HHS Advisory Committee on Minority Health Regarding Definition of Underrepresented Minority (URM)" />

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Testimony to the HHSAdvisory Committee on Minority Health
Regarding Definition of Underrepresented Minority (URM)

July 10, 2002

Good morning , my name is Gem P. Daus with the APIAHF. I am here today to comment on strategies to increase diversity in the health professions, specifically on the definition of under-represented minority (URM).

The Asian & Pacific Islander American Health Forum (APIAHF) is a national advocacy organization dedicated to promoting policy, program and research efforts for the improvement of health status of all Asian American and Pacific Islander communities. We have long understood the importance of workforce diversity and have advocated for policies to promote the adequate supply of culturally and linguistically appropriate health providers.

Recently, the Association of American Medical Colleges’ (AAMC) announced that they were considering changing their definition of “Underrepresented Minority” (URM) and invited public comment. APIAHF submitted comment which I will give you copies of. We encouraged AAMC to change their definition of “Underrepresented Minority”, given the demographic changes in the country since 1970, the last time the definition was amended.

We make the same recommendations to you. And to also let you know that whatever the AAMC decides, that HHScan create its own definition that may go beyond whatever AAMC does.

In fact, the definition in use by the Bureau of Health Professions in HRSA

I would like to commend HHS, and particularly HRSA for being a leader in this field with its Health Professions programs to increase diversity.

HRSA currently uses the following definition of “underrepresented minority” (URM) for its Centers of Excellence program:

Black or African American, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, Hispanic or Latino and any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai

What is notable in this definition is the disaggregation of the Asian category. While in the aggregate, it seems that Asians are overrepresented in the health professions, in fact, when you look at specific ethnicities, it shows that some are not well represented. This is significant because in face many languages and many cultures are contained in that word Asian.

Heterogeneity of “Asian Americans and Pacific Islanders”

Asian Americans and Pacific Islanders are an extremely heterogeneous group, encompassing more than a hundred different languages and dialects, diverse cultural backgrounds, and unique immigration experiences. Many of these groups suffer from high rates of poverty and low rates of education, yet are not now considered Underrepresented Minorities. As an example, for many of the groups, college graduation rates are far below the national average. Overall in the U.S., 20.3% of the population in 1990 held a bachelor’s degree or higher. However, only 17.4% of Vietnamese, 5.7% of Cambodians, 5.4% of Laotians, 4.9% of Hmong, 11.8% of Hawaiians, 10.0% of Guamanians, 8.0% of Samoans, 7.5% of Melanesians, and 5.8% of Tongans held a bachelor’s degree or higher.

Given these low rates of education, high rates of poverty and the wide range of cultural, socioeconomic, and linguistic backgrounds, it becomes clear that the category of “Asian Americans and Pacific Islanders” is extremely heterogeneous. The failure to view AAPIs as separate and distinct communities has resulted in an inaccurate reflection of whether the provider needs of these communities are being met. By viewing AAPIs as a single, homogenous group, the implicit assumption is that a third generation Chinese American physician will be able to provide culturally and linguistically appropriate care to a first generation Cambodian refugee. After all, they are both classified as “Asian American and Pacific Islander”.

Lack of Southeast Asian and Pacific Islander Providers

Currently, many AAPI communities are experiencing a drastic shortage of providers who are able to understand and treat their respective community’s health needs. According to an analysis of the most recent Census data available on the U.S. labor force (1990), Southeast Asian (Vietnamese, Cambodian and Laotian), Hawaiian and other Pacific Islander groups demonstrated lower physician representation compared to the non-Hispanic White ratio.

In 1995, the Asian & Pacific Islander American Health Forum produced a report entitled, “A Feasibility Study on the Establishment of an Asian & Pacific Islander Mentorship Recruitment Network Program”. This report contains, to the best of our knowledge, the most comprehensive analysis of underrepresentation among AAPI groups in the medical profession to date. The study identified the 1990 Census data as the most comprehensive source for obtaining AAPI physician data. Note: Occupational data for the 2000 Census has not been released at this time. Twelve Asian and Pacific Islander ethnic groups and a residual “Other Asian & Pacific Islander” are detailed in the analysis. The twelve groups were: Chinese, Filipino, Japanese, Asian Indian, Korean, Vietnamese, Laotian, Cambodian, Thai, Hawaiian, Samoan, and Guamanian.

In calculating physician to population representation, of the twelve groups, the following groups were identified as underrepresented: Vietnamese, Hawaiian, Guamanian, Samoan, Cambodian, and Laotian.

Additional analyses to assess unique factors that impact health access and services were performed. For instance, language parity between AAPI providers and limited English proficient AAPI populations was considered. The findings were consistent with the physician to population ratios and showed underrepresentation in: Vietnamese, Cambodian, Laotian, Hawaiian, Samoan, and Guamanian communities.

RECOMMENDATIONS

Re-evaluate the Definition of URM Based on AAPI Group Data

The definition of URM has an enormous impact on the diversity and ultimately the cultural and linguistic competency of the health care workforce. We strongly recommend that AAMC revise the definition of URM to include all AAPI sub-populations that are currently underrepresented. It is clear that when lumped together (their numbers “aggregated”), the true physician-to-population ratios are masked, resulting in a very misleading indication of appropriate physician supply. We urge the AAMC to review and potentially revise the databases that it uses in order to capture the necessary race/ethnicity information. We urge AAMC to seek out the data on all the AAPI groups (such that their numbers are “disaggregated” as much as possible).

Occupational data from Census 2000 will be released for all the states by the end of this year. Therefore, it will be possible to update physician-to-population ratios for the various AAPI subgroups. We would encourage AAMC to consider these results in revising the definition of URM. Furthermore, AAMC should consider data on AAPI graduation and rates at US medical colleges, again disaggregated by ethnicity.

Consider Language as a Factor

Currently, the definition of URM does not take language into account. Given the increasing size of the limited English proficient (LEP) population, the need for bilingual providers vastly outstrips the current supply. Studies of limited-English proficient populations in health care settings reveal many disparities in quality of care. While some of these studies are not AAPI specific, it is clear that not speaking English highly impacts the quality of care. The lack of language services results in an impaired exchange of information, loss of language cues that may aid in diagnosis, incomplete patient education, lack of informed consent, less access to services and thus a lower level of preventative care. Without interpreters, physicians may order inappropriate or unnecessary tests and patients may not understand their diagnosis, medication instructions or follow-up care plans. Misunderstanding medication instructions can have fatal consequences.

According to the 1990 Census, approximately 24.2% of AAPIs live in linguistically isolated households, in which none of the individuals aged 14 years or older speaks English very well compared to 2.8% in non-AAPI households . This percentage is much higher for some AAPI subgroups: 60% of Hmong, 55% of Cambodians, 52% of Laotians, 42% of Vietnamese, 35% of Koreans, and 35% of Chinese.

Consider Distribution of Providers Serving as Primary Care Physicians

The supply of primary care physicians is particularly important to meeting the needs of the growing AAPI populations. Through additional analysis of the 1990 Census data, APIAHF has found that AAPI physicians are more likely than the overall physician population to work in hospital settings and less likely to work in physician’s offices. This finding validates the notion that although there may be an “overrepresentative” supply of certain AAPI physicians, there is likely a shortage of providers in primary care settings.

Studies have shown that medical colleges and universities with admission criteria which gives preference to students expressing an interest in primary care produce a higher percentage of primary care generalist physicians than colleges without such provisions. Likewise, programs with admission criteria with gives preference to women, minorities, and students preferring primary care at the onset could produce more students intending to work with underserved populations. Additionally, medical colleges can establish relationships with high schools, community colleges and colleges with large numbers of underrepresented populations to conduct outreach.

Consider Geographic Distribution of Physicians

The distribution of AAPI physicians varies greatly from state to state and region to region. Analysis of California data shows that in addition to those groups already mentioned, Filipino and Thai groups were also underrepresented compared to the non-Hispanic White population. In the state of Hawai’i, even the total aggregated AAPI ratio (169 per 100,000) was well below that of non-Hispanic Whites (404 per 100,000). In Texas, the Korean population was underrepresented, and in Illinois, the Japanese population was underrepresented. This suggests that the definition of underserved minority should be flexible enough to allow for regional needs and differences.

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