Reducing Racial and Ethnic Health Care Disparities Is Essential for Better Health Care Outcomes and for Lowering Health Care Costs
There is a growing realization among healthcare researchers, clinicians, and advocates that a focus on health care disparities is an important aspect of improving healthcare outcomes and that activities toward improvement must bring together many elements of our healthcare delivery system. The populations that have customarily been underserved in the American health care system include African Americans, Latinos, Native Americans, and Asian Americans.
Defining Health Disparities
The term "health disparities" is often defined as "a difference in which disadvantaged social groups such as the poor, racial/ethnic minorities, women and other groups who have persistently experienced social disadvantage or discrimination systematically experience worse health or greater health risks than more advantaged social groups." When this term is applied to certain ethnic and racial social groups, it describes the increased presence and severity of certain diseases, poorer health outcomes, and greater difficulty in obtaining healthcare services for these races and ethnicities. When systemic barriers to good health are avoidable yet still remain, they are often referred to as "health inequities."
An understanding of how race, ethnicity, geography, education, and income impact one’s access to health services can provide valuable insight to health policy experts and advocates. Learning more about these disparities can be a way of lessening these kinds of inequalities. An analysis of the root causes of racial and ethnic disparities and what can be done to eliminate them can serve this end goal. Below are discussions of specific poorer health outcomes and ethnic and racial disparities which can be a result of social determinants. It is important to address how racial and ethnic disparities are not only morally wrong and fiscally unwise, but stress our health infrastructure, including programs such as Medicare and Medicaid.
- What are Health Disparities? http://www.news-medical.net/health/What-are-Health-Disparities.aspx (site visited June 11, 2015)
- Minority Health, http://www.cdc.gov/minorityhealth/populations/REMP/definitions.html (site visited June 10, 2015).
The Elimination of Racial and Ethnic Health Disparities Would Save the U.S. Health Care System Billions of Dollars Annually
A 2011 study estimates that the economic costs of health disparities due to race for African Americans, Asian Americans, and Latinos from 2003 thru 2006 was a little over $229 billion. In a report issued in September, 2009, the Urban Institute calculated that the Medicare program would save $15.6 billion per year if health disparities were eliminated. The study examined a select set of preventable diseases among the Latino and African American communities, including diabetes, hypertension and stroke, and concluded that – if the prevalence of such diseases in the African American and Latino communities were reduced to the same prevalence as those diseases occur in the non-Latino white population – $23.9 billion in health care costs would be saved in 2009 alone.
As the representation of Latinos and African Americans in the general population increases, health care costs could be reduced even further by addressing racial and ethnic health disparities. Therefore, in addition to the compelling ethical and moral reasons to eliminate health disparities, there are economic reasons to do so as well.
- Disparity Implications of the Medicare MTM Eligibility Criteria: A Literature Review, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3623017/ (site visited June 17, 2015)
- Calling for a Bold New Vision of Health Disparities Intervention Research: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.302386 (site visited June 17, 2015)
- “HHS Action Plan to Reduce Racial and Ethnic Health Disparities: Implementation Progress Report 2011-2014.” (site visited November 10, 2015)
Poverty, Race, and Ethnic Background Affect Access to Health Care and the Quality of Health Care
An examination of these disparities at the local and national levels is important in order to highlight the widespread nature of these health inequities.
At the national level, African American men, for instance, are more likely to die from cancer than Caucasian men. While Caucasian women are more likely to develop breast cancer than African-American women, the latter are more likely to die from this particular form of cancer than Caucasian women. While Caucasian men are more likely to develop colorectal cancer than African-American men, the latter are more likely to die from this cancer than the former. On the other hand, African-American men are more likely than Caucasian men to develop prostate cancer. The underlying causes of these disparities are socio-economic policies, health access issues among African-Americans which Caucasian persons are less likely to encounter, as well as a lack of health education.
Among America’s minority populations, race, ethnicity, and poverty are more pronounced than among Caucasian Americans. According to the US Census Bureau, in 2013, 25 percent of Hispanics, 11 percent of persons of Asian descent, and 27 percent of African Americans lived in poverty while only 12 percent of Caucasians lived in poverty. Moreover, the more impoverished one is, the more likely it is that one cannot afford health insurance. In 2012, 23 percent of “poor” and 24 percent of “lower-income” persons in the US lacked health insurance. In 2012, 26 percent of Native American/Alaska Natives, 18 percent of African Americans, 16 percent of persons of Asian descent, and 12 percent of native Hawaiian/Pacific Islanders lacked health insurance. In a 2013 study of the non-elderly uninsured, 32 percent of all Hispanics, 14 percent of all African Americans, and 6 percent of all Americans of Asian/Pacific Islander descent reported they lacked health insurance. The same study looked at all non-elderly, uninsured Americans and found that 71 percent of this population had 1 or more full time workers in the family.
The costs of health care in the United States may also impoverish many American citizens. According to a recent report, 62 percent of persons who filed bankruptcy in 2007 did so as a result of medical expenses.
Minnesota’s 2014 Health Equity Report highlights the disparate mortality rates of various races broken down by age group per 100,000 persons between the years of 2007 and 2011. For the 45 to 64 age group, 772 African American, 1,063 Native Americans, 325 persons of Asian descent, and 434 Caucasian persons died per 100,000 persons. Data from Rhode Island during the years 2011-13 shows the disparities which Hispanics and African Americans face. While 41 percent of Latinos 26 percent of African Americans reported having not having any health insurance during this time, 13 percent of Caucasians in Rhode Island reported the same information. While 31 percent of Hispanics and 22 percent of Native Americans in Rhode Island reported not being able to afford seeing a health care provider during this period, 12 percent of Caucasians reported the same information. The National Center for Health Statistics reported in March 2015 that African-American and Latino children are almost twice as likely as Caucasian children to have untreated tooth decay in primary teeth.
The numbers of Hispanics with health insurance differs nationally. In 2012, the number of uninsured Hispanics was 29 percent and in 2013 this number dipped to 24 percent.
- The Role of Health Insurance Coverage in Reducing Racial/Ethnic Disparities in Health Care, http://content.healthaffairs.org/content/24/2/398.full (site visited June 10, 2015).
- Ethnic and Racial Minorities & Socioeconomic Status, http://www.apa.org/pi/ses/resources/publications/factsheet-erm.aspx (site visited June 15, 2015).
Unaddressed Language Barriers Affect Health Outcomes and Access to Medical Care
Without effective health provider and patient communication in a language both can understand, there is an increased risk of misdiagnosis, misunderstanding about the proper course of treatment and poorer adherence to medication and discharge instructions. Health care providers from around the country have reported language difficulties and inadequate funding of language services to be major barriers to access to health care for limited English proficiency individuals and a serious threat to the quality of care they receive. In one study, over one quarter of limited English proficient patients who needed, but did not get, an interpreter reported that they did not understand their medication instructions. By comparison only 2 percent of those patients who did not need an interpreter, and 2 percent of those who needed an interpreter and received one, did not understand their medication instructions.
- Su Familia, the National Hispanic Family Health Helpline (1-866- SU FAMILIA or 1-866-783-2645 or SuFamilia@hispanichealth.org) has developed a bilingual health call number which can 1.) Help consumers navigate the American health care system, 2.) Find a bilingual provider in one’s area as well as 3.) Provide bilingual resources on a number of health topics such as diabetes, cardiovascular disease, HIV/AIDS, etc.
- Health Finder, National Center for Health Information provides information in Spanish regarding health topics as well as links and descriptions to government agencies and NGOs that may be helpful: http://healthfinder.gov/espanol/#sthash.yUHtaSgR.dpuf (site visited June 10, 2015).
- The National Hispanic Medical Association (NHMA) provides resources to advocates and providers in order to strengthen health care delivery to Hispanic communities. Here is a link for providers: http://www.nhmamd.org/index.php/resources-for-physicians (site visited June 10, 2015).
- Health and Human Services guidelines to physical activity in Spanish (2008): http://www.health.gov/paguidelines/pdf/PAG_Spanish_Booklet.pdf (site visited June 10, 2015).
- https://healthcarespanish.com – a quick reference for providers for commonly used phrases in Spanish.
The National Institution on Deafness and Other Communication Disorder (NIDCD) provides information on its website in Spanish: https://www.nia.nih.gov/espanol/recursos-internet#sthas (site visited June 10, 2015).
Children suffer from racial and ethnic health disparities
According to census figures published in 2012, 50.4 percent of all US children (31.8 million children) are identified as belonging to a racial or ethnic minority. Certain disparities in health access and outcomes are particularly noticeable for children of specific racial/ethnic minorities relative to the population at large: for Latino children, suboptimal health status and teeth conditions and problems getting specialty care; for African American children, asthma, behavior problems, skin allergies and unmet prescription needs; for Native American and Alaska Native children, hearing/visual problems, no usual source of care and unmet medical/dental needs; and for Asian/Pacific Islander children, problems getting specialty care and not seeing a doctor for the past year. According to the 2013 US Census, around 11-12 percent of persons under age 19 with household incomes less than $50,000 per annum were without health insurance. 27 percent of non-native born persons under 19 were without health insurance in 2013. During that same year, 12 percent of Hispanics under the age of 19, 7 percent of African Americans under the same age, and 8 percent of persons under the age of 19 of Asian descent lacked health insurance.
- A website where one can find information concerning where to vaccinate children may include locations which accept many different kinds of public assistance which covers children: http://flushot.healthmap.org/ (site visited June 10, 2015).
- Disparities in Health of Children, http://www.123helpme.com/view.asp?id=48318 (site visited June 12, 2015)
Obesity and Chronic Health Conditions Are Caused in Part by Inadequate Access to Fresh Food
According to a 2012 study, nearly 19 percent of all African American adults over the age of 20 have diagnosed or undiagnosed diabetes. Additionally, African Americans are 77 percent more likely than non-Hispanic Caucasian Americans to develop diabetes. On the other hand, nearly 12 percent of Hispanic Americans have diagnosed or undiagnosed diabetes and Hispanics are 66 percent more likely than non-Hispanic Caucasians to have diabetes.
It has been established that public health strategies designed to improve social and physical environments to create conditions for healthful eating and physical activity can be, in addition to clinical treatment, beneficial for those who are already obese. As an example, "innovative public policy approaches include a variety of policy and environmental initiatives designed to increase fruit and vegetable consumption in underserved areas." Thus, elimination of "food deserts" (see below) in underserved communities can help eliminate chronic diseases, such as diabetes, and help achieve greater equity in health outcomes among racial and ethnic minorities.
- Poverty and Obesity in the U.S., http://diabetes.diabetesjournals.org/content/60/11/2667.full (site visited June 10, 2015)
- Food Security & Food Access, http://www.sustainabletable.org/280/food-security-food-access (site visited June 10, 2015)
Food Deserts Result in Poorer Health Outcomes
There are places in the United States which lack supermarkets which are accessible to neighborhood residents nor served by adequate public transportation. Residents of these neighborhoods must rely on small grocery stores or convenience stores, which carry few – if any – fresh fruits and vegetables. Areas where people have poor access to fresh and healthy food are sometimes known as "food deserts." People who live in food deserts are aware of their lack of accessibility to fresh fruits and vegetables and indicate in surveys a desire to have good access to fresh produce. Thus, unhealthy eating is often the result of structural inadequacies in accessing healthy foods and not necessarily limited to personal dietary choices.
The connection between healthy diets and good health outcomes is well established. This is readily seen, for example, with respect to diabetes and hypertension, two chronic – and preventable – diseases that disproportionately affect ethnic and racial minorities. Thus, the existence of "food deserts" contributes to the continuation of racial and ethnic health disparities. Small scales measures designed to improve access to healthy foods can help change dietary habits. The resulting change in diet for residents of former food deserts leads to better health outcomes and contributes to eliminating ethnic and racial health disparities.
A 2014 study shows that providing access to healthy food does not necessarily mean, however, that eating habits change or that obesity drops in the community. Policymakers must also address how healthy food is perceived.
- Report: one in four Baltimore residents live in a food desert. https://search.yahoo.com/yhs/search?p=Food+deserts&ei=UTF-8&hspart=mozilla&hsimp=yhs-002 (site visited June 10, 2015)
- Food Deserts Explained, http://www.cdc.gov/features/FoodDeserts/index.html (site visited June 10, 2015)
- How to determine how many grocery stores are in your county—the CDC web atlas is regularly updated: http://ers.usda.gov/data-products/food-environment-atlas/go-to-the-atlas.aspx (site visited June 16, 2015).
- If you live in a food desert, the CDC provides helpful information concerning nutrition so that a buyer can make the best out of a trip to a distant grocery store: http://www.cdc.gov/nutrition/everyone/index.html (site visited June 16, 2015).
- A report concerning the availability of nutritious food in a low-income community in Rhode Island during the years 2007-08: http://www.cdc.gov/pcd/issues/2010/mar/08_0257.htm (site visited June 16, 2015).
Limited Transportation to Health Facilities Can Affect Health Outcomes
Costs of living, geographical proximity to health facilities, patient health, socio-economic factors, as well as race might singularly or in concert affect a patient’s access to adequate health services. In some instances, there are options for patients who are not able to drive to be driven to, or to take public transit to a health facility.
- Transportation offered by the Department of Veterans Affairs: http://www.va.gov/HEALTHBENEFITS/vtp/ (site visited June 16, 2015).
- One such non-emergency, ambulatory service is AMR: http://www.amr.net/Contracted-Services/Health-Care-Facilities (site visited June 16, 2015).
- Some states provide a variety of information about coverage of non-emergency, ambulatory transport. See, for example, the Commonwealth of Virginia: http://transportation.dmas.virginia.gov/HealthcareFacilities/FAQs.aspx (site visited June 16, 2015).
- Kaiser Family Foundation’s listing of state requirements of non-emergency transport prior to coverage by Medicaid: http://kff.org/medicaid/state-indicator/non-emergency-medical-transportation-services/ (site visited June 16, 2015).
Although it is commonly believed that health disparities occur simply because of a lack of health insurance and access to health care, disparities exist even after access to the health care system has been improved. New studies have shown, for instance, that there are stark differences in health outcomes of African American and Caucasian patients with the same conditions even when they are treated by the same doctor. Studies have also shown that diagnoses, treatments, and quality of care can vary greatly depending on a number of factors which affect minority communities including language barriers, lack of insurance coverage, and differential treatments based on the population group.
Racial and ethnic minorities are among the fastest growing of all communities in the U.S. and comprised approximately 39 percent of the total U.S. population in 2013. Yet data on health status point to significant evidence of poorer health outcomes among racial and ethnic minorities with respect to death and preventable disease. The challenge for the U.S. is to address adequately poor racial and ethnic minority health status and persistent racial and ethnic health disparities at a time of rapidly increasing racial and ethnic diversity.
- Administration Proposes Permanent and Temporary Extensions of Pandemic-Related Medicare Telehealth – Growing Disparities and Other Concerns Remain August 6, 2020
- Research Underscores Disproportionate Impact of COVID-19 July 29, 2020
- Advocacy Update: Medical Rationing July 16, 2020
- Recent COVID-19 Data Show Disparities in Rate of Infections July 9, 2020
- Research: Low-Income and Communities of Color at Increased Risk From COVID-19 May 21, 2020
- Report: Affordable Care Act Narrowed Disparities in Health Care Access February 27, 2020
- Study Finds Home and Community-Based Services Access Disparities July 18, 2019
- NIH Establishes New Research Program to Address Health Disparities of Chronic Diseases August 29, 2016
- RNs and CNAs Work Fewer Hours in Nursing Facilities that Serve Predominately Ethnic and Racial Minority Residents January 27, 2016
- Remove Barriers to Obtaining Medicare Covered Drugs January 20, 2016
 J. Goldberg, W. Hayes, and J. Huntley. "Understanding Health Disparities," Health Policy Institute of Ohio. November 2004. A quick review of the web pages of our major medical associations bring into the focus the scope of the problems and provides a useful overview of the many important activities that are underway. See for example, the AMA’s work with the National Medical Association, “Eliminating Health Disparities.” The AMA identifies key activities in this arena as: encouraging physicians to examine their own practices to ensure equality in medical care; its discussion of its activities with the National Medical Association through the American Medical Association/National Medical Association Commission to End Health Care Disparities; its research findings and recommendations prompted by a request from Congress, the Institute of Medicine (IOM); its Doctors Back to School project; its AMA Ethics and Health Disparities work; and its “The History of African Americans and the Medical Profession.” See, http://www.ama-assn.org/ama/pub/physician-resources/public-health/eliminating-health-disparities.page (site visited June 2, 2015). See also the work of the National Hispanic Medical Association, http://www.nhmamd.org/(site visited June 2, 2015); and see American Indian Health, http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/CAIANH/NERC/Pages/nerc.aspx (site visited July 2, 2015).
P. Braveman. "International Perspectives on Health Disparities and Social Justice.” Ethnicity and Disease. Vol. 17. Spring 2007. P. Braveman, et. al. "An Approach to Studying Social Disparities in Health and Health Care." American Journal of Public Health. December 2004. 94: 12.
 See What Is Health Inequity?, see http://www.vdh.virginia.gov/OMHHE/healthequity/unnaturalcauses/healthequity.htm (site visited June 17, 2015)
 Thomas A. LaVeist, Darrell Gaskin, and Patrick Richard. “Estimating the Economic Burden of Racial Health Inequalities in the United States” International Journal of Health Services. April 2011.41:2. P. 234.
 Timothy A. Waidmann. “Estimating the Cost of Racial and Ethnic Health Disparities. 22 September 2009. http://www.urban.org/research/publication/estimating-cost-racial-and-ethnic-health-disparities (site visited November 25, 2015).
 American Cancer Society. “Cancer Facts and Figures for African Americans 2013-2014.” 2013. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036921.pdf (site visited May 26, 2015). Page 4.
 Ibid. Page 4.
 Ibid. Page 4.
 Ibid. Page 4.
 Carmen DeNavas-Walt and Bernadette D. Proctor. “Income and Poverty in the United States: 2013.” September 2014. http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-249.pdf (site visited May 27, 2015). Page 21.
 United States Department of Health and Human Services, Agency for Health Care Research and Quality. “National Health Care Disparities Report.” 2013. http://www.ahrq.gov/research/findings/nhqrdr/nhdr13/2013nhdr.pdf (site visited May 27, 2015). pp. 241-2.
 Kaiser Family Foundation. “Key Facts about the Uninsured Population.” 29 October 2014. http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/ (site visited May 26, 2015).
 David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler. “Medical Bankruptcy in the United States, 2007: Results of a National Study.” The American Journal of Medicine. 2009. http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf (site visited May 27, 2015).
 Minnesota Department of Health. “Advancing Health Equity in Minnesota: Report to the Legislature.” February 2014. http://www.astho.org/Programs/Health-Equity/Minnesota-Health-Equity-Report/ (site visited May 29, 2015).
 Rhode Island Department of Health. “Minority Health Facts 2015: Major Health Indicators in the Minority Health Populations of Rhode Island.” http://www.health.ri.gov/publications/factsheets/minorityhealthfacts/Summary.pdf (site visited June 10, 2015). Page 7.
 “NIH Funds Consortium for Childhood Oral Health Disparities Research.” NIH. 18 September 2015. http://www.nih.gov/news/health/sep2015/nidcr-18.htm (September 18, 2015). This article discusses NIH’s awarding $7 million in first year funding to study disparities in childhood oral health.
 United States Census Bureau. “Facts for Features: Hispanic Heritage Month 2014: Sept. 15 – Oct. 15.” 08 September 2014. http://www.census.gov/newsroom/facts-for-features/2014/cb14-ff22.html (site visited June 10, 2015). Jessica C. Smith and Carla Medalia. “Health Insurance Coverage in the United States: 2013.” United States Census Bureau. September 2014. http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf (site visited June 10, 2015). Page 2.
 The California Endowment. "Improving Access to Health Care for Limited English Proficient Health Care Consumers." April 2003. 2:1. http://www.hablamosjuntos.org/resources/pdf/2003TCE_%20improving_access_to_healthcare.pdf (site visited May 27, 2015).
 Kaiser Commission on Medicaid and the Uninsured. “Caring for Immigrants: Health Care Safety Nets in Los Angeles, New York, Miami and Houston. February 2001. http://aspe.hhs.gov/hsp/immigration/caring01/execsum.htm (site visited May 27, 2015). Institute of Medicine. “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health.” 2002. https://www.iom.edu/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx (site visited May 27, 2015). Pages 71-72.
 Dennis P. Andrulis, Nanette Goodman, and Carol Pryor, “What A Difference an Interpreter Can Make: Health Care Experiences of Uninsured with Limited English Proficiency,” The Access Project. April 2002. http://www.hablamosjuntos.org/pdf_files/What_a_Difference.pdf (site visited May 27, 2015).
 U.S. Census Bureau. “Most Children Younger than Age 1 are Minorities, Census Bureau Reports.” 12 May 2012. http://www.census.gov/newsroom/releases/archives/population/cb12-90.html (site visited May 26, 2015).
 Glen Flores. “Achieving Optimal Health and Healthcare for All Children: How We Can Eliminate Racial and Ethnic Disparities in Children’s Health and Healthcare.” First Focus. http://firstfocus.org/resources/report/achieving-optimal-health-healthcare-children-can-eliminate-racial-ethnic-disparities-childrens-health-healthcare/ (site visited May 26, 2015).
 Jessica C. Smith and Carla Medalia. “Health Insurance Coverage in the United States: 2013.” United States Census Bureau. September 2014. http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf (site visited June 10, 2015). Page 13.
 Edward A. Chow, Henry Foster, Victor Gonzalez, and LaShawn McIver. “The Disparate Impact of Diabetes on Racial/Ethnic Minority Populations.” American Diabetes Association. 2012. http://clinical.diabetesjournals.org/content/30/3/130.full#cited-by (site visited June 17, 2015).
 K. Flegal, et al. “Prevelance and Trends in Obesity among US Adults, 1999-2008.” Journal of the American Medical Association. 20 January 2010. 303:3 Page 241. Citing American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention.
 T. Jiang T, et al. “Closing the Grocery Gap in Underserved Communities: the Creation of the Pennsylvania Fresh Food Financing Initiative.” J Public Health Management Pract. 2008. 14: 3. 272-279. K. Glanz, et al. "Strategies for Increasing Fruit and Vegetable Intake in Grocery Stores and Communities: Policy, Pricing and Environmental Change." Prev Med. 2004. 39:2. S75-S80.
 To see if you live in a food desert, please see the Department of Agriculture’s detailed map of food deserts at: http://www.ers.usda.gov/data-products/food-access-research-atlas/go-to-the-atlas.aspx#.Uuv2udJdXTo (site visited May 26, 2015).
 Vehicle access is perhaps the most important determinant of whether a family can access affordable and nutritious food. Thus, for the total U.S. population, between 2.3 and 5.5 percent of all households may be outside of a walking distance to a supermarket and may lack access to a vehicle. Not surprisingly, the percentage of households without access to vehicles is higher in low-income areas. U.S. Department of Agriculture. “Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences.” June 2009. http://www.ers.usda.gov/media/242675/ap036_1_.pdf (site visited May 26, 2015). Pages 3, 6, 15, 18-20.
 Ibid. Page 11.
 Ibid. Page 57. Low-access to supermarkets is most heavily influenced by characteristics of neighborhood and household socioeconomic environments, such as the extent of income inequality, racial segregation, transportation infrastructure, housing vacancies, household deprivation, and rurality. This lends support to the notion that there is indeed a socioeconomic “contextual effect” that should be considered when designing food access policy.
 Steven Cummins, Ellen Flint, and Stephen A. Matthews. “New Neighborhood Grocery Store Increased Awareness of Food Access But Did Not Alter Dietary Habits or Obesity.” Health Affairs. February 2014. 33:2.
Kevin Sack. "Doctors Miss Cultural Needs, Study Says." New York Times. June 10, 2009. http://www.nytimes.com/2008/06/10/health/10study.html?_r=0 (site visited May 26, 2015).
 United States Census. “State and County Quick Facts.” http://quickfacts.census.gov/qfd/states/00000.html (site visited June 16, 2016).
 For more information see: U.S. Department of Health and Human Services. "A Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating Racial/Ethnic Health Disparities." January 2008. http://minorityhealth.hhs.gov/Assets/PDF/Checked/OMH%20Framework%20Final_508Compliant.pdf (site visited May 27, 2015).