Barriers to Diversification of the Health Workforce

Even with this clearly identified need to diversify the health professions and the obvious distance we have to go in California before we achieve that parity, students of color face significant barriers to successfully pursuing health careers. The United States has a long history of excluding minorities from the health professions, and although the civil rights movement ensured equal access under the law, many educational institutions still fall short of achieving this milestone. Financial restrictions, a public climate of hostility towards race and ethnicity-based considerations, and long-standing social and economic forces also play a part in preventing more appropriate diversification of the state’s health workforce.

The difficulty of education financing can serve as a significant barrier to the successful pursuit of a health career for Californians. Students in the California State University (CSU) and University of California (UC) systems have seen multiple fee increases in the past few years: Undergraduate students at CSU campuses have faced a cumulative fee increase of 76 percent since 2002. In the last two years, UC undergraduates have had their fees increased 23 percent, and graduate students have had increases of more than 30 percent. The UC professional school fees have been raised dramatically as well — some schools have seen their tuitions go up almost 40 percent in two years.

These fee increases are compounded by federal legislation regarding college attendance. Legislation passed by Congress in early December 2004 will likely make more than 80,000 low-income students ineligible for federal Pell grants and will reduce the grant amounts for thousands of others. Students who complete studies at health professions educational institutions face what can appear to be insurmountable levels of debt; accounting for inflation, debt levels have risen by more than 150 percent since the 1980s. In 2003, the average debt owed by a private medical school graduate in the United States was $135,000; for public medical school graduates, the total was $100,000. For dentists, the average debt upon graduation was $115,000. Although education for allied health professions tends to be less expensive, training can still run well into the tens of thousands, an insurmountable sum for many California families. A recent national survey asked students who were qualified for medical school, but did not apply, about their reasons for not applying. For students of color, the prohibitive costs of medical schools were the primary reason they cited for not pursuing medical careers. State and private loan repayment arrangements are one way to entice students to pursue health careers; both the state government and nonprofit organizations offer loan forgiveness or repayment in exchange for students providing care in underserved communities when they have completed their training.

In addition, at the state and federal levels, the climate appears to be increasingly hostile towards explicit discussions of health disparities between different racial and ethnic groups and the resulting policies needed to correct these inequalities. California’s Proposition 209, passed in 1996, is probably the most well-known effort at the state level to eliminate state policies that specifically address barriers faced by people of color — in this case, students of color applying to public universities. In December 2003, the federal government released a Department of Health and Human Services report on racial and ethnic disparities in health that, in the final edit, had removed the word “disparities” and downplayed the different health status levels among people of color. These instances reflect a growing institutional bias in the public sector against recognition of, and specific actions to combat, the different circumstances and challenges faced by many people of color, whether regarding their health care or their educational attainment.

Finally, students of color interested in pursuing the health professions face well-documented social barriers. They often attend schools in low-income communities where they are not adequately prepared to graduate from high school, to attend college or to attain professional degrees; teachers and faculty are not adequately trained in methods of teaching and supporting students of color; and professional mentors of color are few and far between. The result, then, is that students of color are less likely to stay in school, less likely to graduate from college, and less likely to be represented in all but the entry levels of the health professions.

Ironically, these barriers persist at a time when California’s health workforce is extremely underresourced. Not only is there a significant disparity between the racial and ethnic makeup of patients and that of providers, but many parts of the state continue to be medically underserved, with fewer providers available than are needed for adequate provision of care. The nursing shortage has reached the halls of Sacramento and the headlines of state newspapers, and other professions — mental health providers, for example — are also in need of expansion and diversification.

The silver lining, perhaps, is that there is increasing publicity regarding health workforce diversity and recognition of increasing diversity in the health professions as a legitimate public health issue, perhaps even a public health crisis. In 2004, two high-profile organizations — the Institute of Medicine and the Sullivan Commission — issued national reports that speak strongly to the need for policy changes to address health workforce diversity. A number of the recommendations are a natural fit for funders interested in partnering with local health professions schools, including implementing changes in the makeup and charge of admissions committees; supporting efforts to alter institutional climates to ensure an emphasis on diversity; providing increased financial resources for students of color pursuing health careers; and working with accreditation bodies and committees to ensure the inclusion of diversity-related standards. A growing body of evidence supporting workforce diversity is being created, nonprofit health advocacy organizations are beginning to engage in workforce diversity work, and a community of individuals and organizations working on the issue in California is slowly emerging.

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