Statements & Findings
The Potential Effects of the Michigan Civil Rights Initiative on Healthcare
Richard Lichtenstein, PhD, MPH*
Tanisha Tate, BA*
*The University of Michigan, School of Public Health, Department of Health Management and Policy
September 2006
Introduction
In November, 2006, Michigan voters will decide whether to approve a constitutional amendment that will have a dramatic impact on many different facets of civic life. The Michigan Civil Rights Initiative (MCRI) is a proposed amendment to the state Constitution that would outlaw programs that give specific consideration to groups or individuals, based on their race, gender, ethnicity or national origin, for education or employment opportunities (Kaufmann 2006). If the initiative passes, it will make affirmative action or outreach programs directed at certain ethnic or racial groups presently operated by any state or local government entities, including public schools and universities, illegal in the state of Michigan. This, in turn, may have serious consequences for programs that focus on the elimination of racial and ethnic health disparities in the state of Michigan and throughout the US.
The Problem of Racial and Ethnic Health Disparites
The United States and Michigan are plagued by large disparities in health status among different segments of the population. These disparities are related to the social circumstances of people from different ethnic and racial groups, including differences in such characteristics as: individual income, power, prestige, education, and occupation; exposure to discrimination; and, community factors such as environmental quality, personal safety and housing conditions. In general, members of racial and ethnic minority groups in the US are exposed to inferior social circumstances than the Caucasian population and, thus, suffer far worse health status. For example, on average, Caucasian females in the US can expect to live more than 4 years longer than African American females. Likewise, Caucasian males have a life expectancy that is over 6 years longer than African American males (National Center for Health Statistics, 2005, Table 27). African Americans in the US also have higher mortality rates than Caucasians for many diseases, including heart disease, stroke, diabetes, prostate cancer, breast cancer, and AIDS. Nationwide, the Infant Mortality Rate, (a measure of the number of babies who die before their first birthday per 1000 live births), is two times higher in the African American population in the US than it is in the Caucasian population (National Center for Health Statistics, 2005, Table 22). In Michigan, the Infant Mortality Rate for African Americans was 17.5/1000 in 2003, nearly three times higher than the Caucasian rate of 6.7 (Michigan Department of Community Health, 2005). Other minority groups, such as Native Americans, Puerto Ricans and Native Hawaiians also have higher infant mortality rates than Caucasians (National Center for Health Statistics, 2004), and for some diseases, such as Diabetes, these groups also suffer greater mortality and illness rates than whites (National Center for Health Statistics, 2005, Table 30). Similar racial and ethnic health disparities are observed when looking at various rates of illness and disability across various minority groups in the US population (National Center for Health Statistics, 2005, Tables 58 and 138).
Unequal Treatment
Besides suffering worse health status than their Caucasian counterparts, minority group patients also receive health care that is inferior to care received by Caucasian patients when they enter the health care system. This disturbing phenomenon was recently highlighted by the prestigious Institute of Medicine in their report “Unequal Treatment.” (Smedley, et al., 2003 ). This report reviews numerous studies in which, for example, white and black patients of the same age and sex, with the same diagnosis, and with the same insurance coverage, receive treatment at the same hospitals or clinics. In almost all of these studies white patients were statistically much more likely to receive high quality, high technological treatment, than black patients. This pattern has been shown for patients with heart disease, who needed coronary bypass surgery (Carlisle et al. 1997; Peterson et al. 1997); colorectal cancer (Cooper et al. 1996); total hip or knee replacement (Harris et al. 1990); prophylactic therapy for HIV (Moore et al. 1994); and, numerous other conditions. In contrast, African Americans appear significantly more likely than Caucasians to receive procedures which most patients try to avoid; such as lower-limb amputation and bilateral removal of the testicles (Gornick et al. 1996). Likewise, in comparison to non-Hispanic white patients, Hispanic patients receive fewer mammograms, Papanicolaou tests, influenza vaccinations, prenatal care, cardiovascular procedures, and less analgesia for metastatic cancer, trauma, and childbirth (Fiscella et al. 2002). This unequal treatment received by minority populations has raised serious doubts about the fairness and equity of care provided by the health care system.
The Need for a Diverse Health Workforce
A growing body of literature suggests that the poor quality of health care received by minority patients in comparison to whites may be due, in part, to poor communications between physicians and their minority patients, lack of cultural sensitivity on the part of physicians, and mistrust of the health care system by minority group members. For example, several studies have shown that African American patients are more likely than whites to feel that their physician failed to give them full information about their diagnosis, treatment and follow-up care. (Kahn et al. 1994; Blendon et al. 1989; Chang et al. 1996). In another study, conducted by Balsa et al. (2003), the authors found that white doctors had more difficulty interpreting the clinical manifestation of depression in black than in white patients due, in large part, to differences in how patients communicated their problems to the physicians. Other research has shown that physicians treating minority patients are “less likely to follow guidelines from nationally recognized organizations for health promotion and disease prevention” than are physicians who care predominantly for white patients (Gemson et al. 1988; Kogan et al. 1994).
In contrast to the rather negative experiences minority patients frequently describe when discussing their interactions with Caucasian physicians, minority patients establish better trust with and, indeed, seek out physicians from their own racial or ethnic group (DeVille 1999). Minority group patients also tend to be more satisfied with the care provided by physicians from their own social group (Saha, et al., 1997).
In sum, these studies describe complex interactions between minority group patients and the health care system, and indicate the need for culturally diverse health professionals who are better able to interact with members of minority groups and to treat them more effectively. (Shi 1999). Thus, one way of pursuing the elimination of racial and ethnic disparities in health and in health care in the US is to assure the availability of physicians who reflect the racial and ethnic diversity of the patient population.
The positive impact of minority physicians on the health care system
Besides their ability to gain the trust of their minority patients, to deal with them in a culturally sensitive manner, and to provide good quality health care, physicians from minority groups also enhance access to the health care system for minority patients by the choices they make on such matters as specialty selection, geographic location of practices and types of patients served. Thus, minority physicians are more likely than their white counterparts to: choose to enter primary care (first contact) practices, rather than sub-specialties; locate their practices in communities that are underserved by other health professionals; and, to care for larger numbers of minority patients (including those covered by Medicaid), in their practices. Among all graduates of U.S medical schools in 1975, black and Hispanic physicians were more likely than non-Hispanic whites to practice in areas with a shortage of physician and to serve black and Hispanic patients (Keith 1985). A 1996 California study showed that Hispanic and black physicians practiced in areas with fewer primary care physicians per capita. Their practices tended to be in poorer areas than those of non-Hispanic white patients (Komaromy 1996). The study further concluded that black and Hispanic physicians located their practices in areas with higher proportions of residents from underserved minority groups. In addition, they care for higher proportions of patients of their own race or ethnic group and patients who are uninsured or are covered by Medicaid. Likewise, a national study conducted by Moy et al., (1995) found that minority physicians were more likely to care for minority, medically indigent and sicker patients. In addition, many minority physicians choose to serve underserved and sometimes remote populations as primary care practitioners. According to the Association of American Medical Colleges’ (AAMC) Medical School Graduation Questionnaire (GQ) (2005), about one-fifth of all medical students graduating in 2004 indicated they planned to locate their practice in underserved areas. Responses differed by race and ethnicity, however. Nearly 51% of Black, 41 % of Native American/Alaska Native, and 33% of Hispanic graduating medical students reported intentions to practice in underserved areas, whereas only 18.4% of Whites reported such plans (AAMC, 2005). Thus, in far greater numbers than Caucasian physicians, minority physicians tend to go into the types of practices that are needed to address the needs of minority populations—practicing primary care in geographic areas that are underserved by other health providers. Given the greater propensity of minority physicians to serve the needs of minority populations, one goal of the health system should be to increase the number of physicians from minority groups who suffer disproportionately poor health status. History has shown, however, that only by pursuing race-conscious admissions policies will health professional schools continue to supply society with even the current number of minority health professionals, much less increased numbers.
The Need for Affirmative Action in Health Professional Schools
Prior to the 1960s, black physicians practicing in the US comprised less than 3 percent of all US physicians. (Most of these black physicians were trained at two historically black medical schools, Meharry and Howard, and not in schools that served the rest of the population.) The implementation of affirmative-action programs in health professions schools in the 1960s, largely influenced by federal legislation, led to dramatic changes in the enrollment of students from minority groups. Between the mid-1960s and the late-1970s, when affirmative-action programs were in force in the nation’s medical schools, the percentage of minority medical students doubled (Shea 1985). However, the percentage of medical students from underrepresented minorities nationwide stopped rising in the late-1970s. Researchers have concluded that this plateau in minority admissions to medical school was, in part, attributable to the Supreme Court’s decision in the Bakke case (US Supreme Court, 1978), in which a white student successfully claimed that race-based quotas had prevented him from gaining admission into the University of California (Nickens 1992). This case stalled affirmative action efforts across the country.
The percentage of minority medical students in US medical schools remained relatively constant at about 9 percent until 1990, when it began to rise again. This increase has been attributed to the introduction of the Association of American Medical Colleges’ “Project 3000 by 2000,” which was designed to expand existing affirmative-action programs (Cohen 2003). The program was largely responsible for the 37 percent increase nationwide in medical students from underrepresented minority groups over five years, (DeVille 1999) and recent figures show that members of the underrepresented minority groups currently make up 12 percent of all medical school students. (The only declines in minority admissions to medical schools during this period occurred, after the passage of two anti-affirmative action ballot initiatives: Proposition 209 in California in 1996, and Initiative 200 in Washington in 1998)
The strong relationship between affirmative-action programs and the number of minority medical students indicates that the medical schools’ enrollment of blacks, Hispanics, and other underrepresented minority group members has been quite responsive to changes in affirmative-action programs. Dismantling these programs without constructing another means to increase diversity in medical school classes may result in a decrease in the number of minority physicians who will graduate from U.S. medical schools and serve U.S. residents. Such a decrease could have extremely negative consequences on the health of America’s minority populations, especially in inner city areas inhabited mostly by African American or Latino populations, like Detroit and Los Angeles.
Conclusion
Minority populations in the United States suffer disproportionately from poor health status and members of minority groups are more likely to die early from a broad range of diseases. Minority populations also fare poorly when they seek care from the health system. They are less likely than a Caucasian patient to receive high quality or high technology care even when they have the same disease and the same insurance coverage. Minority physicians disproportionately serve minority and low-income areas and populations and represent one successful means of trying to eliminate racial and ethnic health disparities in the US. Affirmative action programs have been successful in increasing the number of underrepresented minority students attending medical schools in the US. However, when affirmative action has been challenged in the courts or outlawed by public referenda, the number of underrepresented minority students in medical schools has declined.
Achieving adequate numbers of physicians to meet future population needs requires recruitment strategies specifically designed to attract diverse populations into the health professions. With the growth of the minority population in the US and in Michigan, there is also a growing need for more minority physicians. In the future, minorities will likely continue to experience limited access to health care, face cultural and linguistic barriers to obtaining health care, and receive lower quality care if affirmative action programs are banned and no other means of promoting diversity exist.
Without the ability to use racial and ethnic characteristics of applicants in the admissions process to health professional schools (e.g. medicine, dentistry, nursing, pharmacy, and public health), the number of minority professionals in all of these schools will fall. This is what happened in California after the passage of Proposition 209, and in Washington after the passage of Initiative 200. Dr. Jordan Cohen, former president of the Association of American Medical Schools projected that without the ability to use race and ethnicity as part of the medical school admissions process, the number of Black, Hispanic, and Native American medical students would fall from 1,868 (which was the number enrolled in 2001) to only 526. This 72% decline would bring minority enrollment back to the numbers that existed in the pre-civil-rights era of the 1950s and early 1960s and would mean that only 3% of medical students would come from underrepresented minority groups (Cohen, 2003). This could have disastrous effects on the health of minority patients, particularly on those who live in medically underserved areas like Detroit, Saginaw, and Muskegon and on those who prefer to see physicians who are from the same racial and ethnic group as themselves.
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