America is supposed to be the land of opportunity, where everyone has an equal chance to live a healthy life. In reality however, Americans born wealthy and white have a much greater chance of being healthy than those facing poverty and structural racism.
Over the past 20 years, closing these racial health gaps has become a high priority for the government, health care institutions, public health organizations, and foundations. What kind of progress have we made? A series of articles in the Journal of the American Medical Association on health equity paints a sobering picture. Here are a few of the key takeaways:
- Racial gaps in self-reported health haven’t changed since the turn of the century. A cross-sectional study in JAMA found no significant change in the proportion of people that rated their health as “poor” or “fair” between 1999 and 2018, and no change in the racial gap for self-reported health. The largest difference in health was between low-income Black Americans and high-income whites: In 2018, nearly 25% of Black individuals with low income rated their health as poor or fair health, while only 6% of white individuals with middle or high income did the same. While rates of uninsurance dropped because of the Affordable Care Act, there were still significant racial disparities in 2018. About 18% of Hispanic/Latinx individuals and 9% of Black individuals reported being uninsured in 2018, compared to 6% of white individuals.
- People of color have lower health care spending than white people. From 2002-2016, total health care spending per person in the US was higher for white individuals compared to Black, Hispanic/Latinx, American Indian and Alaska Native, or Asian American and Pacific Islander individuals, even adjusting for age and health conditions. Spending for Black, Hispanic/Latinx, and Asian American individuals on ambulatory care was especially low compared to the national average, reflecting barriers to access for primary and preventive care. Recognizing these access gaps is incredibly important. In one case, a widely-used algorithm labeled Black patients as less ill because they had lower rates of health care spending, resulting in these patients getting less of the care they needed.
- Representation of Black medical school faculty has barely budged over the past twenty years. In 1990, 2.68% of faculty at US medical schools identified themselves as Black or African American. In 2020, 3.84% in 2020 identified themselves as Black or African American, an increase of just over 1 percentage point. Obstetrics and gynecology had the largest proportion of Black faculty in 2020 (8.5%), but no specialty was close to the proportion of Black people in the current US population (13.4%).
- Non-white Medicare beneficiaries are more likely to experience worse outcomes than white beneficiaries. In both fee-for-service Medicare and Medicare Advantage, Black, Hispanic/Latinx, American Indian, or Asian American/Pacific Islander individuals were less likely to have access to a primary care clinician as their usual source of care, access to specialist visits, and be vaccinated for flu or pneumonia, compared to white beneficiaries. However, for non-white beneficiaries enrolled in Medicare Advantage, many of these outcomes were better compared to those enrolled in fee-for-service Medicare.
When explaining these disparities, it is essential to put structural racism front and center. Without highlighting the historical context of segregation, discrimination, mistreatment, and policies that created and reinforced these patterns, we risk blaming disparities on those most impacted.
This research shows how far we still have to go to undoing harm from structural racism, and how much we have to invest in community conditions that determine health. The full issue is well worth a read: Take a look at all the articles on the JAMA website.