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Long-Standing Racial Gaps in Health Care Are Widening

U Texas/Harvard/CUNY/Public Citizen study finds less funding for care, fewer doctor visits for Black Americans; inequities narrowed in the 60s and 70s, started growing in the Reagan era, reached record levels by 2019

WASHINGTON, D.C. – Black Americans receive much less care than their white counterparts, whether measured by doctor visits or by spending for their care, and the gap has grown in recent years according to a study appearing today in JAMA Network Open conducted by researchers at the University of Texas, Harvard University, The City University of New York, and Public Citizen. The study, which assessed health care use going back to 1963, found that since 2014 white Americans have been receiving, on average, 3.2 more doctor visits per year than Black Americans, the largest gap on record. Per-person expenditures for care each year (by insurers, public agencies and patients) are $1,880 lower for Black people compared to white people.

The Black-white health care gaps narrowed after the passage of Medicare, Medicaid, and civil rights protections (including the desegregation of U.S. hospitals) in the mid-1960s. However, the trend toward equality in health care use reversed in the Reagan era (the early 1980s), and disparities have remained stubbornly high. For instance, in 1963, Black people averaged 1.2 fewer doctor visits than their white counterparts, a gap that narrowed to 0.8 fewer visits per year in the 1970s before climbing to the current gap of 3.2 visits.

The authors found lower use of care by Black persons in all age, gender, and insurance subgroups, although gaps were smallest among people of Medicare age (65 or older). The disparities persisted when they controlled for age, sex, and health status. Even among those with private insurance, Black enrollees now average 2.6 fewer doctor visits annually; the racial gap was 4.9 among Medicaid enrollees.

The study found that Black people use slightly more emergency department visits and hospital days, but these differences were too small to offset Black Americans’ deficits in other kinds of care.

The researchers harmonized and analyzed data collected in 29 federal health surveys of 601,803 people conducted between 1963 and 2019. Although the surveys evolved over time, all included information on doctor visits and total costs of the care received, as well as each respondent’s age, gender and race.

The authors concluded that insurance and income differences explain part, but not all, of the Black-white gap in care. Issues like historical mistreatment of Black people by the health care system, racially biased referral patterns by physicians’ offices, and a shortage of Black physicians likely also play a role.

“In health care, progress toward racial equality hasn’t just stopped, it’s been reversed,” said study author Samuel Dickman, MD, a researcher at University of Texas at Austin and physician at Planned Parenthood. “In Southern states where millions of Black people are uninsured, Republican politicians have refused to accept the Affordable Care Act’s Medicaid expansion, widening racial gaps. Equalizing coverage is essential. But we also need to fix the underfunding of hospitals and clinics in Black neighborhoods, medical schools’ unwillingness to train sufficient numbers of Black physicians, and the racist attitudes that persist in many medical institutions and make Black patients feel unwelcome. It adds up to an insidious form of structural racism in the healthcare system.”

Study co-author Alecia McGregor, an assistant professor at the Harvard TH Chan School of Public Health noted, “It’s outrageous that Black people get the least care despite facing some of the greatest risks for adverse health outcomes across the board. But the trends we found tell us how to create a fairer health care system. Civil Rights-era reforms reduced poverty, narrowed health disparities, and enhanced equity, but policies and court decisions since 1980 have undermined social programs, racial justice and voting rights, and exacerbated health inequities. Health care equity – or inequity – is a policy choice.”

Senior author Dr. Steffie Woolhandler, a distinguished professor at CUNY’s Hunter College, lecturer in medicine at Harvard Medical School, and research associate for Public Citizen’s Health Research Group said, “Black patients get the least care and the worst care. Medicare for all reform is the essential first step to health care equity.”