Comments

APIAHF Comments to AAMC
Regarding Definition of Underrepresented Minority

May 15, 2002

Charles Terrell, Ed.D
Division of Community and Minority Programs
Associate Vice President
2450 N Street, NW. Rm 255
Washington, DC 20037

Re: Definition of Underrepresented Minority (URM)

Dear Dr. Terrell:

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.

We are writing to support changing the current Association of American Medical Colleges’ (AAMC) definition of "Underrepresented Minority" (URM). We believe the current definition to be inadequate in addressing the health provider needs of medically underserved populations in the U.S.

Demographic Changes

The current definition of URM was developed in 1970 and has not been changed significantly in spite of large changes in the demographics of the nation. Between 1970 and 2000, the overall Asian American and Pacific Islander (AAPI) population has grown at a rate faster than any other minority population. Between 1990 and 2000 alone, the Asian American population increased by 72%, and the "Native Hawaiian and Other Pacific Islander" population increased by 140%. These increases include those individuals who identified themselves as multiracial (i.e., AAPI and other race). The populations of Cambodian, Hmong, Laotian, Vietnamese, Samoan, Tongan, Guamanian/Chamorro, as well as many other AAPI groups, have seen similar dramatic increases in numbers and percentages.

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.

Poverty rates for the various groups also differ greatly. While nationally, 10.0% of all families lived below the poverty level in 1990, rates of poverty were significantly higher for most Asian American and Pacific Islander groups.

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.

• Non-Hispanic White 251 physicians per 100,000 persons
• Vietnamese 231 physicians per 100,000 persons
• Hawaiian 63 physicians per 100,000 persons
• Guamanian 37 physicians per 100,000 persons
• Samoan 34 physicians per 100,000 persons
• Cambodian 23 physicians per 100,000 persons
• Laotian 16 physicians per 100,000 persons

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.

It is important to note that, while information for these six groups clearly shows a high level of underrepresentation, data for the many other AAPI groups was not available for the study. It is expected that many more AAPI groups are likely to have equally high or higher rates of underrepresentation.

Health Disparities

The shortage of physicians from these underserved communities has contributed to documented barriers to health care, substandard care, and disparate health outcomes. According to the recent Institute of Medicine report, Unequal Treatment, "Racial concordance of patient and provider is associated with greater patient participation in care processes, higher patient satisfaction, and greater adherence to treatment." A number of studies, including a recent report by the Commonwealth Fund has found that Asian Americans are less likely than the overall population to rate their care highly, less likely to be confident about their care, and more likely to indicate having a communication problem with their doctor.

• Numerous other indicators provide evidence of health disparities for these populations. For instance:
• In 2000, 27% of Southeast Asians are uninsured. Overall, 18% of AAPIs were uninsured compared to 14% of non-Latino Whites.
• Women of Vietnamese origin suffer from cervical cancer at nearly five times the rate for white women.
• Cambodians in California had four times the rate of stroke as the white population in the state (107 per 100,000 vs. 28 per 100,000).
• Native Hawaiians have extremely high rates of diabetes. They are over five times as likely as non-Hawaiians to experience diabetes between the ages of 19 and 35, and twice as likely between the ages of 36 and 64.
• Heart disease is the leading cause of death for Hawaiian and Filipino men. It is the second leading cause of death for Japanese and Chinese men.

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.

Develop a Process to Re-evaluate URM on a Regular Basis

Given the rate of demographic and workforce changes in U.S., it is critical to establish a process by which these changes can be incorporated into the concept of "underrepresented minority" on a regular basis.

We thank the AAMC for its willingness to review these definitions and for accepting public comment on this critical issue. If we can be of any assistance to you in this process, please do not hesitate to call Jan Liu, Policy Analyst at 415-954-9952.

Sincerely,

Tessie Guillermo
Executive Director

Encl.

A Feasibility Study on the Establishment of an Asian & Pacific Islander Mentorship Recruitment Network Program. June 30, 1995. Conducted by the Asian and Pacific Islander American Health Forum.

ACCIS Databrief. ACCIS Publication Vol. 1, No. 2. Spring/Summer 1995. Asian & Pacific Islander Center for Census Information and Services.

1990 Profiles of Asians and Pacific Islanders: Selected Characteristics. Population Division U.S. Bureau of the Census. Washington, D.C.

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