Race and Health Care in America

National

A person without stable housing doesn't have a place to keep insulin cold. A person without a car may not be able to get to the doctor until it's an emergency. A low-wage worker is less likely to have health insurance, and therefore more likely to skimp on care they might need.

The big picture: The American health care system delivers far better results for white patients than it does for people of color, and those health disparities are in large part a reflection of broader social and economic inequality.

By the numbers: Structural barriers have created a stark racial divide in Americans' health, at every stage of life.

A Native American child is twice as likely as a white child to die in infancy. Read more about systemic disparities in infant health. 

Lack of health care and healthy food make Black and Indigenous children in the nation’s most disadvantaged counties five times as likely to die as children in other areas of the country. Read more about child health. 

The share of uninsured Hispanic Americans is 2.5 times higher than the share of uninsured white Americans, and Black Americans' lifespans, on average, are six years shorter than white Americans. Read more about adult health. 

Some of America’s health inequity stems from problems discretely within the health care system: Hospitals that primarily serve communities of color, for example, tend to be poorer and often provide lower-quality care.

But many of the differences spill into the health care system from the outside world: They're baked in before a patient ever sets foot inside a hospital or a doctor’s office. 

The coronavirus pandemic has provided a clear example of how quickly social economic disparities become health disparities, and how that profoundly unequal system just keeps perpetuating itself. 

Black, Hispanic and Native Americans suffered disproportionately in the pandemic’s early days because it attacked those with the weakest societal safety nets, including frontline workers, multigenerational households, inmates and homeless people.

The virus isn't racist. But a broader economic system that consistently puts people of color into more vulnerable positions in society will also consistently put their health at risk.

What’s next: This is a many-systems problem with no easy solution, but experts and policymakers are increasingly attuned to “social determinants of health" — factors like income, nutrition and housing that affect our health both directly and indirectly.

How it works: Some of those effects are simple and straightforward: A person living in dirty housing is more likely to encounter lead, mold or other toxins. 

Other effects are more complex: A growing body of research has found a correlation between health outcomes and neighborhood amenities such as parks and mass transit. Having fewer abandoned buildings and more bike lanes helps reduce injuries; having more grocery stores can improve nutrition. 

The results seem clear: In Oregon, moving Medicaid recipients into stable, affordable housing led to a big increase in primary-care visits, a big drop in emergency room visits, and significant improvements in both access to care and the quality of that care.

The bottom line: The health care system collects the effects of systemic racism in housing, transportation, employment and many other facets of American life. And  because those systems are so deeply unequal, people of color experience worse health outcomes, on average, from childhood all the way through to old age.

Join Axios' Mike Allen and Hope King on Tuesday at 12:30 p.m. ET for a Hard Truths event on systemic racism in health care, featuring White House senior adviser Andy Slavitt, White House senior policy adviser Cameron Webb and California Surgeon General Nadine Burke Harris. 

1. The health care system collects the effects of racism

The coronavirus pandemic has provided a clear example of how quickly social economic disparities become health disparities.

Illustration of a baby's hand holding an elderly hand, with a circle and an EKG-like line in the background

Deep Dive: Hard Truths – Health Care

Latin America and Latinos

A person without stable housing doesn&#x27;t have a place to keep insulin cold. A person without a car may not be able to get to the doctor until it&#x27;s an emergency. A low-wage worker is less likely to have health insurance, and therefore more likely to skimp on care they might need.The big picture: The American health care system delivers far better results for white patients than it does for people of color, and those health disparities are in large part a reflection of broader social and economic inequality.

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

Photos via Getty Images; Graphic: Aïda Amer/Axios

2. A timeline of health care disparities

Earlier this year, the CDC called racism a "serious threat" to public health.

Photo illustration of archival imagery on the topic of POC and healthcare. 

Illustration: Aïda Amer/Axios. Photos: H. Armstrong Roberts (ClassicStock), Universal History Archive (Universal Images Group), Archive Photos/Getty Images

<div><figure><div id="av-2021-04-12-ht-timeline-SJHMI" style="max-width:100%"><img alt="Photos via Getty Images; Graphic: Aïda Amer/Axios" class="axios-visual-newsletter-fallback-image" src="https://graphics.axios.com/2021-04-12-ht-timeline/fallbacks/2021-04-12-ht-timeline-fallback.png" width="1200" height="3044"/><img alt="Photos via Getty Images; Graphic: Aïda Amer/Axios" class="axios-visual-apple-fallback-image" src="https://graphics.axios.com/2021-04-12-ht-timeline/fallbacks/2021-04-12-ht-timeline-apple.png" width="750" height="2980"/></div><figcaption>Photos via Getty Images; Graphic: Aïda Amer/Axios</figcaption></figure></div>Join Axios&#x27; Mike Allen and Hope King on Tuesday at 12:30 p.m. ET for a Hard Truths event on systemic racism in health care, featuring White House senior adviser Andy Slavitt, White House senior policy adviser Cameron Webb and California Surgeon General Nadine Burke Harris. <ul><li>Register <a class="gtmContentClick" data-vars-link-text="here" data-vars-click-url="https://hardtruthshealthcare.splashthat.com/?utm_source=events&amp;utm_medium=email" data-vars-content-id="45f3764a-03d2-4a2e-8bee-90e49ec69f18" data-vars-headline="A timeline of health care disparities" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://hardtruthshealthcare.splashthat.com/?utm_source=events&amp;utm_medium=email" target="_blank">here</a>.</li></ul>

Racial disparities have been a constant problem in maternal health care, from rising death rates to the threat of severe COVID-19 among pregnant women. But now experts are hopeful that telehealth can help narrow those disparities.

Why it matters: It's not a complete solution to the racial barriers women of color face. But some experts are optimistic that telehealth — long-distance health care through videoconferences and other technology — can help reduce those barriers by offering flexibility in appointments and better access to diverse providers.

"It is quite remarkable to me how much of a silver lining this has turned out to be for women of color in this space," Ian Hill, senior fellow at the Urban Institute, said of telehealth. "There’s a lot more focus on this issue than there was before, which is great."

The big picture: From sweeping state laws that limit access to reproductive care, to dismissiveness and lack of compassion from their health care providers, the concerns of women of color are often ignored.

In several interviews, pregnant women of color in Fresno, Oakland and San Francisco reported disrespectful treatment from their health care providers — including racism and discrimination — as well as stressful interactions with health care staff and a lack of information, a study shows.

Another study found that women of color reported higher rates of mistreatment by health care providers — like being shouted at or scolded — and that providers were more likely to ignore their pain and anxiety. 

By the numbers: The U.S. had the highest maternal death rate among 11 developed countries in a recent study by the Commonwealth Fund, and it is one of the only countries where the rate is rising significantly.

In 2019, the maternal death rate for Black women was about 2.5 times the rate of white women and 3.5 times higher than Hispanic women, according to the Centers for Disease Control and Prevention’s most recent data. 

What's happening: All 50 states have temporarily or permanently expanded telehealth coverage for Medicaid patients — texting, in-app messaging and video calls — since the pandemic started.

More than 65% of both Black women and Indigenous women and 60% of Hispanic women were covered by Medicaid when they gave birth in 2018.

Data shows pregnant women are at higher risk of developing severe COVID-19. The risk of exposure is five times greater among Black and Hispanic pregnant women. 

The Urban Institute published a brief in October that outlined examples of how states, private insurers and other organizations have tried to address virtual maternal care during the pandemic, especially for women of color.

Alternative providers such as doulas and midwives, who have been shown to be more empathetic and improve health outcomes for pregnant women of color, are now covered virtually, researcher Emmy Burroughs tells Axios.

What's next: There is interest in seeing how "telehealth and technology platforms overall in this space can be used to address power dynamics" in maternal care, said Kimberly Seals Allers, founder of Irth, a Yelp-like ratings app that launched this year to help Black and brown women rate their care. 

"Hospitals wait until someone dies, they have a maternal mortality review board and then they try to fix this from the grave," Seals Allers said. "We’re trying to do something different."

Yes, but: Several experts say expansion of virtual care won't solve every issue in Black and brown mothers' encounters with racist treatment from health care providers.

Language barriers, access to birth control and mistrust of technology are still hindrances that prevent some pregnant women from using these services. 

3. Telehealth brings moms-to-be improved care

Providers see a a slight silver lining in how virtual care can better serve those systemically ignored.

Public health

Coronavirus

Racial disparities have been a constant problem in maternal health care, from rising death rates to the threat of severe COVID-19 among pregnant women. But now experts are hopeful that telehealth can help narrow those disparities.Why it matters: It&#x27;s not a complete solution to the racial barriers women of color face. But some experts are optimistic that telehealth — long-distance health care through videoconferences and other technology — can help reduce those barriers by offering flexibility in appointments and better access to diverse providers.

Living in the nation's poorest, most rural communities can be a death sentence for African American and Native American children. 

Why it matters: Lack of health care and healthy food make Black and indigenous children in the nation’s most disadvantaged counties five times as likely to die as children in other areas of the country, the advocacy group Save the Children found after analyzing federal data.

Two Mexican American children, a girl on the left and a boy on the right, wait for services in a health clinic. 

Mexican American children wait for health care services at Centro De Salud Familiar La Fe in El Paso, Texas. Photo: Russell Contreras/Axios

The details: The poorest families were coping with stress, debt and hunger before the coronavirus pandemic. The outbreak and resulting job losses have stretched millions of families close to the breaking point this past year. 

Families struggling with poverty or underemployment often lack access to health insurance coverage.

Their rural areas and urban enclaves don't have access to quality health care technology and services, advocates say. 

Black and Latino children entering emergency rooms are less likely than white children to receive X-rays, CT scans and other diagnostic imaging tests, according to a 2021 JAMA Network Open study — meaning serious problems could go overlooked.

About 1 in 5 families don't have enough to eat, and 1 in 3 families have had trouble affording medical care, the latest Save the Children's 2021 Child Protection Ranking found. 

Black and Hispanic families are more likely to not have enough food or money to cover housing costs — or the right tools for kids to learn remotely.

54% of rural households with children report they have experienced serious problems caring for their kids, including keeping their children's education going, helping them adjust to major life changes and finding space for physical activity. 

What they're saying: "Our people are too poor for the Affordable Care Act ... but too rich for Texas Medicaid. So you fall in the middle, which means you're uninsurable. Not uninsured, but uninsurable," Jorge Salazar of Centro de Salud Familiar La Fe in El Paso, Texas, told Axios.

Centro de Salud Familiar La Fe, a network of health clinics, serves a predominantly Hispanic area where the median family income is $14,019 a year. That's only 33% of the median income of El Paso County, which is already one of the lowest in the state. 

The network tries to fight disparities through preventive care education via its federally funded community health clinics. It doesn't turn away patients seeking their services as long as there's room.

Amanda Larson who has no running water at her home, carries water for her son Gary Jr. to have a bath in the Covid-19 virus affected Navajo Nation town of Thoreau in New Mexico.

Amanda Larson, who has no running water, carries water for her son Gary Jr. to have a bath in the COVID-19 affected Navajo Nation town of Thoreau, N.M. Photo: Mark Ralston/AFP via Getty Images

Yes, but: A lack of transportation and long distances to affordable health clinics prevent some poor families from receiving routine checkups or basic care.

Residents on the Navajo Nation in Arizona and the Oglala Sioux Tribe in South Dakota have to travel for hours to receive treatment at a clinic. 

An Axios reporter followed a 30-year-old Mexican immigrant mother as she tried to take her four children to dental appointments at Centro de Salud Familiar La Fe on a day off from cleaning houses and offices.

The car-less mother, with children ranging in age from 14 to 2, struggled to find a ride-sharing service that could take her whole family and then had to wait in traffic as trailer trucks from nearby businesses and border crossings clogged up the streets. She arrived late, but the clinic made room for the children.

"I have to work. I can't afford to take any days off," she told an Axios reporter in Spanish, as she tried to get her children to wait calmly. "But I know their health is important."

4. Health disparities hit rural children of color hardest

Lack of health care and healthy food can be a death sentence for African American and Native American children.

Photo illustration of two children playing doctor

Photo illustration: Annelise Capossela/Classicstock/Getty Images

Living in the nation&#x27;s poorest, most rural communities can be a death sentence for African American and Native American children. Why it matters: Lack of health care and healthy food make Black and indigenous children in the nation’s most disadvantaged counties five times as likely to die as children in other areas of the country, the <a class="gtmContentClick" data-vars-link-text="advocacy group Save the Children" data-vars-click-url="https://www.savethechildren.org/us/about-us/media-and-news/2020-press-releases/americas-most-disadvantaged-counties-for-kids#:~:text=This%20year&#x27;s%20Childhood%20Report%2C%20titled,deaths%20by%20homicide%20and%20suicide." data-vars-content-id="bb453829-a6e0-4f26-a000-7399514ff73f" data-vars-headline="Health disparities hit rural children of color hardest" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.savethechildren.org/us/about-us/media-and-news/2020-press-releases/americas-most-disadvantaged-counties-for-kids#:~:text=This%20year&#x27;s%20Childhood%20Report%2C%20titled,deaths%20by%20homicide%20and%20suicide." target="_blank">advocacy group Save the Children</a> found after analyzing federal data.

While the COVID-19 pandemic has exposed serious disparities in access to health care, those differences were baked deep into the American health system long before the coronavirus came along.

Why it matters: These systemic disparities are partly why people of color are more likely to be uninsured and face increased risks for certain chronic conditions — and even have shorter life expectancies.

By the numbers: In 2019 — before the pandemic hit — 11% of Americans under 65 were uninsured, per KFF. Diving a little deeper...

8% of white Americans and 7% of Asians/Native Hawaiians and Pacific Islanders didn't have coverage, compared with 22% of American Indians/Alaskan Natives, 20% of Hispanics and 11% of Black Americans.

The Affordable Care Act helped reduce uninsured rates among people of color, but stark disparities with white people persist, per KFF, especially in states that didn't expand Medicaid. 

Data is not yet available to determine COVID's exact impact, but "we do know the dislocation resulting from the pandemic has exacerbated economic inequities, so it has likely exacerbated health coverage inequities as well," KFF's Larry Levitt says. 

There are also stark racial divides in where people get their coverage. 

Nearly two-thirds of white Americans get their health insurance through their employer. The same is true of only 47% of Black Americans, 43% of Hispanics and 37% of American Indians/Alaskan Natives.

Medicaid, which is usually free, often covers more benefits than employer insurance but may have limited networks of doctors and hospitals.

15% of nonelderly white Americans are covered by Medicaid, compared with 33% of Black Americans and 30% of Hispanics, per KFF.

But those figures can undersell the severity of the disparities in access to care, which is fundamentally an affordability issue. 

More generous coverage is often more expensive. Millions of insured Americans have high out-of-pocket costs, such as deductibles or copays, that they can't afford. 

In 2019, 11% of white adults reported having skipped seeing a doctor over the last year because of cost, whereas 16% of Black adults and 21% of Hispanic adults said the same.

Between the lines: America's health care system — insurers, doctors, hospitals and drug companies — is a business aiming for profitability and happy shareholders. When certain areas don't yield a profit, services can disappear. 

Pharmacies have closed less-profitable stores in poor neighborhoods, creating "pharmacy deserts" that make it harder to fill prescriptions. 

Disparities in the quality of care are often found, too. Black patients tend to receive care at lower-performing hospitals than white patients, even when they live in the same hospital market, a study published last year in NBER found. 

Data: Kaiser Family Foundation analysis of 2018 Behavioral Risk Factor Surveillance System; Chart: Will Chase/Axios

Poor health care contributes to racial and ethnic disparities in health outcomes, too.

People of color are generally more likely to report being in "fair or poor health" than white people, per KFF. 

They also have higher rates of certain underlying health conditions — like HIV,  diabetes and heart disease in Black people — some of which contributed to a higher risk of severe COVID-19. 

The gap in life expectancies between white and Black Americans had generally been shrinking since the 1990s — but the pandemic may have stalled that progress.

In 2019, Hispanic Americans had a life expectancy of 81.8 years, white Americans of 78.8 years and Black Americans of 74.7 years, per the CDC. 

The pandemic caused life expectancy to drop for all three groups, but more for Hispanic and Black Americans than white Americans.

The pandemic also highlighted the vulnerability of Native Americans, who had the highest death rates of all.

5. Less health insurance and more chronic disease

America's health care system — insurers, doctors, hospitals and drug companies — is a business aiming for profitability and happy shareholders.

Photo illustration of a doctor's hands measuring the blood pressure of a patient

Photo illustration: Annelise Capossela. Photo: H. Armstrong Roberts/ClassicStock/Getty Images

While the COVID-19 pandemic has exposed serious disparities in access to health care, those differences were baked deep into the American health system long before the coronavirus came along.Why it matters: These systemic disparities are partly why people of color are more likely to be uninsured and face increased risks for certain chronic conditions — and even have shorter life expectancies.

Race and criminal justice in America

“Equal justice” is carved into the U.S. Supreme Court. But from higher arrest rates to stiffer prison sentences, people of color face harsher treatment in the criminal justice system.

From from higher arrest rates to stiffer prison sentences, equal justice eludes Americans of color.

Photo illustration of handcuffs and two police officers.

Photo Illustration: Shoshana Gordon/Axios. Photo: Kent Nishimura/Los Angeles Times via Getty Images

Deep Dive: Hard Truths - Criminal Justice

“Equal justice” is carved into the U.S. Supreme Court. But from higher arrest rates to stiffer prison sentences, people of color face harsher treatment in the criminal justice system.

Maternal mortality by race/ethnicity

Telehealth brings moms-to-be improved care

Illustration of a hand with an I.V. with yellow crosses around it