Racial inequities persist in health care despite expanded insurance

Two decades ago, only 9% of white Americans rated their health as fair or poor. But 14% of Hispanic Americans characterized their health in those terms, as did nearly 18% of Black Americans.

In recent years, access to care has improved in the wake of the Affordable Care Act, which reduced the number of uninsured Americans across all racial and ethnic groups. But the racial health gap has remained, according to a series of studies published Tuesday in the journal JAMA.

A dismal picture of persistent health disparities in America was described in an issue devoted entirely to inequities in medicine. The wide-ranging issue included research on spending and patterns of care, comparative rates of gestational diabetes and the proportion of Black physicians at medical schools.

The journal's editors committed to a sharper focus on racism in medicine after a controversy in June, in which a staff member seemed to suggest that racism was not a problem in health care. The ensuing criticism led to the resignation of the top editor and culminated with a pledge to increase staff diversity and publish a more inclusive array of papers.

"The topics of racial and ethnic disparities and inequities in medicine and health care are of critical importance," Dr. Phil B. Fontanarosa, interim editor-in-chief of JAMA, said in a statement.

He noted that JAMA has published more than 850 articles on racial and ethnic disparities and inequities.

The new issue offers studies on disparities in the utilization of health care services and in overall health spending. Together, the findings paint a portrait of a nation still plagued by medical haves and have-nots whose ability to benefit from scientific advances varies by race and ethnicity, despite the fact that the ACA greatly expanded insurance.

"We're failing," added Dr. Harlan Krumholz, the study's senior author.

"If our national goals are to improve the population's health and promote more health equity, then we have to admit that whatever we're doing now is not doing the trick," he said. "This should wake us up, and spark us to think of new and better approaches."

Other studies in the journal teased apart factors that may be contributing to the gap, including different patterns of care-seeking. White Americans, for example, are more likely than members of minority groups to visit primary care physicians and specialists in the community, rather than in a hospital or emergency room.

The disparity was seen even when Americans from various racial and ethnic backgrounds shared the same insurance, like Medicare, the government health plan for seniors.

"Access to primary care physicians and specialists in the outpatient setting is really important, because they're managing chronic conditions like diabetes, heart failure, asthma and chronic obstructive pulmonary disease," said Kenton J. Johnston, an associate professor of health management at Saint Louis University and the lead author of the study.

Johnston's study found that minority patients on Medicare have more limited access than white individuals to outpatient health care services.

Despite innovations like Medicare Advantage, which increased access to health care overall, Medicare beneficiaries who are minorities — defined as Black, Hispanic, Native American or Asian-Pacific Islander — still have less access than white or multiracial individuals to a physician who is a regular source of care.

They are also less likely to have influenza and pneumonia vaccinations, and they have more limited access to specialists, the study found.

In Johnston's hometown of St. Louis, as in other cities, fewer health care providers and specialists are found in low-income and minority neighborhoods, which is a function of structural racism and a legacy of residential segregation, Johnston said.

"It's not a question of insurance — it has more to do with the supply side," he added. "If you want to access a good specialist, your choice of cardiologists is going to be different if you live out in the counties that are more affluent versus if you live in the poor areas in northern St. Louis."

Health care spending for Black individuals is $7,361 per year, and a smaller proportion of the funds are spent on outpatient care. The amounts that go to pay for care of Black people in an emergency room and hospital are 12% and 19% higher, respectively, than the nationwide averages.

"This is about poverty, geography and where people live and where primary care clinics are located, and it is about health insurance," said Joseph Dieleman, an associate professor at the Institute for Health Metrics and Evaluation at the University of Washington in Seattle and an author of the study.

But the difference also reflects patient behavior.

"It is also about people's past experiences with the health care system and the quality of care they or their loved ones have received, which leads to hesitation or resistance to accessing health care early," Dieleman said.

The findings may explain some of the disparities in health outcomes, although social and economic factors also play a role, among them poverty, so-called food deserts and neighborhoods that expose residents to pollution and offer few opportunities for physical exercise and recreation.

Overall, Black women face a much higher risk of dying from pregnancy complications than white women, with maternal mortality rates of 41.7 per 100,000 live births for Black women, compared with 13.4 per 100,000 live births for white women.

The disparity persists even when adjusted for factors like age and income, according to an editorial elsewhere in the journal. Black infant mortality rates are also higher, with death rates of 10.62 per 1,000 live births for Black newborns, compared with 4.68 per 1,000 live births for white babies.

Black patients opt for more preventive care when their physician is Black, according to the editorial, and mortality rates for newborns drop sharply when they are cared for by Black physicians.

The proportion of faculty physicians at U.S. medical schools who identified as Black or African American has only slightly increased over the past 30 years, from 2.6% of faculty in 1990 to 3.8% of faculty in 2020, still far less than their proportion of the general population, the editorial said.

The pandemic has highlighted long-standing inequities, taking a greater toll on Black and Hispanic communities. An editorial in the journal noted that the health care system has a long history of racism. Hospitals only desegregated when they were threatened with the loss of federal funds from the Medicaid and Medicare programs, which were enacted in 1966.

"Ending structural racism and inequities in the U.S. health care system has proved to be a challenge," the authors wrote.