Silvia Yee, DREDF Staff Attorney
August 2011
“Aside from the public health issues that most racial/ethnic minorities face, minorities with disabilities experience additional disparities in health, prejudice, discrimination, economic barriers, and difficulties accessing care as a result of their disability—in effect, they face a “double burden.”[1]
Snapshot of Disability and Race
As individuals and family members, we are all affected by functional and activity limitations that arise from health conditions, age, or injury at some point in our lives. The Centers for Disease Control (CDC) state that approximately 62 million (30%) Americans experience either some difficulty with “basic” movement, or cognitive, sensory, or emotional problems. About 14% of people experience “complex activity limitations” in their ability to participate in society, including maintaining a household, working, and pursuing hobbies. Rates of disability also increase with age. About 42 percent of individuals over the age of 65 report disability, compared with 18.6 percent of people who are younger.[2]
While disability affects people of all races, ethnicities, genders, languages, sexual orientations, and gender identities, this does not mean that impairment occurs uniformly among racial and ethnic groups. Disability is identified in differing ways among surveys, but national sources indicate that disability prevalence is highest among African Americans who report disability at 20.5 percent compared to 19.7 percent for non-Hispanic whites, 13.1 percent for Hispanics/Latinos and 12.4 percent of Asian Americans.[3] Disability prevalence among American Indians and Alaskan Natives is 16.3 percent.[4] In raw numbers, over 10.8 million non-institutionalized persons with disabilities (PWD) aged 5 and over are estimated to be members of ethnic minorities.[5]
Unique Barriers Lead to Health Disparities for People with Disabilities in Minority Populations
It is vitally important to distinguish between disability as a natural part of the human condition, and disability-related health disparities that can lead to compromised care, ill health, institutionalization, and premature death. These are not consequences that inevitably follow the simple fact of impairment. Rather, the above opening quotation refers to the many barriers that stand in the way of people with disabilities (PWD) of color having access to quality health care, including the stigma and discrimination that attach to actual or perceived differences attributed to demographic characteristics such as impairment, race, ethnicity, or LGBT status.
Disability health disparities arise from inaccessible physical environments, social assumptions and prejudices, and inflexible policies and procedures that, for example, assume that everyone must be able to independently fill out forms, undress unaided, transfer to high examination tables, and communicate in spoken English to receive standard health care services. For example, a survey of over 2,300 primary care facility sites in California between 2006 and 2010 found that only 3.6% had a wheelchair- accessible weight scale and 8.4% had a height-adjustable exam table, basic equipment that is necessary so people with a range of mobility limitations can transfer safely for examinations.[6] Further consider that African Americans and Hispanics/Latinos over the age of 50 are more likely to have a mobility disability than similarly situated whites, and also use hospital services more often than whites.[7] An Institute of Medicine report has already observed that there are “clear racial differences in medical service utilization rates of people with disabilities that were not explained by socioeconomic variables” and “’persistent effects of race/ethnicity [in medical service utilization] could be the result of culture, class, and/or discrimination.’”[8] Equipment inaccessibility in many out-patient provider offices leads to fewer preventive tests, missed diagnoses, and delayed care,[9] and this in turn disproportionately affects minorities that experience higher incidences of mobility disabilities.
In short, the relationship between race and disability is a complex one that needs to be freshly viewed as race and disability together may have a previously unaccounted cumulative impact on creating health disparities. Consider the following additional examples.
- 31 percent of PWD report fair or poor health in comparison to 6 percent of the general population.[10] Among adults with a disability, 55.2 percent of Hispanic persons, and 46.6 percent of African Americans, report fair or poor health, as compared with 36.9 percent of whites.[11]
- Adults with disabilities have a 400 percent elevated risk of developing Type II diabetes.[12] Diabetes is also a rapidly growing health challenge among Asian Americans and Pacific Islanders who have immigrated to the United States, affecting about 10 percent of Asian Americans, with 90-95 percent of these having type 2 diabetes.[13] Despite the high correlation between diabetes and vision loss, printed self-care and treatment instructions in alternative formats such as Braille, large font type, CD, or audio recording, and accessible glucometers, are rarely available.
- 4.6 percent of Deaf people are infected with HIV/AIDS, four times the rate for the African-American population,[14] the most at-risk racial group in the U.S. that “accounted for half of all new HIV diagnoses and just under half of new AIDS diagnoses in 2009.”[15] Gay and bisexual men, another group heavily impacted by HIV/AIDS, have a 19 percent rate of infection, and 44 percent of those infected were unaware of their HIV status.[16] Measures to target HIV/AIDS outreach and information to LGBT people of color who experience multiple health barriers must also consider the factor of hearing impairments on effective communication of health information.
- Adults with disabilities are three times more likely to commit suicide than peers without disabilities.[17] Three out of five people with serious mental illness die 25 years earlier than other individuals, from preventable, co-occurring chronic diseases.[18] At the same time, African Americans with severe mental health disabilities are less likely than whites to access mental health services, more likely to drop out of treatment, more likely to receive poor-quality care, and more likely to be dissatisfied with care.[19] Asian Americans and Hispanics are less than half as likely as whites to receive mental health treatment.[20]
- People with significant vision loss experience a greater prevalence of obesity, hypertension and heart disease, and cigarette use than the general public.[21]
- People who are Hispanic have higher rates of visual impairments than people who are African American, and both groups have higher rates of vision impairment than people who are white.[22]
- 15 percent of PWD report not seeing a doctor due to cost in comparison to 6 percent of the general population.[23] At the same time, adults with annual household incomes of less than $25,000 are more likely to report having a disability than adults with an annual household income equal to or greater than $25,000.[24] PWD and members of racial minorities often share socio-economic characteristics and related health access barriers due to the expense of maintaining health with a disability. PWD are much more likely to experience various forms of material hardship— including food insecurity, not getting needed medical or dental care, and not being able to pay rent, mortgage, and utility bills—than people without disabilities, even after controlling for income and other characteristics.[25]
- Among people who are deaf, women of color appear to experience the greatest health disparities and difficulty accessing appropriate health care. They tend to have lower incomes and poorer health, and to be less educated compared with white women. Among women of color, African American Deaf women appear to experience the greatest health disadvantages.[26]
The importance of appropriately disaggregated data is also raised because the non- homogenous categories “people with disabilities” and “racial and ethnic minorities” experience different, and often surprising, specific health disparities. American Indians are 6 percent less likely to recover from traumatic brain injury than any other racial group due to unequal access to care.[27] People with developmental disabilities are often assumed to have greater access to care as a population that presumably visits care providers all the time, and yet this population experiences high rates of preventable health conditions such as fractures, skin conditions, obesity, poor oral health, and vision, hearing, and mental health problems.[28] A multinational study of 16,000 adults in 12 countries, found that 68 percent falsely believe that people with intellectual disabilities had the same or better health care as the general population.[29]
Need for Data on Race and Disability in Health Context
It cannot be assumed that because PWD of color may need more health care services, they actually get that health care easily, or that they receive appropriate health care, especially when additional factors such as coverage limitations, physical inaccessibility and lack of policy modification, and stereotypes are at play. PWD of color or who are members of other minority groups are very likely to be encountering instances and forms of “double discrimination” that no single movement is effectively identifying or actively working to address.
While the correlations above are clear, the extent of the connections, the direction of any causative links, and the impact of multiple systemic health barriers in the lives of PWD of color are unknown because little data respecting the interaction of race and disability has been collected and/or analyzed with those connections in mind. What kind of care are African-Americans with mental health disabilities receiving? Is the older Asian immigrant recently diagnosed with diabetes given treatment instructions in both a language and a regular print format that he cannot read? Are Hispanic families enduring food insecurities to ensure a family member receives durable medical equipment items that are not covered or are limited by insurance? The disability and racial minority communities cannot accurately understand how to tackle these myriad barriers and disparities without much more information on how disability and minority cultures and stereotypes, as well as additional variables such as socio-economic status, sexual orientation, and gender coalesce around health and illness.
Disability Rights Education & Defense Fund extends special thanks to Blake Atkerson, 3rd year law student at UC Hastings College of the Law, and Priscilla Huang, Policy Director at Asian & Pacific Islander American Health Forum, for contributing to this report.
Endnotes
[1] HHS Advisory Committee on Minority Health, Assuring Health Equity for Minority Persons with Disabilities: A Statement of Principles and Recommendations (July 2011) at 11.
[2] Altman, Barbara & A. Bernstein, Disability and Health in the United States, 2001-2005” (Hyattsville, MD: National Center for Health Statistics, 2008) at 5.
[3] Brault, Matthew, Americans With Disabilities: 2005, Current Population Reports, P70-117, U.S. Census Bureau, Washington, DC, 2008. Many of the differences between the disability rates by race and Hispanic origin can be attributed to differences in the age distributions of their populations. For example, Hispanics are predominantly younger than non-Hispanic whites. [Blake – Note about Asian underreporting, or is that too specific to mental health?]
[4] U.S. Census Bureau, 2009 American Community Survey, S1810. Disability Characteristics 1 year estimates, available at 2009 American Community Survey.
[5] Id. The 10.8 million figure is derived from subtracting the total number of PWD who identify as non-Hispanic or Latino white from the total number of those with a disability aged 5 and over.
[6] Mudrick, N.R.; Breslin, M.L.; Yee, S.; and Liang, M. (2010). Accessibility of Primary Health Care Provider Settings for People with Disabilities: Information from Health Plan Audits [Slides]. Presented at the annual meeting of the American Public Health Association, Denver, CO, November 8.
[7] Bowen, M., & González, H.. (2008). Racial/Ethnic Differences in the Relationship Between the Use of Health Care Services and Functional Disability: The Health and Retirement Study (1992-2004). The Gerontologist, 48(5), 659-67.
[8] Institute of Medicine (IOM). 2007. The Future of Disability in America. Washington, DC: The National Academies Press, p. 92.
[9] Healthy People 2020 has noted that PWD experience health disparities of delayed care, lower likelihood of preventative care, and higher incidence of tobacco use, obesity, and high blood pressure.
[10] Seth Curtis and Dennis Heaphy, Disability Policy Consortium: Disabilities and Disparities: Executive Summary (March 2009), p. 3.
[11] Center for Disease Control Website, Disability and Health [Accessed July 14, 2011].
[12] Curtis & Heaphy, p.3.
[13] Asian American Diabetes Initiative, Joslin Diabetes Center, http://aadi.joslin.org/content/asian/why-are-asians-higher-risk-diabetes] (2010).
[14] Curtis & Heaphy, p. 8.
[15] Avert, United States Statistics by Race and Age, (2009).
[16] Centers for Disease Control and Prevention. (CDC) HIV and AIDS among gay and bisexual men, September 2010, available at: Fast Facts (PDF).
[17] Curtis & Heaphy, p. 3.
[18] Assoc. of University Centers on Disabilities, “Letter to Kathleen Sebelius”. Citing (Colton & Manderscheid, 2006; Manderscheid, Druss, & Freeman, 2007.
[19] Whitley, R., & Lawson, W.. (2010). The Psychiatric Rehabilitation of African Americans With Severe Mental Illness. Psychiatric Services, 61(5), 508-11.
[20] 2008 National Healthcare Disparities Report. Table 15_3_1.1a & 15_3_1.1b Report
[21] Michele Capella-McDonnall, “The Need for Health Promotion for Adults Who Are Visually Impaired,” Journal of Visual Impairment and Blindness 101, no. 3 (March 2007).
[22] Id. Note that a vision impairment is a visual disability not correctable by glasses or other modifications.
[23] Curtis & Heaphy, p. 3.
[24] Curtis & Heaphy, p. 3.
[25] Shawn Fremsted, “Half in Ten: Why Taking Disability into Account is Essential to Reducing Income Poverty and Expanding Economic Inclusion,” Center for Economic and Policy Research, (2009), p. 2.
[26] National Council on Disability, The Current State of Health Care for People with Disabilities, September 30, 2009.
[27] Whitfield, H., & Lloyd, R. (2008). American Indians/Native Alaskans With Traumatic Brain Injury: Examining the Impairments of Traumatic Brain Injury, Disparities in Service Provision, and Employment Outcomes. Rehabilitation Counseling Bulletin, 51(3), 190-192.
[28] Special Olympics Resource Sheet on Disability Disparities, available at Resource Sheet.
[29] Special Olympics citation.