October 20, 2006, Issue #212
AHRQ News and Numbers
While more than one-third of Hispanics under age 65 do not have health
insurance, the portion without insurance among those who are not U.S.
citizens is far larger—nearly two-thirds. By comparison, about a quarter of
Hispanics who are U.S. citizens are uninsured. Among Hispanics overall,
about 12 percent of non-citizens have public health insurance, such as
Medicaid. The rate is about 30 percent for those who are U.S. citizens.
[Source: Agency for Healthcare Research and Quality, MEPS, Statistical
Brief #143: Health Insurance Status of Hispanic Subpopulations in 2004:
Estimates for the U.S. Civilian Noninstitutionalized Population under Age
65 statistical brief.]
The above inequities fit with health care outcomes as in Eight Americas
They fit with education and higher education outcomes and with income
distributions in the US by race and ethnicity
They fit the same patterns as medical school admissions levels to medical
school at 1 in 1000 for Mexican American males to 1 in 1300 for Mexican
American females, lowest of all by ethnicity and gender and race (1
allopathic medical student per 200 in the population is average, 1 in 20
for Asian Indian, 1 in 60 for all Asian, all top income quintile origin
students, 1 in 400 for rural or Black, 1 in 800 for lower income rural, 1
in 2000 or more for lowest income quintile) Of all of the lower income race
and ethnicity groups including rural born students, only Mexican American
males had greater probability of admission than females. In all other lower
income groups, males had lower levels of admission. Black females and rural
females at 1 in 300 compared to Black males at 1 in 600 and rural males at
1 in 500. The barriers for Hispanic females may include some
cultural/family issues regarding higher education or medical school. Gender
interactions with income otherwise penalize male higher education and
medical school admission.
The admissions ratios are even lower for allopathic private schools as seen
at end.
The divisions apparent between income levels are also seen in admissions.
Mexican American medical student admissions varied by income level from
1997 - 2004. The highest income quartile or those from parents making over
$100,000 increased from 42 to 97 or 108%. These highest income types
replaced those from the lowest income quartile or those with parent income
less than $40,000. Middle income groups stayed much the same.
Overall Mexican American medical student admissions still lag behind.
Mexican American population growth is 90% per decade while Mexican
American physician growth is flat or 418 matriculating in 1997, 403 in
2001, and 434 in 2004. To keep pace or help relieve inequities, Mexican
American physicians should have doubled. Expansion is not likely to improve
matters as the education pipeline has not been improved. Mexican American,
Black, and rural admissions did not increase during the last medical school
expansion as percentages stayed much the same. The additional opportunity
of expansion did not target lower income or rural or diverse students and
no change resulted. The current undisciplined medical school expansion is
also not likely to improve diversity in income, race, ethnicity, or
geographic origin for currently admitted students.
Mexican American medical students graduating from 1994 - 2000 had 19% FP
choice, about 60% greater than average and similar to other low and middle
income medical students and rural born students. Family medicine choice is
less likely in the highest income groups however and future choices will
decline with admissions changes and under the current health policy.
Mexican American and Hispanic family physicians are found in academic and
military locations at 3 - 5%. Puerto Rican females have 7% military choice,
the highest of any female group.
Mexican American FPs have 27 - 32% underserved location or 4 times the
national average of 7%. They have the highest rate of return within 60
miles of their residency location - a bonus for states investing in medical
education and FP residency programs. Mexican American male family
physicians have 30% underserved location, the same as Native males and only
Native females with 40% underserved location had greater distribution.
Given changes in admissions, declines in choice of family medicine, and
deteriorating health policy, medical students are not expected to
distribute as well as in the past, especially in the highest MCAT schools
with 0 - 3 total family medicine graduates for each class.
In the allopathic private schools outside of the 3 historically Black
medical schools or 5400 of the 16000 annual graduates, the percentages of
medical students compared to population are significantly below the
representation in the population. Also those admitted to these schools have
a good shot at research or subspecialty careers, but are largely lost to
family medicine and the doubling of distribution to rural and to
underserved areas provided by the family medicine career choice,
Rural born (20% of the population, 7% of allo private medical students, 12%
allo public), 46% rural choice if choosing FP
Lower income origin born in county with income less than $9000 in 1969 in
1989 $ (42% of the population, 11% of allo private medical students, 25%
allo public ), 30% underserved choice if choosing FP
Black (13% of the population, 6% of allo private medical students, 6% allo
public), 27% underserved choice if public school or Historically Black
school and choosing FP (higher if inner city FP residency training)
Mexican American (7.2% of the population, 2% of allo private medical
students, 3% allo public), underserved choice if choosing FP (higher if
inner city FP residency training)
Also choice of pediatrics results in 66% generalist peds practitioners but
69% remain in major medical centers. Family physicians remain 99% active,
98% in family medicine, and 90% in primary care. Other primary care types
have less than 40% active and remaining in primary care, including nurse
practitioners and physician assistants. About half of NPs are inactive and
10% of PAs are inactive and both have lost significant active practitioners
to hospital, ER, surgery, women's health, geriatrics, and other major
medical center careers where they are trained and receive higher salaries
and as they support and even replace more expensive subspecialty
physicians. PAs have declined from 40% working with FPGPs to 28% in just 10
years. Lack of health policy support and better income with choice away
from primary care removes all forms of primary care except FP. For FP the
current health policies mean lower choice of FP in allopathic graduates,
but FP maintains incoming residents by osteopathic, Caribbean, and
international medical school graduates. Many persisting in their
determination to become a physician were turned down or never applied to
allopathic schools.
Family physicians are 50% of Community Health Center physicians and 61% in
rural CHCs.
Loss of humble origin students by age 8 in child development, by 50% or
less high school graduation, by college, by college completion, by
admissions exclusion
Loss of humble origin medical students to elite non-distributional medical
schools (up to 25% lost),
and loss of humble origin types away from family medicine means greatly
diminished physician distribution.
Distribution is about education and admissions of students not connected to
major medical centers, training outside of major medical centers, and
health policy supportive of patients outside of major medical centers.
Education and admissions is strike one. Training 100% in major medical
centers is strike 2. Current health policy is strike 3.
Detroit takes the Series in 5 games
Robert C. Bowman, M.D.
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