February 17, 2010 — African-Americans have long been underrepresented among health care professionals. As of 2005, blacks made up slightly more than 8 percent of first-year medical students in the United States – roughly half of their share of the U.S. population (15.4 percent in 2007), and just 1 percent more than their share of ﬁrst-year medical students in 1975.
The study, "The Educational Pipeline for Health Care Professionals: Understanding the Source of Racial Differences," is based on research done while lead author Jessica Howell was a visiting professor of economics at U.Va. during the 2005-06 academic year. It appears in the Winter 2010 issue of the Journal of Human Resources.
This study, the first to examine the educational pipeline for black health care professionals, is based upon the National Longitudinal Study class of 1972, a comprehensive longitudinal survey of more than 13,000 Americans who graduated from high school in 1972, including about 1,450 African-Americans.
The cohort was tracked into their 30s, long enough to collect data on college attendance and graduation, post-collegiate schooling and career choices, Howell said. The representation of blacks in the 1972 cohort declined from 11 percent at the point of high school graduation, to 9 percent at college entry, to 7.2 percent at college graduation, and to 4.1 percent at the stage of entry to the health professions (which, for this study, included physicians, therapists, dentists, registered nurses, pharmacists, psychologists, optometrists, dietitians and veterinarians, among others.)
Howell and her team modeled the changes in the cohort at each stage along the educational pipeline. The modeling found that when personal background factors (including rural versus non-rural location and parents' educational attainment) were taken into account, black students were more likely than others both to enter college and to graduate from college. Although this finding may seem surprising to some, this general finding has been well documented by social scientists, Howell said.
The majority of the differences in the representation of blacks and whites at the post-baccalaureate stage of entry to a health profession can be traced to gaps generated much earlier in the educational pipeline, Howell said, and stem from factors like parents' education level and students' attending schools with lower per-pupil spending, higher poverty rates, and lower average scores on standardized tests.
"The flow of blacks into the health care professions has been reduced at an early stage in the educational pipeline, so we must go back in the pipeline to open up that spigot," Howell said. "This research and other research confirm that you have to go back further in that pipeline than many people realize."
Remedies that narrow the pre-college educational gaps between black students and other students, Howell said, would improve not just the proportion of blacks in health care, but would also affect any number of professions, such as black representation in law or in business management.
Although the majority of "leakage" in the educational pipeline toward health care professions occurred due to pre-college factors, there was also some leakage at the point when blacks made post-college decisions about what type of graduate schooling and career to pursue.
Controlling for background characteristics and the type of college attended, measured by both institutional selectivity and status as a historically black college or university, black college graduates were "substantially" less likely than other college graduates to pursue post-baccalaureate health care programs, the study found.
This post-college leakage can probably be explained by financial incentives, the study suggested. Alternatives to medical school, such as MBA programs and law schools, are pathways to professions where the gap in wages between blacks and whites narrowed rapidly in the 1970s and 1980s, making those fields more financially attractive.
Proposals to provide subsidies to encourage blacks to enter the health care professions could reduce the post-college leakage, but would not address the main cause of black underrepresentation, said study co-author Steven Stern, a U.Va. professor of economics who served as Howell's doctoral adviser at U.Va. (Howell completed her Ph.D. in 2004.)
The fact that much of the difference in pre-college outcomes can be traced to parental education levels, Stern said, suggests that if the average educational achievement of blacks continues to rise, related ramifications such as black underrepresentation in health care will become less of an issue over time.
The ratio of black to white health care professionals has ticked up slightly over the past two decades, but those modest gains have been driven by an erosion in the number of whites choosing health professions rather than a sustained increase in blacks choosing health care, Howell added.
The study's five additional co-authors hail from several departments at U.Va.: Ivora Hinton, a coordinator of data analyses and interpretation at the School of Nursing; Elizabeth Merwin, a professor and associate dean for research at the School of Nursing; Sarah Turner, a professor of economics and education; Ishan Williams, assistant professor of nursing; and Melvin Wilson, a professor of psychology.
February 17, 2010