Diverse State, Diverse Needs

Health care providers who deliver culturally responsive care are aware of and sensitive to these diverse values, beliefs, and behaviors. Receiving culturally responsive care is associated with better health outcomes and more positive experiences with the health care system.

According to the 2021 Colorado Health Access Survey (CHAS), about one in 14 (6.9%) Coloradans reported needing health care that was responsive to a particular need or part of their identity, most often due to their disability, language, sexual orientation, or experience with violence or abuse.

People who reported that their identity or personal history made a difference in the care they needed were more likely to report being treated with less respect by health care providers. They were also more likely to avoid getting health care when they needed it due to their fear of being treated unfairly.

Colorado providers and policymakers are working to strengthen fluency in culturally responsive care across the health care workforce, but they can do more to ensure that the health care system meets the unique needs of all Coloradans.

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The Need for Culturally Responsive Care

According to the 2021 CHAS, an estimated 388,000 Coloradans needed culturally responsive care. The most common reasons people reported for needing this care were disability status, experience with abuse or violence, language, and/or sexual orientation (see Table 1). CHI’s work in stigma and health equity leads us to believe that this is very likely an undercount, indicating that many more Coloradans need some form of culturally responsive care than are reflected in the data. Additionally, those who need culturally responsive care due to characteristics like refugee status or experiences with homelessness are likely being undercounted. The CHAS is only administered to those with home mailing addresses and is only offered in English and Spanish, which means this data excludes people experiencing homelessness and people who speak neither English nor Spanish, two groups that are likely to need culturally responsive care.

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Intersectionality in Health Care

Nearly three out of four people who needed culturally responsive care reported that more than one characteristic affected the care they needed; more than half reported at least three. Some Coloradans identified six or more characteristics that made a difference in the care they needed (see Figure 1).

How the Colorado Health Access Survey Defines Culturally Responsive Care and Discrimination

To understand Coloradans’ need for culturally responsive care, CHI asked the following questions in a series. This brief defined those who answered “yes” to the first question as needing culturally responsive care. Our definition of culture is expansive and includes socioeconomic factors and personal histories that can guide health decisions.

• Does your language, race, religion, ethnic background, culture, gender identity, sexual orientation, disability, or other personal history, such as domestic violence or refugee status, make a difference in the kind of health care you need?
• Which of the following makes a difference in the kind of care you need: language other than English; race; religion; ethnic background or culture; gender identity; sexual orientation; a disability or physical, mental, or cognitive condition; experience with violence or abuse (such as domestic violence); experience with homelessness; asylum seeker or refugee status; other (specify)? Respondents could choose as many responses as they felt appropriate.
• In the last 12 months, have all of your health care providers met those needs?
• Thinking back to the health care providers who did not meet your needs, did your experience with them impact your ability to get the care you needed or the quality of care you received?
• The CHAS also asked respondents who were 18 and older about discrimination in the health system. While this concept is related to culturally responsive care, this question focused on experiences in the health care system, as opposed to health care needs. The question was:
• In the last 12 months when seeking health care, did you feel you were treated with less respect or received services that were not as good as what other people get?

These overlapping experiences and identities affect the type of care people needed. One common set of factors that combined to affect the health care Coloradans needed is language, culture, and race. Of people who said that the language they speak affected their health care needs, 43.5% also reported needing culturally responsive care due to their culture and 38.3% due to their race.

The most common reason people reported needing culturally responsive care on the 2021 CHAS was a disability. Of this group, 39.6% reported that their history with abuse or violence affected the care needed and an additional 22.1% reported sexual orientation also affected their health care needs. Some people who needed culturally responsive care due to a disability also reported that their gender identity (17.5%) or their experiences with homelessness (15.2%) affected their needed care.

To offer comprehensive culturally responsive care, providers need to incorporate intersectionality — the notion that different identities can overlap and interact to create unique experiences, such as privilege, disadvantage, or discrimination — when providing care to patients, understanding that many dynamics shape their patients’ experiences and needs.

In the United States, people with disabilities are disproportionately likely to be victims of abuse or to experience homelessness. The same is true for LGBTQ people, particularly youth and youth of color. Providers need to be aware that their patients’ experiences affect the care they need and their perceptions of or trust in the health care system. Similarly, in treating LGBTQ Coloradans with disabilities, doctors providing intersectional, culturally responsive health care must consider not only how sexual orientation and disability can independently impact patients’ health care needs but also how those overlapping identities can affect the care that patients need. For instance, research has found that LGBTQ patients with disabilities often face additional difficulties within the health care system because they have to “come out” multiple times to providers — by explaining both their disability and their sexual orientation — and navigate multiple identities when seeking care.

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Culturally Responsive Care and Income

People who had household incomes at or below 200% of the Federal Poverty Level (FPL) — or $53,000 for a family of four in 2021 — were almost twice as likely to report needing culturally responsive care (10.5%) as those with incomes above 200% (5.9%). This difference held true when income level was further broken down (see Figure 2).

The most common characteristics that affected care for Coloradans with incomes under 200% of the FPL were disability (63.0%), experiences with violence or abuse (29.8%), language (28.8%), and culture (22.4%).

The cutoff for many government aid programs is around 200% of the FPL. For instance, benefits for the Supplemental Nutrition Assistance Program (SNAP), which was previously called the Food Stamp Program, generally cut off at 200%, and the Child Health Plan Plus (CHP+) covers those with household incomes up to 260% of the FPL. Furthermore, Health First Colorado, the state’s Medicaid program, caps income-based eligibility at 138% of the FPL. Many lower-income Coloradans receive benefits through some or all of these programs, and they are disproportionately likely to need culturally responsive care.

This means that safety net providers — or other providers who know they are working with Medicaid, CHP+, and SNAP patients — need to be aware that their patients are disproportionately likely to need culturally responsive care. Although the CHAS did not ask Coloradans whether their income affected the care that they needed, income likely does affect these Coloradans’ experiences within the health care system and the care that they need.

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Who Receives Culturally Responsive Care?

In Colorado, most people who needed culturally responsive care (74.8%) reported that providers met those needs in the past year. Still, more than a quarter of people who needed culturally responsive care — over 71,000 Coloradans — did not receive that care (25.2%). Nearly all of these Coloradans (93.9%) reported that not having their needs met affected the quality of care they received (see Figure 3).

Culturally Responsive Care and Discrimination

Adults who needed culturally responsive care, whether or not they received it, were more likely to report receiving disrespectful or lower-quality treatment in the past year (20.1%) than those who did not need it (2.2%) (see Figure 4).

The CHAS also asked Coloradans whether they skipped care because they were afraid of receiving unfair treatment. Nearly one-fifth of Coloradans who needed culturally responsive care reported skipping care due to fear of unfair treatment (see Figure 5).

The cutoff for many government aid programs is around 200% of the FPL. For instance, benefits for the Supplemental Nutrition Assistance Program (SNAP), which was previously called the Food Stamp Program, generally cut off at 200%, and the Child Health Plan Plus (CHP+) covers those with household incomes up to 260% of the FPL. Furthermore, Health First Colorado, the state’s Medicaid program, caps income-based eligibility at 138% of the FPL. Many lower-income Coloradans receive benefits through some or all of these programs, and they are disproportionately likely to need culturally responsive care.

This means that safety net providers — or other providers who know they are working with Medicaid, CHP+, and SNAP patients — need to be aware that their patients are disproportionately likely to need culturally responsive care. Although the CHAS did not ask Coloradans whether their income affected the care that they needed, income likely does affect these Coloradans’ experiences within the health care system and the care that they need.

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Policy Implications

Colorado policymakers have prioritized ensuring that Colorado has a culturally and trauma-responsive health care workforce in recent years. In 2021, policymakers passed the Colorado Option (HB21-1232), which required the Division of Insurance (DOI) to ensure that all carriers offering a Colorado Option Standardized Health Benefit Plan develop a provider network that is culturally responsive and representative of the community it serves. Although this work is still in its early stages, the DOI has created regulations directly informed by the experiences of people who need culturally responsive care. These regulations require carriers to prove that their networks are culturally responsive, which may include diverse workforces; training in cultural competency for providers, front office staff, and customer service representatives; enhanced language access requirements; and availability to see patients outside traditional business hours.

This year, the legislature passed HB22-1267, which allocates $900,000 in grant funding for nonprofits and statewide provider associations — such as the Colorado Pharmacists Association — to develop trainings on culturally responsive care with a focus on intersectionality. However, for these trainings to truly be successful, they will need to be developed or strongly informed by patients who need culturally responsive care.

Outside the legislative arena, certain health systems, particularly safety net clinics, have taken steps to expand their hours outside of traditional work hours, proactively hire multilingual providers and translators, provide trauma-responsive victim services, educate providers about a range of healing practices, create more inclusive patient forms and portals, and employ peer navigators and community health workers with whom patients may be more comfortable. Other clinics have worked to build trust by engaging with community leaders, such as church and temple leaders, and hiring providers who are culturally reflective of the patients they serve. Safety net clinics have often pioneered these services and approaches because of their considerable experience working with patients who need culturally responsive care. In their efforts to provide more culturally responsive care, other providers and health systems may choose to emulate these safety net clinics.

Providing culturally responsive care is an ongoing, evolving process that requires health care staff and providers to learn and use new information and skills. Next steps may include encouraging medical providers, other service providers, and other health care staff to participate in trainings and incorporate culturally responsive practices into their daily patient interactions. Policymakers may also want to take steps to educate and develop a more diverse workforce, one which is reflective of and responsive to all Coloradans. This can include not only updating medical education but also moving upstream to recruit diverse Coloradans to medical school and other health education programs. It will be important to evaluate whether these efforts improve patients’ health care experiences and reduce health disparities. These efforts are more likely to be successful if they center the voices and experiences of patients who need culturally responsive care.

Conclusion

Colorado is a diverse state, which means that the health care system must be prepared to respond to a diverse range of needs. People’s lived experiences and identities are integral to how they experience health and their interactions with the health care system.

The CHAS suggests that Coloradans are not always receiving care that matches their needs. This analysis also suggests that, by understanding how people’s various identities and characteristics interact to inform their experiences with the health care system, providers and health systems can build trust and ultimately reduce health disparities. It is essential that policymakers and providers prioritize trainings and systems changes that promote culturally responsive care, so that all Coloradans have access to care that supports their health and well-being.

Karam Ahmad, Jeff Bontrager, Lindsey Whittington, and Jackie Zubrzycki contributed to this report