Health Policy Report Card
Amal N. Trivedi, M.D.,
M.P.H., Brian Gibbs, Ph.D., Laurie Nsiah-Jefferson, M.P.H.,
In the first "report card" to evaluate all 50 states on
their progress in addressing disparities in minority health
care, researchers have found that high- and low-performing
states tend to cluster geographically. Indeed, location was
the only factor that consistently correlated with
Using four report-card measures—insurance gap, physician
workforce diversity, presence of a state Office of Minority
Health, and the number of race or ethnicity vital statistics
categories reported by the state—the research team found
that "region of the country was a significant predictor of
performance on all four measures." In particular, the
researchers noted, states in the West tended to score
poorly—below the national average—on three of four measures.
"Creating a State Minority Health Policy Report Card,"
Amal N. Trivedi, M.D., M.P.H., of Harvard Medical School,
and colleagues report on these results and others. The
study, supported by The Commonwealth Fund, together with
several other foundations and federal agencies, is published
in the March/April 2005 issue of Health Affairs, which
focuses on racial and ethnic health disparities.
Data and Methods
Trivedi and colleagues opted not to evaluate the states
based on disparities in health outcomes "but rather on more
proximate measures of effort, leadership, capacity, and
infrastructure that would be sensitive to direct policy
interventions." They devised the following four key
- Insurance gap. Used to compare insurance
coverage—specifically, rates of uninsurance—for
minorities relative to whites. Defined as the percentage
of the state's low-income, nonelderly minorities who are
uninsured, divided by the percentage of low-income,
nonelderly whites who are uninsured.
- Physician workforce diversity. Used to
measure the degree to which a state's physician
composition reflects its demographic composition.
Underrepresented minority (URM) physicians were defined
as African American, Native American, and Latino. This
figure represents the factor by which the number of URM
physicians must be increased to reach population parity
- Presence of a minority health office.
Through a telephone survey, the researchers assessed the
status and strength of existing offices, as illustrated
by funding, staffing, scope of activities, and history.
- Number of race or ethnicity statistics.
Federal health statistics data are reported using one
ethnicity and five race categories, as stipulated by the
Office of Management and Budget (OMB). For this measure,
the researchers obtained the most recently published
state vital statistics and analyzed how each state
reported its mortality data. This number could range
from one to five.
The insurance ratios of the states varied considerably.
While 11 states showed minimal differences between
minorities and whites, 13 states had a 50–100 percent
difference. Similarly, while the proportion of URM
physicians in a few states reflected the local
demographic composition, 18 states would need to raise
their number of such physicians by a factor of 4.5 to
11.5 to achieve parity with white colleagues.
State minority health offices also showed tremendous
variation in financial and human resources allocations.
For example, California, which has a minority population
of more than 17 million, has an Office of Minority
Health budget of $275,000, or 1.5 cents per minority
resident. By contrast, Minnesota, a state with a
minority population of about 500,000, allocates $9.5
million to its office—resulting in per capita spending
1,200 times higher than that of California.
Health statistics data collection also varied widely.
Nearly half of the states report mortality data using
three or fewer race or ethnicity categories. In
Mississippi, for instance, a report from 2001 describes
the racial breakdown as "white" and "non-white." None of
the states report on all six OMB categories.
The research team found that geographic region was a
significant predictor of performance on all four report
card measures. Western states had larger insurance
disparities, less diverse physician workforces, and were
less likely to have an Office of Minority Health than
the national average. However, they were more likely to
report more race and ethnicity categories. States in the
South had significantly fewer insurance disparities, but
also collected data in fewer categories.
While the four report card measures are not
comprehensive, the authors acknowledge, these variables
do reflect important aspects of minority health policy.
Recent health disparities legislation introduced in the
U.S. Senate (S. 2091), for example, included key
provisions to target minority populations for enrollment
in Medicaid, increase the diversity of health
professions, and expand health data collection.
Multifaceted interventions like these will be necessary,
the researchers say, to eliminate disparities and
achieve health equity.
Facts and Figures
- Only 30 of 50 states have a dedicated office of
- Nearly one-third of the states report mortality
data using a "white-other," "black-white," or
"black-white-other" racial breakdown.
- States with the highest proportion of minorities
had physician workforces that were the least
reflective of their demographic composition.
- The study found no consistent association
between the four performance measures and either
state fiscal capacity or percentage of minorities in
Creating a State Minority Health Policy Report Card,
Amal N. Trivedi, M.D., M.P.H., Brian Gibbs, Ph.D.,
Laurie Nsiah-Jefferson, M.P.H., et al, Health
Affairs March/April 2005 24 (2): 388–96