Changing Racial and Ethnic Composition of the Population

1. Population Forecasts
2. Implications of the Changing Racial and Ethnic Composition of the Population for the Supply of Health Workers
3. Implications of the Changing Racial and Ethnic Composition of the Population for the Supply of Health Workers
   1. Physician Supply
   2. Nurse Supply

Advocates for increased minority representation in the health workforce argue that increasing the number of minority physicians will improve access to care for minorities and vulnerable, underserved populations. These advocates argue that increased representation of minorities in the health workforce not only will increase equity, but will also improve the efficiency of the health care delivery system.

This section explores the changing racial and ethnic composition of the population and its implications for the future demand for and supply of health professionals. The four main findings are the following.

First, Hispanics and non-whites have different patterns of health care use compared to non-Hispanic whites. Some of the disparities in use can be attributed to differences in access to care. The literature suggests that cultural differences regarding appropriate use of health care services also help explain differences in health care use.

Second, as minorities increase as a percentage of the U.S. population, the percentage of total health care services provided to minority patients will also increase. In 2000, physicians spent an estimated 31 percent of patient-care hours providing services to minorities. By 2020, physicians will spend an estimated 40 percent of patient-care hours with minority patients.

Third, minorities are underrepresented in the physician and nurse workforces relative to their proportion of the total population, and are overrepresented in lower-paying health professions such as nurse aides and home health aides. As minorities constitute a growing percentage of the working-age population, their representation in the professional health workforce will naturally rise. The U.S. will increasingly rely on minority caregivers.

Fourth, the literature suggests that minority physicians have a greater propensity than do non-Hispanic white physicians to practice in urban communities designated as physician shortage areas. An increase in minority representation in the physician workforce could improve access to care for the population in some underserved areas.

3.1 Population Forecasts

The latest census figures highlight the fact that the United States is becoming increasingly racially and ethnically diverse. Furthermore, higher birth rates among racial and ethnic minority groups, relative to non-Hispanic whites, and immigration suggest that this trend will continue. Exhibit 3.1 contains population forecasts used in the PARM that show the current and projected distribution of the population across the three race/ethnic groups modeled in the PARM. Whereas non-Hispanic whites constituted approximately 69 percent of the population in 2000, they will constitute an estimated 61 percent of the population in 2020. Between 2000 and 2020, African Americans (both Hispanic and non-Hispanic) will increase from approximately 12.3 percent to 13.1 percent of the population; all other minorities (including Hispanic whites) will increase from approximately 19 percent to 26 percent of the population. Growth in the Hispanic population is the major contributor to growth in the minority population.

Exhibit 3.1. Population Distribution by Race

Source: Modified version of Census Bureau middle series projections.

Racial and ethnic minority populations are unevenly distributed geographically. The proportion of a State's population that is minority varies substantially by State, and minorities are disproportionately located in inner cities.

3.2 Implications of the Changing Racial and Ethnic Composition of the Population for the Demand for Health Workers

The extant literature explores the degree to which and reasons why race and ethnicity may affect health care use. Differences between racial and ethnic groups in use of a wide range of health care services have been documented in the literature. Much of these utilization differences are attributed to differences in access to care and cultural differences regarding the use of health care services. A better understanding of differences in health care utilization by race and ethnicity, the causal factors of these differences, and whether these differences will persist in the future allows for better predictions of future demand for health workers.

Below is a sample of the literature that describes differences in health care utilization by race or ethnicity.

• Mueller, Patil and Boilesen (1998) analyzed data from the 1992 National Health Interview Survey (NHIS) and found racial disparities in use of physician services even after controlling for factors such as insurance status, geographic location and other patient characteristics. The disparity in use of physician services by race was not statistically different from zero for those patients living in urban areas, but the disparity was statistically different from zero for patients living in rural areas. Insurance status and location (urban versus rural) are greater determinants of use of physician services than is patient race.
  
• Hargraves, Cunningham and Hughes (2001) found small differences in access to care and health care use of non-Hispanic whites and minorities enrolled in managed care plans. Whereas approximately 78 percent of non-Hispanic whites have a regular provider, only 74 percent of Hispanics and African Americans have a regular provider. Whites have slightly higher use of specialists. In their last physician visit, 28 percent of non-Hispanic whites saw a specialist compared to 26 percent for African Americans and 22 percent for Hispanics.
  
• Burns et al. (1996) use Medicare claims from ten States to examine differences in mammography use between elderly African American and white women. They find that African American women had lower use rates than white women across all levels of primary care. These authors cite additional research that finds that physicians are more likely to encourage elderly white women to obtain mammograms than elderly African American women, highlighting concerns about provider attitudes.
  
• Peterson et al. (1994) analyzed the use of cardiac procedures of men treated at Veterans Affairs Medical Centers. These authors find that African Americans are less likely than their white counterparts to undergo selected cardiac procedures. The authors suggest several reasons for the differences in treatment, including: (1) differences in severity, (2) consumer preferences, and (3) differences in how providers may weigh the risk and benefit of invasive procedures differently for African Americans than for whites.
  
• Todd et al. (1993) studied analgesic use in emergency departments and find that ethnicity was a strong predictor of the lack of use of analgesics.
  
• Mitchell et al. (2000) analyzed Medicare inpatient data to compare differences between African Americans and whites in the use of diagnostic and therapeutic services for cerebrovascular disease. These authors control for differences in factors such as health care needs and ability to pay. Still, they find that "black patients were significantly less likely to receive non-invasive cerebrovascular testing, cerebral angiography, or carotid endarterectomy compared to white patients (p. 1413)."

Not all studies find differences by race or ethnicity in use of health care services. For example, Horner et al. (1997) found no differences by race and ethnicity in the use of inpatient rehabilitation services for elderly stroke victims after adjusting for differences in patient risk.

Access to affordable medical insurance is often cited as a major determinant of access to care. People in racial and ethnic minority groups in 1999 were more than twice as likely as nonminorities to be uninsured. The Census Bureau estimates that, in 1999, 89 percent of non-Hispanic whites had some form of medical insurance while only 79 percent of African Americans and 67 percent of Hispanics were insured. ^[7] US Census, http://www.census.gov/hhes/hlthins/hlthin99/hi99tc.html These statistics are important because the literature has established a link between access to care and health status (e.g., Drake and Lowenstein, 1998). Specifically, people without medical insurance tend to receive less preventative care and have higher rates of hospitalization for potentially avoidable problems. Drake and Lowenstein note that in California during the year of their study (1993), approximately 14 percent of African Americans and 37 percent of Latinos were uninsured, compared to 12.5 percent of whites.

An analysis of the 1999 NHIS found that 9 percent of non-Hispanic whites, 16.4 percent of African Americans, and 26.3 percent of other minorities (including Hispanic whites) were without health insurance on the date surveyed in 1999. The PARM divides the population into three insurance categories: insured in a fee-for-service arrangement, insured in an HMO, and uninsured. Exhibit 3.2 shows that the proportion of each racial/ethnic group in an HMO is relatively similar, controlling for age and sex, but the percentage insured in a fee-for-service arrangement and uninsured vary substantially by race/ethnicity.

Language and cultural differences also are cited as factors affecting health care utilization. With the growing population of Hispanics in the U.S. and immigration from non-English speaking countries, language is playing an increasingly important role in the provision of health care services. Consider the following findings in recent studies.

• Kravitz et al. (2000) found that Spanish-speaking patients who visited the General Medicine and Family Practice Clinics at the UC Davis Medical Center were less likely to follow up with recommended laboratory studies compared to English-speaking patients. In addition, patients needing a translator required more physician time per visit. The authors applied regression models to estimate the impact of language on physician time per visit. They found that Spanish- and Russian-speaking patients averaged 9.1 and 5.6 additional minutes of physician time, respectively, compared to English-speaking patients after controlling for other determinants of physician time per visit.

Exhibit 3.2. Percent Distribution of the Population by Demographic Group Across Three Insurance Categories

Source: Analysis of the 1999 NHIS.

• Derose and Baker (2000) analyzed survey data for 465 Spanish-speaking Latinos and 259 English speakers of various ethnicity who presented to a public hospital emergency department in Los Angeles. The survey asked participants to assess their English-speaking ability; indicate the number of visits to a physician during the prior three months; and provide information on the participants' health status, socioeconomic status, and demographic characteristics. The authors found that of participants who had at least one visit to a doctor during the previous three months, those with limited English proficiency had 22 percent fewer visits, on average, compared to participants with good-to-excellent English proficiency. The study controlled for patient characteristics that could be correlated with the use of physician services such as health conditions and insurance status. In practice, therefore, language and communication may be significant barriers to access to care.

In addition to differences across racial groups and English/non-English speakers in access to and use of health care services, there are significant differences in measures of health status that affect the type of care demanded. Keppel, Pearcy, and Wagener (2002) find that compared to non-Hispanic whites, many minority populations have higher infant mortality rates, higher rates of infants with low birth weight, higher age-adjusted rates of heart disease death, higher rates of tuberculosis, and disparities in many other measures of health care.

Freiman (1998) argues that the relationship between race or ethnicity and demand for health care services is a complex function of cultural, socioeconomic, and other considerations. Consequently, Freiman concludes that separate demand equations should be estimated for people in different racial or ethnic groups. To support his conclusions, Freiman presents findings from a multiple regression analysis of the 1987 National Medical Expenditure Survey where statistical tests performed indicate significant differences in the estimated coefficients of demand equations-estimated separately for non-Hispanic whites, African Americans, and Hispanics-that control for important determinants of health care use.

The PARM provides insight on the proportion of patient care hours that physicians spend providing care to patients in three race/ethnic groups. These estimates, like those described for people in different age categories in the preceding section, are based on patterns of health care use, the size of the population in each demographic group, and the average amount of time physicians spend with patients per encounter. In physicians' offices and in hospital outpatient settings, the average time spent per visit can differ by patient depending on the patient's demographic characteristics and insurance status. In the other settings, however, there are insufficient data to test the hypothesis that physician time per visit is independent of patient demographics and insurance status. Note that differences in the age and sex distribution of the population, by race, contribute to differences in the proportion of patient care hours spent with patients of different races.

In 2000, physicians spent approximately 69 percent of patient care hours with non-Hispanic whites, 13 percent with African Americans, and 18 percent with other minorities (Exhibits 3.3 and 3.4). Although the proportion of total patient care hours approximated the proportion of the population in each racial group, the distribution of hours varied by physician specialty. African Americans, who constituted approximately 12 percent of the U.S. population in 2000, used a disproportionately higher percentage of total patient care hours of emergency medicine physicians (38 percent), obstetrician/ gynecologists (17 percent), and pediatricians (16 percent). They received proportionately fewer hours from "other" surgical specialties (8 percent) and general surgeons (9 percent). The population in the "other" race/ethnicity category, which constituted approximately 19 percent of the total population in 2000, received a relatively larger proportion of radiology (31 percent) and pathology (29 percent) services, but a relatively smaller proportion of patient care hours from urologists (11 percent), ophthalmologists (11 percent), and general and family practitioners (13 percent).

If the distribution of insurance status for non-Hispanic whites were applied to other racial minorities, the total demand for physicians in 2000 would have risen significantly (see Section 5, Scenario 5) but the percentage of patient care hours by racial group would have remained relatively unchanged. The percentage of total physician patient care hours spent with non-Hispanic whites would decline by two percentage points while the percentage spent with African Americans and other minorities would rise by one percentage point for each group. For most specialties, the change in percent of time spent with patients in each race/ethnicity group changes by less than two percentage points. The largest change is for obstetrics/gynecology services. Under this scenario, the percentage of hours spent with non-Hispanic white patients would fall by three percentage points while the percentage of hours spent with patients in the "other" category (which includes Hispanics) would rise by three percentage points.

If health care utilization patterns and physician productivity patterns remain constant over time, in 2020 physicians will be spending approximately 14 percent of patient care hours with African Americans and 26 percent of hours with patients of other minority groups, again percentages roughly comparable to each group's share of the total population.

Physical therapists, optometrists, and podiatrists are seen to spend a disproportionate amount of time with non-Hispanic whites relative to their share of the population (Exhibit 3.4). While the gap for African Americans is small (and non-existent in the case of podiatrists), the gap for other minority groups was large in 2000 and projected to remain so in 2020.

Exhibit 3.3: Distribution of Total Patient Care Hours, by Patient Race: Total Active Physicians in Patient Care

Exhibit 3.3: Distribution of Total Patient Care Hours, by Patient Race: Total Active Physicians in Patient Care (Text Only)

Exhibit 3.4. Estimated Percentage of Patient Care Hours, by Race of Patient