white Medicare beneficiaries make out-of-pocket payments for deductibles and copayments (McBean and Gornick, 1994), this burden could contribute to less employ of ambulatory medical intendance and to the postponement or abstention of treatment.

Contrasts among dissimilar groups are evident if one focuses on a few procedures that alleviate some major sources of morbidity and mortality, procedures supported past strong scientific evidence and practitioner consensus. Jencks et al. (2000) identified 24 such measures that they labeled measures of the quality of intendance for Medicare beneficiaries, and 21 of these have been compared across racial and ethnic groups (Hebb et al., 2003), including such inpatient measures equally warfarin for patients with atrial fibrillation and such outpatient measures as mammograms at least every 2 years. Receipt of appropriate treatment by each racial or ethnic group is compared with the percentage receiving advisable treatment overall in Figure 10-one. Racial and ethnic minorities announced to be at some disadvantage, peculiarly for outpatient rather than inpatient procedures. Hispanics and American Indians and Alaska Natives, overall, may receive intendance that is every bit inadequate as that for blacks, though because of small numbers and issues with racial and ethnic identification, the figures must be treated with circumspection. People enrolled in both Medicare and Medicaid (of any racial or indigenous group) also receive less adequate care than boilerplate, suggesting a socioeconomic dimension to poor care. Notwithstanding, their disadvantage is sometimes smaller than that of particular racial and ethnic groups.

Effigy ten-1

Treatment for minorities in comparison with all Medicare beneficiaries: Differences in percentage receiving treatment. SOURCE: Information in Hebb et al. (2003).

Such differences in the receipt of medical procedures are consistent with a larger literature, mostly for before years, that finds systematic racial and indigenous differences in the receipt of a broad spectrum of therapeutic interventions (Geiger, 2002; Constitute of Medicine, 2002; Mayberry et al., 2000). Blacks and sometimes other minorities are less likely to receive a diverse range of procedures, ranging from high-technology interventions to basic diagnostic and treatment procedures, and they experience poorer quality medical intendance than whites.

Differences in patient preferences and inappropriate use past whites of some procedures may play a role in the differences. For case, Schneider et al. (2001) show that the black-white difference in angioplasty tin be explained by inappropriate or at least questionable use of the procedure for whites. Still, they find that this explanation does not fully account for differences in bypass surgery. The design of differences betwixt blacks and whites appears robust even when such factors are considered, and it persists in studies that adjust for differences in health insurance, socioeconomic status, stage and severity of disease, comorbidity, and the type of medical facility (Institute of Medicine, 2002).

Weighed against such evidence is 1 recent study of a nationwide sample of about 30,000 Medicare patients hospitalized with heart failure in 1998 and 1999 (Rathore et al., 2003). Blacks were slightly more probable than whites to receive appropriate handling (ACE inhibitors and measurement of left ventricular ejection fraction). They were more likely to exist readmitted simply had lower mortality rates up to a year later hospitalization. None of these differences, however, was significant after controlling for patient medical history and other patient, physician, and infirmary characteristics. This written report, drawing on the same database every bit Hebb et al. (2003) and reaching substantially similar conclusions in the area of handling of congestive heart failure (run across Figure ten-one), shows that fifty-fifty blacks, despite falling brusque of standard handling more often than others, are not necessarily disadvantaged in every handling area.

Some differences in quality of care may reverberate the particular institutions and health care providers on which minorities depend. Regardless of insurance coverage, blacks and Hispanics are virtually twice as probable equally whites to receive intendance from a hospital-based provider (Institute of Medicine, 2002). In particular, they are nigh 1.6 times more likely than whites to be treated at condom-cyberspace urban hospitals. Some evidence also suggests that minority patients are more than likely than whites to be treated by less proficient physicians (Mukamel et al., 2000).

GEOGRAPHIC AND INSTITUTIONAL VARIATION

1 gene that needs to be more consistently taken into account in studying racial and ethnic differences is the role of geography or residential area. Access to loftier-quality care varies considerably by area—past land, betwixt rural and urban areas, besides as beyond smaller communities (Waidmann and Rajan, 2000; Wennberg and Cooper, 1999). Since racial and indigenous groups are unevenly distributed across communities, geographic variation in health care has the potential to explicate some health care differences. For instance, states with large proportions of blacks tend to provide less appropriate treatment to all myocardial infarction patients, whether blackness or non, than states with smaller proportions of blacks (Chandra and Skinner, 2004).

The relationship betwixt geographic variation and racial and ethnic differences in health care is circuitous. Some geographic variation may be due to racial factors related to residential segregation by race. But some variation in care is clearly not geographic, as when variations be within geographic areas. Several studies have institute racial and ethnic differences in care in a single facility (e.m., Baker et al., 1996; Chung et al., 1995; Lowe et al., 2001; Moore et al., 1994; Ng et al., 1996; Peterson et al., 1997; Todd et al., 1993, 2000); a unmarried geographic location (Herholz et al., 1996; Ramsey et al., 1997; Segal et al., 1996); and, in the case of cardiovascular illness, even subsequently a wide range of hospital characteristics are considered (Geiger, 2002).

Wellness care tin also vary within health systems, though some studies evidence similar handling for different racial groups. In the Veterans Administration health system, for instance (where differences in insurance coverage are minimized), black-white differences exercise non appear for the handling of colorectal cancer (Dominitz et al., 1998) but have been shown in the handling of heart disease (Oddone et al., 1998; Peterson et al., 1994; Sedlis et al., 1997; Whittle et al., 1993), gall-bladder disease (Arozullah et al., 1999), and mental health (Kales et al., 2000). In Department of Defense force medical facilities, no black-white differences were found in the treatment of prostate cancer (Optenberg et al., 1995) or cervical cancer (Farley et al., 2001). Similarly, no differences were found in handling of acute myocardial infarction through catheterization and revascularization procedures, only whites were more likely than minorities to be considered for future catheterization (Taylor et al., 1997).

To produce overall differences in intendance, the choice of hospitals or clinics that different groups attend and variations in treatment inside those institutions could reinforce each other, or cancel each other out, or i or another factor could exist more important. An example of the first possibility is one study of inadequate pain management, which establish that all patients treated in settings where the patient population was primarily black or Hispanic were more probable to receive inadequate analgesia than those treated in settings where the patient population was primarily white (Cleeland et al., 1997). In addition, minority patients were more likely to be undermedicated for pain than white patients and more probable to have the severity of their hurting underestimated by physicians. In dissimilarity, in a five-state study, Kahn et al. (1994) found that blacks received poorer care in acute intendance hospitals than whites in the same hospitals, simply because more blacks in the study were seen at higher-quality urban teaching hospitals, their overall quality of intendance was no worse. Finally, focusing on astute myocardial infarction, Skinner et al. (2003) found that, nationwide, blacks received intendance at lower-quality hospitals, where they tended to make up a larger proportion of the patients. Within groups of hospitals with different proportions of black admissions, however, white patients actually received poorer intendance than blacks, as reflected in thirty-twenty-four hours mortality rates adjusted for various factors.

STEREOTYPING BY PROVIDERS

Some differences in medical care may be due to stereotypes of different groups held by health intendance providers. The authors of Unequal Treatment (Establish of Medicine, 2002) debate that unconscious or unthinking discrimination based on negative stereotypes, even in the absenteeism of witting prejudice, may contribute to systematic bias in care.

This argument is based on a chain of reasoning. Stereotypes are mutual in American society for various racial and ethnic groups. National information prove that whites view blacks, Hispanics, and Asians more than negatively than they view themselves, with perceptions of blacks being the most unfavorable and perceptions of Hispanics existence essentially more negative than perceptions of Asians. For case, 29 percent of whites concord with the statement that nearly blacks are unintelligent, while 6 percent of whites say the aforementioned of most whites. Similarly, many more whites say that nigh blacks are prone to violence (51 percent) than those who say the same about most whites (sixteen per centum) (Davis and Smith, 1990; Williams, 2001b). Such stereotypes can exist activated, and bear on beliefs, nether conditions of time pressure, when quick judgments must exist made on complex tasks, with cognitive overload and in the presence of such emotions as anger and anxiety (van Ryn, 2002). In the typical health care see, some of these conditions are present, particularly cognitive complexity and fourth dimension pressure level.

The possibility that some health intendance providers may hold particular stereotypes is suggested by a few studies in which physicians were found to view their black patients more negatively than white patients (Finucane and Carrese, 1990; van Ryn and Burke, 2000). For case, van Ryn and Shush (2000) establish that—.fifty-fifty later on adjusting for patient age, sexual activity, socioeconomic status, sickness or frailty and overall wellness, and patient availability of social support—physicians viewed blackness patients, compared with whites, as less kind, congenial, intelligent, and educated, less likely to attach to medical advice, and more likely to lack social support and to abuse alcohol and drugs. Experimental studies of physicians (Schulman et al., 1999; Weisse et al., 2001) and medical students (Rathore et al., 2000) provide evidence that the experimental manipulation of hypothetical patients' characteristics such as race can lead to variations in provider perceptions.

Simply do stereotypes actually touch on patient care? In that location is little evidence on this issue, though i may hypothesize various possibilities. For instance, a wellness care provider may translate symptoms in line with beliefs about group differences. These beliefs might be based on generalizations from clinical experience (Satel, 2000Satel, 2001-2002), or a provider may also select treatments based on stereotypical assumptions nigh patient beliefs. Some research tackles this latter possibility. A national sample of AIDS care physicians predicted that, amongst hypothetical patients, black men would be less probable to adhere to antiretroviral therapy—a generalization that may be right for some therapies just not others (come across below). Since potential adherence to therapy is a cistron in decisions to outset handling, the inference might exist drawn that blackness men would be less likely to receive such care, simply this potential effect of stereotypes was non actually demonstrated (Bogart et al., 2001). Somewhat similarly, van Ryn et al. (1999; cited in van Ryn and Fu, 2003) constitute that physicians rated black patients, in comparison with white patients, as more probable to be lacking in social support and less likely to participate in cardiac rehabilitation. The likelihood of such participation is a cistron in recommending revascularization, but the researchers did not link any difference in recommendations to the stereotype.

Whether medical decisions are actually affected by stereotypes is therefore not known. It would be useful to make up one's mind how oft stereotypes are activated, in what circumstances, and what medical decisions are indeed afflicted. In principle, stereotypes would not be a problem if treatment decisions were entirely individualized (as suggested earlier, in the genetics department, as a long-term goal). Nevertheless, negative stereotypes could all the same brand the provider-patient interaction uncomfortable, which could hamper such individualization by restricting the full exchange of data. Such processes may well be important in particular private cases but their overall contribution to less appropriate care for minorities, or to explaining racial and ethnic differences in wellness in later life, remains uncertain.

PATIENT BEHAVIOR

Differences in patient cocky-intendance—a behavior near which stereotypes may exist—are themselves unconfirmed. Patient self-intendance covers behavior ranging from seeking wellness intendance to compliance with prescribed therapies. Compliance with complicated new therapies, such as those to control insulin-dependent diabetes and for HIV, has been shown to exist better among those, including older adults, with more than educational activity. Notwithstanding, with education controlled, neither blacks nor Hispanics differ significantly from whites in these self-maintenance behaviors (Goldman and Smith, 2002). But other studies have documented differences by race. For instance, persistence with statin therapy amid older patients—which tends to decline over fourth dimension and is also related to socioeconomic status—declines more, regardless of status, amid blacks and other nonwhite patients than in white patients. In fact, blackness subjects had ii.7 times the odds of suboptimal persistence with statin therapy compared with whites, the racial deviation existence greater than that on any other predictor analyzed (Benner et al., 2002).

Somewhat inconsistent results likewise take been shown for the apply of screening tests. Winkleby and Cubbin (2004) show that, at ages 45-64, black and Hispanic women do not differ from whites with regard to having had a Pap examination or a mammogram in the preceding ii years. However, when the proportions of women having had such tests are adjusted for education and income, blacks and Hispanics are significantly more than likely to exist screened than whites. This result too holds for Hispanics aged 65-74; for blacks the differences were not significant at that historic period. However, Medicare reimbursement records tell the opposite story. Blackness and Hispanic women aged 52-69 less oftentimes receive a mammogram paid for under Medicare fee-for-service than the boilerplate beneficiary of this programme (Effigy 10-i; Hebb et al., 2003). In addition, Strzelczyk and Dignan (2002) show that nonwhite women in the Colorado Mammography Project are less likely than whites to adhere to a recommended follow-upward screening. Such credible inconsistencies may accept explanations, but they suggest that the role of patient cocky-care in racial and ethnic differences has not been clearly established.

1 needs to nourish, to brainstorm with, to differences across specific diseases or conditions. Psychosis and substance abuse, for case, are related to contrasting differences. Blacks with psychotic disorders visit psychiatrists less oftentimes than whites. But blacks with substance abuse disorders take more psychiatric visits than whites (Kales et al., 2000). Other factors, from socioeconomic status to differences in cultural beliefs relating to fatalism (Nelson et al., 2002) too complicate the motion-picture show. In improver, blacks and Hispanics are reported to distrust health intendance providers and expect discriminatory treatment more often than whites (LaVeist et al., 2000; Lillie-Blanton et al., 2000), but whether this affects their credence of recommended treatments or compliance with prescribed regimens has not been clearly demonstrated.

NEEDED Enquiry

Improvements in health intendance past themselves are unlikely to either eliminate social inequalities in health or achieve optimal levels of population wellness (Firm and Williams, 2000; Kaplan et al., 2000).

Some prove indicates that medical care explains merely 10 percent of variation in adult mortality (U.S. Department of Health, Education, and Welfare, 1979), which has led to the widely held view that medical care makes a limited contribution to population differences in health status (Adler et al., 1993). All the same, medical care may have a greater consequence on the health status of vulnerable populations, such as racial and ethnic minorities and low-condition groups among older adults, than on the population in general (Williams, 1990). What this effect could be, what differences really exist beyond those now documented, how they interact with multiple vulnerabilities in the older population, and how health intendance should exist properly structured to address differences are all issues that require attending.

Enquiry Need 14: Place differences in health care—admission, use, and quality—for racial and ethnic minority populations other than blacks.

To date, well-nigh inquiry on differences in care has focused on blacks and whites, partly reflecting the absence in the Medicare file of high-quality ethnic identifiers for other groups. The few studies that have identified differences in quality and intensity of care for other groups leave the extent of the differences faced by Hispanics, American Indians and Alaska Natives, and Asians unclear (Institute of Medicine, 2002).

Research Need fifteen: Determine the reasons for differences in health intendance quality, focusing on the contributions of geographic variation, characteristics of wellness care institutions, provider behavior and stereotypes, and patient adherence to recommendations for care.

Multiple factors are well-nigh certainly involved, as they are with differences in wellness outcomes, and need to be assessed against each other. Medical care may vary because of the health needs of different groups, or the types of care they seek, prefer, or can afford, or because of insurance coverage, provider behavior, or the policies and procedures of hospitals and health systems. Research attention is desirable across multiple dimensions of wellness care.

Geographic Variation Why care varies across areas is poorly understood. Some variation may be due to less adequate services in poor areas that are predominantly minority. However, geographic variation that is not rooted in any racial or ethnic factor could still produce racial and ethnic differences in care. Different ways to ascertain geographic areas, unlike patterns across areas for various medical procedures, and the circuitous and changing settlement patterns for racial and indigenous groups all complicate the research challenge.

Health Care Institutions The specific characteristics of health care institutions and systems that affect racial and ethnic differences in care crave attention. Financial, structural, and institutional factors need consideration, taking into account features of medical procedures, such as their cost, and the degree to which medical consensus exists nearly particular treatments.

Provider Behavior and Stereotypes Whether, and if and then how, provider decisions about treatment are influenced past stereotypes requires consideration. Negative stereotypes and the unrecognized discrimination connected with them could contribute to systematic bias in the delivery of medical care. Evidence that this really happens, and that medical decisions are sometimes inappropriate for this reason, does non exist.

Patient Compliance Racial and ethnic differences in acceptance of therapies and compliance with prescribed regimens deserve description. Differences across groups are unclear and may depend on the specific medical weather, procedures, and prescriptions. The reasons for any differences also require study—whether they are due to differences in the way patients are treated or advised, in the cultural groundwork of each patient, or in other factors.