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Me dical Manage m e nt o f Vulne rable
and Unde rs e rve d Patie nts
Prin cip le s , Pra ctice , a n d Po p u la tio n s
Se co n d Ed itio n
Section Editors
PRINCIPLES
Andrew B. Bindman, MD
Professor, Department of Medicine, School of Medicine
University of California , San Francisco
San Francisco, California
Kevin Grumbach, MD
Professor and Chair, Department of Family and Community
Medicine, School of Medicine
Priscilla Chan and Mark Zuckerberg San Francisco General
Hospital and Trauma Center
PRACTICE
Alicia Fernandez, MD
Professor, School of Medicine
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
Dean Schillinger, MD
Professor and Chief, Division of General Internal Medicine
University of California San Francisco
Center for Vulnerable Populations
School of Medicine
POPULATIONS
Teresa J. Villela, MD
Professor and Vice Chair, Department of Family Community
Medicine
School of Medicine
Chief of Service, Department of Family Community Medicine
Margaret B. Wheeler, MD, MS

Professor, Department of Medicine
School of Medicine
Me dical Manage m e nt o f
Vulne rable and Unde rs e rve d
Patie nts
Prin cip le s , Pra ctice , a n d Po p u la tio n s
Se co n d Ed itio n
Talmadge E. King, Jr., MD

Dean, School of Medicine
Vice Chancellor-Medical Affairs
Margaret B. Wheeler, MD, MS

Professor, School of Medicine
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney oronto
Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and
Populations, Second Edition
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Library of Congress Cataloging-in-Publication Data
Names: King, almadge E., Jr., editor. | Wheeler, Margaret B., editor.
itle: Medical management o vulnerable and underserved patients :
principles, practice, and populations / [edited by] almadge E. King, Jr.,
Margaret B. Wheeler.
Description: Second edition. | New York : McGraw Hill Education Medical,
[2016] | “A Lange medical book.” | Includes bibliographical re erences and index.
Identif ers: LCCN 2015046071| ISBN 9780071834445 (pbk. : alk. paper) | ISBN
0071834443 (pbk. : alk. paper) | ISBN 9780071834018 (ebook) | ISBN
007183401X (ebook)
Subjects: | MESH: Delivery o Health Care | Vulnerable Populations | Health
Services Accessibility | Minority Groups | Medical Indigency | Health
Services Needs and Demand | United States
Classif cation: LCC RA418.5.P6 | NLM W 84 AA1 | DDC 362.1/0425—dc23 LC record available at
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Talmadge E. King, Jr.:
I thank Mozelle for her love, support, and encouragement and to Talmadge and Almetta
King for teaching me the value of hard work and education. In addition, I thank my
daughters, Consuelo and Malaika , for their loving support and my granddaughters,
Madison and Siena , for keeping it real.
Margaret B. Wheeler:
To my patients and teachers for their guidance and nurturing, my students and
colleagues for their inspiration, and my family for unstinting support.
Andrew B. Bindman:
I thank my parents, Arthur and Bernice, who have encouraged me to contribute toward
making a constructive difference in people’s lives. I also thank my wife, Rebecca and our
three wonderful children, Sarah, Julia , and Jacob, who have made an enormous positive
impact on my own life.
Alicia Fernandez:
To the memory of my parents, Hector and Paulina B. Fernandez. De tal árbol,
tal a stilla .
Kevin Grumbach:
With appreciation to my family, colleagues, students, and patients, for all they have
taught me.
Dean Schillinger:
I thank George Schillinger for demonstrating the potential for resilience in the face
of vulnerability and for imbuing me with a belief that doctoring requires the head,
hands, and heart; Zahava Schillinger for instilling in me the confidence and diligence
to accomplish my goals; Nahum Joel for conveying his pa ssion regarding science and
the pursuit of social justice; Ariella Hyman for partnering with me in this struggle; and
Eytan, Gabriel, and Micaela , who, when work becomes overwhelming, always bring me
back to the simple joys of life.
Teresa J. Villela:
To Amado, Carolina , Elvira , Marcelo, Florentina , Gilberto, and Rosario, with great
respect and gratitude, and to my brothers and sisters for all they have taught me.
Co nte nts
Contributors ix 8. Advo cacy 79

Preface xvii Ricky Y. Choi, MD, MPH, Laura Gottlieb, MD, MPH,
and Alice Hm Chen, MD, MPH
PART 1 PRINCIPLES 1
PART 2 PRACTICE 89
1. Vulne rable Po pulatio ns , He alth
9. Practical S trate g ie s in Addre s s ing
Dis paritie s , and He alth Equity: An Ove rvie w 2
S o cial De te rm inants o f He alth in
Kevin Grumbach, MD, Paula Braveman, MD, MPH,
Nancy Adler, PhD, and Andrew B. Bindman, MD Clinical S e tting s 90
Laura Gottlieb, MD, Rishi Manchanda , MD,
and Megan Sandel, MD
2. He alth-Care Dis paritie s : An Ove rvie w 13
Andrew B. Bindman, MD, Kevin Grumbach, MD, and
Bruce Guthrie, MB, BChir, PhD 10. Cre ating a Co nte xt fo r Effe ctive
Inte rve ntio n in the Clinical Care
o f Vulne rable Patie nts 104
3. Financing and Organizatio n o f Dean Schillinger, MD, Neda Ratanawongsa , MD,
He alth Care fo r Vulne rable Po pulatio ns 25 MPH, Teresa Villela , MD, and George William
Christopher B. Forrest, MD, PhD, Jessica E. Saba , PhD
Hawkins, MSE, and Ellen-Marie Whelan, NP, PhD
11. Cre ating the Me dical Ho m e fo r

4. Le gal Is s ue s in the Care o f
Unde rs e rve d Patie nts 115
Unde rs e rve d Po pulatio ns 35
Reena Gupta , MD, and Thoma s Bodenheimer, MD
Sara Rosenbaum, JD
5. Principle s in the Ethical Care o f 12. Pro m o ting Be havio r Change 124
Unde rs e rve d Patie nts 49 Jennifer E. Hettema , PhD, Christopher Neumann,
Bernard Lo, MD and Robert V. Brody, MD PhD, Bradley Samuel, PhD, Daniel S. Lessler, MD,
MHA, and Christopher Dunn, PhD
6. Co m m unity Engage m e nt and Partne rs hip 60

Naomi Wortis, MD and Ellen Beck, MD 13. As s e s s ing and Pro m o ting Me dicatio n
Adhe re nce 137
Sharon L. Youmans, PharmD, MPH,
7. A Glo bal Pe rs pe ctive o n the Care o f and Kirsten Bibbins-Domingo, MD, PhD
Me dically Vulne rable and Unde rs e rve d
Po pulatio ns 69
Stephanie Taché, MD, MPH, Sarah Macfarlane, MSc, 14. Navigating Cro s s -Cultural Co m m unicatio n 149
PhD, Megan Mahoney, MD, and Kevin Grumbach, MD JudyAnn Bigby, MD and Alicia Fernandez, MD
vi
Contents v ii
15. Im proving the Co m m unicatio n Exchange : 25. Wo rk, Living Enviro nm e nt,
A Fo cus o n Lim ite d He alth Lite racy 159 and He alth 277
Debra Keller, MD, MPH, Urmimala Sarkar, MD, Michael Guarnieri, MD, Janet Victoria Diaz, MD,
MPH, and Dean Schillinger, MD and John R. Balmes, MD
16. Gro up Me dical Vis its fo r Unde rs e rve d 26. Care o f the Fo o d Ins e cure Patie nt 289
Po pulatio ns 168 Hilary Seligman, MD, MAS and Jona s Hines, MD
Pooja Mittal, DO, Hali Hammer, MD,
and Margaret Hutchison, CNM
27. Clinical Care fo r Pe rs o ns w ith a His to ry
o f Incarce ratio n 299
17. Applying Inte ractive Mo bile He alth Emily H. Thoma s, MD, Nathan Birnbaum, BA,
(m He alth) Te chno lo g ie s fo r Vulne rable Jacqueline P. Tulsky, MD, and Emily A. Wang, MD, MAS
Po pulatio ns 180
Courtney R. Lyles, PhD, Dean Schillinger, MD, 28. Care o f the Ho m e le s s Patie nt 311
and John D. Piette, PhD Margot Kushel, MD and Sharad Jain, MD
18. Applying Principle s and Practice o f 29. Im m ig rant He alth Is s ue s 320

Quality Im prove m e nt fo r Be tte r Care Margaret Wheeler, MD, Teresa J. Villela , MD,
o f the Unde rs e rve d 193 and Susana Morales, MD
Claire Horton, MD, MPH, Urmimala Sarkar, MD,
MPH, and Alicia Fernandez, MD
30. Rural He alth Care : Co m m unitie s , Sys te m s ,
and Patie nt Care 332
19. Inte rdis ciplinary Mo de ls o f Care fo r David V. Evans, MD, Toby Keys, MPH,
Hig h-Ris k Patie nts 204 and Steven Meltzer, PA-C
Michelle Schneidermann, MD and Elizabeth
Davis, MD
31. Providing Care to Patie nts Who S pe ak
Lim ite d Eng lis h 343
Alice Hm Chen, MD, MPH, Elizabeth A. Jacobs,
PART 3 POPULATIONS 213 MD, MPP, and Alicia Fernandez, MD
20. Unde rs e rve d Childre n: Pre ve nting Chro nic

Illne s s and Pro m o ting He alth 214 32. The Care o f Le s bian, Gay, Bis e xual, and
Patricia Barreto, MD, MPH, Joanna Mimi Choi, MD, Trans ge nde r Patie nts 353
and Neal Halfon, MD, MPH Anne Rosenthal, MD, Patricia Robertson, MD,
Shane Snowdon, MA, and Barry Zevin, MD
21. Vulne rabilitie s o f Ado le s ce nce and Yo ung

Adultho o d 226 33. The Me dical Tre atm e nt o f Patie nts w ith
Erica Mona sterio, MN, FNP-BC, Ellen M. Scarr, Ps ychiatric Illne s s 366
PhD, FNP-BC, Naomi Schoenfeld, MS, FNP-BC, Christina Mangurian, MD, J. Ryan Shackelford, MD,
and William B. Shore, MD and James W. Dilley, MD
22. The Fam ily as the Co nte xt fo r Care 245 34. Wo m e n’s He alth: Re pro ductio n and
George William Saba , PhD and Teresa J. Villela , MD Beyo nd in Po o r Wo m e n 381
Elizabeth Harleman, MD, Carolyn Payne, MD,
and Jody Steinauer, MD, MAS
23. The Hidde n Po o r: Care o f the
Olde r Adult 254
Katrina Booth, MD, C. Seth Landefeld, MD, 35. Intim ate Partne r Vio le nce 395
and Helen Chen, MD Palav Babaria , MD, MHS, Brigid McCaw, MD, MS,
MPH, and Leigh Kimberg, MD
24. Care o f the Dying Patie nt 265

Jeffrey Stoneberg, DO, Tracy Schrider, LCSW, 36. Traum a and Traum a-Info rm e d Care 408
ACM, and LaVera M. Crawley, MD, MPH Leigh Kimberg, MD
v iii Contents
37. Obe s ity as a Clinical and S o cial Pro ble m 425 42. Dis ability and Patie nts w ith Dis abilitie s 494
Ann Smith Barnes, MD, MPH, Marisa Rogers, Lisa I. Iezzoni, MD, MSc, and Margot Kushel, MD
MD, MPH, and Cam-Tu Tran, MD, MS
43. HIV/ AIDS : Im pact o n Vulne rable

38. Chro nic Pain Manage m e nt in Po pulatio ns 507
Vulne rable Po pulatio ns 438 Ronald H. Goldschmidt, MD, Joanna Eveland, MD,
Soraya Azari, MD, Barry Zevin, MD, and Jacqueline P. Tulsky, MD
and Michael B. Potter, MD
44. Care o f the S o cially Co m plicate d

39. Principle s o f Caring fo r Pe o ple Who Patie nt in the Ho s pital 518
Us e Alco ho l and Othe r Drug s 452 Margaret Stafford, MD, Leslie Dubbin, RN, PhD,
Alexander Y. Walley, MD, MSc Lawrence Haber, MD, and Jeff Critchfield, MD
40. To bacco Us e 463 45. Caring fo r Ours e lve s While Caring

Maya Vijayaraghavan, MD, MAS, fo r Othe rs 532
and Steven A. Schroeder, MD Diana Coffa , MD
41. De ntal Care : The Fo rgo tte n Ne e d 478

Index 544
Francisco Ramos-Gomez, DDS, MS, MPH, Carolyn
Brown, DDS, and Susan Fisher-Owens, MD, MPH
Co ntributo rs
Nancy Adler, PhD Ellen Beck, MD

Director, Center for Health and Community Professor of Medicine,
Professor, Department of Psychiatry Department of Medicine, Division of General Internal
School of Medicine Medicine (DGIM)
University of California San Francisco (UCSF) School of Medicine, University of California San Francisco
San Francisco, California Priscilla Chan and Mark Zuckerberg San Francisco General
Soraya Azari, MD San Francisco, California
Assistant Clinical Professor of Medicine Kirsten Bibbins-Domingo, PhD, MD, MAS

Division of General Internal Medicine (DGIM), Priscilla Chan
and Mark Zuckerberg San Francisco General Hospital and Lee Goldman, MD Endowed Chair in Medicine
Trauma Center Professor of Medicine and of Epidemiology and Biostatistics
University of California San Francisco School of Medicine, University of California San Francisco
San Francisco, California San Francisco, California
Palav Babaria, MD, MHS JudyAnn Bigby, MD
Medical Director, Highland Hospital Adult Medicine Clinic Senior Fellow

Alameda Health System Mathematica Policy Research
Oakland, California Cambridge, Ma ssachusetts
Assistant Clinical Professor, Department of Medicine
Andrew B. Bindman, MD
San Francisco, California Professor
Department of Medicine
John R. Balmes, MD School of Medicine
University of California San Francisco (UCSF)
Professor, Department of Medicine
Professor, School of Public Health Nathan Birnbaum B.A.
University of California , Berkeley
Medical Student
Ann Smith Barnes, MD, MPH School of Medicine
University of California , Irvine
Associate Professor, Irvine, California
Department of Medicine
Baylor College of Medicine Thomas Bodenheimer, MD
Houston, Texa s
Department of Family and Community Medicine
Patricia Barreto, MD, MPH Priscilla Chan and Mark Zuckerberg San Francisco General
Senior Research Scientist University of California , San Francisco
UCLA Center for Healthier Children, Families & Communities San Francisco, California
ix
x Contributors
Katrina Booth, MD Diana Coffa, MD

Assistant Professor Residency Program Director, Family and Community Medicine
Medical Director, Acute Care for Elders (ACE) Unit Assistant Professor
Division of Gerontology, Geriatrics, and Palliative Care Department of Family and Community Medicine
University of Alabama at Birmingham School of Medicine
Birmingham VA Medical Center University of California San Francisco
Birmingham, Alabama Priscilla Chan and Mark Zuckerberg San Francisco
Paula Braveman, MD, MPH
Professor, Department of Family Community Medicine
LaVera Crawley, MD, MPH, MDiv(Eq)
School of Medicine, University of California San Francisco
San Francisco, California Program Manager for Palliative Care Education
and Research;
Palliative Care Chaplain, Alta Bates Summit
Robert V. Brody, MD Medical Center
Professor, Department of Medicine, Division of General Internal Berkeley, California
Medicine (DGIM) School of Medicine
Jeff Critchfield, MD
General Hospital and Trauma Center Professor, Department of Medicine, University of California
San Francisco, California San Francisco School of Medicine;
Chief Medical Experience Officer and Medical Director of
Risk Management, Priscilla Chan and Mark Zuckerberg
Carolyn Brown, DDS
San Francisco General Hospital;
Dental Director, Programs and Development Professor, Department of Medicine, Division of Hospital
San Francisco Native American Health Center Medicine,
San Francisco, California School of Medicine,
Helen Chen, MD General Hospital and Trauma Center
Chief Medical Officer, Hebrew Rehabilitation San Francisco, California
Center/ Hebrew Senior Life
Boston, Ma ssachusetts
Elizabeth Davis, MD
Director of Care Coordination, San Francisco Health Network
Alice Hm Chen, MD, MPH Primary Care, San Francisco, California
Chief Medical Officer, San Francisco Health Network; Assistant Professor
Professor of Medicine, Division of General Internal Medicine (DGIM),
School of Medicine, Division of General Internal Medicine School of Medicine
(DGIM) University of California San Francisco
University of California San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center
General Hospital and Trauma Center San Francisco, California
Janet Victoria Diaz, MD
Ricky Y. Choi, MD, MPH
Consultant, Pulmonary and Critical Care Medicine
Department Head of Pediatrics, Asian Health Services California Pacific Medical Center
Community Health Center San Francisco, California
Oakland, California
James W. Dilley, MD
Joanna Mimi Choi, MD, MPH
Professor, Department of Psychiatry
Assistant Professor, Department of Pediatrics School of Medicine, University of California
UCLA Fielding School of Public Health San Francisco
Los Angeles, California San Francisco, California
Contributors xi
Leslie Dubbin, PhD, MS, RN Laura Gottlieb, MD, MPH

Assistant Adjunct Professor, Department of Social and Department of Family and Community Medicine,
Behavioral Sciences School of Medicine, University of California San Francisco,
School of Nursing, University of California San Francisco San Francisco, California
Kevin Grumbach, MD
Christopher Dunn, PhD
Professor and Chair, Department of Family and Community
Associate Professor Medicine,
Psychiatry and Behavioral Sciences School of Medicine, University of California San Francisco,
University of Wa shington San Francisco, California
Seattle, Wa shington
Michael Guarnieri, MD, MPH
David V. Evans, MD
Fellow, Division of Pulmonary Medicine,
Rosenblatt Family Endowed Professor of Rural Health, Associate School of Medicine, University of California San Francisco,
Professor, Department of Family Medicine, University of San Francisco, California
Wa shington School of Medicine, Seattle, Wa shington
Reena Gupta, MD
Joanna Eveland, MD
Assistant Professor of Medicine,
Department of Family and Community Medicine, Department of Medicine
School of Medicine, University of California San Francisco, Division of General Internal Medicine (DGIM)
Priscilla Chan and Mark Zuckerberg San Francisco School of Medicine
General Hospital and Trauma Center University of California San Francisco
San Francisco, California Priscilla Chan and Mark Zuckerberg San Francisco
Alicia Fernandez, MD San Francisco, California
Professor, Department of Medicine,

Bruce Guthrie, MB, BChir, PhD
Division of General Internal Medicine (DGIM),
School of Medicine Professor of Primary Care Medicine, Population Health Sciences
University of California San Francisco Division,
Priscilla Chan and Mark Zuckerberg San Francisco University of Dundee, Dundee, Scotland.
San Francisco, California Lawrence A. Haber, MD
Assistant Professor, Department of Medicine,
Susan Fisher-Owens, MD, MPH
School of Medicine, University of California San Francisco,
Associate Clinical Professor of Pediatrics; Associate Clinical Priscilla Chan and Mark Zuckerberg San Francisco
Professor of Preventive and Restorative Dental Sciences, General Hospital and Trauma Center
School of Medicine, Division of General Internal Medicine San Francisco, California
(DGIM)
University of California San Francisco Neal Halfon, MD, MPH
Professor, Department of Pediatrics, Department of Health
Policy and Management, UCLA Geffen School of Medicine;
UCLA Fielding School of Public Health, Department of Health
Policy and Management; UCLA Luskin School of Public Affairs,
Christopher B. Forrest, MD, PhD
Department of Public Policy; Director, UCLA Center for Healthier
Professor of Pediatrics and Health Care Management, Children Families and Communities, Los Angeles, California
Children’s Hospital of Philadelphia and the University of
Pennsylvania School of Medicine, Philadelphia , Pennsylvania Hali Hammer, MD
Director of Primary Care
Ronald H. Goldschmidt, MD
San Francisco Department of Public Health
Professor, Department of Family and Community Medicine Professor Family and Community Medicine, School of Medicine
School of Medicine, University of California San Francisco University of California San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center General Hospital and Trauma Center
x ii Contributors
Elizabeth Harleman, MD Sharad Jain, MD

Professor, Departments of Medicine and Obstetrics, Gynecology Professor, Department of Medicine,
and Reproductive Sciences, School of Medicine, University of California San Francisco,
School of Medicine, University of California San Francisco, Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center, San Francisco, California
Debra Keller, MD, MPH
Jessica E. Hawkins, MSE Assistant Professor, Department of Medicine,
Research Associate, Children’s Hospital of Philadelphia and the School of Medicine, University of California San Francisco,
University of Pennsylvania School of Medicine, Philadelphia , Priscilla Chan and Mark Zuckerberg San Francisco
Pennsylvania General Hospital and Trauma Center
Jennifer E. Hettema, PhD
Toby Keys, MA, MPH
Associate Research Professor, Department of Family and
Community Medicine, Education Specialist, RUOP
University of New Mexico, Medical Student Education Section
Albuquerque, New Mexico Department of Family Medicine
School of Medicine
University of Wa shington
Jonas Z. Hines, MD Seattle, Wa shington
Staff Physician, Tom Waddell Health Center,
San Francisco Department of Public Health, Leigh Kimberg, MD
Claire Horton, MD, MPH Priscilla Chan and Mark Zuckerberg San Francisco
Associate Professor, Department of Medicine General Hospital and Trauma Center
School of Medicine, Division of General Internal Medicine San Francisco, California
(DGIM)
University of California San Francisco Margot Kushel, MD
Priscilla Chan and Mark Zuckerberg San Francisco Professor, Department of Medicine,
General Hospital and Trauma Center School of Medicine, University of California San Francisco,
Margaret Hutchison, MSN, CNM San Francisco, California
Professor, Department of Obstetrics, Gynecology and
Reproductive Sciences, C. Seth Landefeld, MD
School of Medicine, University of California San Francisco, Chair, Department of Medicine, Spencer Chair in Medical
Priscilla Chan and Mark Zuckerberg San Francisco Science Leadership,
General Hospital and Trauma Center University of Alabama at Birmingham, Birmingham, Alabama
Daniel S. Lessler, MD, MHA
Lisa I. Iezzoni, MD, MSc
Chief Medical Officer, Wa shington State Health Care Authority,
Professor of Medicine, Harvard Medical School; Director, Professor, Medicine and Health Services,
Mongan Institute for Health Policy, Ma ssachusetts University of Wa shington, Olympia , Wa shington
General Hospital, Boston, Ma ssachusetts
Bernard Lo, MD
Elizabeth A. Jacobs, MD, MPP
President and CEO, The Greenwall Foundation, New York,
Professor of Medicine and Population Health, University of New York;
Wisconsin School of Medicine and Public Health; Associate Vice Professor of Medicine Emeritus;
Chair for Health Services Research, Department of Medicine and Director Emeritus, Program in Medical Ethics,
Health Innovation Program, University of Wisconsin-Madison, University of California ,
Madison, Wisconsin San Francisco, California
Contributors x iii
Courtney R. Lyles, PhD Susana Morales, MD

Assistant Professor of Medicine, Division of General Internal Associate Professor of Medicine,
Medicine, Department of Medicine,
School of Medicine, University of California San Francisco Weill Medical College of Cornell University,
Priscilla Chan and Mark Zuckerberg San Francisco New York, New York
General Hospital and Trauma Center,
Christopher Neumann, PhD
Sarah Macfarlane, PhD, MSc Assistant Professor,

Department of Family and Community Medicine,
Professor, Department of Epidemiology and Biostatistics, School of Medicine, University of New Mexico,
School of Medicine and Global Health Sciences, University of Albuquerque, New Mexico
California , San Francisco, San Francisco, California
Carolyn Payne, MD
Megan Mahoney, MD
Resident, Department Obstetrics and Gynecology, Tufts Medical
Associate Chief of Primary Care, Associate Professor, Division of Center, Boston, Ma ssachusetts
General Medical Disciplines, Department of Medicine, Stanford
University, Palo Alto, California
John D. Piette, PhD
Rishi Manchanda, MD, MPH Senior Research Career Scientist, VA Ann Arbor Center for
Clinical Management Research; Professor of Health Behavior
President, HealthBegins, Los Angeles, California and Health Education, University of Michigan School of Public
Health; Professor of Internal Medicine, University of Michigan
Christina Mangurian, MD Medical School; Director University of Michigan Center for
Managing Chronic Disea se, Ann Arbor, Michigan
Associate Professor, Department of Psychiatry,
Priscilla Chan and Mark Zuckerberg San Francisco Michael B. Potter, MD
Professor, Department of Family and Community Medicine,
Brigid McCaw, MD, MPH, MS General Hospital and Trauma Center
Medical Director, Family Violence Prevention Program, San Francisco, California
Kaiser Permanente, Oakland, California
Francisco Ramos-Gomez, DDS, MS, MPH
Steven Meltzer, PA Professor, Section of Pediatric Dentistry,
Faculty, MEDEX Northwest Physician Assistant Program, School of Dentistry, University of California Los Angeles,
Department of Family Medicine, University of Wa shington Los Angeles, California
School of Medicine, Seattle, Wa shington
Neda Ratanawongsa, MD, MPH
Pooja Mittal, DO Associate Professor of Medicine, Division of General Internal
Associate Professor, Department of Family and Community Medicine,
Medicine, School of Medicine, University of California San Francisco
School of Medicine, University of California San Francisco, Priscilla Chan and Mark Zuckerberg San Francisco
Patricia A. Robertson, MD
Erica Monasterio, MN, FNP-BC
Professor and Director of Medical Student Education
Professor, Director, Family Nurse Practitioner Program, Family Division of Maternal-Fetal Medicine
Health Care Nursing; Division of Adolescent and Young Adult Department of Obstetrics, Gynecology and
Medicine, Reproductive Sciences,
School of Nursing, University of California San Francisco, School of Medicine,
San Francisco, California University of California , San Francisco
x iv Contributors
Marisa Rogers, MD, MPH Dean Schillinger, MD

Associate Professor of Medicine, Professor, Department of Medicine
Perelman School of Medicine, University of Pennsylvania , Chief of Division of General Internal Medicine (DGIM)
Philadelphia , Pennsylvania School of Medicine
Sara Rosenbaum, JD General Hospital and Trauma Center
Harold and Jane Hirsh Professor of Health Law and Policy, San Francisco, California
Department of Health Policy, Milken Institute School of Public
Health, George Wa shington University, Wa shington, DC Michelle Schneidermann, MD
Anne Rosenthal, MD School of Medicine,
University of California , San Francisco,
Associate Medical Director, Ma xine Hall Health Center
San Francisco Department of Public Health,
General Hospital and Trauma Center, San Francisco, California
Assistant Professor, Department of Medicine,
School of Medicine
University of California San Francisco Naomi Schoenfeld, MS, FNP-BC
San Francisco, California Nurse Practitioner, Family Health Center,
Priscilla Chan and Mark Zuckerberg San Francisco General
George William Saba, PhD Hospital and Trauma Center; Assistant Clinical Professor,
Family Nurse Practitioner Program, Family Health Care
Professor, Department of Family Community Medicine, Nursing,
School of Medicine, University of California San Francisco University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco San Francisco, California
San Francisco, California Tracy Schrider, LCSW, ACM
Administrative Supervisor of Social Work,
Bradley W. Samuel, PhD Sutter Health-Alta Bates Summit Medical Center,
Associate Professor; Director, Behavioral Health Education; Berkeley, California
Clinical Director, Behavioral Health Integration in Primary
Care, Department of Family and Community Medicine, Steven A. Schroeder, MD
University of New Mexico School of Medicine, Albuquerque,
New Mexico
School of Medicine,
University of California San Francisco,
Megan Sandel, MD, MPH San Francisco, California
Associate Professor of Pediatrics and Public Health,

Boston University Schools of Medicine and Public Health, Hilary K. Seligman, MD, MAS
Boston, Ma ssachusetts Associate Professor, Departments of Medicine
and Epidemiology and Biostatistics,
School of Medicine,
Urmimala Sarkar, MD, MPH
Associate Professor, Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco
School of Medicine, Division of General Internal Medicine General Hospital and Trauma Center
(DGIM) San Francisco, California
Priscilla Chan and Mark Zuckerberg San Francisco J. Ryan Shackelford, MD
San Francisco, California Assistant Professor
Department of Psychiatry
Medical Director of Behavioral Health Homes
Ellen M. Scarr, PhD, FNP-BC Community Behavioral Health Services and
Professor, Family Health Care Nursing, Community Oriented Primary Care
School of Nursing, University of California San Francisco, San Francisco Public Health Department
Contributors xv
William B. Shore, MD Cam-Tu Tran, MD, MS

Professor of Clinical Family and Community Medicine, Associate Professor,
University of California , San Francisco, School of Medicine Department of Pediatrics,
University of California , San Francisco School of Medicine, University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center General Hospital and Trauma Center
Shane Snowdon, MA Jacqueline P. Tulsky, MD

Harvard Divinity School, Professor, Department of Medicine
Cambridge, Ma ssachusetts School of Medicine
Margaret Stafford, MD General Hospital and Trauma Center
Assistant Professor, Department of Family and Community San Francisco, California
Medicine;
School of Medicine
Maya Vijayaraghavan, MD, MAS
Director of Education, Family Medicine Inpatient Service, Assistant Professor,
Priscilla Chan and Mark Zuckerberg San Francisco Department of Medicine, Division of General Internal Medicine
General Hospital and Trauma Center, (DGIM)
San Francisco, California School of Medicine
Jody Steinauer, MD, MAS General Hospital and Trauma Center
Professor, Department of Obstetrics, Gynecology and San Francisco, California
Reproductive Sciences,
School of Medicine
Teresa J. Villela, MD
Priscilla Chan and Mark Zuckerberg San Francisco Professor, Department of Family Community Medicine,
General Hospital and Trauma Center School of Medicine, University of California San Francisco,
Jeffrey N. Stoneberg, DO
Medical Director, Palliative Care,
Alexander Y. Walley, MD, MSc
Alta Bates Summit Medical Center,
Oakland, California Assistant Professor of Medicine, Clinical Addiction Research and
Education Unit, Section of General Internal Medicine, Boston
University School of Medicine, Boston, Ma ssachusetts
Stephanie Taché, MD, MPH
Director, Refugee Clinic, Dresden
Emily A. Wang, MD, MAS
Assistant Professor Family and Community Medicine
School of Medicine Associate Professor, Department of Internal Medicine,
University of California , San Francisco Yale University School of Medicine,
Priscilla Chan and Mark Zuckerberg San Francisco New Haven, Connecticut
Margaret Wheeler, MD
Emily H. Thomas, MD, MS
University of California , San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
Resident in Internal Medicine General Hospital and Trauma Center
SFGH Primary Care San Francisco, California
xvi Contributors
Ellen-Marie Whelan, PhD, NP Sharon L. Youmans, PharmD, MPH

Senior Advisor, CMS Center for Medicare and Medicaid Professor of Clinical Pharmacy and Vice Dean,
Innovation, Baltimore, Maryland University of California San Francisco School of Pharmacy,
Naomi Wortis, MD
Barry Zevin, MD
Professor, Department of Family and Community Medicine,
School of Medicine, University of California San Francisco, Clinical Lead, Transgender Health Services;
San Francisco, California Medical Director, Homeless Outreach Team,
Priscilla Chan and Mark Zuckerberg San Francisco San Francisco Department of Public Health,
Pre face
In the near decade since we published the irst edition o worldwide and believe that the concepts and approaches
this book, research has irmly established that populations are relevant to medical practice globally.
o lower socioeconomic status and rom minority racial he purpose o this book is to o er the theoretical
and ethnic backgrounds have worse health and o ten background and practical knowledge required to teach
receive a lower standard o health care. Worse health out- clinicians to care or vulnerable, underserved patients
comes attributed to inequity in distribution o resources, both at the individual and system levels. In this book, we
initially termed disparities in health and health care, are aim to illuminate the complexities o caring or vulnera-
now more aptly and pointedly re erred to as inequities in ble, underserved patients. We provide both an appreci-
health and health care. hese inequities are attributed to ation o the need to address inequities at multiple levels
broad social orces that shape the way we live and how and practical suggestions or how to improve the care
medicine is practiced. With this perspective, a person’s o vulnerable populations. We aim to “enable” health-
and a community’s health and the health care they receive care workers, students, and other interested parties to
are measures o social justice. contribute to the solution. We ocus on issues o patient
As clinicians, there is perhaps no more distressing care that are common among underserved patients and
medical research than that which suggests that health- suggest ways to use our materials as teaching tools or
care workers and the health-care system contribute to health pro essions trainees in both didactic and clinical
inequities in health or vulnerable populations. Studies settings.
reveal that health-care workers continue to eel ill pre- Our book is intended as a basis or teaching the core
pared when caring or vulnerable patients, especially principles and skills required to care or our most com-
those who are chronically ill, the elderly, addicted, men- plex patients—the vulnerable and underserved—where
tally ill, victims o violence, or rom minority or disadvan- our clinical skills must be the most astute. Our text is
taged backgrounds. Hence, health-care workers may be appropriate or students, residents and practitioners
the third actor in a “triple jeopardy” vulnerable patients (medical students, nurses, pharmacists, physician’s assis-
ace when it comes to health care: not only are these tants, public health, and other health-care practitioners)
patients more likely to be ill and to have di iculty access- both in clinical, community, or social medicine classes
ing care, but when they do, the care they receive is more and in practical experiences, including, but not limited
likely to be suboptimal. Fortunately, training health-care to, primary care rotations and clerkships in amily med-
workers to care or vulnerable patients makes a di erence. icine, pediatrics, internal medicine, women’s medicine,
With training, they are more willing to work with these and psychiatry. As teaching hospitals are the major pro-
populations and provide better care. viders o care to uninsured, poor, and minority patients in
We hope the second edition o our book will be part the United States, the book is also intended as a resource
o an ongoing process o improving our pro essions’ abil- or teachers and trainees who practice in these settings
ity to discharge its obligation to enhance social justice by as well as public health-care settings internationally. Post-
both delivering comprehensive care or all patients and graduate trainees (e.g., residents and ellows) rom all dis-
challenging the policies that undermine health or under- ciplines could use this text or didactics in behavioral and
privileged patients and health-care access and delivery. clinical medicine, and quality improvement. Finally, it can
Although grounded in health care as it is practiced in also serve as a rapid, yet comprehensive re erence or all
the United States, we draw rom evidence and practices practitioners.
x v ii
x v iii Pre ace
he book is organized into three sections: Principles, o care delivery to improve the e ectiveness o medical
Practice, and Populations. Chapters in each section dis- care, such as the patient-centered medical home, group
cuss ways in which both the individual practitioner medical visits, and use o interactive health technologies;
and the health-care system may be more responsive to as well as quality improvement and case management
patients with these characteristics to assure they receive programs. he third section, Popula tions, examines par-
accessible, high-quality care, thereby reducing the inequi- ticular conditions or social circumstances that can lead
ties in health care that are both causes and consequences to worse care. Chapters consider approaches to patients
o vulnerability. We present clinical approaches to many with histories o trauma, mental illness, intimate partner
issues that complicate caring or socially vulnerable violence, and addiction, or example. Care o patients with
patients. Many chapters eature both Key Concepts and limited English pro iciency, history o incarceration, gay,
Common Pitfalls, and end with a Core Competency high- lesbian and transgender patients, children, adolescents,
lighting important concepts and skills or quick and easy and the elderly are subjects o others. In addition, this
re erencing. section addresses common situations that uniquely com-
Putting together a book o this scope and magnitude plicate the care o vulnerable populations such as envi-
was no easy task and involved making certain decisions ronmental and occupational illnesses; the care o socially
that not all readers may agree with. For example, while complicated hospitalized patients; end-o -li e health care;
trying to keep the length o the book as manageable as chronic pain management; dental health; the care o
possible, we were orced to exclude some relevant topics patients with HIV/AIDS; and patients with disabilities.
and decided to allow some overlap o content in those We end with a chapter that addresses the prevention o
areas that are most critical. In addition, we welcomed di - practitioner burnout.
erences o opinion among authors, provided the issues We are deeply appreciative to the authors or their
were clearly stated and the reasons or the author’s opin- outstanding contributions to both editions o the book.
ion documented. Although the authors o some chapters have changed, we
he irst section, entitled Principles, lays out the theo- wish to acknowledge the in luence and contribution o
retical groundwork o the book. opics discussed include those who laid the oundation in the original chapters. We
overview o the concepts o medical vulnerability and would also like to acknowledge the support and patience
inequities in health and health care; inancing and organi- o the sta at McGraw-Hill. We especially wish to rec-
zation o health care or vulnerable populations; laws and ognize the e orts o James Shanahan or believing in the
regulations governing the care o medically underserved project since its inception and to Amanda Fielding, Kim
populations in the United States; and ethical dilemmas Davis, Laura Libretti, and Kritika Kaushik or bringing it
that arise in the clinical care o medically underserved to ruition. Finally, we are orever grate ul to our patients
populations. We also present chapters on engaging com- or allowing us to participate in their care, our students
munities, on a global health-care perspective and pro- or inspiring us to do better, and our amilies or their
moting physician advocacy. he second section, Pra ctice, generous support.
considers overarching themes and skills necessary to care almadge E. King, Jr., MD
or patients. In particular, this section concentrates on Margaret B. Wheeler, MS, MD
population medicine and systems approaches to improv- Andrew B. Bindman, MD
ing care to vulnerable patients. opics discussed include Alicia Fernandez, MD
the importance o building a therapeutic alliance and Kevin Grumbach, MD
assessing or vulnerability; supporting health behavior Dean Schillinger, MD
change and adherence; principles o e ective communi- eresa J. Villela, MD
cation when cultural or literacy barriers may exist; models
PART 1
Principle s
CHAP TERS
1 Vu ln e ra b le Po p u la tio n s , He a lth Dis p a ritie s , a n d He a lth
Eq u ity: An Ove rvie w
2 He a lth -Ca re Dis p a ritie s : An Ove rvie w
3 Fin a n cin g a n d Orga n iza tio n o f He a lth Ca re fo r Vu ln e ra b le
Po p u la tio n s
4 Le ga l Is s u e s in th e Ca re o f Un d e rs e rve d Po p u la tio n s
5 Prin cip le s in th e Eth ica l Ca re o f Un d e rs e rve d Pa tie n ts
6 Co m m u n ity En ga g e m e n t a n d Pa rtn e rs h ip
7 A Glo b a l Pe rs p e ctive o n th e Ca re o f Me d ica lly Vu ln e ra b le
a n d Un d e rs e rve d Po p u la tio n s
8 Ad vo ca cy
Ch a p te r 1
Vulne rable Po pulatio ns , He alth

Dis paritie s , and He alth Equity:
An Ove rvie w
Kevin Grum bach, MD, Paula Brave m an, MD, MPH, Nancy Adle r, PhD, and
Andrew B. Bindm an, MD
Objectives
• Define the terms vulnerable populations, health disparities, and health equity.
• Distinguish among differences in health, health disparities, and health-care disparities.
• Understand the relationship between social vulnerability and health disparities, and the
pathways mediating this association.
• Recognize the ethical and human rights principles underlying efforts to achieve health
equity
• Identify actions health professionals may take to change the social conditions that create
vulnerability and produce health disparities.
IN TRO D UC TIO N their skills to respond effectively to the health-care

needs of vulnerable patients but also to take action to
“Vulnerable” derives from the Latin word for wounded.
change the fundamental social conditions that produce
Populations can be vulnerable for a variety of reasons. In
vulnerability.
this chapter, we focus on populations that are wounded
by social forces that place them at a disadvantage with
respect to their health. Vulnerability is visible in the
WHAT A RE HEA LTH A N D HEA LTH-CA RE
variation across social groups in levels of resources and
D IS PA RITIES ?
social influence and acceptance, as well as in the inci-
dence, prevalence, severity, and consequences of health Webster’s dictionary defines disparity as a difference.
conditions. “Difference” sounds like a neutral concept. It may seem
This chapter provides an over view of the concept logical that different people have different states of health,
of vulnerability. It begins by introducing the notion of requiring different kinds and quantities of care. For
health disparities, distinguishing it from simple differ- example, elderly people are expected to be less healthy
ences in health, and defining the closely related concept than young adults. People who ski are more likely to suffer
of health equity. It describes evidence of health dispari- leg fractures than people who do not.
ties, particularly by socioeconomic status (SES) and race/ Concern for health disparities is not about all differ-
ethnicity. It then discusses conceptual models for under- ences in health, but rather about a subset of differences
standing the pathways between social vulnerability and that are avoidable and suggest social injustice. Although
poor health status. It concludes by suggesting that health few readers of this book probably were moved to righ-
professionals have a responsibility not only to develop teous indignation by the health differences cited in the
2
Chapter 1 / Vu ln er able Pop u lat ion s, H ealt h Disp ar it ies, an d H ealt h Eq u it y: An O ver vie w 3
example of skiers and more frequent broken bones, the RO LE O F S O C IO ECO N O M IC C LAS S
following observations are likely to prompt qualitatively A N D RAC E/ETHN IC ITY IN HEA LTH
different reactions: A baby born to an African-American D IS PA RITIES
mother in the United States is more than twice as likely
Profound and pervasive disparities in health associated
to die before reaching her or his first birthday as is a baby
with a range of socioeconomic factors such as income or
born to a white mother.1 A World Bank study of 56 coun-
wealth, education, and occupation have repeatedly been
tries revealed that, overall and within virtually every
documented in the United States and globally.2,7-9 Despite
country, infant and child mortality were highest among
ongoing debates about whether causation has been defini-
the poorest 20% of the population and lowest among the
tively established, considerable evidence has accumulated
best-off 20% of the population; the disparities were large
demonstrating, at a minimum, the biological plausibility
in absolute as well as relative terms.2
of those associations.10,11 Similarly, virtually wherever data
on health according to race or ethnic group have been
HEALTH DIS PARITIES measured, racial or ethnic disparities in health also have
often been observed; these disparities sometimes, but not
“Health disparities” is a shorthand term denoting a spe- always, have disappeared or been markedly reduced once
cific kind of health difference between more and less priv- socioeconomic and other contextual differences have
ileged social groups. It refers to differences that adversely been accounted for.12-14
affect disadvantaged groups that are systematic and
persistent, not random or occasional, and that are at least
theoretically amenable to social intervention. The social S OCIOECONOMIC STATUS
groups being compared are differentiated by their under-
Social class shows a strong association with health and
lying social position, that is, by their relative position in
longevity. Higher SES provides individuals with more
social hierarchies defined by wealth, power, and/or pres-
material, psychological, and social resources, which can
tige; this includes socioeconomic, racial/ethnic, gender,
benefit their health. There is no standardized method for
and age groups and groups defined by disability, sexual
defining or measuring social class in the clinical setting,
orientation or identity, or other characteristics reflecting
and this information is not routinely collected as a part of
social privilege or acceptance.3-5
health-care encounters. Some of the typical dimensions of
social class used in research studies include occupation,
HEALTH-CARE DIS PARITIES income, and education level, which are all components of
what is generally referred to as socioeconomic status.
Disparities in health care, as opposed to disparities in Some of the most compelling evidence about the asso-
health, refer to systematic differences in health care ciation between SES and health comes from the White-
received by people based on these same social character- hall study in the United Kingdom. This research on
istics. Although disparities in health care account for only British civil servants demonstrated a linear association of
a relatively small proportion of disparities in health, they higher occupational grade with lower 10-year mortality.15
are of particular importance to health-care providers and This was a striking finding because significant differences
are discussed in detail in the next chapter. in mortality occurred in a population in which all par-
ticipants were employed and had health-care coverage.
Despite the relative homogeneity of the group, those in
HEALTH EQUITY higher occupational grades had significantly lower rates
For individuals concerned about vulnerable and under- of a number of diseases as well as lower mortality. These
served populations, one overarching objective is eliminat- differences remained 25 years later, even after some of
ing health disparities. A slightly different way of framing the civil servants had retired from their jobs.16 A similar
this aspiration is to state that the goal is to achieve health SES and health gradient has been observed in the United
equity. This frames the objective as a positive one (achiev- States. A 2010 study using national data observed step-
ing equity) rather than a negative one (eliminating dispar- wise incremental gradients of health improving as either
ities). This approach mirrors defining health as a positive income or educational level rose, for scores of indicators
state of well-being and not just the absence of disease. across the life course.8
Health equity may be understood as a desired state of
social justice in the domain of health, and health dispar-
INCOME AND HEALTH
ities as the metric used to measure progress toward this
state. A reduction in health disparities is evidence of mak- Analyses of the SES gradient generally reveal a sharp drop
ing progress toward greater health equity.6 in mortality as income increases from the most extreme
4 Part 1 / Principles
58 65
Me n Wome n
60.3
55.7 60
)
56 58.1
5
57.0
2
56.4
e
)
g
5
53.8 55
a
2
54 52.3
t
51.7
e
51.4
a
(
g
y
a
50
c
t
n
52 47.1
a
51.4
a
(
t
y
c
c
e
45
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n
a
50
e
t
49.2
c
e
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f
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i
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L
x
48
e
e
f
35
i
L
Le s s tha n High-s chool S ome colle ge Colle ge gra dua te
46 high s chool gra dua te
Educa tiona l a tta inme nt
44
<100% FP L 100%-199% FP L 200%-399% FP L ≥400% FP L Fig u r e 1-2 . Educational attainm e nt and life expe ctancy at
Fa mily income a s pe rce nta ge of fe de ra l pove rty leve l (FP L) age 25 in the United State s . This figure de scribe s the numbe r
of ye ars that adults in diffe re nt e ducation groups can expe ct
Fig u r e 1-1. Family income and life expectancy at age 25 in the
to live beyond age 25. For example , a 25-ye ar-old man w ith a
United States. This figure describes the number of years that
high school diplom a can expe ct to live 51.4 additional ye ars
adults in different income groups can expect to live beyond age
and re ach an age of 76.4 ye ars . (Source : CDC/NCHS, National
25. For example, a 25-year-old man with a family income below
Health Inte rview Survey Linked Mortality File , 2006. National
100% of the federal poverty level can expect to live 49.2 additional
Ce nte r for He alth Statistics. He alth, Unite d State s 2011: With
years and reach an age of 74.2 years. (Source: CDC/NCHS,
Spe cial Feature on Socioe conom ic Status and He alth. Hyattsville,
National Health Interview Survey Linked Mortality File, 2006.
MD: 2012. http://w w w.cdc.gov/nchs /data/hus/2011/fig32.pdf.)
National Center for Health Statistics. Health, United States 2011:
With Special Feature on Socioeconomic Status and Health. Hyatts-
ville, MD: 2012. http://www.cdc.gov/nchs/data/hus/2011/fig32.pdf.)
as income increases (albeit with a sharper drop in
the lower portion of the distribution), the association
categories of poverty toward more moderate poverty, and
between mortality and education is more discontinuous.
a continued but more gradual drop in mortality as incomes
For all-cause mortality and each of the specific causes,
rises above this moderate poverty level. The National Lon-
the death rates are lower for those with more educa-
gitudinal Mortality Survey in the United States showed a
tion (Figure 1-2). To the extent that education provides
difference of more than 6 years of life expectancy at age 25,
information, knowledge, and skills that improve health,
between those who were poor and those with incomes
each additional year of education should contribute
more than four times the poverty level; there was a 2-year
somewhat equally to improved health. However, educa-
difference in life expectancy at age 25 between those with
tional attainment also serves a credentialing function.
intermediate-level incomes (200– 399% of poverty) and
As a result, there is a greater benefit of achieving years
the higher-income group (Figure 1-1).8
of schooling that result in a degree or credential than of
Above and beyond one’s own economic status, there
additional years that do not. Thus, the benefit of com-
is some evidence that the distribution of income across
pleting the 12th year of schooling, which results in a high
a population makes a difference. Although still being
school degree, is greater than the benefit of completing
debated, income inequality itself may be bad for people’s
any other single year of high school (referred to as the
health, irrespective of the average overall standard of liv-
“sheepskin” effect).
ing in a society. As discussed in Chapter 7, cross-national
The data linking education and health can more clearly
comparisons indicate that nations with less income
be interpreted as a causal effect of education and health
inequality have better overall health indicators than
than is the case for income and health. While poor health
nations at a comparable level of economic development
can reduce one’s income,18 education occurs earlier in life
with more unequal income distribution.17
than do most serious diseases, and this temporal ordering
Wealth is another measure of economic status. Wealth
provides a strong rationale for attributing the association
includes not just income, but also the value of assets such
to the impact of education on health.
as home ownership, real estate, and investments—assets
Data in the United States on SES and health have been
that often accumulate among families over generations.
limited. While public health monitoring and epidemio-
Wealth tends to have an even more inequitable distribu-
logic surveys frequently collect information on race and
tion across a population than does income.
ethnicity, they less often include information on income
or education. Until recently, death certificates had only
EDUCATION AND HEALTH
data on race and ethnicity, but now include information
In contrast to the relationship between income and on education but not occupation, income, wealth, or
health, which demonstrates a continued drop in mortality other SES variables.
RACE/ ETHNICITY distinctions between the concept of race and ethnicity are
an oversimplification of this socially defined construct,
Race and ethnicity often are combined and referred to as
and we use the term “race– ethnicity” to communicate a
one concept. Nevertheless, the concept of race as com-
more holistic notion of this concept.
monly used tends to evoke differences in skin color and
Disparities by race– ethnicity are present in the United
other superficial secondary characteristics, whereas eth-
States for such diverse health indicators as infant mor-
nicity incorporates the concept of culture.19
tality, cancer mortality, coronary heart disease mortality,
The health implications of classification of both racial
and the prevalence of diabetes, HIV infection, or stroke
and ethnic groups derive primarily from the social con-
(Table 1-1). Two clear observations can be made about
struction and impact of being labeled as belonging to one
these health outcomes categorized by race and ethnicity.
or another group. Apart from a small number of genes
First, African Americans experience the greatest mor-
that code for skin color and other superficial secondary
bidity and mortality on every reported indicator, and the
characteristics, and a few genes that are linked to geo-
gap often is substantial. For example, African Americans
graphic origin which confer risk for specific diseases,
experience 12.7 deaths for every 1000 live births, com-
there is little biologic basis for health disparities among
pared with Asian or Pacific Islanders, who experience 4.5
racial and ethnic groups. Advances in genomics have
deaths. Second, no other group shows consistently poor
exposed the concept of race as predominantly a social
health outcomes across all indicators. Whites show poorer
construct, rooted in historical biases and social stratifica-
outcomes than groups other than African Americans on
tion based on ancestry and superficial phenotype rather
many of the reported health indicators (e.g., overall can-
than emanating from fundamental genetic differences
cer mortality). American Indians and Alaska natives have
among populations perceived to be of different “races.”
the second highest rates of infant mortality, and Hispanics
There is no gene or set of genes that are exclusive to one
or Latinos have the second highest prevalence of diabe-
race and that can be used to define those belonging to a
tes. Asian Americans and Pacific Islanders show the most
race. Stated another way, one cannot look at a person’s
favorable profile.
DNA and tell definitively that she or he is Asian, African
One limitation of these conclusions is that they are
American, Latino, or white. The genetic variation among
based on large groupings by race– ethnicity. These broad
people within a racial and ethnic group is much greater
categories may obscure substantial variation in health
than the variation across groups.20
within some of the groups. Members of the same major
Despite the lack of definitive genetic determinants,
racial– ethnic group from different countries and areas of
race and ethnicity have important influences on health.
origin have different degrees of disadvantage and health
Based on historical conventions, US federal agencies use a
risk. For example, among Latinos and Hispanics in the
two-item approach to classification. The first item is con-
United States, the infant mortality rate is 4.9 among
sidered to represent race, and includes five major groups:
Cubans and 7.3 among Puerto Ricans. The importance
African American or black, American Indian or Alaska
of looking at subgroups also may differ by disease. For
native, Asian, native Hawaiian or other Pacific Islander,
example, Asian Indians have the lowest rates of all-cause
and white. The second item is considered to measure eth-
mortality, yet they have relatively high rates of coronary
nicity, and consists solely of a dichotomous categorization
heart disease compared with other Asian groups.21
of Hispanic or non-Hispanic. In our view, such categorical
Ta b le 1-1. He a lth Dis p a ritie s b y Co n d itio n a n d Ra ce –Eth n icity
Race/Ethnicity
Black/African Hispanic/ Asian and Pacific American Indian

Health Condition and Specific Example White American Latino Islander and Alaska Native
Infant mortality: rate per 1000 live births 5.5 12.7 5.6 4.5 8.4
Cancer mortality: rate per 100,000 173 206 120 108 158
Lung cancer mortality: rate per 100,000 49 52 21 25 40
Female breast cancer mortality: rate per 100,000 22 31 15 11 15
Coronary heart disease: mortality rate per 100,000 118 141 87 67 92
Stroke: mortality rate per 100,000 38 56 30 32 30
Homicides, per 100,000 2.6 19.9 6.6 2.2 9.0
HIV infection: prevalence per 100,000 adults 17 128 50 15 32
Diabetes: prevalence per 100 adults 6.8 11.3 11.5 10.2 DSU
DSU, data are statistically unreliable.

Source: CDC Health Disparities and Inequalities Report, United States, 2013. MMWR 2013;62(Suppl), No. 3; National Cancer Institute, SEER Cancer Statistics Review
1975– 2011.
DUAL EFFECT OF S OCIOECONOMIC STATUS AND even identify populations on racial or ethnic grounds.
RACE/ ETHNICITY Consequently, authorities in many European countries
have made a deliberate decision not to collect data on race
The overlap between race/ethnicity and SES makes it dif-
and ethnicity.”24
ficult to disentangle the relative contributions of each of
As social scientists continue to investigate the complex
these factors toward health.22 Both African Americans
interplay among race– ethnicity, social statuses, and health
and Hispanics are overrepresented in lower SES cate-
status, the prevailing wisdom is that both race– ethnicity
gories. Data from the 2010 census reveal that 30.3% of
and SES matter.7 Race– ethnicity can confer a vulnerability
whites 25 years of age and older are college graduates,
rooted in experiences of racism and social oppression that
compared with 19.8% of African Americans and 13.9% of
is not completely reducible to socioeconomic disadvan-
Hispanics. Similarly, there are large differences in income
tage. At the same time, focusing exclusively on disparities
by race/ethnicity. For example, in 2009 the median fam-
by racial and ethnic groups overlooks the contribution of
ily income was $38,409 for African Americans, whereas it
socioeconomic inequalities to these disparities. The fol-
was $62,545 for whites. If one uses a measure of net worth
lowing section examines in detail the pathways through
(wealth) instead of income, the economic differences by
which social vulnerabilities such as minority race– ethnic-
race/ethnicity are even more dramatic.
ity or low SES translate into poor health status.
For some health outcomes, differences in the United
States between African Americans and whites become
much less significant once analyses control for income
and/ or education. For other health outcomes there HEA LTH D IS PA RITIES A N D PATHWAYS
continue to be differences associated with race/ ethnicity O F VU LN ERA BILITY
that are not explained by socioeconomic class alone23 Phyllis Gripman has been driving a bus for 22 years. The stress
(Figure 1-3). of keeping on schedule despite traffic congestion and impa-
The relative emphasis on disparities according to tient commuters contributes to her poorly controlled blood
race– ethnicity and SES varies in nations across the globe, pressure. She often skips taking her diuretic medication when
reflecting differences in both demographic characteristics working to avoid the need for bathroom stops, which could
put her behind schedule. Frequently, passenger complaints
and social history. A comparative analysis of US and EU
about the bus service are coupled with derogatory comments
approaches to health equity observed, “With a history
about the fact that she is a woman and African American.
marked by the legacy of slavery and discrimination, the
United States has adopted a racially oriented perspective Tho Van fled his native Cambodia to escape the Pol Pot
on certain social concerns to ensure equitable treatment regime. He has nightmares reliving watching his brother
under the law and safeguard civil rights. In Europe, by being tortured to death. He often must rely on his daughter
contrast, experience with ethnic group genocide during to translate during his medical visits. He avoids discussing
World War II has caused great reluctance to segment or his nightmares in front of his daughter. He worries about his
teenage son, who has joined a gang and is truant from school.
30 Walter Jones has been homeless since his discharge from the
Bla ck, non-his pa nic army following the Iraq War. He has been in and out of reha-
h
t
l
a
His pa nic bilitation programs for his heroin addiction. He is managing
e
25 23.9
h
White , non-his pa nic
to stay clean while in a methadone maintenance program.
r
i
a
20.9
f
/
He initiated evaluation for other medical problems at the
r
20 19.2
o
18.3
o
Veteran’s Administration medical center, but did not follow
p
15.6 14.8
h
t
up for treatment after he overheard a physician refer to him
i
15
w
as “that noncompliant homeless drug addict who’s wasting
s
11.2
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0 These three examples identify individuals with social
P
<100% 100-199% 200-399% ≥400%
characteristics that make them vulnerable to experiencing
Fa mily income (pe rce nt of fe de ra l pove rty le ve L)
health disparities. Viewed within the framework of health
Fig u r e 1-3 . Se lf-rate d he alth s tatus according to race –e th-
disparities, defined in the preceding as health differences
nicity and incom e in the Unite d State s . (Source : CDC/NCHS,
National He alth Inte rview Survey 2010, Fam ily Core and Sam - between more and less privileged groups, “vulnerability”
ple Adult Que s tionnaire . National Ce nte r for He alth Statis tics . consists of those social characteristics, such as minor-
He alth, Unite d State s 2011: With Spe cial Fe ature on Socioe co- ity race– ethnicity and low SES, that are associated with
nom ic Status and He alth. Hyatts ville , MD: 2012. w w w.cdc.gov/ health disparities. How do these characteristics ultimately
nchs /data/hus /2011/056.pdf.) result in inferior health status?
PATHWAYS BETWEEN DEMOGRAPHIC crowded, noise is pervasive, pollutants and toxins

CHARACTERISTICS AND HEALTH STATUS are prevalent, and facilities for exercise are sparse.
Mr. Jones’ lack of housing is a particularly glaring
The conceptual model displayed in Figure 1-4 synthesizes
example of vulnerability in his physical environment.
ideas from a variety of models that have been proposed to
3. Social environment. Vulnerable populations also often
explain the pathways between demographic characteris-
face an oppressive social environment, including factors
tics and health status.25-29
such as institutional and other forms of racism, hous-
This model proposes that poor health culminates from
ing segregation, and low levels of social capital (gen-
several major forces:
erally defined as the resources that come from strong
community and interpersonal relationships). Commu-
1. Genetic endowment and epigenetic processes. Everyone
nities with greater social capital and collective efficacy
is born with a genetic endowment that offers relative
(i.e., more able to organize and garner resources) have
protection against, or vulnerability to, certain condi-
lower morbidity and mortality.30,31 Mr. Van’s expe-
tions. Ms. Gripman, the bus driver, may have inher-
rience of political violence and social disruption as a
ited a disposition to develop essential hypertension.
refugee from Cambodia poignantly represents a social
Mr. Jones, the homeless veteran, may have a genetic
environment that has adverse effects on health and the
susceptibility to opiates that abetted his addiction to
receipt of health care (see Chapter 29 and 36).
heroin. However, health and illness are determined not
4. Behavior and lifestyle. Unhealthful behaviors such as
just by one’s genetic makeup but by “epigenetic” pro-
smoking and substance use are more prevalent among
cesses. Exposures and experiences across one’s life can
people with less education, and sedentary lifestyles
determine whether specific genes are activated or are
and high-fat diets are more common among African
suppressed. The occurrence of disease thus depends
Americans and those with low SES.32 The reasons for
not just on the “hardwiring” of genetics but also on the
these high rates of prevalence are complex and also are
“software” of epigenetics.
heavily influenced by differences in physical and social
2. Physical environment. The air, water, food, toxins, and
environments, chronic stress, and delivery of health
physical dangers to which one is exposed may have a
care (see Part 3: Populations).
profound impact on health. Minorities and the poor
5. Chronic stress. Researchers have begun to identify the
are more likely to reside in neighborhoods and work
toxic effects of chronic stress related to lack of eco-
settings with unhealthful physical environments;
nomic and social resources or experiences of discrimi-
therefore, this is a socially mediated influence on their
nation. McEwen 33 developed the concept of “allostatic
health (see Chapter 25). For example, housing is often
load” to describe the biological processes involved in
responses to chronic stress. Allostatic load scores have
been found to be higher among African Americans
than among whites and greater among those with less
Oppre s s ion education.34 Allostatic load scores, in turn, have been
shown in a sample of older adults to predict physical
Ge ne tic e ndowme nt and cognitive decline, the onset of new cardiovascu-
lar disease, and mortality over a 7-year period.35,36
P hys ica l e nvironme nt The types of occupational stresses experienced by
Ms. Gripman have also been associated with unfavor-
Ra ce -e thnicity
able health outcomes.37
S ocia l e nvironme nt
He a lth
6. Health care. Inadequate access to and quality of health
dis pa ritie s care is a final pathway to health disparities. Structural
S ocioe conomic
s ta tus Be ha vior inequalities in the distribution of health-care resources,
such as physicians and hospitals, across communities,
S tre s s may lead to inequity in access to and quality of care.
The interpersonal process of delivering care may be
deficient because of factors such as discrimination or
He a lth ca re
lack of cultural or non-English language competence
among health-care workers. For example, a clinic with
Re s ilie ncy greater availability of interpreters and culturally appro-
Fig u r e 1-4 . A conce ptual m ode l that s ynthe s ize s ide as from priate mental health services might afford Mr. Van
a varie ty of m ode ls propos e d to explain the pathways be twe e n greater opportunity for effective treatment of his post-
de m ographic characte ris tics and he alth s tatus . This m ode l pro- traumatic stress disorder, resulting in better health sta-
pos e s that poor he alth culm inate s from s eve ral m ajor force s . tus and well-being (see Chapters 14, 29, 31, 33).
Although Figure 1-4 presents this model in a relatively supply relative to demand, is especially relevant to health
linear form, it is important to recognize that the forces disparities.42
producing health disparities function in a more dynamic,
multidirectional manner involving interactions and feed-
DISTRIBUTIVE JUSTICE
back loops among all the elements displayed. For exam-
ple, chronic stress from war trauma may have contributed The ethicist John Rawls has provided a framework for
to Mr. Jones’ adoption of unhealthful behaviors such as considering the principle of distributive justice and its
alcohol and drug use as a mechanism to cope with stress. application to health equity. In defining how one would
Poor health or a chronic medical condition, such as know what was just an allocation of resources to different
Ms. Gripman’s hypertension, may increase stress levels. groups in a society, Rawls43 introduced the notion of “the
Moreover, these factors all operate at multiple levels, veil of ignorance.” In his view, policies allocating resources
ranging from the individual to the broader community should be made as if one were operating behind a “veil
and social institutions. The cumulative negative force of of ignorance” about the social group into which one had
these pathways may be viewed as representing the social been born. If I did not know whether I would be born
vulnerability that produces health disparities. rich or poor, black or white, male or female, into a family
Most analyses have concluded that health care explains living in a rural area or one in an urban area, how would
only about 10– 20% of population health outcomes, with I recommend allocating resources? Rawls believed that,
social, environmental, and behavioral factors being the under those circumstances, most people would prefer
most powerful determinants. As one leading public health that resources be allocated according to need.
advocate in the United States concluded about the pow-
erful effect of social and environmental conditions, “Your
HUMAN RIGHTS AND THE RIGHT TO HEALTH
ZIP code may be more important to your health than your
genetic code.”38 Human rights frameworks and principles provide a uni-
versally recognized frame of reference for initiatives to
reduce health disparities between more and less advan-
RES ILIENCE
taged social groups. When the term “human rights” is
In contrast, individual and collective resilience—the encountered, most people think of civil and political
capacity to develop positively despite harmful environ- rights, such as freedom of speech and freedom from cruel
ments and experiences—represents the positive vector of or arbitrary punishment. However, human rights also
these pathways that may act as a countervailing force and encompass economic, social, and cultural rights, such
produce better health outcomes. One example of the pos- as the right to a decent standard of living, which in turn
itive effects that can result from individual and collective includes rights to adequate food, water, shelter, and cloth-
resiliency is reflected in the finding that first-generation ing requisite for health as well as the right to health itself.
immigrants appear to have a health advantage across Almost every country in the world has signed agree-
virtually every group.39 This may partially result from ments that include health-related rights. The right to
the “healthy immigrant” effect, in which there is differ- health is a cornerstone underlying efforts to achieve
ential selection for those who have the characteristics health equity. The World Health Organization’s constitu-
(including better health) that allow them to emigrate to tion 44 defined the right to health as the right of everyone
the United States.40 It may also reflect protective effects to enjoy the highest possible level of health. The right
of traditional diets, supportive social networks, or other to health can be operationalized as the right of all social
health practices of first-generation immigrants. The find- groups (defined by social position) to attain the level of
ing of lower mortality among older Mexican Americans health enjoyed by the most privileged group in society.
living in neighborhoods with a higher density of Mexican The right to health thus provides the basis for comparing
Americans supports this view.41 The researchers attrib- the health experienced by different social groups, always
uted this difference to the protective effects of the con- using as the reference group the most privileged group in
centration, which may buffer Mexican Americans from a given category.4
the “unhealthful aspects of US culture.”
RACIS M AND HEALTH
ETHICA L A N D HU M A N RIG HTS
One final conceptual framework useful for understanding
P RIN C IP LES
vulnerability derives from a model developed by Jones
Ethical and human rights principles underlie the notion for understanding racism and its impact on health.45
of health equity. “Distributive justice,” that is, normative Jones proposes that racism operates at three levels:
ethical principles designed to allocate resources in limited institutionalized, personally mediated, and internalized.
Institutionalized racism refers to the structural elements Subsequent chapters comprehensively discuss approaches
of racism that are “codified in our institutions of customs, to delivering more accessible, effective, and responsive
practice and law so there need not be an identifiable health care and social services to vulnerable patients.
perpetrator.” Examples are housing segregation, school However, the most effective treatment for the problems of
inequality, and the history of Jim Crow laws in the United vulnerable patients would be to change the fundamental
States. Personally mediated racism is the prejudice and social conditions that are the sources of vulnerability and
discrimination experienced in daily encounters, rang- primary determinants of health disparities.
ing from overt racial slurs to the less explicit racism of Is it appropriate to expect health-care professionals
the prejudicial judgments made by teachers, clinicians, to engage in arenas (e.g., health-care policy making) for
shopkeepers, and other social contacts. Internalized rac- which they are not trained? Without becoming policy
ism is defined as “acceptance by members of the stigma- makers themselves, health professionals have made major
tized races of negative messages about their own abilities contributions to health-care policy debates by speaking
and intrinsic worth.” Internalized racism manifests itself out in diverse forums, contributing their time to support
as lack of self-esteem and devaluing of the sense of self- other activities of groups advocating for policies to reduce
worth. These types of racism may interact: for example, health-care disparities, and/or providing financial sup-
one study found that the impact of reported experiences port for such groups.
of discrimination on risk of cardiovascular disease of At some time, nearly every health-care provider has
African-American men was moderated by internalized experienced the frustration of providing an effective
racial group attitudes.46 treatment for a patient’s health problem, only to send
Although developed for understanding racism, Jones’ the patient back to the same circumstances in the phys-
model is applicable to all the “-isms” that create social ical or social environment that caused or triggered the
vulnerability. For example, the levels proposed by Jones illness. An example is treating an asthma attack and then
apply to sexism. Sexism operates at an institutional level discharging the patient to the same substandard housing
(e.g., objectification of women by mass media and enter- permeated with allergens. Virtually every clinician knows
tainment, inadequate laws, and lax enforcement to protect the frustration of prescribing regimens of medications,
women against violence and sexual abuse), interpersonal diet, and/or exercise to patients whose life circumstances
level (e.g., prejudice in hiring and promotion decisions), make the successful implementation of those care plans
and internalized level (e.g., victimization, lowered expec- very unlikely. For example, people who live in neighbor-
tations for achievement). The same principles apply to hoods without stores that sell affordable fresh produce
vulnerabilities based on social class, sexual orientation, gen- or in which outdoor exercise is unsafe or infeasible do
der identity, immigrant status, and other characteristics.7 not have the same opportunities to follow recommended
regimens as those who live in more health-promoting
neighborhoods.
TREATIN G VU LN ERA BILITY:
However, most health-care professionals probably feel
A D D RES S IN G THE RO OT CAU S ES
that fulfilling their own personal professional expecta-
For health professionals to successfully attend to the tions as providers of high-quality health care, informed
health needs of vulnerable populations, they must rec- by the latest evidence, is difficult enough without adding
ognize how vulnerability manifests itself at each of these expectations that they change their patients’ life circum-
levels for each patient’s particular constellation of vulner- stances as well. In addition, health-care professionals feel
abilities. Social consciousness is required to identify the ill equipped to change circumstances outside of the realm
factors that perpetuate vulnerability at the institutional of health care that they are trained and experienced to
level, whether in health-care organizations or other com- provide. However, there are many feasible ways in which
munity institutions; to change these conditions requires health-care providers can contribute to health equity,
translating awareness into social advocacy. Insight and beyond their influence on reducing disparities in health
reflection are necessary to enhance awareness of the care. Pragmatic strategies for engaging in advocacy to
biases and misassumptions—both obvious and subtle— address social and environmental determinants of health
that reinforce vulnerability at the personally mediated are discussed in Chapter 8. Methods for integrating inter-
level. Finally, for clinicians to effectively care for vulnera- ventions to address social determinants into routine
ble populations also require healing of patients’ internal- clinical practice are discussed in Chapter 9.
ized wounds—the despair and devaluation of self-worth Health-care organizations as diverse as Kaiser Perma-
that thwart healthful living and healthy relationships. nente in the United States and the Cuban National Health
What health-care providers can do to promote health Service are finding common ground on a shared focus on
equity by improving health care for socially vulnerable and the goal of population health, not just the health of indi-
underserved patients is addressed throughout this book. vidual patients. This focus is providing motivation and
incentives for health professionals to address the social relationships among human rights and health equity pre-
and environmental determinants that influence the health sented in this chapter.
of the populations they serve.
D IS C U S S IO N Q U ES TIO N S
CO N C LU S IO N
1. Review the data on health disparities shown in Table 1-1.
Patients like Ms. Gripman, Mr. Van, and Mr. Jones need a. What are some of the reasons that African Ameri-
excellent health professionals who understand the needs cans as a group have such poor health status relative
and circumstances of vulnerable populations and can to whites? Consider the different pathways mediat-
deliver high-quality care to vulnerable patients. A public ing vulnerability and health status (e.g., social envi-
health perspective compels health professionals to not ronment, physical environment) in suggesting the
only heal the wounds of vulnerability but also eradicate various mechanisms possibly mediating the associ-
the primary causes of those wounds. Health professionals ation between African American race/ethnicity and
committed to health equity do not need to become pol- poor health.
icy makers, or abandon health-care delivery, to make sig- b. The infant mortality rates for Latinos and non-
nificant contributions to efforts to alter the fundamental Latino whites are nearly identical, despite Latinos
conditions breeding vulnerability and producing health as a group having much lower incomes and educa-
disparities. tional status than whites. What might be the factors
that confer a “protective effect” for Latino birth
outcomes and infant health in the face of socioeco-
KEY CON CEPTS nomic disadvantage?
2. Many public health advocates call for the complete
• Vulnerable populations are those with a disadvantaged elimination of health disparities in the United States.
position in social hierarchies defined by wealth, power, Is this goal reasonable and feasible, or will societies
and/or prestige, placing them at risk for poor health. always have inequities in health because of differences
• Health disparities are potentially avoidable, systematic in income, education, occupation, and related aspects
differences in health status that are associated with of SES among different members of a society?
social vulnerability and are at least theoretically ame- 3. Try to locate some data on public health measures in
nable to social intervention. your own county, city, or community. (Your local or
• Several different pathways mediate the association state health department may be a source of information
between social vulnerability and health disparities,
comparing neighborhoods or social groups on health
including genetic endowment, physical environment,
indicators such as infant mortality rates, age-adjusted
social environment, behavior and lifestyle, chronic
stress, and health care. mortality rates, cancer deaths, and preventable hos-
• Health equity refers to the absence of disparities in pitalizations.) Use these data to identify a vulnerable
controllable or remediable aspects of health. A reduc- social group (e.g., homeless persons, minorities) or a
tion in health disparities is evidence of making prog- vulnerable neighborhood that appears to experience a
ress toward greater health equity. health disparity. What are the most important factors
• The ethical principle of distributive justice and inter- in your local community contributing to this health dis-
national human rights principles provide a universally parity? Develop an action plan for how you and your
recognized frame of reference for initiatives to achieve colleagues could address these factors and improve the
health equity. health of the identified vulnerable population. Make
• In addition to promoting health equity by delivering sure to consider interventions outside of the formal
high-quality health care to vulnerable populations, health-care system in developing your action plan.
health professionals also can make meaningful contri-
butions to improving the fundamental social conditions
that create vulnerability and produce health disparities. RES O U RC ES
http://www.cdc.gov/omh/AboutUs/disparities.htm. Centers for
Disease Control. Healthy People 2010: Goal of Eliminating
Racial and Ethnic Health Disparities.
AC KN OWLED G M EN T http:/ / www.kaiseredu.org/ topics_reflib.asp?id=329&parenti-
d=67&rID=1. Kaiser Family Foundation. Race, Ethnicity and
The authors acknowledge the contributions of Sofia Health Care: The Basics.
Gruskin, JD, MIA, of the Francois Xavier Bagnoud Center
for Human Rights, Harvard University School of Pub- http://www.macses.ucsf.edu/. MacArthur Foundation Research
Network on Socioeconomic Status and Health.
lic Health, to the development of the concepts of the
Chapter 1 / Vu ln er ab le Pop u lat ion s, H ealt h Disp ar it ies , an d H ealt h Eq u it y: An O ver view 11
http:/ /www.sph.umich.edu/ miih/ index2.html. The Michigan 16. Marmot MG, Shipley MJ. Do socioeconomic differences
Initiative on Inequalities in Health. in mortality persist after retirement? 25 year follow up
of civil servants from the first Whitehall study. BMJ
http://www.ucsf.edu/csdh/. The UCSF Center on Social Dispar-
1996;313(7066):1177-1180.
ities in Health.
17. Wilkinson RG, Pickett KE. Income inequality and popula-
tion health: a review and explanation of the evidence. Soc
Sci Med 2006;62:1768-1784.
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Ch a p te r 2
He alth-Care Dis paritie s :

An Ove rvie w
Andrew B. Bindm an, MD, Kevin Grum bach, MD, and Bruce Guthrie , MB, BChir, PhD
Objectives
• Define the term health-care disparities.
• Describe the patient and provider factors that influence access to and the use of
health-care services.
• Review the characteristics of patients who are at increased risk for health-care disparities.
• Identify actions health professionals can take to promote equity in health care.
IN TRO D UC TIO N with common chronic diseases: two-thirds of patients

with high blood pressure are inadequately treated; the
The previous chapter defined health disparities as sys-
majority of patients with diabetes have glycohemoglobin
tematic, yet potentially modifiable, differences in health
(A1C) levels >7%; and half of the patients hospitalized with
between more and less privileged social groups. This
congestive heart failure are readmitted within 90 days of
chapter focuses more narrowly on health-care dispari-
discharge.
ties. After defining this term, the factors that contribute
Furthermore, many studies have shown that social sta-
to health-care disparities, the patients affected by these
tus can contribute to the quality of care a patient receives.
inequities in access to and quality of care, and strategies
Social status may alter health-care professionals’ percep-
to eliminate health-care disparities are discussed focusing
tions of patients’ needs or the way in which patients inter-
on these issues in the US health-care setting.
act with health services and this in turn may influence
the quality of care that is received. In the United States,
for example, patients from racial and ethnic minor-
Q UA LITY O F CA RE A N D HEA LTH-CA RE
ity groups as compared with white patients experience
D IS PA RITIES
more frequent barriers to care, more limited treatment
The Institute of Medicine has defined quality as “the options when presenting for care, and greater deficits in
degree to which health services for individuals and popu- the quality of care. Such health-care disparities are seen
lations increase the likelihood of desired health outcomes in association with measures of social status throughout
and are consistent with current professional knowledge.”1 the world. For example, in the United Kingdom, quality
Quality can be impaired in different ways, such as over- of care for patients with diabetes is positively associated
use, underuse, and misuse. There are major deficiencies with income.2
on all of these accounts in the quality of care provided by These health-care inequities reflect systematic differ-
the US health-care system. For example, there are major ences in access to or quality of care between more and
deficiencies in the quality of care provided to patients less privileged groups that cannot be explained by the
13
Mr. Mason had a process of care that was more consis-

Acce s s to ca re
tent with evidence-based guidelines than the care received
Clinica l a ppropria te ne s s by Mr. Dixon. The inferior process of care received by
a nd ne e d
Dis s imila ritie s
Mr. Dixon contributed to him having a worse clinical
Pa tie nt pre fe re nce s
e
outcome (recurrence of symptomatic coronary heart dis-
r
in ca re
a
c
Ope ra tion of he a lth-ca re ease) than Mr. Mason. Of particular concern are the types of
h
t
sys te ms a nd le ga l a nd
l
health-care disparities illustrated in this case that contribute
a
re gula tory clima te
e
Dis pa rity
h
to inequities in health outcomes (health disparities).
f
Dis crimina tion: bia s e s , in ca re
o
y
s te re otyping a nd
t
i
l
a
unce rta inty
u
Q
Non-minority Minority
Po pulatio ns with e qual ac c e s s to he althc are Most investigators agree that health-care processes have
Fig u r e 2 -1. Mode l of he alth-care dis paritie s . The Gom e s and
a relatively modest role in explaining health disparities—
McGuire m ode l view s he alth-care dis paritie s as re s ulting from perhaps explaining only 10–20% of the variation in health
characte ris tics of the he alth-care s ys te m , the s ocie ty’s le gal outcomes among different groups.4 On the other hand,
and re gulatory clim ate , dis crim ination, bias , s te re otyping, and health disparities resulting from health-care disparities
unce rtainty. Not all dis s im ilaritie s in care are cons ide re d a dis - clearly are in the purview of the people working in the
parity in care . (Adapte d from Gom e s C, McGuire T. Ide ntifying health-care system and are amenable to change. Health
the s ource s of racial and e thnic dis paritie s in he alth-care us e . professionals have a particular obligation to eliminate dis-
Bos ton, MA: De partm e nt of He alth Care Policy, Harvard Me di- parities in access to and quality of care that contribute to
cal School, 2001. Cite d in Sm e dley BA, Stith A, Ne ls on A, e ds . health inequity for vulnerable populations.
Une qual tre atm e nt: Confronting racial and e thnic dis paritie s in
he alth care . Was hington, DC: National Acade my Pre s s ; LaVe is t
TA, Is aac L. Exam ple s of Racial Dis paritie s in He alth Care .
BEHAVIO RA L M O D EL A P P LIED TO
Baltim ore , MD, 2005.) HEA LTH-CA RE D IS PA RITIES
Why is a patient like Mr. Dixon less likely than a patient like
Mr. Mason to receive high-quality care? One of the most
differences in the need for care or preference for care frequently used models for conceptualizing access to care
among the individuals in these groups (Figure 2-1). is the behavioral model developed to explain differences in
care received by different people or groups of people.5 The
behavioral model proposes analyzing the care people receive
M EAS U RES O F Q UA LITY: P RO C ES S ES by looking at three fundamental categories of factors: need,
O R O U TCO M ES O F CA RE predisposing characteristics, and enabling resources. Gelberg
and colleagues have revised the model based on their work
William Mason and Peter Dixon are admitted to the same
with homeless populations, proposing a behavioral model
hospital on the same day with the same diagnosis: ST wave
for vulnerable populations that includes both traditional
elevation myocardial infarction (STEMI). Mr. Mason, a white
business executive, is promptly rushed to the cardiac cathe- categories and vulnerable domains (Table 2-1).6
terization suite where he receives coronary angioplasty and
stenting. He is discharged home on aspirin, clopidogrel, a NEED FOR CARE
statin, a beta-blocker, and an angiotensin-converting enzyme
inhibitor. Three months later, he is able to garden without It is axiomatic that people with a greater need for health
experiencing angina. Mr. Dixon, an African American who care, all other things being equal, make greater use of
is an intermittently employed construction worker, is admit- health-care services. For example, a patient with diabe-
ted to the coronary care unit but does not receive a coronary tes has a greater than average need for health care. How
arteriogram during his hospital stay. He is discharged home much need depends on the severity of the diabetes, and
on a statin and calcium channel blocker. Two weeks later, he
whether there are complications or other chronic condi-
is readmitted with unstable angina.
tions. Having diabetes per se does not necessarily con-
stitute a disparities-related vulnerability (although it is
certainly a risk factor for adverse health outcomes such
Applying a quality-of-care framework developed by Don- as heart disease and kidney failure). On the other hand,
abedian, health-care disparities can be observed to occur some clinical conditions may in and of themselves confer
in the processes or outcomes of care.3 Processes of care a social vulnerability. Prime examples are the socially stig-
are the actions health-care providers take to diagnose, matizing conditions of learning disabilities, mental illness,
treat, and manage patients’ health-care needs. Health and substance use, where the conditions themselves can
outcomes, such as morbidity and mortality, are, in part, alter the presentation of illness and where health profes-
consequences of these health-care actions. sionals’ perceptions can contribute to inadequate care.
Chapter 2 / H ealt h - C ar e Disp ar it ies: An O ver vie w 15
Ta b le 2-1. Th e Be h a vio ra l Mo d e l Ap p lie d to Vu ln e ra b le PREDIS POS ING CHARACTERISTICS

Po p u la tio n s Predisposing characteristics refer to health beliefs and
Need culture, care-seeking behaviors, trust in health care and
other social institutions, and related characteristics that
Tra ditiona l Doma ins Vulnera ble Doma ins may influence whether, when, and from whom an indi-
Perceived health Perceived health
vidual decides to obtain health care when needed. Health
• General population health • Vulnerable population health
conditions conditions education may assist individuals to make well-informed
Evaluated health Evaluated health decisions about using health-care services.
• General population health • Vulnerable population health Patients from vulnerable groups such as ethnic minor-
conditions conditions ities may understandably be less trusting of the health-
care system because of personal or collective experiences
Predisposing Characteristics
of social injustice in that setting. One glaring example of
Tra ditiona l Doma ins Vulnera ble Doma ins this is the Tuskegee Syphilis Experiment.7 Between 1932
Demographics Social structure and 1972, the US Public Health Service conducted an
• Age • Country of birth unethical study at the Tuskegee Institute in Alabama in
• Gender • Acculturation/Immigration/
which African-American patients with syphilis were left
• Marital status Literacy
• Veteran status • Sexual orientation untreated in order to observe the “natural” progression of
Health beliefs • Childhood characteristics syphilis—despite the discovery in the 1940s of penicillin as
• Values concerning health • Residential history/ a highly effective treatment for this infection. African
and illness Homelessness Americans cite the Tuskegee experiment as one reason for
• Attitudes toward health • Living conditions
concern that medical research may exploit rather than aid
services • Mobility
• Knowledge about disease • Length of time in the them.8 Personal experience of racism contributes even
Social structure community more significantly to mistrust of medical care.9
• Ethnicity • Criminal behavior/Prison The human resources deployed in the health-care sys-
• Education history tem also may contribute to vulnerable patients’ mistrust
• Employment • Victimization
of the health-care system and predisposition against
• Social networks • Mental illness
• Occupation • Psychological resources using health-care services. Physicians tend to come from
• Family size • Substance abuse backgrounds that are more privileged and, by virtue of
• Religion their occupation and income, have a socioeconomic
status that on average is higher than that of the popu-
Enabling Resources lation of patients they serve. In the United Kingdom,
Tra ditiona l Doma ins Vulnera ble Doma ins nearly 60% of medical students come from families
Personal/Family resources Personal/Family Resources in the top 20% of income distribution.10 This can con-
• Regular source of care • Competing needs tribute to a sense of social distance between physicians
• Insurance • Hunger and patients. In addition, the ethnic and cultural back-
• Income • Public benefits
grounds of many health professionals are different from
• Social support • Self-help skills
• Perceived barriers to care • Ability to negotiate system the characteristics of patients who seek their services.
Community resources • Case manager/Conservator African Americans, Latinos, and Native Americans are
• Residence • Transportation underrepresented within the health professional work-
• Region • Telephone force. These three minority groups comprised 26.6% of
• Health services resources • Information sources
the US population 16 years and older during 2008– 2010,
Community resources
• Crime rates but contributed only 11.3% of the physicians, 17.2% of
• Social services resources physician assistants, 15.1% of the registered nurses,
9.0% of the dentists, and 9.8% of pharmacists in the
Source: Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable
populations: Application to medical care use and outcomes for homeless people. United States.11 African-American patients cared for by
Health Serv Res 2000;34:1273-1302. African-American physicians report that their physicians
include them more in medical decision making and that
they are more satisfied with their care than those who
are cared for by non– African-American physicians.12
In the preceding case, might there have been some difference Similarly, Spanish-speaking patients are more satisfied
between Mr. Dixon’s clinical presentation that made it appear with the care they receive from Spanish-speaking phy-
that Mr. Dixon had less clinical need for urgent coronary sicians.13 In the United Kingdom, South Asian patients
stenting? report higher enablement after consultations with physi-
cians with whom they share a language.14
Is it possible that both Mr. Mason and Mr. Dixon were financial resources to allow them to overcome barriers to
offered urgent cardiac catheterization by their physicians, care associated with the lack of health insurance.
but Mr. Dixon might have declined to have the procedure Until the passage of the Patient Protection and Afford-
performed because of less trust in his physicians and nurses? able Care Act (ACA) in 2010 and its implementation in
2014, many low-income individuals were eligible only for
public coverage on an emergency basis through Medicaid
when they became so ill that they required hospitaliza-
ENABLING RES OURCES tion. Patients with a chronic disease who only have epi-
sodic health insurance coverage for hospitalizations are
Enabling resources are factors that promote access to
less likely than those with continuous coverage to receive
effective health care. These resources may be at the
appropriate treatment in the ambulatory setting that
community or personal level. Community-level enabling
could prevent the pain and suffering associated with com-
resources are the assets of the local health-care system
plications of their illness.19 The impact of this is apparent
and other social services. The presence of a community
in cross-national comparisons with countries that have
clinic that provides financial assistance for low-income
universal health insurance coverage. For example, the
patients or has interpreters on site are enabling resources
United States has greater disparities in hypertension con-
that contribute to improving access to care, particularly
trol across socioeconomic groups than the United King-
in low-income and minority communities where pri-
dom where health insurance coverage is universal.20
vate physicians are less likely to practice.15 The access to
Individuals from racial and ethnic minority groups
care barriers associated with the scarcity of physicians in
are more likely than whites to be uninsured, a situa-
certain communities can be compounded by the lack of
tion that contributes to racial and ethnic disparities in
another community “enabler,” reliable transportation.
health care. In 2012, prior to the full implementation
Among the most obvious and fundamental resources
of the ACA in the United States, 29% of Latinos, 19%
that make care easier for a person to access are financial
of African Americans, 15% of Asians, and 11% of non-
resources: health insurance and the financial means to pay
Latino whites were uninsured.21 Variations in average
for those health-care costs not covered by insurance. Lack
income between racial and ethnic groups explain much,
of health insurance is the single greatest impediment to
but not all, of the differences in rates of health insurance
access to care in the United States and results in unnec-
by race and ethnicity.
essary morbidity for affected individuals and inefficient
use of health-care resources.16 Numerous studies have
demonstrated that the uninsured are less likely than those Might it have been the case that Mr. Dixon was uninsured,
with health insurance to have a regular source of health and that is why his physicians did not provide the same
care, have fewer physician visits, are less likely to receive resource-intensive care received by Mr. Mason?
appropriate preventive services, and are more likely to
delay receiving needed medical care. The uninsured are
30% to 50% more likely than privately insured persons to
HEA LTH-CA RE D IS PA RITIES : THE
have some deterioration in their health resulting from a
EVID EN C E
chronic condition such as diabetes or asthma that ulti-
mately necessitates a hospitalization that could have been As discussed in Chapter 1, race/ethnicity and socioeco-
prevented with timely ambulatory care.17 nomic status are powerful predictors of a person’s health
Other research has demonstrated that the uninsured status. These same factors are also strongly associated
present for care with more advanced stages of cancer, with access to health care and quality of care. There is
including breast, colorectal, prostate, and skin cancers. ample evidence indicating that the differences in care
Delay in diagnosis is one of the reasons that the unin- received by Mr. Mason, a high-income white man, and
sured have shorter life expectancies than insured persons. Mr. Dixon, a working-class African-American man, are
The Institute of Medicine estimates that the age-specific indicative of pervasive differences in processes of care
mortality rate is 25% higher in the uninsured than in the in the United States based on race/ethnicity and class.
privately insured population.18 Reported disparities in care related to income are worse
Not surprisingly, socioeconomic class is a strong in the United States than in countries that provide uni-
predictor of health insurance status. Although 80% of versal health insurance coverage.22 Disparities in health
the uninsured live in families with a working adult, the care associated with race and ethnicity are less well doc-
majority of uninsured persons have family incomes fall- umented outside of the United States, making it difficult
ing at the lower end of the income scale. Without finan- to compare deficiencies in quality by race and ethnicity in
cial assistance, these individuals have a limited ability the United States with those that may be present in other
to purchase health insurance coverage and few personal countries.
RACE/ ETHNICITY Be tte r S a me Wors e

100
Individuals from minority groups are less likely than
whites to have a regular source of care or to have had 42
37 12
a doctor visit in the past year. Minorities are also more 80 82
72 13
likely to report delays in receiving needed care. Summa-
rizing a series of national access to care indicators, the 68
Agency for Health Research and Quality determined that 60

access to care is generally better for non-Latino whites
t
n
81
e
c
than for members of all other racial and ethnic groups
r
15
e
P
15
in the United States. The Agency found that when com- 40 75 61
86
pared with whites on measures of access to care, Latinos
scored worse on 62%, Native Americans on 43%, African
35
Americans on 33% and Asians on 24%.23 Even more con- 20
cerning is the finding that between 2000–2002 and 2010– 48 9 10

37
28
)
16
7
2011, the number of access measures in which disparities
3
7
6
=
3
1
)
0
(n
4
by race and ethnicity improved over time was small. As
1
11
4
(n
)
n
=
8
6
tio
=
1
)
n
9
n
9
tio
1
(
compared with non-Latino whites, Latinos improved on
n
10
ita
(
ite
=
ita
lim
ite
(
=
(n
im
ite
.w
h
(n
3 and declined on 1 of 14 measures. There were no rela-
y
.w
ite
l
h
it
s
y
e
.w
iv
h
it
m
vs
.w
ct
iv
n
tive improvements or declines for Native Americans over
co
vs
ct
a
a
vs
si
l/A
in
r
ic
a
A
e
ck
ith
h
A
time. African Americans had 1 of 14 access measures and
e
a
ig
ith
la
e
.h
is
.n
e
H
.n
vs
Asians had 2 of 12 access measures improve relative to
vs
vs
r
c
o
si
o
x
those for non-Latino whites.
P
a
le
B
p
m
o
The National Healthcare Disparities Report applied
C
quality indicators for preventive, prenatal, neonatal, can-
cer, and cardiac care, as well as care for chronic conditions Fig u r e 2 -2 . In 2010–2011, analys is pe rform e d by the Age ncy
such as diabetes, asthma, and HIV/AIDS—measures that for He alth Re s e arch and Quality as a part of the National
extend beyond more general indicators of access to care He althcare Dis paritie s Re port (2013) found that African Am e r-
(e.g., ability to obtain medical care when needed) to assess icans (blacks ) and His panics re ce ive d wors e care than w hite s
whether patients received specific services appropriate to for about 40% of quality m e as ure s . Am e rican Indian/Alas kan
their medical needs (Figure 2-2). Results indicate that in Native s (AI/AN) re ce ive d wors e care than w hite s for one -third
2010– 2011, African Americans received poorer quality of quality m e as ure s . As ians re ce ive d wors e care than w hite s
of care than whites for more than 40% of the measures. for about one -quarte r of quality m e as ure s but be tte r care
Latinos and Native Americans were also less likely than than w hite s for about 30% of quality m e as ure s . Poor pe ople
re ce ive d wors e care than high-incom e pe ople for about 60%
non-Latino whites to receive a high quality of care. The
of quality m e as ure s . Pe ople w ith bas ic or com plex activity
reasons for these differences remain ill defined, but it has
lim itations re ce ive d wors e care than pe ople w ith ne ithe r type
been shown that the US health-care system’s organiza- of activity lim itation for about one -third of quality m e as ure s and
tion contributes to inequities in health care. For example, be tte r care for about one -quarte r of quality m e as ure s . (Bas e d
minority patients commonly receive care concentrated on Figure H.7 Available at: http://w w w.ahrq.gov/s ite s /de fault/
within a relatively small group of physicians who report file s /publications /file s /2013highlights .pdf.)
that they do not have access to the full range of clinical Key: AI/AN = Am e rican Indian/Alas ka Native ; n = num be r of
resources needed to provide quality care.24 m e as ure s .
Be tte r = Population re ce ive d be tte r quality of care than
re fe re nce group.
HEALTH INS URANCE S am e = Population and re fe re nce group re ce ive d about the
s am e quality of care .
Do these differences in health care according to race/
Wo rs e = Population re ce ive d wors e quality of care than
ethnicity simply reflect the fact that minorities are less re fe re nce group.
likely than whites to have private health insurance? No te : For e ach m e as ure , the m os t re ce nt data available to
Indeed, differences in access to and quality of care are our te am we re analyze d; for the m ajority of m e as ure s , this
partly attributable to differences in their health insurance re pre s e nts data from 2010 to 2011. Bas ic activity lim itations
status; however, these differences persist even among include proble m s w ith m obility, s e lf-care , dom e s tic life , or
individuals with the same type of insurance coverage. activitie s that de pe nd on s e ns ory functioning. Com plex
For example, within Medicare, a public health insur- activity lim itations include lim itations expe rie nce d in work
ance program for the elderly that is designed to provide or in com m unity, s ocial, and civic life .
a uniform benefit to its beneficiaries, non-whites have
higher rates of preventable hospitalizations for ambula- Americans and Latinos are less likely than whites to
tory care– sensitive conditions and worse blood pressure, receive opiates for pain management of broken limbs.29-32
diabetes, and lipid control than white beneficiaries.25,26 Although these studies did not specifically investigate
Thus, the evidence suggests that patients like Mr. Mason patient preferences, the findings suggest that physi-
and Mr. Dixon often receive unequal care even when they cians’ assessments of patients’ need for care are influ-
have the same type of health insurance. enced by not only physiologic information but may also
be influenced, consciously or subconsciously, by race or
ethnicity. Some studies of patients with acute coronary
S OCIOECONOMIC STATUS
syndromes, similar to the coronary events experienced
Although less research in the United States has examined by Mr. Mason and Mr. Dixon, have examined detailed
health-care disparities associated with an individual’s information on coronary anatomy and failed to find clin-
socioeconomic status, the limited findings are consistent ical differences in underlying disease status that would
with the notion that those with less social status experi- explain the difference in rates of revascularization for
ence worse quality of care. Findings from the National African-American and white patients.33-35
Healthcare Disparities Report indicate that individuals Other studies have compared rates of refusal of recom-
who are poor or who live in less affluent communities mended major procedures between white and minority
receive fewer preventive care services such as mammo- patients and found relatively small differences in refusal
grams and dental visits, have higher rates of avoidable rates that do not explain the observed differences in the
hospitalizations, and are more likely to receive inappro- use of these health-care services across racial and ethnic
priate medications when they see a physician for care.23 groups.34,36 Thus, research suggests that differences in
These socioeconomic disparities do not seem to be exclu- rates of patient refusal of invasive procedures rarely
sively due to inequities in insurance coverage. For exam- explain why patients like Mr. Dixon tend to be less
ple, even in the United Kingdom where there is universal likely than patients like Mr. Mason to undergo coronary
coverage and health care is free at the point of care, pri- revascularization.
mary care practices serving lower-income populations A final consideration is whether some disparities
have historically had lower quality of preventive care.27,28 represent inappropriately excessive care for privileged
patients rather than inappropriately low use among vul-
nerable populations. Several studies have investigated
NEED AND PREDIS POS ING FACTORS
this question for patients with coronary heart disease.
If differences in health care according to race/ethnicity Investigators demonstrated that white patients were
and socioeconomic status are not entirely attributable more likely than African-American patients with the
to differences in a dominant “enabling” factor such as same severity of illness to receive coronary artery bypass
health insurance, could non– health-care system factors surgery.37 Comparison of the results of white and Afri-
explain these differences? For example, perhaps there are can-American Medicare patients who received coronary
differences in health-care needs, such as disease severity, artery bypass surgery against well-established clinical
or predisposing factors, such as patient beliefs and pref- criteria has revealed that some white patients were more
erences, that might account for the differences found in likely than African-American patients to be inappropri-
the National Healthcare Disparities Report. Rather than ately “overtreated” using surgery.38 However, the degree
representing health-care inequity, might these observed of undertreatment among African-American patients was
differences in the use of health care simply represent a substantially greater than the amount of overtreatment
health-care system responding reasonably to patients among white patients. Furthermore, one study has shown
with differing needs and interests? that African-American patients with cardiovascular dis-
Many of the findings on health-care differences that ease had a higher mortality than white patients because
appear in the National Healthcare Disparities Report the African-American patients received lower use of
and similar analyses are based on data obtained from appropriate surgical treatments.35 Even for low-cost car-
patient surveys and administrative records (e.g., billing diovascular treatments such as prescribing of aspirin,
records) that lack clinical detail about patients’ clini- African Americans are less likely to receive appropriate
cal needs and preferences for care. Some studies have therapy than white patients for all levels of coronary heart
found that the magnitude of the differences in patterns disease risk.39
of care is diminished after more thoroughly account- After conducting an extensive literature review of
ing for differences in the need and preferences for care studies comparing the use of health-care services across
across patient groups. However, in most cases, the dif- racial and ethnic groups, and across a wide spectrum of
ferences in care patterns persist. For example, studies in clinical conditions, the authors of the Institute of Med-
emergency departments have demonstrated that African icine’s Unequal Treatment report concluded that they
were “struck by the consistency of the research findings: improvement has and can be accomplished. This section
even among better controlled studies, the vast majority summarizes some of the key approaches that health pro-
indicated that minorities are less likely than whites to fessionals can adopt to reduce health-care disparities.
receive needed services, including clinically necessary
procedures.”40,41 The report also concluded that most of
RECOGNIZE HEALTH-CARE DIS PARITIES AS A
the differences in care could not be explained by differ-
PROBLEM
ences in patient preferences or the need for care. They
concluded that discrimination and health system char- Although many health-care professional organizations
acteristics (e.g., lack of interpreters or fragmentation in have endorsed a position that all patients, regardless of
care) are the main basis for the differences in care that race, ethnic origin, nationality, primary language, or reli-
minorities receive. gion, deserve high-quality health care,43 considerable evi-
dence documents that many inequities exist and persist
over time in actual practice. One recent study found that
BIAS, STEREOTYPING, AND DIS CRIMINATION
physicians, medical students, and members of the public
It is difficult for research to measure directly and objec- have very different views about health-care disparities,
tively the attitudes and motivations underlying the behav- with physicians being the least likely to agree that there is
ior of clinicians. Thus, determining whether health-care unfairness in the health-care system based on a patient’s
disparities can be attributed to bias, stereotyping, or dis- race or class.44 Thus, one of the first steps in eliminating
crimination tends to be a “diagnosis of exclusion.” The health-care disparities is to inform health professionals of
Institute of Medicine’s Unequal Treatment report raises the problem so that effective interventions can be estab-
serious concerns that health-care disparities may result lished to reduce the inequities. Although progress is slow
from bias, stereotyping, and potentially racism among and uneven, health professionals have demonstrated that
people working in the health-care system, especially given they are capable of making adjustments to decrease dis-
that the lower-quality health care received by racial and parities. For example, the provision of an interpreter for
ethnic disparities cannot be explained by differences in patients with limited English proficiency was once seen
the need for care, or patient preferences. This sort of bias as an exception, but it is increasingly common and rec-
and stereotyping may be subconscious. These issues are ognized as a necessary accommodation for patients who
not confined to the United States. For example, there is a require this assistance.45
report of bias and stereotyping related to patients’ ethnic-
ity among health professionals in the United Kingdom.42
UNIVERS AL HEALTH INS URANCE
While less studied, it seems likely in the context of other
well-documented social inequities that this sort of bias, After numerous attempts spanning more than a century,
stereotyping, and even discrimination also occurs among the United States through the passage in 2010 of the ACA
health professionals in the United States and elsewhere took a significant step toward universal health insur-
based on other patient characteristics such as gender and ance coverage.46 The ACA is expected to cover more
social class. than 26 million of the estimated 55 million uninsured
Americans through either Medicaid or subsidized private
insurance, depending on an individual’s income level.47
A D D RES S IN G HEA LTH-CA RE
Extensive research documenting the critical importance
D IS PA RITIES
of health insurance for gaining access to high-quality
The Institute of Medicine has proposed a broad set of rec- care contributed to the passage of the law. The Institute
ommendations at the policy, health system, provider, and of Medicine estimated that a lack of health insurance
patient levels that can contribute to eliminating health- accounts for 18,000 deaths annually in the United States.18
care disparities (see “Core Competency”).40 These rec- As noted earlier, minorities and low-income individuals
ommendations include strategies such as increasing the are particularly likely to be uninsured, and therefore stand
diversity of the health-care workforce, structuring pay- to gain the most from this law.
ment systems so that they support equitable distribution Despite its efforts to expand insurance coverage, the
of health-care resources, and increasing patient education ACA falls short of the fully universal coverage that exists
programs that can empower patients, particularly those in most developed nations. Individuals in the United
from vulnerable groups, to take a greater role in their States who are undocumented immigrants are not eli-
own medical decision making. This book explores many gible for Medicaid or subsidized private insurance cov-
of the actions that can be taken by health policy decision erage under the ACA; most of these individuals and
makers, health professionals, educators, and researchers families will therefore remain uninsured and continue
to eliminate disparities in health care. It is clear that to delay seeking care and have unmet health-care needs.
Challenges to implementing the ACA also impede its in higher-income urban neighborhoods rather than in
improving access to care and reducing health-care dis- inner-city and rural communities.
parities. The Supreme Court, in response to challenges The quality of health-care providers available to dif-
to the law’s legitimacy under the Constitution, upheld ferent groups of patients may vary as well. One analy-
most of the key components of the ACA but made sis of racial differences in Medicare patients’ outcomes
the expansion of coverage through state-administered after coronary artery bypass graft surgery found that the
Medicaid programs optional for states to implement, increased mortality among African-American patients
rather than mandatory as called for by the ACA. As of compared with whites disappeared after controlling
September 2015, 30 states and the District of Columbia for the quality of the hospital care where patients were
had elected to expand Medicaid coverage under the obtaining their procedures.49 Health-care organizations
ACA. Since full implementation of the ACA, about should reach out to surrounding community members
18 million uninsured people have gained coverage. How- and involve community representatives in planning and
ever, many low- income Americans living in states that quality improvement initiatives.43
have not elected to expand Medicaid coverage-mainly The organization of the health-care delivery system
states in the southern region of the United States with may also play a role in reducing health-care disparities.
large concentrations of economically disadvantaged, While it is unclear whether it is due to the financing or
uninsured populations-continue to not benefit from the organization of providers in these arrangements,
expanded Medicaid coverage. Were all of the states to there have been some reports of improvement in health-
expand Medicaid coverage, an additional 5 to 6 million care disparities in Medicare- and Medicaid-managed
uninsured individuals would gain coverage.48 care.50,51
States also face a challenge in educating those who are
uninsured about the necessary steps to enroll in health
PROVIDERS IN UNDERS ERVED AREAS
insurance programs. Despite the fact that coverage will
either be free or highly subsidized by the federal govern- One of the most important of the non– insurance- related
ment, many uninsured individuals may perceive it to be enabling resources is the human resources of the health-
too costly to sign up for coverage. Language and other care system: the physicians, nurses, pharmacists, dentists,
communication barriers may complicate the ability to physician assistants, and many other essential health-
educate uninsured individuals about the potential ben- care workers. Health-care disparities related to human
efits of seeking coverage and the methods for doing so. resource enabling factors may result from geographic
Some uninsured may falsely believe that they will place maldistribution, at least in part. Research has shown that
their legal immigration status at risk by seeking health communities in California with a relatively high propor-
insurance coverage (see Chapter 29). tion of minority residents have a much lower supply of
Participating in advocacy efforts to help patients take physicians, dentists, nurse practitioners, and physician
advantage of new coverage opportunities afforded by assistants than neighborhoods that have fewer minor-
the implementation of the ACA is one way to address ity residents.15,52,53 This research also has shown that
disparities. Health professionals can help educate patients African-American and Latino health professionals are
about the widened array of public and private insurance much more likely than their white counterparts to work
programs in the United States, in order to more effectively in underser ved communities with fewer health-care
assist individual patients to navigate the health-care resources. Similarly, health professionals who grew up in
financing bureaucracy and successfully obtain the cover- rural communities are more likely to ultimately practice
age they may be entitled to receive (see Chapter 4). in rural communities than those who grew up in urban
areas.
Those who gain coverage as a part of the ACA will
ACCES S AND DELIVERY OF HEALTH S ERVICES
increase the demand for health-care services to address
Universal health insurance is a critical step on the way to unmet needs due to a previous lack of coverage. This
achieve health-care equity, but as the experience of other increased demand among the newly insured will stress
countries shows, on its own it is unlikely to be enough. the capacity of the health-care system particularly in areas
Even when insured, vulnerable populations still face that had high rates of uninsured individuals and an inad-
deficiencies in the enabling resources that would permit equate number of available physicians. One strategy for
them to obtain equitable health outcomes. Some of these addressing health-care disparities related to maldistribu-
deficiencies may be related to inequalities in the distri- tion of human resources is to recruit more underrepre-
bution and availability of facilities and technology, such sented minorities and students from rural backgrounds
as the preferential location of specialty hospital units into the health professions.
Adequate payment rates are also an important strategy patients with end-stage renal disease found that dispari-
for increasing the number of practitioners in underserved ties by race in the adequacy of dialysis treatment dimin-
areas. Medicaid is the dominant payer in most under- ished after the adoption of an evidence-based treatment
served communities; in most states, Medicaid payment guideline.58 This study suggests that guidelines, along
rates to physicians and other practitioners are substan- with monitoring and feedback of clinical performance
tially lower than from the fees paid by other insurers.54 benchmarked to an evidence-based guideline, may reduce
Low payment rates in Medicaid discourage physicians the degree of subjective judgment and potential bias in
from participating in the care of low-income patients.55 clinicians’ clinical decision making, thereby helping to
The ACA included a Medicaid payment increase for pri- mitigate health-care disparities. A related and promising
mary care practitioners to encourage physicians to par- approach is for health-care delivery organizations and
ticipate in the Medicaid program, but there are concerns payers of care to define explicit guidelines or standards in
that this policy’s impact may be muted because the pay- the process of care for certain conditions, and to monitor
ment increases were only in effect during 2013 and 2014. processes of care for different patient populations with
Other countries go even further to support primary these conditions based on race/ethnicity, socioeconomic
care practitioners’ ability to care for the poor. For exam- status, or other characteristics to ensure that all groups
ple, in the United Kingdom, the National Health Service achieve an equivalently high standard of quality.
has encouraged physicians to work in less affluent areas by
paying higher capitation rates to general practitioners in
PAYMENT INCENTIVES
those communities and by preventing new practices open-
ing in more affluent areas with adequate supply of phy- Payment incentives tied to health-care quality can increase
sicians. Although these policies have produced a nearly accountability in health care. While the focus of these
equal distribution of general practitioners per 1000 popu- activities is typically on health-care quality for a popula-
lation across neighborhoods, this distribution is still con- tion as a whole, there is some research from the United
sidered by some to be inequitable given the much higher Kingdom, where this approach has been widely adopted
burden of illness and health-care needs in disadvantaged in primary care, that pay for performance can contribute
communities. From the perspective of need, the least afflu- to reducing health-care disparities as well. The United
ent therefore can remain underserved even in a univer- Kingdom implemented a program in 2004 to reward pri-
sal coverage system (although the degree is typically less mary care practices based on their quality measured by
extreme than in systems without universal coverage).56,57 48 clinical indicators. The average quality improved in
practices over time. While measured quality was initially
lower in practices serving less affluent patients, differ-
CLEAR COMMUNICATION AND CULTURALLY
ences were almost eliminated by year 3.59 This indicates
COMPETENT CARE
that disparities are amenable to intervention, but they
Providers’ assessments of patients’ need for care have a require sufficient time to be effective. Eliminating ethnic
subjective component and patients’ preferences for care disparities has proven to be more challenging and they
are somewhat dependent on the information patients have not narrowed down as rapidly over time as socioeco-
receive from providers. Thus, one strategy is to improve nomic disparities in the United Kingdom’s primary care
health professionals’ cultural competence so that they pay-for-performance program.60
can more effectively evaluate and communicate with
diverse patient populations. Increasing the racial, ethnic,
CO N C LU S IO N
and socioeconomic diversity of health professionals and
incorporating within health professions training programs The evidence for the existence of health-care disparities
curricula on the interpersonal and communications skills is overwhelming. Disparities exist in access to care and in
necessary for effectively caring for vulnerable populations the quality of care that is delivered once patients access
might accomplish this. the health-care system. Recognizing health-care dispar-
ities as a problem is an important first step, but recog-
nition alone will not bring about positive change. The
GUIDELINES OR STANDARDS IN THE PROCES S
passage of the ACA provides a major opportunity in the
OF CARE
United States to decrease health-care disparities related
Implementation of evidence-based clinical guidelines to financial barriers to care; however, the experience in
that establish an explicit standard of care that is applied the United States and internationally suggests that health-
to all patients with the same clinical status or health-care care coverage alone will not be sufficient to fully achieve
need appears to be a way to reduce disparities. A study of health-care equity.
KEY CON CEPTS • Support the use of interpretation services where com-
munity needs exist.
• Health-care disparities reflect systematic differences in • Support the use of community health workers.
access to or quality of care between more and less priv- • Use multidisciplinary treatment and preventive care
ileged groups that cannot be explained by the differ- teams.
ences in the need for care or preference for care among
Patie nt Educatio n and Em pow e rm e nt
the individuals in these groups.
• Implement patient education programs to increase
• Minorities and low-income individuals suffer health-
patients’ knowledge of how to best access care and par-
care disparities in part because they have less access to
ticipate in treatment decisions.
high-quality care.
• Even among those patients who have accessed care and
Cross -Cultural Education in the He alth Profe ss ions
whose needs have become visible to the health-care
• Integrate cross-cultural education into the training of
system, there are systematic differences in the receipt
all current and future health professionals.
of services by groups of patients who vary by charac-
teristics of social privilege.
Data Co lle ctio n and Mo nito ring
• Provider bias, stereotyping, and perhaps even racism
• Collect and report data on health-care access and use
may contribute to health-care disparities.
by patients’ race, ethnicity, socioeconomic status, and
• Recognizing health-care disparities as a problem is an
(where possible) primary language.
important first step, but providers need to participate
• Include measures of racial and ethnic disparities in
in a broad range of changes at the policy, system, and
performance measurement.
provider level in order to eliminate them.
• Monitor progress toward the elimination of health-
care disparities.
• Report racial and ethnic data by Office of Management
and Budget categories, and use subpopulation groups
CORE CO MP ETEN CY where possible.
Ins titute o f Me dicine Re co m m e ndatio ns fo r Re s e arch Ne e ds

Addre s s ing He alth-Care Dis paritie s Ge ne ral • Conduct further research to identify sources of racial
Re co m m e ndatio ns and ethnic disparities and assess intervention strategies.
• Increase awareness of racial and ethnic dispari- • Conduct research on ethical issues and other barriers
ties in health care among the general public and key to eliminating disparities.
stakeholders.
• Increase health-care providers’ awareness of disparities. Source: Institute of Medicine. Insuring America’s Health.
Washington, DC: National Academies Press, 2004.
Le gal, Re g ulato ry, and Po licy Inte rve ntio ns
• Avoid fragmentation of health plans along socioeco-
nomic lines. D IS C U S S IO N Q U ES TIO N S
• Strengthen the stability of patient– provider relation-
ships in publicly funded health plans. 1. African-American women get breast cancer at the same
• Increase the proportion of underrepresented US racial rate as white women, yet African-American women are
and ethnic minorities among health professionals. more likely to die from this disease. Does this represent
• Apply the same managed care protections to publicly a health-care disparity? How would you determine if the
funded HMO enrollees that apply to private HMO problem results from access barriers or the quality of
enrollees.
care women receive once they have been diagnosed with
• Provide greater resources to the US Department of
cancer?
Health and Human Services Office for Civil Rights to
enforce civil rights laws. 2. Should you include information on a patient’s race
in the history and physical examination? Should you
He alth Sys te m s Inte rve ntio ns include other information on the patient’s social class
• Promote the consistency and equity of care by evi- such as education, occupation, or income? In what ways
dence-based guidelines. do you think it is helpful or harmful for patient care to
• Structure payment systems to ensure an adequate sup- include this information?
ply of services to minority patients, and limit provider 3. Are there health-care disparities where you practice
incentives that may promote disparities. medicine? How well does your practice setting meet
• Enhance patient– provider communication and trust by the health-care needs of everyone in your commu-
providing financial incentives for practices that reduce
nity? Which groups of patients are excluded? Within
barriers and encourage evidence-based practice.
the practice, do you think some patients receive
suboptimal care? How might you assess your practice Health Workforce Chartbook - Part I: Clinicians. 2013.
to determine if there are health-care disparities? What Available at http:/ / bhpr.hrsa.gov/ healthworkforce/ sup-
policy, system, and provider level changes do you think plydemand/usworkforce/chartbook/chartbookpart1.pdf.
would be most useful for eliminating health-care dis- 12. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs
DM, Powe NR. Patient-centered communication, ratings of
parities in your practice setting?
care, and concordance of patient and physician race. Ann
Intern Med 2003;139:907-915.
RES O U RC ES 13. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-
physician racial concordance and the perceived quality and
http://health-equity.pitt.edu/index.html. Minority Health and
use of health care. Arch Intern Med 1999;159:997-1004.
Health Equity Archive
14. Freeman GK, Rai H, Walker JJ, Howie JG, Heaney DJ, Max-
http://www.ahrq.gov. Agency for Health Research and Quality. well M. Non-English speakers consulting with the GP in
their own language: A cross-sectional survey. Br J Gen Pract
http:// www.amsa.org/hp/uhcres.cfm. American Medical Stu-
2002;52:36-38.
dents Association.
15. Komaromy M, Grumbach K, Drake M, et al. The role of
http:/ / nursingworld.org/ readroom/ r wjpaper.htm. American black and Hispanic physicians in providing health care for
Nurses Association. underserved populations. N Engl J Med 1996;334:1305-1310.
16. Hargraves JL, Hadley J. The contribution of insurance cover-
http://www.kff.org. Kaiser Family Foundation Commission on
age and community resources to reducing racial/ethnic dis-
Medicaid and the Uninsured.
parities in access to care. Health Serv Res 2003;38:809-829.
http://www.pnhp.org. Physicians for a National Health Program. 17. Hadley J. Sicker and poorer--the consequences of being
uninsured: A review of the research on the relationship
http:/ / www.census.gov/ hhes/ www/ hlthins/ hlthins.html. U.S.
between health insurance, medical care use, health, work,
Census Bureau.
and income. Med Care Res Rev 2003;60(2, Suppl):3S-75S;
discussion 76S-112S.
18. Institute of Medicine. Insuring America’s Health. Washing-
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Ch a p te r 3
Financing and Org anizatio n

o f He alth Care fo r Vulne rable
Po pulatio ns
Chris tophe r B. Forre s t, MD, PhD, Je s s ica E. Haw kins , MSE, and Elle n-Marie Whe lan, NP, PhD
Objectives
• Describe the core functions of health-care financing.
• Explain how health-care financing may be tailored to address the challenges that vulnera-
ble populations face.
• Describe the provisions in the Affordable Care Act and how they affect the financing and
organization of health care.
• Describe the types of providers that constitute the safety net.
• Explain why the organization and financing of the health-care safety net does not
adequately meet all the health needs of vulnerable populations.
• Articulate the arguments for increasing the numbers of primary care safety net providers
to improve the access for vulnerable populations.
IN TRO D UC TIO N Without a means to pay, patients forgo necessary health

services resulting in worsening health.
John Walsh is a 56-year-old man with essential hypertension
and type 2 diabetes. Since being laid off from full-time work,
In 2010, President Obama signed into law the Afford-
Mr. Walsh and his dependents, a wife and two children, were able Care Act (ACA). The ACA establishes an individual
left without insurance. Neither of his part-time jobs, as a mandate for health insurance coverage and has numerous
security guard and a deliveryman, offered any health insur- provisions to assist low-income individuals with financing
ance benefits. to obtain health insurance. Nonetheless, the ACA has not
removed all barriers to health care, nor has it resulted in
universal coverage for Americans. The high costs of care
and the dearth of providers serving vulnerable popula-
Mr. Walsh and his family members have slipped through tions are persistent and substantial challenges.
the cracks of a fragmented system of health-care insur- A safety net system exists to care for those who face
ance coverage. The United States has lagged behind barriers in access to care, such as Mr. Walsh. The safety net
almost all developed nations in establishing universal is a geographically variable patchwork of providers avail-
health-care coverage. In 2013, there were approximately able to care for individuals with barriers to care, such as a
40 million uninsured people in the United States.1 The lack of insurance or those residing in a community that is
majority of the uninsured live in households with at least medically underserved because of an inadequate supply of
one full-time working adult.2 Absence of insurance cre- practitioners. Individuals with low family income, minor-
ates obstacles to obtaining health care in a timely way. ity status, rural residence, limited English proficiency, and
25
poor health status are more vulnerable to not receiving To tal in billio ns , $2,793.4
needed health care, and when they do obtain care, they
are more likely to receive it from safety net providers.
Even in nations with universal financial coverage, safety Out-of-pocke t,
Me dica id, 15%
net programs often exist to address the needs of popula- 12%
tions with special access challenges, such as the homeless,
recent immigrants, and residents of remote rural regions.
The financing and organization of the health system
are the starting points for understanding how health Me dica re , 20%
P riva te ins ura nce ,
care is delivered to populations. No health system has 33%
enough resources to meet the demands of every patient
served, not even the United States, which spends close to
18% of its gross domestic product on health. The ways
in which health care is financed and organized represent
choices about who will receive what services under which Othe r third pa rty
Othe r he a lth
pa ye rs , 8%
conditions.3 ins ura nce
progra ms , 3%
This chapter describes the financing of health care
in the United States, changes in the financing of health Fig u r e 3 -1. National he alth-care s ource of funds , 2012.
insurance coverage related to the ACA, and the archi- (Source : Ce nte rs for Me dicare and Me dicaid Se rvice s , 2012
tecture of the safety net available to care for vulnerable National He alth Expe nditure Data [Online ]. Available at http://
w w w.cm s .gov/Re s e arch-Statis tics -Data-and-Sys te m s /Statis tics -
populations.
Tre nds -and-Re ports /NationalHe althExpe ndData/Dow nloads /
table s .pdf.)
HEA LTH S YS TEM FIN A N C IN G

that a patient pays up to a maximum out-of-pocket limit),
Financing of health systems can be characterized by the and copayments (a fee paid at the time of every visit).
sources of health system funds and by how the collected These three types of payments are forms of cost sharing,
funds are structured, whether by pooling to spread risk and are used by insurers to reduce utilization and shift
and ensure financial security of individuals and families costs to individuals using services. For low-income fam-
or requiring patients who lack insurance coverage to pay ilies, cost sharing can be so burdensome that they forgo
directly in order to receive services. necessary care with inimical effects on their health.4
A second type of out-of-pocket payment results from
direct payments made to providers by patients with no
REVENUE COLLECTION
insurance. Direct payments offer no financial protection
Revenue collection refers to where the money to pay and can be very burdensome for vulnerable populations.
for health care comes from (i.e., the funding sources) The distribution of the various sources of health sys-
and how these resources are obtained (i.e., contribution tem revenue in the United States is shown in Figure 3-1.
mechanisms). Nearly all health system revenue in devel- Note that health system revenue in the United States is
oped nations comes from individuals—as workers, as tax collected in approximately equal proportions using pub-
payers, and as patients. In the United States, public funds lic and private sector mechanisms. This pluralistic mix of
are raised as taxes on workers, such as the Medicare wage revenue contributions to the health system is one of the
tax, or from federal and state income taxes, and a limited many obstacles in the United States to achieving a system
amount from corporate and other types of taxes. Private of universal coverage.
sector funds come from insurance premium contribu-
tions that employees and their employers make. Employ-
RIS K POOLING
ers consider their portion of the premium payment to be
part of their employee’s total compensation package; so, When revenue is collected on a prepaid basis (rather than
in fact, it is the employee who actually pays both their at the time care is received), and aggregated across many
own and their employer’s contributions. individuals, an insurance risk pool is formed. Protecting
Out-of-pocket payments that insured patients incur individuals from the financial impact of health-care costs
when they use health services are the second source of is best achieved with prepayment and risk pooling. At
private sector funding. An out-of-pocket payment may be the individual level, health-care events are largely unpre-
made in the form of deductibles (a fixed amount of money dictable and, when they occur, can be costly. By pooling
that a patient is responsible for paying before the insurer resources, health insurers, whether they are private plans
also pays), coinsurance (a percentage of health-care costs or government-sponsored insurers, spread the risk of
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because his coat is white he is difficult to care for, which to a certain
extent, is the truth. His coat should be curly, but wiry in texture. In
action the dog is quick, proud and graceful.
The Italian Greyhound is another old breed; in fact he is one of the
oldest among the toys. He is in every sense of the word, a miniature
greyhound and good specimens are extremely graceful. Because of
his short coat and his generally slight appearance he is a dog that
will not permit of much exposure, though those who breed them say
that the Italian greyhound will stand the cold and the inclement
winter of the north as well as any of the toy breeds, which statement
is rather doubtful. For a clean, neat dog about the house, however,
he is very commendable. In the matter of intelligence he does not
grade up with some of the other varieties described, although he is
very alert and watchful.
The Toy Black and Tan Terrier is another breed that is rather difficult
to rear, although his short black and tan soft coat commends him as
an indoor dog, for he is clean at all times and only a slight brushing
once a day will keep him in condition. They have been breeding this
variety so small that most of the specimens seen at the present time,
have become apple-headed and they are as lacking in intelligence
as they are in appearance. However, a black and tan weighing over
ten pounds makes an excellent dog, many of them becoming keen
ratters, though it is to be understood that the small ones would not
do for that purpose. Personally, if I wished to have a black and tan at
all, I should take the Manchester, of which the toy black and tan is a
miniature. The breed is not very popular in this country or England at
the present time.
Among the toy terrier varieties must be included also, the Yorkshire,
the Maltese and the kindred varieties. These are very pretty
specimens for the fancier of oddities, but they require untold care to
keep them in condition, both as to coat and flesh, hence the time
spent upon them as house companions is scarcely worth the returns
that one obtains.
The Brussel Griffon is another foreign dog that seemed to evoke
considerable interest some years ago, but this breed also is an
oddity. He is a monkey-faced, hard-coated dog with the pronounced
whisker and the general wire appearance of broken-coated terriers.
His weight ranges to nine pounds as the maximum for “big” dogs,
while for the smaller varieties, it is six pounds. It may readily be seen
from this that the breed is more ornamental than useful, but a livelier,
more active little dog cannot be imagined than this diminutive griffon
whose place of origin is said to be Belgium.
THE SCHIPPERCKE, TOGO.

Another Belgian dog is the Schippercke, a terrier-like animal of about
ten pounds in weight. Very fiery and quick to take offense, he is not a
suitable dog for children, but as a watch dog he will give the alarm at
the slightest noise; furthermore, he is not averse to backing up his
bark with his bite. He is a very faithful dog, and once he becomes
attached to one person or a family, he will remain faithful unto death.
That is one of the features that appeals to most of us and one is apt
to forgive his shortcomings. Very few kennels are now breeding this
variety in America. The dog is black in color, with a wiry-like coat,
and a well pronounced mane. His nose is sharp, his eyes small and
black and his ears erect. The dog is a tailless variety; although only a
small percentage of the puppies are born with this mutilation. The
others have their tails removed, or gouged out when they are quite
young, in fact this should be done before they leave their dam. In
selecting a puppy it is well to take one with not a show of white hair
and see that the ears are small, the back short, the coat dense, the
eyes well set, and showing that “foxy” expression which is so
characteristic of this breed and the Pomeranian.
The Pug, once a very popular breed, has now practically gone out of
vogue, although indications point to its resuscitation. The breed,
speaking in broad terms, is not a particularly intelligent one, though
the dog’s short coat, his cleanly habits, and his generally odd
appearance stamped him one of the favorites of three decades ago,
and it is possible that he may return to favor once more.
CHAPTER II.
Suitable Breeds. Group Two—Terriers.
The terrier family is a large one in all its ramifications, and the
embryo dog lover, wishing to possess one of this variety will have a
wide field to go over. The terrier should have more action than the
toy varieties and if it is possible, a place should be provided where
he can romp out of doors for at least two or three hours a day. If that
is not feasible, then he must be taken to some park or open place
where he can run and exercise, for a terrier that is kept confined is
as entirely out of his environment as a fish would be out of water.
KEARN’S LORD KITCHENER.
Among the many breeds of terriers, there are a number which enjoy
equal popularity. The Boston Terrier is the great American product;
he is strictly an evolution of this country and has grown in popularity
in keeping with his qualities. The Boston is a clean, well-knit dog of
trappy appearance, with a short head that is a mean between the
bulldog and the terrier expression, if such a thing can be. He comes
in various weights up to twenty five pounds, and, as a matter of fact,
one finds them going as high as thirty and thirty-five, for the Boston
is a mixture and does not always throw true to type. The present
accepted dictum is, however, that the maximum weight should be
twenty-five pounds. At dog shows the weights are divided by classes
under fifteen pounds, fifteen pounds and under twenty, twenty
pounds and not exceeding twenty-five. The demand for the smaller
weights seems greatest, but one finds more uniformity in the medium
weights—that is, from fifteen to twenty pounds. The Boston terrier
may be good for no practical purposes, but he is alert and will prove
to be a fair guardian of the home. The appeal with this dog is his
absolute trimness, his clean cut appearance, and his short coat. For
people living in flats he is one of the most desirable dogs. In
purchasing one of this breed it is well to see the dog before paying
the money. While there are unscrupulous dealers of all breeds, it
seems that more irresponsible people have taken up the sale of this
breed than any other. I do not mean by this that there are not a large
number of very responsible breeders, but it is the dealer—the vendor
of dogs—whose word cannot always be taken at face value,
therefore, in buying any breed, see that you are obtaining what you
are paying for, and in buying a Boston, be sure of it from every
angle.
THE SMOOTH-COATED FOX TERRIER,
CH. SABINE RECRUIT.
Fox Terriers, both wire-haired and smooth, are also very popular in
this country, the former probably more so at the present time than
the latter, although the smooth is much more easily kept, is just as
keen and alert, makes a varmint dog the equal of any, and as a
house companion has many advantages over his wire-haired cousin;
the latter is a beautiful dog when his coat is kept just right, but if not,
he is an abomination. Incidentally it may be said that it is both a
science and an art to keep the coats of any of the broken-haired
varieties of terriers in good order.
THE WIRE-HAIRED FOX TERRIER,
CH. PRIDE’S HILL TWEAK ’EM.
In temperamental characteristics there is little difference, if any,
between the smooth and the wire-haired varieties, and if the dog is
to be kept in the house mostly, perhaps the former would prove more
satisfactory. Prices of both of these varieties have been soaring here
of late, but this refers only to the show specimens. It is always
possible to procure a “waster” either because he does not conform to
the show standard in the finer points, is oversize, or for some other
reason. The fox terrier, as in fact practically all terriers, except the toy
varieties and possibly Bostons, are men’s dogs, and they can furnish
considerable sport if they are trained on various kinds of “varmints.”
In this connection it might be said that they take to this class of work
very readily, as they have been specifically bred for this purpose
since the earliest days.
THE IRISH TERRIER, CELTIC DEMON.

The Irish Terrier, is a wire-coated dog, usually brick red or wheaten
in color. He is a handsome dog, but like the wire-haired fox terrier,
his coat must be kept right. For gameness, there are few terriers his
equal and he has been rightly named “Daredevil.” The Irish terrier is
a trifle larger in size than the fox terrier. He has all of that varminty
look, that fiery eye and alert expression, indicative of the dog of
quick action, and furthermore, he is a most intelligent animal and
makes one of the best dogs for the home that may be imagined.
Since the rise in popularity of some of the other smaller terrier
breeds, the Irish has fallen somewhat in the estimation of the
fanciers, but those who have bred him for years and have a
specimen or two about would not part with the fiery Irishman for all of
the other terriers combined.
The Irish terrier answers in many respects the call for an all-purpose
dog, except that he is not so large as the Airedale and therefore
could not hold his own in fighting big game, though for his inches, no
better dog ever lived, and I have, on one or two occasions, seen Irish
terriers in bear packs which proved to be just as valuable as some of
the larger breeds; they were certainly just as game, and being very
quick and shifty, they could do considerable damage and still come
away uninjured, where a larger dog might suffer the consequences
of his temerity. The Irish terrier is essentially the dog for those who
do not care to keep an Airedale, but want one as game and as
fearless as any dog that lives.
Still another breed that comes between the small terriers and the
Airedale is the Welsh Terrier. A dog that in many points resembles
the Airedale, particularly in texture and color of coat, although the
head is of somewhat different formation. Welsh terriers never
became common in this country. Possibly because of the rapid rise
of the Airedale and partly because he was not exploited like some of
the other breeds. For the person wanting but one dog, however, the
Welsh terrier is an excellent companion, a good watch dog with all
the terrier proclivities, such as going to earth for game, and just as
keen on rats and other small furred animals as the other varieties.
To the uninitiated the Welsh terrier is a miniature Airedale. In height
he should be about sixteen inches, but should not have the
appearance of being leggy, nor on the other hand, of standing too
low on the leg. The markings—that is, color and coat, are similar to
the Airedale; black or grizzle saddle, with tan head, legs and
underbody. Like in Airedales, the rich deep tan and jet black bodies
are most admired. His average weight should be about twenty-two
pounds, though a pound one way or the other is not a handicap.
While white is not desirable, a small spot on the breast or toes does
not disqualify.
A dog that attracted quite a bit of attention at the New York show of
1922, was the Kerry Blue Terrier. There were only half a dozen
specimens of the breed shown and as far as this country is
concerned, it is a new variety, although it is said that it is one of the
oldest of Irish breeds. The dog is essentially an Irish terrier in a blue-
gray wire coat. It is said that the modern brick colored or wheaten
Irish terrier is descended from the Kerry blue and that by generations
of selection in breeding the red coats were finally obtained, but it
seems that fashion is again going back to the original colors and that
is how it transpires that the Kerry blues are coming into vogue. This
terrier has all the good qualities of the more modern reds. To the dog
lover wishing to own a dog that is somewhat out of the ordinary, the
Kerry blue will appeal, though owing to the present scarcity, it is quite
likely that prices will run high.
THE WEST HIGHLAND WHITE TERRIER, MOROVA.
A very desirable small terrier which came into vogue twelve or fifteen
years ago, is the West Highland White Terrier, one of the border
varieties said to be of ancient origin, but brought to his present
perfection by scientific breeding and selection. The general
appearance of the West Highland white terrier, as we know the
breed today, is that of a small, game, hardy-looking terrier,
possessed of considerable self esteem, and like all good terriers,
has that “varminty” appearance that is such a distinguishing mark of
this group of dogs. He is a stockily built animal, showing strength
from every angle, short legs, deep in the chest, with ribs extending
well to the powerful loin; very strong in quarters and in fact, with all of
his strength, he impresses one as having considerable activity, which
he really has, for there is no quicker and more nimble terrier on four
feet than the West Highlander when it comes to a fight with rats or
other “varmints,” even much larger.
The color of the West Highlander is pure white; any other color, the
creamy or grey shade, is objectionable. The coat is also very
important and fanciers of the breed are more particular about this
feature than any other. As a matter of fact, a coat that meets with the
perfection that the standard calls for, is rare indeed. We hear much
of the so-called double-coat, but in this breed it is demanded. The
outer coat consists of harsh hair, about two inches long and
absolutely free from curl. The under coat, which resembles fur, is
short, soft and close. It is a real weather-resisting jacket such as we
want on Airedales and various other wire-coated terriers, but which
is found so seldom, even in this variety.
The West Highlander weighs from twelve to eighteen pounds;
bitches usually ranging from the minimum figure to sixteen pounds,
while the dogs average about two pounds more to the maximum
weight. In height they measure from eight to twelve inches at the
shoulder. For the prospective owner, who does not object to white
dogs nor to the long coat, the West Highlander white terrier will make
an excellent companion, though his comparative scarcity will
probably keep the prices at a high figure for some time to come.
A near relative to the West Highlander is the Cairn Terrier, a dog of
similar size and characteristics of the other Scottish varieties. The
dog is not very popular at this date, but being a newly cultivated,
though an old breed, the prices are still prohibitive. In all essentials,
however, the Cairn terrier will fill the same place as any of the small
terriers.
THE SCOTTISH TERRIER, CH. THE LAIRD.

The ever popular Scottish Terrier, or Scottie, as he is more
affectionately called, is virtually one of the near relatives of the two
breeds just described. He has been long and slow in coming to his
own in this country, but having once attained a foothold in America
he is likely to retain his place when many of the creations of faddists
are forgotten. He has been becoming more popular every year as a
show dog, though he never will attain the popularity accorded some
of the other terrier breeds. What is more significant, however, he is
rapidly making himself more and more endeared to the one-dog
owner. As a companion about the premises, the house or the
stables, the Scottie is par excellence. A first class vermin dog, an
alert watchman and game to the core, the Scottie will indeed fill the
requirements of anyone wishing to own one small dog, for size and
all other conditions must sometimes be taken into consideration.
The general appearance of the Scottie is that of a sharp, bright,
active dog. His expression is his distinguishing mark, for he is always
on the qui vive, ready, as it were, “for something to turn up.” The
head is carried well up. He appears to be higher on the leg than he
really is; this is due to his short, wiry coat, which is like bristles, and
about two inches long all over the body. He has a compact
appearance, nevertheless, his legs seem to be endowed with almost
an abnormal amount of bone. His back is short, his ribs well sprung,
his loin and quarters well filled up and in every essential, he is
powerfully put together. He carries his ears erect and they are
always alert. His eyes are small and of a very dark hazel color, his
tail, which is never docked, is about seven inches long and is carried
with a slight upward bend, which under excitement is apt to be
carried still more gaily. In height he should be from nine to twelve
inches and in weight the maximum is twenty pounds. Dogs going
over that are considered too large. Of recent years this breed has
been becoming more popular in all parts of the country and at the
present time good specimens may be bought at a very reasonable
figure; that is, puppies at weaning age, or a little later. Naturally,
more matured dogs, with the earmarks of becoming bench show
flyers would still command a price that the average one-dog owner
would not care to pay for a mere home companion. The breed is
very intelligent and easily broken to all the natural pursuits of the
terrier.
THE SEALYHAM TERRIER, BARBERRYHILL GIN RICKEY.
The Sealyham Terrier is another breed that has come into popularity
recently, and with an active club here in America to foster it, it has
made rapid strides during the past four or five years. In the eyes of
the tyro he is a short-legged, over-weighted wire-haired fox terrier,
although the standard emphasizes the fact that he should not
resemble the latter breed either in character, expression or shape
and such resemblance “should be heavily penalized.” As a matter of
fact, in head properties there is nothing to indicate the fox terrier in a
Sealyham of correct type. His head is of a different formation. The
skull is wide between the ears and as the dog is describes as being
the ideal combination of the Dandie Dinmont and the bull terrier of
twenty pounds in weight, this skull formation is supposed to be the
mien between the two. It is slightly domed and rounded, with
practically no stop and a slight indentation running down between
the brows. The jaws are long, powerful and level, much wider and
heavier than in the fox terrier. The nose is black and the nostrils wide
apart. The ears are of medium size and set low, carried closely
against the cheek, which characteristic is insisted upon since a
forward ear carriage would resemble a fox terrier too much. The coat
is dense and wiry; longer than that in which the wire-haired fox terrier
is usually shown, and it should be especially profuse on head, neck
and throat. The body is compact and the tail is docked and must be
carried gaily. The color should be a white ground although patches of
lemon, tan, brindle or badger-pied markings are permissible on head
and ears, though black spots are objectionable and while they do not
absolutely disqualify, dogs with such markings should be severely
penalized. The size of the dogs should be from nine to twelve inches
and bitches slightly less. Weight in this breed is not any particular
criterion and very frequently a ten-inch dog may be so compactly
and sturdily built that he might weigh twenty-four pounds, while a
larger one of rangier type could easily go considerably less. The
Sealyham’s sphere is similar to that of the other short-legged terrier
breeds; indeed, there are so many dogs of similar characteristics
that the question has frequently been asked, “Why is a Sealyham?”
THE DANDY DINMONT TERRIER, CH. BLACKET, JR.

The Dandie Dinmont antedates the Sealyham by many years and is
a dog which became famous in literature. It will be remembered by
those who read Walter Scott that the hero for which the breed was
named is Dandie Dinmont, one of the noted personages in “Guy
Mannering.” The quaint character is well drawn in this novel of Sir
Walter, but his dogs, Mustard and Pepper, and Old Mustard and Old
Pepper, etc., are even more minutely described. No doubt at that
time this type of terrier was quite common in the border country, but
it remained for dog fanciers to fix the name upon this particular
variety.
The size of the Dandie is eight to eleven inches at the shoulder and
the length of the dog measuring from the top of the shoulder to the
root of the tail should not be more than twice the dog’s height,
preferably one or two inches less. Weight ranges from fourteen to
twenty-four pounds, but the ideal weight is about eighteen pounds.
These weights are estimated for dogs that are in good working
condition. The color is mustard and pepper and it was because of
these uniform and pronounced colors that the quaint farmer in
Scott’s novel could not get away from the names; all of them, as
previously said, were Mustards and Peppers, either young or old.
The pepper in the present-day Dandie Dinmont ranges from dark
bluish to a silvery grey, but the intermediate shades are preferred.
The Mustards vary from reddish brown to a pale fawn, the head
being a creamy white. Nearly all specimens have a patch of white on
the breast.
The coat is the important point, and characterizes the Dandie
Dinmont. The hair should be about two inches long; that from the
skull to the root of the tail, a mixture of hard and soft hair, which
gives a crisp feel to the hand, but the hard hair should not be wiry as
in most broken-haired terriers; the coat is in every sense of the word
what is called piley. The hair on the under part of the body is softer
and lighter in color than on top. The skin on the under body should
accord with the color of the dog.
The Dandie Dinmont is an odd looking creature, but game to the
core and a vermin dog. He is also an excellent watch dog and does
not hesitate to attack an intruder who might presume to trespass
upon his master’s domain. To those who want a rather out of the
ordinary looking dog the Dandie Dinmont will be the answer, for he
will not only attract attention, but also fill every requirement.
The Bedlington is coated very much like the Dandie Dinmont, but
stands up higher on the leg. He is described as the smartest, the
largest and the gamest of the English terriers, but this was before the
advent of the Airedale. His height is from fifteen to sixteen inches at
shoulder, his back is slightly arched, while the dogs average in
weight about twenty-four pounds, the bitches going slightly less. The
origin of this dog is said to be in crosses in which the Dandie
Dinmont and probably the otter hound might have figured. In this
respect he approaches the Airedale in his early history. The
Bedlington never became popular in this country and as a matter of
fact, even in England he is not found in great numbers.
WAR CHIEF OF DAVISHILL.

The Airedale is the largest of the terrier varieties. Indeed, he is such
a large dog that he does not really belong in that class, for while
possessing most of all the other terrier attributes, he does not go to
earth for his quarry and this, in the strictest sense is what all terriers
are supposed to do. Be that as it may, the Airedale has become the
most popular of allround dogs, not only here in America, but in every
part of the world. Whether or not too much “refinement” in breeding
this dog for bench show purposes will eventually ruin him for the
allround utility dog that he is, still remains a mooted question, but
one thing is quite certain; he has found a place in the hearts of
sportsmen and this class will always breed types which will retain
their usefulness, hence the history of this breed here in America may
eventually parallel that of the English setter, in that there are two
types—one for actual use, the other for show only. It seems assured,
however, that the useful Airedale and the fined-down show dog are
growing wider apart each year. The reader who is especially
interested in the Airedale, is referred to my previous book, “The
Airedale for Work and Show.”
The Bull Terrier, a smooth coated white dog, makes an attractive
animal for the premises. He may not be so certain as a companion
for children unless brought up in their company from puppyhood, but
he is a good vermin dog and also a watchful guardian of the home. A
pure bred white bull terrier without the admixture of bulldog blood like
one finds so many among the brindled varieties, commands a good
price, but he is worth the money. Because of his pure white color he
may not be so easily kept immaculately clean, but having a short
coat, he is easily washed and in his case frequent bathing can do
little or no harm, which cannot be said of a number of breeds.

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Medical Management of Vulnerable and

Underserved Patients: Principles,

Margaret B. Wheeler, MD, MS

Talmadge E. King, Jr., MD

Margaret B. Wheeler, MD, MS

Previous edition copyright © 2007 by T e McGraw-Hill Companies, Inc.

T is book was set in Warnock Pro by Cenveo Publisher Services.

T is book is printed on acid- ree paper.

Library of Congress Cataloging-in-Publication Data

Contributors ix 8. Advo cacy 79

11. Cre ating the Me dical Ho m e fo r

6. Co m m unity Engage m e nt and Partne rs hip 60

18. Applying Principle s and Practice o f 29. Im m ig rant He alth Is s ue s 320

20. Unde rs e rve d Childre n: Pre ve nting Chro nic

21. Vulne rabilitie s o f Ado le s ce nce and Yo ung

24. Care o f the Dying Patie nt 265

43. HIV/ AIDS : Im pact o n Vulne rable

44. Care o f the S o cially Co m plicate d

40. To bacco Us e 463 45. Caring fo r Ours e lve s While Caring

41. De ntal Care : The Fo rgo tte n Ne e d 478

Nancy Adler, PhD Ellen Beck, MD

Assistant Clinical Professor of Medicine Kirsten Bibbins-Domingo, PhD, MD, MAS

Palav Babaria, MD, MHS JudyAnn Bigby, MD

Medical Director, Highland Hospital Adult Medicine Clinic Senior Fellow

Katrina Booth, MD Diana Coffa, MD

Leslie Dubbin, PhD, MS, RN Laura Gottlieb, MD, MPH

Professor, Department of Medicine,

Elizabeth Harleman, MD Sharad Jain, MD

Courtney R. Lyles, PhD Susana Morales, MD

Sarah Macfarlane, PhD, MSc Assistant Professor,

Marisa Rogers, MD, MPH Dean Schillinger, MD

Associate Professor of Pediatrics and Public Health,

William B. Shore, MD Cam-Tu Tran, MD, MS

Shane Snowdon, MA Jacqueline P. Tulsky, MD

Ellen-Marie Whelan, PhD, NP Sharon L. Youmans, PharmD, MPH

Vulne rable Po pulatio ns , He alth

IN TRO D UC TIO N their skills to respond effectively to the health-care

Ta b le 1-1. He a lth Dis p a ritie s b y Co n d itio n a n d Ra ce –Eth n icity

Black/African Hispanic/ Asian and Pacific American Indian

DSU, data are statistically unreliable.

PATHWAYS BETWEEN DEMOGRAPHIC crowded, noise is pervasive, pollutants and toxins

He alth-Care Dis paritie s :

IN TRO D UC TIO N with common chronic diseases: two-thirds of patients

Mr. Mason had a process of care that was more consis-

Ta b le 2-1. Th e Be h a vio ra l Mo d e l Ap p lie d to Vu ln e ra b le PREDIS POS ING CHARACTERISTICS

RACE/ ETHNICITY Be tte r S a me Wors e

Agency for Health Research and Quality determined that 60

cerning is the finding that between 2000–2002 and 2010– 48 9 10

Ins titute o f Me dicine Re co m m e ndatio ns fo r Re s e arch Ne e ds

Financing and Org anizatio n

IN TRO D UC TIO N Without a means to pay, patients forgo necessary health

HEA LTH S YS TEM FIN A N C IN G

THE SCHIPPERCKE, TOGO.

THE IRISH TERRIER, CELTIC DEMON.

THE SCOTTISH TERRIER, CH. THE LAIRD.

THE DANDY DINMONT TERRIER, CH. BLACKET, JR.

WAR CHIEF OF DAVISHILL.

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