'Entrenched' racial disparities remain in health care

Racial inequities in health care have fluctuated in severity for decades but data show that one constant remains: the disparities persist.

Samuel L. Dickman, MD, the medical director for primary care at Planned Parenthood South Texas, and colleagues sought to understand how much progress has been made in equalizing health care access in the United States during the past 6 decades. Their findings were published in JAMA Network Open.

“This study’s findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access,” the researchers wrote. “Reform efforts should include training more Black healthcare professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.”

Financial barriers may disproportionately reduce Black people’s use of care, the researchers wrote, considering that more Black adults report skipping care because of cost and that “a much greater percentage of Black than white people in the U.S. are uninsured.”

However, when limiting analyses, racial disparities remained, which “points to factors other than insurance coverage,” according to Dickman and colleagues.

The researchers conducted a repeat cross-sectional analysis using data from 29 U.S. surveys conducted between 1963 and 2019. Based on data from 154,859 Black people and 446,944 white people, Dickman and colleagues found that “disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened.”

“Policy changes are needed to address entrenched racial inequalities in the U.S. healthcare system,” they wrote.

One example of these racial inequities is overall care use, measured in dollars per capita. According to the researchers, white people’s overall health care use exceeded Black people’s every year.

The gap narrowed from $1.96 in the 1960s to $1.26 in the 1970s. Despite this, it widened again and eventually reached its peak at $1.46 in the 1990s. In subsequent periods, the researchers wrote, it remained between $1.31 and $1.39.

From 2014 to 2019, the absolute white-Black expenditure gap per capita was $1,880 — “larger than during any other period,” Dickman and colleagues wrote.

“The white-Black gap in expenditures is at an all-time high, as measured by inflation-adjusted dollars, and both absolute and relative disparities in ambulatory care visit rates are larger today than in 1963,” the researchers wrote. “Now, as in the past, Black people in the U.S. experience a greater burden of ill health, suggesting that care is distributed inversely to need.”

In 1963, the gap in in ambulatory care visits was 1.2 visits per year (95% CI, 1.0-1.4). That number decreased to 0.8 visits per year (95% CI, 0.6-1.0) in the 1970s.

From 2014 to 2019, however, the number increased to 3.2 visits per year (95% CI, 3.0-3.4).

While comparing data from privately insured people aged 18 to 64 years, white people used “far more” ambulatory care than Black people — 2.6 more visits per year (95% CI, 2.4-2.8) — from 2014 to 2019, according to Dickman and colleagues.

In the hospital, Black people spent slightly more days as inpatients (0.09 days; 95% CI, 0.02-0.15) and had slightly more ED visits per year (0.04 visits; 95% CI, 0.03-0.05) compared with white people.

Large disparities also exist in dental care, the researchers found. These increased between the 1970s and 1990s — when white people had 113% and 123% more dental visits — and narrowed to 86% (95% CI, 80-91) in 2014 to 2019.

The researchers wrote that the racial differences “could represent underuse by Black individuals, overuse by white individuals, or both,” although they did connect the disparities to social change.

The widening gaps that the researchers observed in the 1980s “coincided with waning civil rights enforcement, increasing incarceration (especially for Black men), and stagnating Medicaid enrollment and expenditures (as a share of national health expenditures),” the researchers wrote.

“Although observational studies cannot prove causation, the attenuation of disparities in health care use after 1963 coincided with the implementation of Medicare and Medicaid (which outlawed segregation in medical facilities), the advent of community health centers, and new civil rights protections that improved Black individuals’ access to housing, jobs, education, and the ballot box,” the researchers wrote.