Racial and ethnic disparities in health and health care are well documented (Smedley, Stith, and Nelson 2002). Yet, a full understanding of the causal mechanisms of these disparities remains elusive. Three threads of work stimulated this paper. First, patient preferences may play a pronounced role in explaining disparities--patients' values and beliefs, including their level of trust in clinical advice, influence the level of care they receive (Smedley, Stith, and Nelson 2002). Specifically, a patient's comfort level with an intervention can influence his or her willingness to seek or accept treatment, be it physical or emotional. Second, physicians' advice and behavior may vary depending on perceived patient attributes (Smedley, Stith, and Nelson 2002). Third, racial and ethnic minorities have lower levels of trust and satisfaction with their providers--physicians, hospitals, health plans, and the health care system in general (Meredith and Sui 1995; Auslander et al. 1997; Taira et al. 1997; Morales et al. 1999; Doescher et al. 2000; LaVeist, Nickerson, and Bowie 2000; Murray-Garcia et al. 2000; Morales et al. 2001; Weech-Maldonado et al. 2001; Collins et al. 2002; Corbie-Smith, Thomas, and St. George 2002; Shi et al. 2003).

We wondered whether trust and satisfaction could be explained by the type of plan in which many racial and ethnic minorities find themselves. Prior studies suggest that individuals--regardless of race and ethnicity--enrolled in more heavily managed care plans like capitated or group model health maintenance organizations (HMOs) report less favorable assessments of the care provided by their physicians. Racial and ethnic minorities are more likely to be enrolled in restrictive, tightly managed care plans than whites, thereby explaining their lower levels of trust and satisfaction (Center for Studying Health System Change 2000). Unequal Treatment astutely points out that much of the previous research on racial and ethnic disparities controls for insurance status on a very general level (e.g., insured versus uninsured, privately insured versus publicly insured, etc.), but it does not adequately control for the generosity or restrictiveness of a particular insurance coverage. Findings from this research therefore leave open the possibility that racial disparities in care result to some degree from the disproportionate enrollment of racial and ethnic subgroups in more restrictive health plans (Smedley, Stith, and Nelson 2002). Our study attempts to fill this gap ill the literature on trust and satisfaction.

From a public policy standpoint, it is important to understand these differences because trust and satisfaction have been linked to health outcomes (Morales et al. 2001). Patient assessments of health care are associated with service utilization (Zastowny, Roghmann, and Cafferata 1998), the decision to switch health plans (Newcomer, Preston, and Harrington 1996; Allen and Rogers 1997; Schlesinger, Druss, and Thomas 1999), and treatment compliance (Hall and Dornan 1990).

BACKGROUND

The literature on trust and satisfaction with health care among members of racial and ethnic subgroups ranges across provider types--physicians, hospitals, plans, and the entire health care system. Previous research suggests that members of racial and ethnic minority groups have lower levels of trust in their physician and/or hospital (Saha et al. 1999; Doescher et al. 2000; LaVeist, Nickerson, and Bowie 2000; Corbie-Smith, Thomas, and St. George 2002; Shi et al. 2003). Findings on satisfaction, however, seem to vary based on the subgroup in question and the provider or care setting, which ranges across physician, medical staff, and health plan (Meredith and Sui 1995; Taira et al. 1997; Morales et al. 1999; Doescher et al. 2000; LaVeist, Nickerson, and Bowie 2000; Murray-Garcia et al. 2000; Phillips, Mayer, and Aday 2000; Morales et al. 2001; Weech-Maldonado et al. 2001). Some studies indicate that Latinos/Hispanics are less satisfied with the care provided by physicians and health plans than whites, while others suggest that African Americans are less satisfied. Finally, most findings suggest that Asians and Pacific Islanders have lower levels of satisfaction with their physicians, health care, and/or health plans than whites (Meredith and Sui 1995; Taira et al. 1997; Murray-Garcia et al. 2000; Weech-Maldonado et al. 2001). And, research indicates that dissatisfaction with the health care system may be related to perceived racism (Auslander et al. 1997; LaVeist, Nickerson, and Bowie 2000).

The literature regarding racial and ethnic disparities in trust and satisfaction with provider does not control for the restrictiveness of health plans, despite a strong association between health plan restrictiveness and lower ratings of trust and satisfaction. For example, Reschovsky, Kemper, and Tu (2000), Kemper et al. (2002), and Kao et al. (1998) all find that consumer assessments of satisfaction and trust with physician care are lower in more heavily managed plan settings. Newcomer, Preston, and Harrington (1996) found that individuals who reported higher levels of satisfaction with physician quality and physician--patient relationships were less likely to disenroll from their HMOs. Managed health plans that allow greater provider choice and have fewer gatekeeping restrictions are associated with higher levels of patient satisfaction and trust with physician (Forrest et al. 2002; Haas et al. 2003).

We hypothesized that controlling for the type of health plan in which an individual was enrolled would reduce racial and ethnic disparities in trust and satisfaction. Because of data limitations, we restrict our analysis to respondents' perceptions of trust and satisfaction with physician care, rather than hospital, health plan, or any other provider type. To better understand patient perceptions of the health care system with respect to their physicians, our study asks: does the distribution of individuals across types of health plans explain differences in levels of trust and satisfaction with physician care by racial and ethnic background?

DATA AND METHODS

Data Source

We used data from the Community Tracking Study (CTS) 1998-1999 Household and Followback Surveys for our analysis. The CTS is a longitudinal study of health system change and its effects on individuals nationwide as well as within 60 randomly selected sites across the nation. The study is conducted by the Center for Studying Health System Change. The Household Survey contains information on basic demographics, insurance coverage, service utilization, usual sources of care, trust and satisfaction, chronic health conditions, and risk behaviors. The Followback Survey provides more detailed information about the health plans of individuals who reported private insurance coverage. The Followback information was collected by contacting the employer or health plan associated with a respondent's private coverage and asking about insurance plan characteristics such as product type, in- and out-of-network coverage, and provider payment methods (Center for Studying Health System Change 2002a).

A detailed explanation of the CTS sampling methods is published elsewhere (Kemper et al. 1996; Metcalf et al. 1996). Briefly, the Household Survey is a multistage, clustered sample with stratification based on 60 randomly selected sites and a supplemental national survey. Households are randomly selected for telephone interview using computer-assisted telephone interviewing technology. The majority of respondents are selected through random digit dialing, but households without telephones are also represented in the sample. The survey is conducted in Spanish when necessary. The full 1998-1999 household sample consists of over 58,000 individuals and 32,000 families, and the followback sample consists of more than 22,000 individuals. The response rate for the Household Survey was 63 percent, and the match rate for the Followback Survey was 59 percent. (1)

For this study, we include individual-level data for adults, age 18 years and over. Individuals who reported insurance coverage through a military plan were excluded from our" analysis. The data are weighted to control for clustering, stratification, and nonresponse so that results may be extrapolated to the noninstitutionalized population of the continental United States.

Dependent Variables: Measures of Trust and Satisfaction