SPECIAL ISSUE
Cultural Competency as It Intersects With 
Racial/Ethnic, Linguistic, and Class Disparities 
in Managed Healthcare Organizations
Ruth Enid Zambrana, PhD; Christine Molnar, MS; 
Helen Baras Munoz, PhD; and Debbie Salas Lopez, MD
Culture in and of itself is not the most central variable in the This paper examines the definitions of cultural com-
patient-provider encounter. The effect of culture is most pro- petence within the context of access to care and identi-
nounced when it intersects with low education, low literacy skills, fies Medicaid managed care experiences in select states
limited proficiency in English, culture-specific values regarding the
authority of the physician, and poor assertiveness skills. These to describe the experiences of underrepresented low-
dimensions require attention in Medicaid managed care settings. income racial/ethnic minorities within managed care
However, the promise of better-coordinated and higher quality systems. Building on extant empirical literature, we
care for low-income and working-poor racial/ethnic populations? propose strategies to enhance competent and high-
at a lower cost to government?has yet to be fully realized. This quality care for racial and ethnic groups in managed
paper identifies strategies to reduce disparities in access to health-
care that call for partnerships across government agencies and care systems. A computerized literature search was con-
between federal and state governments, provider institutions, and ducted for the years 1999-2003 using the following key-
community organizations. Lessons learned from successful prece- words: Medicaid managed care, disparities; access to
dents must drive the development of new programs in Medicaid services; health services accessibility; access to primary and
managed care organizations (MCOs) to reduce disparities. preventive care, co-payments; cost sharing; low-income,
Collection of population-based data and analyses by race, ethnici-
ty, education level, and patient?s primary language are critical minority, Latino/Hispanic, African American/Black; quality
steps for MCOs to better understand their patients? healthcare sta- of care, and Medicaid managed care policy. The databases
tus and improve their care. Research and experience have shown searched included MEDLINE, Social Science Citation
that by acknowledging the unique healthcare conditions of low- Index, and Science Citation Index. In addition, govern-
income racial and ethnic minority populations and by recruiting ment and Kaiser and Commonwealth Foundation reports
and hiring primary care providers who have a commitment to treat
underserved populations, costs are reduced and patients are more were reviewed. A version of this paper was presented at
satisfied with the quality of care. the Conference on Diversity and Communication in
(Am J Manag Care. 2004;10:SP37-SP44) Health Care: Addressing Race/Ethnicity, Language, and
Social Class in Health Care Disparities convened in
Minority populations?Hispanics, African February 2000 by the Office of Minority Health of theAmericans, Asian Americans, and other people US Department of Health and Human Services inof color?currently comprise 28% of the popu- Washington, DC.
lation of the United States, and this figure is projected
to increase to 40% by 2030.1 Racial and ethnic minori- Cultural Competence: Past and 
ties, especially those with low incomes and limited Emerging Definitions
English proficiency (LEP), experience multiple barriers In the past, cultural competence has been called cul-
to healthcare, encounter lower access to and availabili- tural sensitivity, cultural responsiveness, or cultural
ty of healthcare, and experience less favorable health appropriateness; the name ?cultural competence? is
outcomes.2-9 Multiple barriers to healthcare access exist
?such as language, economics, geography, and cultural
familiarity?even when minorities are insured at the
same level as nonminorities.10,11 The emerging aware- From the Department of Women?s Studies and The Consortium for Race, Gender, andEthnicity, University of Maryland, College Park, Md (REZ); the Community Health Access
ness in the United States over the past 3 decades of Department, Community Service Society of New York, NY (CM); Management Sciences
what is termed ?disparity? has presented innumerable Development, Washington, DC (HBM); and the Department of Medicine and the Divisionof Academic Medicine, Geriatrics and Community Programs, University of Medicine and
challenges, partly because of the lack of scholarship that Dentistry?New Jersey Medical School, Newark, NJ (DSL).
examines the intersections of socioeconomic, racial, Prepared for the Conference on Diversity and Communication in Health Care:Addressing Race/Ethnicity, Language, and Social Class in Health Care Disparities;
and ethnic statuses. Questions remain regarding how to Washington DC; February 17-18, 2000. This study was sponsored by the Office of Minority
improve access and quality of care for economically dis- Health, US Department of Health and Human Services.Address correspondence to: Ruth Enid Zambrana, PhD, University of Maryland, 2101
advantaged and culturally distinct groups. Woods Hall, College Park, MD 20742. E-mail:rzambran@umd.edu.
VOL. 10, SPECIAL ISSUE THE AMERICAN JOURNAL OF MANAGED CARE SP37
SPECIAL ISSUE
recent.12 Cultural competence is defined as a ?set of ized.28 Several attributes of culturally competent care
congruent behaviors, attitudes, and policies that come are useful in examining its meaning within managed
together in a system, agency or profession that enables care settings: 
that system, agency or profession to work effectively in
cross-cultural situations.?2,13 Cultural competence, as ? When culture-specific health beliefs and health
behaviors, gender, race, ethnicity, age, and low
originally conceived, emerged as an issue because of socioeconomic status are part of a shared dialog
public health efforts to make healthcare services more between provider and patient, both communica-
responsive to underserved populations in both rural and tion and delivery of care are more effective.29
urban areas. As the number of patients of diverse racial, ? Providers who are aware of and address potential
ethnic, cultural, and linguistic backgrounds increased in communication difficulties, and who provide lin-
the United States, the need to produce culturally com- guistically appropriate and literacy-appropriate
petent providers who incorporate patients? world view information in the patient?s native language, inter-
30
into management decisions also grew. act more effectively with patients.
The release of the national standards for culturally ? Culturally competent providers consider the pa-
and linguistically appropriate services in 2001 drew tient?s needs and preferences within the context of
attention to the need for culturally and linguistically his or her cultural beliefs and practices, and
understand the importance of these factors in the
competent healthcare services for diverse popula- treatment plan.25
tions and attracted the attention of policymakers,
medical schools, public health systems, and healthcare Culture in and of itself is not the most central vari-
providers.12,14 The Institute of Medicine?s report able in the patient-provider encounter. The effect of cul-
Unequal Treatment concluded that ethnic and racial ture is most pronounced when it intersects with low
gaps in care beyond access-related factors were attrib- education, low literacy skills, LEP, culture-specific
utable to a range of patient-level factors (patient prefer- values regarding the authority of the physician, and
ence, treatment refusal, clinical appropriateness of poor assertiveness skills. It is precisely this intersection
care), provider-level factors (bias, stereotyping, uncer- that has been poorly understood or ignored. Yet these
tainty), and system-level factors (lack of interpreters, dimensions require attention in Medicaid managed care
geography, managed care system).15 settings.
Health disparities are associated with factors such as Expanding the definition of cultural competency has
patients? perceived discrimination16 and mistrust of the implications for underrepresented minority groups. The
healthcare system,17 poor or ineffective communication ability to take into account individual and institutional
between patient and physician,18 and healthcare pro- factors, the known health consequences of poverty, and
viders? lack of cultural competence and sensitivity.19,20 barriers to healthcare access could lead to new mecha-
Other contributing factors to healthcare disparities are nisms and interventions to address health disparities.
social factors such as socioeconomic status and racism, Healthcare access, health outcomes, and patient satis-
and systemic factors such as access to care and com- faction could be improved, and long-term costs for man-
munication barriers.21-23 To ensure quality healthcare aged care organizations (MCOs) could be reduced. 
and access for minority populations, care must be con-
gruent with patients? cultural, linguistic, and literacy Emergence of Managed Care as a 
needs. A recent study of a large staff-model HMO found Policy Solution to Improve Access and
that interpreter services can increase delivery of health- Reduce Costs for Medicaid Programs
care to non?English-speaking patients by facilitating The trend toward managed care began in the late
patient-physician understanding, which affects patient 1980s, when the cost of healthcare services escalated at
adherence and accuracy of diagnosis and treatment, an alarming rate, as evidenced by Medicaid costs, which
while fostering trust and increased satisfaction with were increasing by an average of 30% annually during
care.24 Quality healthcare is culturally competent and that period.31 Simultaneously, the number of uninsured
patient centered.25 Culturally competent care can in the population continued to increase and presented a
improve the continuity of a patient?s care and health challenge to those concerned with providing access to
outcomes by increasing the understanding between healthcare services for the poor and working poor. As a
patients and providers.18,26,27 result, commitments to legislate major changes in
When healthcare providers and organizations healthcare that would address the issues of cost and
understand and effectively respond to the diverse cul- access to healthcare services became part of the nation-
tural and linguistic needs of patients, the benefits of a al health agenda. Yet the failure of the healthcare
true patient-clinician relationship are more fully real- reform plan and all competing proposals introduced
SP38 THE AMERICAN JOURNAL OF MANAGED CARE SEPTEMBER 2004
Cultural Competency and Managed Care
during the 103rd Congress suggests that the primary of any effort to reduce ethnic and racial disparities in
focus of this national debate was predominantly to con- healthcare. 
trol the cost of healthcare and to support managed care
as a viable solution.32 Managed care advocates promot- State Experiences With Low-income and 
ed the notion that a well-run managed care system Medicaid Recipients: Issues and Challenges
could provide quality healthcare while at the same time States can move toward managed care either by
reducing costs.33,34 allowing voluntary enrollment or by instituting a
In an effort to control rising healthcare costs and mandatory enrollment program. In some cases, the vol-
limit the utilization of services, public purchasers are untary option comes first and is used as an experi-
increasingly relying on managed care models. By the mental enrollment strategy, often followed by a more
year 2000, almost all states had begun to offer the option of structured and systematic mandatory model. The
managed care to their Medicaid beneficiaries, with varying rapid expansion of Medicaid managed care was seen by
degrees of success. Remaining states continue to study the states as a way to improve the quality of care by
plans to transition and restructure state and county sys- encouraging more primary healthcare services and
tems to managed care.35 Managed care has continued to less emergency room utilization. In the second gener-
expand as states experience pressure to contain costs ation of managed care, states are moving to ensure
and is increasing in both Medicaid and State Children?s quality of care by incorporating innovative approach-
Health Insurance Program (SCHIP) programs. The es designed to guarantee that both psychosocial needs
number of Medicaid clients enrolled nationwide in man- and medical needs are met.40 The states of Oregon and
aged care has increased dramatically, with a 3% enroll- Washington have taken the lead in this regard, as
ment in 1983, a 23% enrollment in 1994, and a 58% MCOs are mandated to develop a continuum of servic-
enrollment as of December 31, 2001.36 es that meet the needs of Medicaid populations. Most
Managed care, which is based on the premise that states, however, are lagging behind and have not devel-
regular use of primary and preventive care can prevent oped the capacity to meet the comprehensive needs of
illness and reduce costs, holds great promise for deliv- low-income and underrepresented racial/ethnic minor-
ering quality and cost-efficient healthcare to low- ity populations.41
income families, many of whom face overwhelming Medicaid managed care experience in 5 states (Cali-
barriers to care. But while more Medicaid recipients and fornia, Minnesota, New York, Oregon, and Tennessee)
low-income children are enrolling in managed care consistently shows that Medicaid managed care con-
plans, the promise of better coordinated and higher fronts more challenges than commercial managed care
quality care for low-income and working-poor efforts because the Medicaid population of low-income
racial/ethnic populations?at a lower cost to govern- women and children, the disabled, and the elderly
ment?has yet to be fully realized.37 have unique needs that require initiatives to be tai-
Medicaid beneficiaries are more likely to have poor lored so that they are responsive to these popula-
health status and therefore incur higher costs for tions.41 States vary significantly in their requirements
healthcare services.38 Further, a large majority of for services such as translation, outreach, and trans-
Medicaid patients lack transportation, live in medically portation. Oregon, for example, has no such require-
underserved communities, are less likely to have con- ment; and Minnesota adopted special services only after
tinuous telephone service, and tend to use the emer- it was evident that certain supportive services were an
gency room as a regular source of care. In 30% of Aid to essential and necessary part of providing access for
Families and Dependent Children households, at least 1 the poor.
family member reported having a disability.5 More than However, in the long term, the stability of Medicaid
50% of Medicaid beneficiaries belong to racial/ethnic managed care programs is uncertain. Private HMOs
minorities.39 In general, underrepresented racial/ethnic have dropped out of the Medicaid market when the prof-
minority groups are poorer, have more chronic health it margin has declined.42 Although competition for
conditions (eg, asthma, diabetes, heart disease), engage Medicaid business is fierce in most states, the prof-
in more high-risk behavior, and have less access to itability of serving Medicaid clients may diminish if
providers. As a result, they are more expensive to care Medicaid officials try to reduce reimbursement rates
for. However, unfavorable health status is associated whenever they conclude that a MCO is making exces-
with poverty and limited access to quality health serv- sive profits. If the federal contribution to Medicaid
ices, not with minority status. The performance of man- declines, there will be additional pressure to decrease
aged care systems in providing care for publicly insured HMO reimbursement rates. If Medicaid officials intro-
populations in different states must be examined as part duce program improvements to reduce adverse selec-
VOL. 10, SPECIAL ISSUE THE AMERICAN JOURNAL OF MANAGED CARE SP39
SPECIAL ISSUE
tion, the profitability of Medicaid clients will diminish ment. Despite the fact that there is no competition
even further. among providers to serve uninsured patients, the tran-
sition of Medicaid recipients (another patient popula-
Enrollment and Outreach tion traditionally served by safety-net providers) into
Addressing disparities in the recruitment and enroll- managed care plans has produced competition for
ment of Medicaid beneficiaries into managed care plans Medicaid enrollees that has implications for safety-net
is critically important for the health of low-income and providers.47 The ability of community-based organiza-
racial and ethnic populations. In the early wave of tions, public hospitals, and public clinics, the tradition-
recruiting Medicaid clients, many MCOs engaged in al safety net for the poor and medically indigent, to
recruitment and enrollment tactics that did not protect compete in the Medicaid managed care environment
the rights, options, and choices of the client population. and to negotiate contracts and appropriate payment
Both Oregon and Minnesota do not allow any direct rates is uncertain. 
marketing by health plans, because direct marketing by In California, state Medicaid officials have developed
plans has been associated with abuse of rights in a managed care model (the 2-plan model) designed to
Medicaid managed care. Initially, the New York market- protect safety-net providers. In contrast, New York
ing was conducted from door to door, a practice that has State Medicaid officials have neither designed nor
since been suspended. implemented a safety-net protection plan. Instead, the
There is evidence that some MCOs have engaged in state tasked its 57 counties to design and implement
discriminatory practices, including refusing to provide their own initiatives to protect the provider safety net.43
services to entire geographic areas and populations.37,43 Lipson and Naierman argue that this decentralized
The Office of Civil Rights of the US Department of approach does not provide for clear universal guidelines
Health and Human Services has  been called on to or clear lines of accountability that would ensure the
investigate Medicaid managed care enrollment and mar- systematic strengthening and protecting of the safety-
keting practices.44 Some MCOs also have been found to net infrastructure.48 The potential lack of long-term
engage in additional ?skimming? or ?creaming? prac- MCO commitment to the Medicaid population increas-
tices such as locating their membership office on the es the need to preserve a strong medical safety net to
second floor (without access to elevators), or training serve the poor and medically indigent.49
their enrollment counselors to visually assess whether Safety-net providers have historically been able to
the enrollee would need a lot of services in order to cross-subsidize care for the uninsured using Medicaid
enroll only the healthiest members.6,44 States have payments, but as Medicaid dollars decrease while unin-
found that if managed care structures are to benefit all sured patients increase, providers are forced to turn to
enrollees, the states must establish marketing guide- grant money to subsidize their operations. Thus, few to
lines and prohibit these discriminatory practices. no resources remain for public health programs and
Populations with low education, low literacy, and/or health education efforts. But in some communities, the
LEP are particularly vulnerable in the transition to result is even worse: public hospitals, federally qualified
managed care. Notices informing enrollees of their health centers, and health clinics are shutting their
rights often go unread because they are not understood doors or drastically reducing their services.6 The chal-
or have not been translated into the appropriate lan- lenge is not only to contain costs and provide quality
guages of the population. States implementing manda- healthcare, but more importantly, to secure the future
tory enrollment in Medicaid managed care have found viability of safety-net providers delivering healthcare
that these groups are least likely to respond to enroll- services to the poor and uninsured. Furthermore,
ment notices and are more likely to be automatically strengthening safety-net providers under managed care
enrolled by the state.45 may be the only way of ensuring that the poor and unin-
sured populations continue to be served. 
Safety-net Providers Andrulis argues that the entire tradition of public-
The transition from a fee-for-service system to a sector healthcare is threatened by managed care, as the
managed care system poses a major challenge, with sig- intensity and growth of the competition might be too
nificant implications for the future viability of safety-net powerful for it to withstand.50 He raises 2 central issues:
providers that deliver healthcare to the poor and near (1) Although community healthcare centers might
poor.46 Given the high proportion of uninsured persons become attractive to MCOs as a way of gaining entry
in the US population (particularly the Latino popula- into certain neighborhoods, it still remains unclear
tion), safety-net providers that serve this community whether MCOs would invest adequate funds to deliver
are doubly challenged in the managed care environ- effective healthcare services to low-income and work-
SP40 THE AMERICAN JOURNAL OF MANAGED CARE SEPTEMBER 2004
Cultural Competency and Managed Care
ing-poor populations, or whether any autonomous role ? Provide financial resources to support partnerships
would remain for community-based organizations  under between local government, MCOs, and community
such partnerships. (2) Although in the past a fully vest- agencies for outreach and enrollment in publicly
ed public sector provided and financed healthcare, the funded programs. The involvement of community-
emergence of a ?residual public sector? or an entirely based healthcare organizations in improving access
to healthcare for low-income, racial/ethnic com-
?divested public sector? is possible given the current munities has become increasingly apparent. Many
questioning by policymakers and state and local govern- states and counties are beginning to formalize
ments regarding what role, if any, the public sector has these relationships (particularly in SCHIP pro-
to play in the new managed care environment.50 grams), and these efforts must be evaluated.46
A review of the nonprofit sector in managed care sug- ? Improve government purchasing. Public pur-
gests that to ensure the survivability of the system, chasers need training on rate setting to establish
innovative models of joint partnership and ownership of payment rates that do not discourage MCOs from
managed care enterprises by community providers serving high-risk populations. The costs of provid-
need to be explored.51 Although the healthcare reform ing culturally and linguistically competent health-
debate addressed the need to better define expectations care should be included in capitation rate-setting
methodologies. 
for the nonprofit sector as a provider of free services, it
did not adequately envision the role of the nonprofit- ? Provide federal subsidies to MCOs that serve low-
income vulnerable populations to ensure the pro-
sector providers as entrepreneurs who would assume an vision of supplemental services such as
ownership role in the system. Unless the nonprofit sec- transportation, medical supplies, and medications.
tor assumes an ownership role in managed care, servic- ? Mandate the inclusion of minority, linguistically
es for the poor will be compromised.52,53 competent, and culturally competent providers in
Community-based organizations providing safety- managed care networks. 
net healthcare services require particular attention, ? Conduct radio and television mass media educa-
because they serve a disproportionate number of tion campaigns to help people understand their
uninsured. The ability of community-based organiza- rights as MCO enrollees.
tions to compete in the managed care marketplace and
gain entry to Medicaid contracts will solidify their Primary Care Capacity in Low-income 
position as safety-net providers serving low-income and Racial/Ethnic Communities
and racial ethnic groups in their community. However, Primary care capacity (ie, having enough primary
the majority of community-based organizations work care practitioners to meet people?s needs for healthcare)
within an organizational environment that has few is a critical link to improving the health status of low-
financial and personnel resources available?which income, minority, and LEP populations. People who
makes them less able to compete and negotiate in have access to convenient primary care facilities where
their environment.54 Community-based organizations care is available in their language receive higher quality
that provide healthcare services to the poor and near care and are less likely to experience serious illness; for
poor are mandated by their governance not only to those with chronic conditions such as asthma, diabetes,
provide culturally competent healthcare but also to and hypertension, many hospitalizations are avoidable.55
advocate on behalf of these patients for their rights. Underrepresented racial/ethnic communities have
The transition to managed care poses additional chal- long been plagued with a paucity of medical profession-
lenges for these organizations. Organizations adapting als. In New York City, for example, there are 232 physi-
to the managed care environment generally lack the cians in office-based practice per 100 000 residents. In
technological resources, cash reserves, and sophisti- 9 low-income, primarily minority communities, the rate
cated accounting systems needed to be part of a was as low as 21.6 physicians per 100 000. These com-
provider network, despite the fact that they carry the munities experienced a severe shortage in primary care
heaviest burden for delivering healthcare services to capacity within a city that has immense physician
the poor and underserved.54 resources.56 Racial/ethnic practitioners are more likely
Managed care organizations can meet their goals of to serve minority and poorer patients, and racial/ethnic
lowered costs and improved access to care by tailoring health researchers are more likely to be interested in
their services to the needs of the population they serve problems relevant to minority and historically under-
and by working closely with local community-based served populations.57 African American physicians are
providers to increase access, enhance the trust of more likely than others to treat patients who are African
clients, and utilize existing community resources. American and/or on Medicaid; Latino physicians are
Strategies include: more likely than others to treat patients who are Latino
VOL. 10, SPECIAL ISSUE THE AMERICAN JOURNAL OF MANAGED CARE SP41
SPECIAL ISSUE
and/or uninsured.58 Racial/ethnic minority patients also Culturally Competent Practices
are more likely to feel that their physicians involved There is no universal understanding among
them in decisions about their care when the patient and providers and researchers of what culturally competent
the physician are of the same sex and race.59 care is, how to measure or evaluate appropriate care, or
Over the past several years, the number of African how to define successful programs. There are several
Americans and Latinos admitted to medical school has reasons for this: no established standards define com-
declined. Although racial and ethnic minority groups petent care; the costs of providing appropriate care (eg,
represented 19.4% of the US population in the 1990 US interpreter services) often are not reimbursed; many
Census, they represented only 10.9% of the 1997 med- public officials, healthcare facilities, and providers are
ical school matriculants. The shift away from a national unaware of their obligations or unwilling to provide lin-
acceptance of affirmative action is having a negative guistic and culturally appropriate healthcare to their
61
effect on the ability to recruit and retain minority stu- patients ; and institutional practices often tend to dis-
dents and faculty in the health professions. After regard the healthcare needs of those who are unable to
Proposition 209 in California and the Hopwood decision pay, have public insurance, or are unable to negotiate
in Texas, Louisiana, and Mississippi, applications of the system due to low education and literacy skills,
minorities to medical schools in these states declined and/or access constraints. In addition, cultural compe-
17% (2.3 times more than the national average), accept- tence involves a dynamic interplay among socioeco-
ed applications of minorities declined 27% (7 times more nomic status, race, ethnicity, and language?an
than the national average), and minority matriculants interplay that definitions and interpretations of the
declined 26% (6 times more than the national average).60 term do not always acknowledge.
At the federal level, repeatedly documented strategies Local clinics, health centers, and individual providers
have been recommended to increase the number of have provided leadership in bringing high-quality, cul-
underrepresented minorities in the health professions turally competent healthcare to the communities they
through investments in pipeline programs, mentoring serve. Yet many publicly financed programs continue to
programs, and incentive programs for both providers and be uninformed about the unique characteristics of the
MCOs, and more scholarship funds targeting low-income, populations they serve. This information gap is associat-
underrepresented racial and ethnic groups.57,58 Although ed with provision of less effective services, particularly
federal efforts are required to increase African American for those who have a low income and LEP. (See the arti-
and Latino representation in medicine and the health cle by Carter-Pokras et al in this issue for a complete dis-
62
professions, MCOs can enhance the number of primary cussion of LEP. ) Several studies have shown that
care physicians and health professionals by recruiting language is important when a person does not have
professionals who have a commitment to practicing in health insurance, has limited education, and has a low
7,22
underserved areas, by creating opportunities for intern- income. In those instances, qualified medical inter-
ships and residencies in MCOs, and by providing finan- preters?who are aware not only of language appropri-
cial incentives to underrepresented minority primary ateness but also of literacy and culture-specific health
care physicians to work in underserved communities. In beliefs and behaviors?are crucial in bridging the lan-
addition, federal and state governments can strengthen guage and culture chasm between patient and physician
the efforts of MCOs through the following strategies: to effectively communicate health issues.
24
Training for health professionals on the provision of
? Increase the reimbursement rate for MCOs that culturally appropriate care also lacks systematic and
serve Medicaid and SCHIP individuals, and provide comprehensive standards. Schools of medicine, nursing,
incentives such as tax credits to encourage MCOs and public health offer courses on cultural competency.
to recruit the participation of more providers in But the quality and depth of these offerings varies dra-
underserved areas. matically, from a single lecture per semester to an entire
? Create financial incentives for MCOs to reimburse course on cultural differences. To date, no clear guide-
primary care providers who practice in neighbor- lines or comprehensive standards exist on how to prepare
hoods with a primary care shortage at an above-
average rate. healthcare providers to become culturally competent.
? Strengthen existing efforts and create new oppor- When 118 US and 15 Canadian medical schools were sur-
tunities through the Health Resources and veyed, few schools (United States: 8%, Canada: 0%) had
Services Administration to support primary care separate courses addressing cultural issues and only 35%
improvement, especially in MCOs that are located of US schools addressed the cultural, economic, and
in minority communities (eg, National Health insurance status issues of the largest minority groups in
Service Corps, Bureau of Health Professions). their particular states.63,64 Managed care organizations
SP42 THE AMERICAN JOURNAL OF MANAGED CARE SEPTEMBER 2004
Cultural Competency and Managed Care
can institute continuing education or required training examines differences by demographic characteristics.
for all healthcare professionals regarding the culture- Managed care organizations, in conjunction with pub-
specific health beliefs and clinical, economic, and lan- lic health agencies, can make better efforts to both
guage issues experienced by the population they serve. capture these data and produce regular reports that
To institutionalize a set of practices that ensure show results by demographic and geographic strata.
equal treatment for all, both federal and state legislative As noted in a recent report on national healthcare dis-
policies should mandate a set of strategies that account parities, ?More complete healthcare data could
for socioeconomic status and its associated literacy, enhance understanding of why differences on health
language, and cultural dimensions. These policies and healthcare exist and would help to determine the
should be monitored at the provider-institutional level appropriate interventions for specific populations.?66
to ensure compliance: Delivery of healthcare to Medicaid managed care
groups provides an opportunity to improve access and
? Mandate standards on culturally and linguistically
appropriate services to ensure culturally compe- quality of care for Medicaid-eligible, low-income, under-
tent healthcare. Consider making mandatory the represented racial/ethnic minority groups. Research and
standards recently issued by the Office of experience have shown that by acknowledging the
Minority Health.14 unique healthcare conditions of low-income racial and
? Establish minimum standards to compel training ethnic minority populations and by recruiting and hiring
institutions to incorporate cultural competency primary care providers who have a commitment to treat
into academic requirements. underserved populations, costs are reduced and patients
? Adjust reimbursement rates to reflect any are more satisfied with the quality of care. Managed care
increased costs associated with implementation of organizations are important to ensure that the financing,
the Office of Minority Health standards for cultur- provisioning, and monitoring of healthcare improve so
ally and linguistically appropriate services in that high-quality services can be provided for histori-
healthcare, particularly the provisions of language
interpretation sources. cally underrepresented racial and ethnic groups, low-
income groups, and non?English-speaking groups.
Conclusion
This paper identifies strategies to reduce disparities Acknowledgments
in access to healthcare that call for partnerships across Dr Zambrana acknowledges the research assistance of
government agencies and between federal and state Clare Jen, doctoral student in the Department of Women?s
Studies at the University of Maryland, College Park. Ms
governments, provider institutions, and community Molnar acknowledges the assistance of Doreena Wong,
organizations. In a recent article, Zambrana and National Health Law Program, Inc; Geraldine Sanchez
Carter-Pokras examine the most promising practices in Agilpay, Association of Schools of Public Health; and
state reform strategies to increase health insurance Patrick C. Hines, Student National Medical Association. 
coverage for eligible low-income racial and ethnic pop-
ulations.65 Lessons learned from successful precedents
must drive the development of new programs in REFERENCES
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