Disparity in the Number of Minority Healthcare Executives

Introduction

Historically, white males have represented the ideal manager in appearance, values, and behaviors, resulting in overt or subtle discrimination in selection, evaluation, and promotion practices in corporate America. Because women and minorities could not meet this ideal, they were often passed over for advancement. The author discusses key areas of diversity management for healthcare administrators to consider: the elements of diversity, the reasons behind diversity management, and solutions for addressing many of the issues involved.

Skilled administrators are in great demand to manage the hospitals, primary and ambulatory care centers, community health centers, nursing homes, health departments, managed care organizations, mental health centers and hospitals, and integrated delivery systems. Hospitals and health service agencies are known to be among the most complex organizations in our society and the most challenging to manage. Health services administrators strategically plan, organize, coordinate, and provide directional leadership in health services organizations. Leaders in health services organizations face numerous challenges. Included among the challenges are changes in the financing and payment structures, greater accountability for quality while containing costs, uncertainties created by new policy initiatives, turbulence in the competitive environment, pressures to provide uncompensated care, separate requirements imposed by the public and private payers, and preserving the integrity of the organization through maintaining the highest ethical standards.

Historically, the top manager in most large health institutions was a physician or a nurse with little or no training for an administrative role. The recognized need for specially trained, nonclinical, health-oriented administrators stems from the complex nature of the health industry and the historical context within which the institutions and health professions operate (Satcher, D. 2001).. Leaders are needed who understand the sociology of medicine and the complex pattern of interactive relationships and constraints that govern the delivery of health services. This is especially true when the focus is on health disparities and the recognized need for cultural competence in providing health to medically underserved populations.

The main thrust of this paper is to review and discuss issues related to the under representation of Blacks among the front-line providers (FLPs) of health care and to consider strategies to increase their presence and participation in the health-care workforce. The basic premise is that there is a correlation between the under representation of Blacks in the health professions and their overrepresentation in morbidity and mortality profiles. In essence, it is reasoned that if Blacks were present among front-line providers and other professions in proportion to their presence in the general population, their health disparities would be reduced and overall health status would significantly improve (Smedley, Stith & Nelson, 2003; Pogue et al., 2002). It has been recognized that self-identifying as Black does not necessarily mean that an individual is an African American or a U.S. citizen.

Corporate America has often been characterized as being run by “corporate cultural natives” (Barzansky, 2003)–white AngloSaxon, Protestant, heterosexual men of at least average height and weight with no visible impairments. This historical “white male” stereotype once defined the appearance, values, and behaviors of the ideal manager (Berliner, 2002), resulting in overt or subtle discrimination in selection, evaluation, and promotion practices (Bieszk, 2003). That is, because women and minorities striving for management positions could not meet this ideal, they were frequently passed over for advancement (Berliner, 2002). That segment of the workforce encountered the “glass ceiling” often found in today’s organizations, because of which, once an individual has reached a certain level, he or she cannot advance up the professional ladder.

The U.S. Department of Labor found in their report (2003) found that the glass ceiling existed at a much lower level than previously thought. Their investigators also reported the following:

• Minorities had plateaued at lower levels of the workforce than women.
• Monitoring for equal access and opportunity (especially as managers moved up the corporate ladder to senior management) was almost never considered a corporate responsibility.
• Appraisal and total compensation systems were not monitored.
• Placement patterns showing few women and minorities in upper levels of management were consistent with research data.
• There was a general lack of adequate human resources records.

The report also described artificial barriers that can individually hinder the advancement of qualified women and minorities. These barriers included various recruitment practices and the failure to include women and minorities in “corporate developmental exercises” such as key rotational assignments, mentoring, and training.

America is undeniably one of the most diverse places in the world. Yet it rose to the top using a “one-size-fits-all” approach to managing employees. That practice worked well in the past, because historically, most of the workforce was white and male. However, the environment has changed. Having to deal with a diverse workforce is new for many managers and supervisors, and one of the main problems they face is that no formal model exists to deal with the many related issues.

Organizations are beginning to discard the old stereotype of the “ideal manager” and to embrace the idea that good managers come in both genders, all ages, and all racial, ethnic, and cultural types (Kimball, 2002). The face of healthcare organizations is changing into a montage of these different dements, and today’s healthcare administrator must ensure that the disparate pieces of this montage fit together harmoniously and that the talents and abilities of each employee are maximized. If skillfully incorporated, the resulting diversity can bring a competitive advantage to the healthcare organization.

To reach that point, healthcare administrators must grasp several concepts. First, they must understand what diversity entails. Second, there must be an understanding of the purpose behind diversity management. Third, healthcare administrators must understand that other biases exist in their workplace. Finally, managers should be aware of solutions they can employ to deal with the issues of diversity management.

Understanding and dealing with diversity are not easy tasks. For the most part, people are most comfortable listening to those who think, act, and look like them. According to Thomas Dolan, president and chief executive officer (CEO) of the American College of Healthcare Executives, “These biases often have nothing to do with gender or race but. Rather, is a reflection of our tendency to gravitate toward people who think and act like us. We tend to have confidence in others who remind us of ourselves. But building staffs with mirror images of ourselves is a sure way to main-rain the status quo, stifle innovation, and perpetuate a perception that diversity is not truly embraced by the organization.” (AAMC 2002)

Although many people do not feel comfortable dealing with people who differ from them, that difference can actually add value to an organization. Managers and supervisors are creatures of culture: they tend to react to culturally different people in the same manner as their peers do. Therefore, prejudices found in the community are acted out in the workplace (Epstein, 2001). An organization should mirror the community or society it represents while endeavoring to minimize the biases. It stands to enhance its growth by tapping the resources it receives from a diverse workforce.

Other reasons for an organization to embrace diversity management are to (a) foster better morale, (b) promote heightened creativity, (c) improve decision making, and (d) accomplish social justice (Bureau of Labor Statistics, 2003). According to the National Institutes of Health (2001), patients benefit when they have a healthcare team of diverse professionals with whom they can easily identify. In addition, employees frequently state that as workplace diversity increases, the ambiance becomes livelier (Deaton, 2002). Creativity experts assert that inventiveness is fostered in settings with people of a variety of backgrounds who differ from one another along many dimensions. Also, decisions are improved when the decision makers possess different perspectives and handle dissenting views before they move forward. Diverse groups of employees also bring new outlooks to their organizations that affect service delivery and generate productive dialogue. Most people want to create workplaces in which all persons can contribute to their fullest potential. Yet despite increasing diversity in the workplace, research suggests that effective diversity management is not at work in many healthcare organizations.

Successful diversity management entails understanding and effectively dealing with barriers in language, culture, gender, age, ethnicity, marital status, religion, sexual orientation, abilities, and disabilities any characteristic that differentiates one individual from another. (Melnick, 2001) Identifying diversity as being only about gender or skin color has engendered a narrow perspective of diversity management (Ivancevich and Gilbert 2000) and resulted in an incomplete transformation of organizational culture (Bureau of Health Professions, 2002). One such narrow definition of diversity management is “the commitment on the part of organizations to recruit, retain, reward, and promote minority and female employees” (Ivancevich mad Gilbert 2000, 76). Diversity management can be defined in a broader sense as “the commitment on the part of organizations to recruit, retain, reward, and promote a heterogeneous mix of productive, motivated, and committed workers including people of color, whites, females and the physically challenged” (Brown, 2002). Using the broad definition of diversity management is the first step toward improving organizational culture with respect to diversity.

The increased diversity in today’s workplace demands more attention than did past environments. In 1960, some 60 percent of U.S. workers were white males, but tomorrow’s workforce is expected to be predominantly female and ethnically diverse. In 2002, there were approximately 12 percent African Americans, 4 percent Asians, and 10 percent Hispanics in the workforce (U.S. Department of Labor, 2003). Today’s workforce also contains more educated women. By 2010, white males will be a minority group, representing only an estimated 40 percent of all workers (NCHS, 2002).

Gender Gap

Women and minorities are significantly under-represented in both position and pay in healthcare organizations. According to a study conducted by the American College of Healthcare Executives (ACHE), female healthcare executives earned an average of 19 percent less than their male counterparts (ACHE, 2001). The study also found significantly more males than females in CEO and upper-level positions. Although both groups reported that opportunity, existed to ascend the organizational hierarchy, only about 11 percent of female healthcare executives, compared with 25 percent of male healthcare executives, have achieved CEO positions (UWeil and Mattis 2001). In addition, on average women with master’s degrees had accrued fewer years of managerial experience than men since receiving their degrees (Butters, 2002).

There are several reasons for the disparities that exist between men and women. First, men and women are perceived to have different management skills. The ACHE data showed that 53 percent of men and 82 percent of women perceive women as demonstrating more nurturing skills at work. The same percentages of individuals see men as competitive, assertive risk takers who benefit more from advancement opportunities. However, the data also showed that 57 percent of men and 69 percent of women believe that men and women are equal in their leadership qualities (Kovner, 2002).

Second, the ACHE study found differences in types of education and work experience. In 2000, there were more men than women with specialized training in health administration. Men were more likely to have completed residency positions than women. In addition, men were more likely than women to begin their career in general management, financial services management, ancillary services, or clinical services. (ACHE, 2001) Women, on the other hand, were more likely to begin in nursing management or planning and marketing (UWeil and Mattis 2001).

Third, the study reported differences in responses to work and family demands. Overall, fewer female than male healthcare executives were married, which may suggest that women more often have to choose between having a career and having a family (UWeil and Mattis 2001). Thirty-nine percent of women believed that family and home obligations fall disproportionately on them, but only 8 percent of men felt that way about their situation. Regarding spousal support of the healthcare executives sampled, 67 percent of wives were willing to relocate to help their husbands obtain a better position, but only 41 percent of husbands were willing to do the same for their spouses. (Smothers, 2001)

Finally, there were differences in career aspirations. About 60 percent of female executives stated that they had planned to achieve higher positions within 5 years. However, more male healthcare executives wanted to become CEOs within 5 years, and twice as many men as women aspired to become CEOs. In addition, higher proportions of men than women stated that they were willing to relocate to advance their career (UWeil and Mattis 2001).

Although a gender gap continues in healthcare management, it may be narrowing in some areas. For example, in 2002, 38 percent of women in healthcare management reported being the first female in their company to hold their current position. These women were also more satisfied than their 2000 counterparts regarding the support they received from their bosses and the promotion opportunities available to them (NCHS, 2002).

Disparities for Minorities

There are few minorities at the top and middle levels of the organizational pyramid (Marmot, 2002). Minorities are well represented in the healthcare workforce; however, they have not entered the executive ranks in proportion to their numbers. Only about 5 percent of healthcare executives are African American (Griffin 2001). In fact, according to the Institute of Diversity in Health Management, only 1 percent of CEOs in health services organizations are African American or a member of another minority group (Griffin 2001).

As stated in National Center for Health Statistics data from 1998 and 2002, researchers found that African Americans held fewer top management positions, worked less often in hospitals, earned 13 percent less, and were less satisfied with their jobs than whites, even though they had similar levels of education and experience in the healthcare field. In a narrowing of the gap since 1998, figures from 2002 showed no significant differences in the proportions of male managers from various racial and ethnic groups who held top positions. In 1998, 56 percent of whites, 42 percent of African Americans, 43 percent of Hispanics, and 51 percent of Asian Americans were general managers. In contrast, significantly more white women held such positions that year than women from other racial and ethnic groups (Maxey, 2002). About 45 percent of African American and white women held managerial positions in 1998, but by 2002 only 32 percent of African American women respondents held general management positions. In addition, 44 percent of Hispanic women and 33 percent of Asian American women respondents said that they held general management positions (McGinnis, 2002).

In compensation, female minorities fared worse than their male counterparts when compared with white male healthcare executives. In 2001, African American women earned 17 percent less than white male healthcare executives. Hispanic women earned 19 percent less and Asian American women earned 20 percent less than white male healthcare executives. African American men earned 18 percent less than their white male counterparts in 1992 and 12 percent less in 2001–a slight improvement (Mechanic, 2002). Hispanic men earned 11 percent less and Asian American men earned 4 percent less than white male healthcare executives. The study also found that these disparities did not pertain to the level of education or work experience; if minorities possessed the same amount of education and years of experience as their white male counterparts, they still were not paid as well as whites.

In both 1998 and 2002, African American women expressed less satisfaction than white males regarding pay and fringe benefits, security, sanctions and treatment they received when they made a mistake, respect from their supervisors, and autonomy. Asian American women expressed the highest level of satisfaction with regard to security and autonomy but were least satisfied among the groups with their pay and fringe benefits (Mechanic, 2002). African American men experienced a decline between 1998 and 2002 in their satisfaction with pay and fringe benefits and with regard to the level of respect they received from their supervisors.

According to the ACHE study, there were several factors contributing to the continued differences in the career outcomes of minorities and whites. They include education, early career experiences, the opportunities offered in their current organizations, career expectations and aspirations, and general attitudes.( ACHE, 2001)

African American men were less likely to have a graduate degree than white, Asian American, or Hispanic men, according to the 2001 data, In addition, with the exception of Hispanic women, more than half of all the groups earned their graduate degrees in healthcare management. Hispanics were most likely to launch their careers in public health agencies, and in general, minorities were more likely to begin their careers in governmental organizations. In both 1998 and 2002 minorities were less likely than whites to start their careers in private hospitals. More African Americans continued to take part-time jobs or less desirable positions became of financial need or lack of opportunity. About 60 percent of African Americans, 35 percent of Asians, 30 percent of Hispanics, and I0 percent of whites said that they had been negatively affected by racial or ethnic discrimination. (Meredith, 2002) African Americans expressed the least satisfaction with their progress toward meeting their overall career goals. Whites appeared to be promoted in their organizations to a greater extent than minorities, and white women were twice as likely to hold CEO or chief operating officer positions as minority women.

Minorities and whites also characterized their current organizations differently. While more minorities reported that their organizations set targets for hiring minorities, they also said that their evaluations were less thorough or careful than those given to whites. Minorities also said that they believed their white colleagues failed to share professional development and career-related information with them. (van Ryn, 2000) Further, more minorities than whites stated that the quality of all their collegial interactions–with both minorities and whites-could be improved. African Americans stated that their organizations did not treat them as fairly as their white counterparts that minorities needed to be more quailed to obtain positions, and that race relations needed to be improved. About 40 percent of African Americans and less than 5 percent of whites said that they experienced racial or ethnic discrimination from 1998 to 2002, including lack of opportunity in hiring and in the areas of promotion, fair compensation, and job evaluation. (Roberts, 2002)

Twice as many African American and Asian American women as white women said that they were likely to leave their current position within the next 12 months. Fewer African American men than other men said that the chances were slight that they would “definitely not leave” in the next 12 months. (Satcher, 2000) Although fewer minorities than whites expected to remain with their current employers, they shared similar aspirations to become CEOs and to work for a variety of healthcare organizations.

In several key areas little or no progress had been made toward dosing the gap between whites and minorities, in some cases, the reverse was found to be true. For example, a higher proportion of white women now work as senior level executives than African American women. In addition, the gap between white and African American women’s salaries widened, and there were a lower proportion of African Americans to whites who worked in hospitals. African American females remained less satisfied than white women in matters of pay, security, sanctions imposed when errors are made, autonomy, and supervisors’ respect. For men, there was a greater similarity between African Americans and whites who achieved high-level management positions and, correspondingly, a narrowing of the salary gap. However, African American men were less satisfied with pay and fringe benefits. African American men are still experiencing a 12 percent gap when compared to whites.

Some Challenges facing today’s Health-Care Workforce

Health-care workers are the key variable in the health-care delivery system in that they are at the front line of interaction between the multiple stakeholder interests in health-care delivery. Multiple stakeholder interests include, but are not limited to, the public or recipients of health-care services, suppliers of health-care products, and the proper use and allocation of technology.

Despite advances in technology and changes in the social, economic, and political environment, the health-care worker ultimately determines the availability, adequacy, and cost of health services. Consequently, activities designed to improve health-care access, enhance quality and reduce racial disparities, and control costs must take into account the production, supply, distribution, and use of the health-care workforce. Similarly, any change in organization, financing, technology, or evaluation also impacts the health-care workforce.

The health-care system continues to change, at an ever-increasing rate and toward increasing degrees of complexity. These changes are reflected in the who: the number and complexion of the types of workers that will be needed; in the what: the nature of their practice and work; and the where: geographic, organizational, and technological settings. The historic roles for physicians, nurses, and other health-care workers are being altered and transformed. Managed care, competition, the patterned increase in corporatization, the development of integrated delivery systems, and advances in medicine and technologies are all impacting the health workforce. Health-care workers are reevaluating their role and their relationship to all components of the health-care delivery system.

Recommendations

To address the concerns regarding the great disparities in health and the under representation of Blacks in the health-care workforce discussed in this chapter (and elaborated on in other chapters) within the sociopolitical and economic contexts of American society will require innovative and long-term commitment of societal resources. A number of organizational policies and program efforts, at both the macro and micro level, have been undertaken in the past to help alleviate the problem, and some have reported varying degrees of success (Skrepcinski & Niendorff, 2000). While some of these policies and program efforts are ongoing, we offer the following recommendations.

Improvements in the Educational and Economic Status. Improvements in the educational and economic status of Blacks must be at the heart of any successful strategy to bridge the gap and eliminate disparities. On the educational side, pipelines must be created and expanded at the early stages in order to facilitate recruitment and enhance retention of Blacks with an orientation to science and the health professions. This means, among other things, giving budgetary substance and programmatic meaning to the bold slogan “No Child Left Behind.” The focus with funding must be on the entire spectrum, from Headstart to postbaccalaureate. Entrepreneurship and economic self-sufficiency must become an integral part of the pedagogy in order to achieve the necessary improvements in economic status. Throughout the spectrum of education, students must be reminded and the lesson must be taught that ‘to do good’ and ‘to do well’ are not mutually exclusive.

Cultural Competence. Cultural competence is an important factor related to the issue of health disparities (Maxey, 2002). Such competence is best developed in a diverse and culturally sensitive environment. Culture refers to those nonbiological, humanly transmitted beliefs and traits that determine and influence how we relate to the social (to other people), political (to the government) and economic (to the resources) spheres of life. Since these traits are not transmitted through the genes, educators and health professionals should be trained about the nature and importance of cultural competence.

A More Positive Ambience. Health professional schools should provide a more positive ambience conducive to learning for minority students. This will be facilitated by the presence of a proportionate number of Black and minority faculty persons who will provide role models for the minority students.

• An Afrocentric Curriculum. Where appropriate, a scientifically based Afrocentric curriculum should be utilized throughout the educational spectrum. Such curricula would reflect the historic and contemporary contributions of Blacks to the fields of science, medicine, and the related health professions.
• Recruitment and Retention. Aggressive recruitment campaigns that are innovative, comprehensive, and long-term in nature must be undertaken. In addition to the students, the mobilization and participation must involve mentors, parents, and partners in the diverse educational and professional communities in both the public and private sectors. Retention is equally important and merits serious attention. This is especially true at the early stage of the pipeline, where the school dropout rate is unacceptably high for African American males.

Clearly, the healthcare industry has work to do to address narrowing the wage and advancement gaps experienced by females and minorities as compared to males and whites. To begin, we should all ask ourselves the following questions:

1. Do I treat all people with respect regardless of age, race, religion, or sexual orientation?
2. Do I encourage people of different back-grounds to work together to create unity?
3. Am I sensitive to cultural differences?
4. Do I believe that all people are created equal?
5. Do I pay equal attention to each ethnic group’s work performance?
6. Do I value opportunities to learn more about people of other ethnic backgrounds?
7. Am I no more critical of one ethnic group than another?
8. Do I believe that people need people regardless of ethnicity?
9. Am I now more fearful of one ethnic group than another?
10. Do I support efforts to promote diversity?

ACHE recommends the following measures be taken to improve workplace diversity. Minorities and women should obtain graduate degrees, pursue postgraduate fellowships, and approach practicing healthcare executives to serve as mentors and counselors to them.

Practicing healthcare executives should:

• publicize career advancement opportunities such as continuing education, networking events, and job vacancies inside the organization and elsewhere;
• develop and disseminate specific criteria for advancement that can be helpful in identifying and promoting qualified minorities;
• conduct regular reviews of senior management salaries to ensure salaries are equitable and nondiscriminatory.

Additional steps that should be taken include:

• checking the organization’s vision and value statements to ensure that they are in line with diversity goals;
• communicating regularly with the executive management committee about how diversity will affect hospital operations;
• surveying employees to get their feedback on the organization’s top diversity issues and informing them about industry trends and strategies;
• developing a comprehensive plan to address such workforce issues as family responsibilities, poor work skills, and negative work attitudes;
• taking a cautious approach to downsizing and early retirement programs; and 09 providing opportunities for building skills and changing attitudes.

In addition, healthcare organizations should train management to embrace diversity and review performance appraisals and reward systems so they are consistent with the organization’s diversity goals. Finally, the National Institutes of Health suggest that healthcare organizations appoint a diversity program manager and maintain contact with the Department of Health and Human Services to play an active role in extinguishing the racial and ethnic disparities in healthcare.

Conclusion

Racial and cultural diversity are the hallmarks and core strengths of American democratic society. However, this cherished diversity is not reflected on a proportional basis, especially for Blacks, among front-line providers in the health-care workforce. The under representation of Blacks in the health-care workforce is a problem of crisis proportion. The issue of health disparities and the under representation of Blacks among FLPs, which urgently needs to be addressed, will require multiple and targeted strategies. Recognition of the problem and the enactment of policies aimed at establishing parity in the number of Blacks among FLPs will require enlightened leadership, an unwavering political will, and a steadfast commitment to the proposition that life, liberty, and the pursuit of happiness are among the endowments and rights granted to all people by their Creator. The frontal assault on affirmative action undertaken by powerful political interests threatens to undermine the good-faith initiatives and efforts by institutions and individuals in our society who seek to increase the population of participants in the workforce from the Black and other underrepresented minority communities.

Change requires the support of executive management. Healthcare administrators who are directly involved in diversity programs need to communicate regularly with their executive management committee and department heads so that they understand the effects of changes in employee benefits on overhead and changes in diversity initiatives on operations.

In addition, further research is needed. Ivancevich and Gilbert (2000) suggest four alternatives to traditional diversity management research: (a) researcher-administrator partnerships, (b) researcher observation within organizations, (c) detailed case histories and analysis, and (d) third-party evaluations of diversity management initiatives, Ivancerich and Gilbert (2000) also suggest a move beyond comparisons between African Americans and whites. Multiracial research could reveal insights that might help administrators practice more effective diversity management with an array of workers. In an increasingly diverse society, knowledge about individuals, groups, and programs should not exclude any segment.

References

American College of Healthcare Executives (ACHE). 2001. Public policy statement: Enhancing minority opportunities in healthcare management. Chicago, IL.: American College of Healthcare Executives.

Association of American Medical Colleges (AAMC). (2002). Minority Student Opportunities in United States Medical Schools , 16th ed. Washington, DC: AAMC.

Barzansky, B., & Etzel, S. (2002). Educational programs in U.S. medical schools, 2001–2002. Journal of the American Medical Association , 288 , 1067–1072.

Berliner, H.S., & Ginzberg, E. (2002). Why this nursing shortage is different. Journal of the American Medical Association , 288 , 2742–2744.

Bieszk, N., Patel, R., Heaberlin, A., Wlasuk, K., & Zarowitz, B. (2003). Detection of medication nonadherence through review of pharmacy claims data. American Journal of Health-System Pharmacy , 60 , 360–366.

Brown, R.S., Schwartz, J.L., Coleman-Bennett, M., & Sanders, C. (2002). The Black and White of dental education in the United States: Enrollment and graduation trends. Journal of the National Medical Association , 92 (11) , 536–543.

Bureau of Health Professions. (2002). Dental Initiative, Topic of Interest #3. Oral health disparities. U.S. Department of Health and Human Services.

Bureau of Labor Statistics (January 2003). Occupational Outlook Handbook , 2002–2003 Edition. Bulletin 2540. U.S. Department of Labor.

Butters, J.M., & Winter, P. (2002). Professional motivation and career plan differences between African American and Caucasian dental students: Implementation for improving workforce diversity. Journal of the National Medical Association , 94 , 492–504.

Deaton, A. (2002). Policy implications of the gradient of health and wealth. Health Affairs , 21 (2) , 13–30.

Epstein, A.M., & Ayanian, J.Z. (2001). Racial disparities in medical care. New England Journal of Medicine , 344 , 1471–1473.

Griffin, M. 2001. The healthcare industry: Multi-disciplinary opportunities leading to careers in health care. The Black Collegian Online. Web.

Ivancevich, J. M., and J. A. Gilbert. 2000. Diversity management: Time for a new approach. Public Personnel Management 29(1):75-77, 84-87.

Kimball, B., & O’Neil, E. (2002). Health care’s human crisis: The nursing shortage. Princeton, NJ: Robert Wood Johnson Foundation.

Kovner, C.T., & Salsberg, E.S. (2002). The health care workforce. In A.R.Kovner & S.Jonas (Ed.), Health care delivery in the United States (7th ed.). New York: Springer.

Marmot, M. (2002). The influence of income on health: Views of an epidemiologist. Health Affairs , 21 , 31–46.

Maxey, R. (2002). NMA develops strategic plan against health disparities. Journal of the National Medical Association , 94 , 288–289.

McGinnis, J.M., Williams-Russo, P., & Knickman, J.R. (2002). The case for more active policy attention to health promotion. Health Affairs , 21 , 78–93.

Mechanic, D. (2002). Disadvantage, inequality, and social policy. Health Affairs , 21(2) , 48–59.

Melnick, D., & Rouse, B. (Eds.). (2001). Portrait of health in the United States. 1st ed. Lanham, MD: BERNAN.

Meredith, L.S., & Griffith-Forge, N. (2002). The road to eliminating health disparities. Medical Care , 40 , 729–731.

National Center for Health Statistics (NCHS). (2002, August). Health, United States with Chartbook on Trends in the Health of Americans. USDHHS Publication No. 1232, Hyattsville, MD.

National Institutes of Health (NIH). 2001. Strategic and annual operating plan 2000–Key initiative: Diversity management. Web.

Phillips, K.A., Mayer, M.L., & Aday, L.A. (2000). Barriers to care among racial/ethnic groups under managed care. Health Affairs , 19 , 65–75.

Pogue, V.A., Norris, K.C., & Dillard, M.G. (2002). Kidney disease physician workforce: Where is the emerging pipeline? Journal of the National Medical Association , 94 (Suppl) , 39S–44S.

Roberts, E.M. (2002). Racial and ethnic disparities in childhood asthma diagnosis: The role of clinical findings. Journal of the National Medical Association , 94 , 215–223.

Satcher, D. (2000). Eliminating racial and ethnic disparities in health: The role of the ten leading health indicators. Journal of the National Medical Association , 92 , 315–318.

Satcher, D. (2001). American women and health disparities. Journal of the American Medical Women’s Association , 56 , 132–134.

Skrepcinski, F.B., & Niendorff, W.J. (2000). Peridontal disease in American Indians and Alaska Natives. Journal of Public Health Dentistry , 60 (Suppl 1) , 261–266.

Smedley, B.D., Stith, A.Y., & Nelson, A.R. (2003). Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. In B.D.Smedley, A.Y.Stith, & A.R.Nelson (Eds.), Washington DC: National Academies Press.

Smothers, G. 2001. Managing a diverse workforce, Advance for Health Information Professionals (October 8):21-22.

U.S. Department of Labor. Bureau of Labor Statistics. (2003, January). Occupational Outlook Handbook (2002–2003 ed.). Bulletin 2540.

UWeil, P., and M.C. Mattis, 2001, Narrowing the gender gap in healthcare management, Healthcare Executives 16(6):12-17.

van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physician’s perceptions of patients. Social Science and Medicine, 50, 813–828.