Race v. class when addressing disparities
A new study documents dramatic disparities in health outcomes for different ethnic and racial groups. But is pouring more money into the health care system the answer?
The Commonwealth Fund today released a new report documenting the wide disparities in health outcomes for America’s major ethnic and racial groups. Not much has changed over the two decades that TCF has conducted such studies. Blacks and Hispanics have less access to care, receive lower quality care, and suffer worse health outcomes when compared to whites and Asian-Americans.
The study provided a state-by-state analysis of health system performance based on 25 measures of access, quality and outcomes. Even in the states with the best composite scores, where every group did better than the national average (Rhode Island, Massachusetts and Connecticut led the pack), whites scored nearly twice as high as the national average while Blacks and Hispanics trailed their state co-inhabitants by 20 to 30 points on the study’s 100-point scale.
In the worst performing states — Oklahoma, Arkansas, West Virginia and Mississippi — no group, not even whites, equaled the national average on care access, quality and outcomes. Yet Blacks and Hispanics in those states still lagged 20 points or more behind their white co-residents.
The think tank scholars who authored the report offered a range of policy options for reducing racial health disparities in the U.S. First and foremost: Move rapidly. to universal health care coverage, which will give minorities better access to a system where 25 million people remain uninsured. Under-insurance — where patients are left with huge co-pays and, all too frequently, medical debts — also prevents a disproportionate number of people in America’s minority communities from receiving adequate care in a timely manner.
They called for a reinvigorated primary care system so that more individuals from minority groups gain access to preventive care, routine screening to catch serious problems early, and better coordinated specialist care. They also called for training and hiring more minority physicians and other health professionals, who will be better equipped than their white counterparts to handle the distrust that keeps many members of minority communities from accessing the system.
“You can’t have quality without addressing equity,” said Laurie Zephyrin, senior vice president for advancing health equity.
True enough. But what is the best way to redress inequity?
The implicit answer from the Commonwealth Fund’s study is that the health care system needs to do a better job at creating programs that address the specific health needs of minority groups. But will that be sufficient and is it achievable politically?
The states with the worst performance overall and, in several cases, the worst disparities in health outcomes also ranked among the poorest states in America. They are also far more rural than the best-performing states, have smaller minority populations, and, if MAGA-Republican dominated, failed to expand Medicaid.
A recent study by the U.S. Agriculture Department found the early mortality rate for the working-age population (under 54) was 43 percent higher in rural areas than in urban areas, thanks to so-called deaths of despair (drug overdoses, suicides and gun violence). A quarter century ago, the rates were about equal.
Wealth yields health
If there is one thing we know about America’s lagging performance when it comes to overall population health, it is that health outcomes are closely related to one’s wealth, income and educational status. The better off and more educated you are, the longer and healthier lives you live.
A Black low-wage worker in Massachusetts on Medicaid will get much better health care compared to the impoverished white worker in Oklahoma who has no insurance because the state didn’t expand Medicaid to cover more low-wage workers. But both will probably endure substantially worse health outcomes than someone who went to college, lives in a nice house and has enough money to send the kids to college and save for retirement.
The health inequities that Blacks and Hispanics face closely parallel the inequities in wealth, income and educational attainment that exists among various ethnic groups in the U.S. Here are three charts that document those inequities:
Wealth
Income
Education
After many years of following public policy debates, I have become convinced that in a country as persistently racist at ours, it makes more sense to develop race-neutral programs when seeking to redress inequities. That includes inequities in health outcomes.
Blacks and Hispanics do face injustices in accessing health care. The quality of care they receive from non-minority providers can be inferior. They are often mistreated, their pains dismissed.
Their communities are more likely to spawn disease. They live in areas that are, on average, more polluted. They have less access to food stores that are well-stocked with fresh fruits and vegetables and healthy protein choices. Minorities work at more dangerous jobs, whose daily routines are more likely to lead to chronic back pain and arthritis, lung diseases and stress.
But that can also be said of many communities in the states where white people are faring poorly, or even in the better-performing states where working class communities have been devastated by deindustrialization and the only jobs available are in the poorly-paid service economy comprised of warehouses, big box stores and low-end eating establishments.
The first plank in any platform seeking to redress health inequality should be a set of programs aimed at reducing the levels of income, wealth and education inequality in our society. These programs would benefit all Americans, but they would benefit minority communities the most because they suffer disproportionately from inequality in each of those realms. Making them universal holds out the best hope for making them politically palatable.
Richard Kahlenberg, a non-resident scholar at Georgetown University, has been sounding this theme for many years, as did William Julius Wilson, whose classic work When Work Disappears was published in 1996. As Kahlenberg put it recently in an interview with WBUR radio in Boston: "When we focus exclusively on race and ignore the class issues, we are missing a huge part of what makes society unfair in America today."
Overall, I agree with your conclusion, but it feels like ceding the field to the racists. Of course, concentrating on a class based solution doesn’t prohibit us from looking at specific race-based programs as well – which are necessary:
“Notably, the pregnancy-related mortality rate for Black women who completed college education or higher is 5.2 times higher than the rate for White women with the same educational attainment and 1.6 times higher than the rate for White women with less than a high school diploma.“
https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-maternal-and-infant-health-current-status-and-efforts-to-address-them/#:~:text=Notably%2C%20the%20pregnancy%2Drelated%20mortality,than%20a%20high%20school%20diploma.
Here in Cuyahoga (Cleveland, OH) county there are programs targeted at improving pregnancy outcomes among black women.
https://www.news5cleveland.com/news/local-news/cleveland-hosts-its-first-black-maternal-health-equity-summit
djb
Finland addresses some health issues at school - vaccines, dental, vitamins, food (school breakfast and lunch), mental health (send appropriate workers to home where indicated by student behavior). “Students can’t study or learn if they are sick, hungry, or disturbed.”
One program in Kentucky sends kids home on Friday with a backpack of meals for the weekend.
“Poverty in America” by Matthew Desmond - stores in low-income city neighborhoods - as you say, but also more expensive than what white people pay - if I recall correctly
They always corrected Covid rates by race for age, but I wonder why they don't for median income, or correct family income for number of workers per family.
The average age of whites in the US is 42; 30 for Hispanics (google search) looking at a population pyramid of whites - its because of the boomers.