Guide on Racism, Inequality, and Health Care for African Americans.

CONTENTS OF THIS ARTICLE

The healthcare system in America has been the subject of debate for decades. While there is no simple solution for all Americans, African Americans and other people of color have been disproportionately underserved and denied access to quality healthcare coverage and care – a disparity that continues today.

African Americans are among the most economically disadvantaged demographics, leading to health issues like food deserts, lack of local healthcare providers, substandard living accommodations, and inaccessible healthcare coverage.

The ACA (Affordable Care Act), enacted in 2010, sought to address unaffordable healthcare coverage and make it accessible to every American through a required expansion of Medicaid in all 50 states. This move ensured that every American making from 100% up to 138% of the federal poverty line (FPL) would qualify for Medicaid coverage, helping to close the gap between the financial qualifications for Medicaid and the often exorbitant cost of private healthcare.

While the implementation of the ACA resulted in 20 million Americans gaining healthcare coverage, the Supreme Court’s 2012 decision essentially made Medicaid expansion optional for states and has led to 12 holdout states deciding to decline that expansion.1

The lack of Medicaid expansion has created a coverage gap for more than 2 million Americans, who have incomes below the federal poverty line but earn too much money to qualify for Medicaid under their individual state’s rules. Some studies estimate that up to 60% of those in the healthcare coverage are people of color.2

The Real Impact of The Coverage Gap

The healthcare coverage gap exists most egregiously in southern states, where the African American population is the highest in the country. Seven of the twelve holdout states, still declining Medicaid expansion, have a 15% or higher African American population.3 These states include Georgia, Florida, South Carolina, North Carolina, Mississippi, Alabama, and Tennessee.

The coverage gap created by many states’ refusal to expand Medicaid affects low-income individuals and families of all races. However, African Americans are the most economically disadvantaged group in the country, and the highest concentrations of African Americans live in the southern states that have declined to expand Medicaid. These facts show a clear picture of the disparities between healthcare access for blacks compared to their white counterparts.

It is not just the decision not to expand Medicaid in these twelve holdout states, as many of them have also proposed oppressive work and community engagement requirements for Medicaid eligibility, a move that the Trump administration supported but has been flatly rejected by the Biden administration.4

There are many examples of the disproportionality of black households compared to others, which further exacerbate the likelihood of falling into the healthcare coverage gap.

One stark example is reported by the US Bureau of Labor Statistics, in which forty-one percent of black households are maintained by women, with no opposite- sex spouse present, a percentage one and a half times higher than single women- led Hispanic households, and nearly four times greater than white households.5

In states that have not expanded Medicaid, households like these are much more likely to fall into the coverage gap because while earnings may still be below the federal poverty line, many southern states cap Medicaid eligibility for parents at about forty percent of the FPL.

Additionally, several states deny Medicaid coverage to any resident without children, regardless of how low his or her income may be.

No doubt expanding Medicaid benefits those whose earnings are below the federal poverty line, and there is a direct connection to the most disadvantaged groups in the country — people of color.

Disparities in Health Outcomes

Health outcomes are changes in health that result from measures of specific health care investments or interventions. These changes are influenced by preventative care, pre-screenings for chronic illnesses like heart disease and diabetes, preventing death after a heart attack, regular physical exams, dental care, mental health resources, and healthy lifestyle education.

There have been drastic disparities in health outcomes for African Americans compared to their non-Hispanic white counterparts for decades. While higher rates of education, higher earnings, and the ACA’s enactment have helped narrow the gap somewhat, the disparities are still glaring.

Why, with all the progress, is there still a massive disparity between the health outcomes of African Americans and white Americans?

This disparity is an issue that has been widely studied and generally agreed upon in the context of broader inequality. In short, institutional and normalized racism has led to medical bias, stereotyping and clinical uncertainty.

Factors like geographical location, access to health providers, and economic status are structural deficiencies in communities of color.

Geographical Location

Some of the most significant health issues facing communities of color are diabetes and other chronic illnesses resulting from poor diet and lack of fresh and healthy foods. More often than not, the culprit is a lack of access to fresh and affordable foods. Locations known as food deserts are high-poverty areas where residents do not have access to supermarkets, farmer’s markets, and other sources for fresh fruits, meats, and vegetables. Food deserts are located in urban and rural areas, and most families in these areas do not have transportation to access distant resources for healthy food.

According to the USDA, the higher the minority population, the more likely the area is to be a food desert in all but very densely populated urban areas. Additionally, the USDA reports that residents in the Northeast are far less likely to live in a food desert than their southern counterparts.6

Many identified food deserts, mostly populated with people of color, lack other vital services and infrastructures like healthcare centers, parks, recreational areas, quality schools, and other learning institutions. All of these deficiencies play a significant role in health outcomes.

Geographical location matters when it comes to environmental health since the air we breathe affects health outcomes. In many low-income areas, one would not need to look far to find super-polluters like diesel engines, power plants, refineries, freight trains, and other sources of air pollution. Breathing in the toxic mix of chemicals unleashed upon low-income and minority communities can lead to asthma, cardiovascular health issues, and cancer.9

The results of geographical location, pollution, and their ties to asthma in African Americans are precise. Black Americans are 1.5 times more likely to have asthma, five times more likely to visit the emergency room due to asthma, and three times more likely to die from asthma. 10

This statistic is yet another result of historical racial discrimination in which low-income and minority neighborhoods are surrounded by industrial areas, truck routes, rail lines, and other areas with high levels of air pollution, all of which have devastating effects on health outcomes.

Healthcare Providers

In many communities of color, a core element of quality health severely lacks – quality primary care providers. Especially in low-income neighborhoods, residents have no more than community health centers, outpatient centers, and hospital emergency rooms for medical care, none of which tend to offer high- quality medical care. Additionally, mental health care is virtually inaccessible in many of these low-income areas.

Most minority, low-income neighborhoods in America lack high-quality healthcare providers and services.

Access to quality healthcare for residents of these areas is often as difficult to access as affordable and healthy food, further disproportionately affecting health outcomes.

Further, trust in a healthcare provider is essential, and studies have shown that patients who trust their doctors are far more likely to follow instructions and keep follow-up appointments. However, with patients who see little more than a nurse on their doctor visits, it is impossible to develop and build trust to inspire and motivate follow-up appointments and follow medical recommendations.

The entire country is entering a healthcare provider shortage on a broader scale, as approximately forty percent of US doctors will be old enough to retire in the next decade.7 The current pipeline for medical students would require an additional 45,000 new doctors to care for the Hispanic community alone in ten years. Additionally, the nation’s upcoming medical force severely lacks persons of color, which ties directly into the trust gap between doctors and patients.

Not only has the retirement-aged American population grown by nearly forty percent, the current physician workforce severely lacks diversity throughout its ranks, from resident doctors to those in positions of influence and leadership.8

Trust in medical professionals is pivotal in improving health outcomes, but mistrust is most pervasive in the retirement-aged and near-elderly African American population. It is not surprising that this population would be so distrusting of the medical community, considering the history between the two.

Many older African Americans either lived through or have direct relatives who experienced gruesome experiments on enslaved people or the audacious Tuskegee syphilis study, in which treatment was withheld from black men so that doctors could study the course of the disease. Many of these family stories and memories significantly contributed to hesitancy over the COVID-19 vaccination.

Between lacking access to quality healthcare, mistrust in the medical community, and implicit bias from the medical community, low-income, elderly, and geographically disadvantaged African Americans often find themselves void of options when it comes to improving their health outcomes.

Chronic Health Conditions Among African Americans

African Americans live longer these days, with the death rate declining some twenty-five percent over seventeen years.11 Yet, African Americans’ overall health and propensity to suffer and die from chronic health conditions is staggering. African Americans are generally at a much higher risk from chronic health conditions. Moreover, much of the cause behind that fact is the same institutional and normalized racism that continues to fuel poor health outcomes for low-income minority demographics in America.

Leading Causes of Death

For the African American population, some of the most common chronic illnesses and causes of death are so pervasive that studies have shown that the black population is more likely to die at early ages from all causes between stroke, diabetes, and high blood pressure.

The leading causes of death for African American males include:

• Heart disease
• Cancer
• Unintentional injuries
• Homicide

Likewise, the leading causes of death for African American females include:

• Heart disease
• Cancer
• Stroke
• Diabetes

Although many illnesses like heart disease and diabetes can be genetic in nature, lifestyle and environmental factors influence these outcomes, even if there is a genetic predisposition present.

Heart disease is the nation’s number one killer across virtually every demographic, but it is present in excessively high percentages in African American men and women. Some of the most common conditions and life influences that can lead to heart disease include obesity, unhealthy diet, physical inactivity, smoking, and excessive alcohol use.

Many of these can be generalized as voluntary lifestyle choices, but if we take a closer look at how segregated housing, food deserts, lack of healthcare access, and pollution have played imperative roles in the health outcomes for African Americans, the perspective skews.

This article has outlined how low-income African Americans and other minorities have been subjected to substandard resources, living environments, and lack access to healthcare for prevention and treatment through service shortage and lack of healthcare coverage.

Low-income minority neighborhoods are often entirely devoid of fresh and affordable foods. Without transportation to get to healthy food options – and the money to afford the often exorbitant cost – options for food are restricted within the neighborhood, which offers no more than corner stores and liquor stores fully stocked with cigarettes, and cheap fast-food restaurants serving up the most unhealthy cuisine. In most low-income neighborhoods, there is no infrastructure with things like recreational centers, parks, playgrounds, and pools for exercise. Furthermore, pollution is rampant, as virtually every low- income, minority neighborhood is surrounded by highways, rail lines, truck routes, and other primary pollutants.

These environmental and racially biased community and housing designs work only to exacerbate and accelerate poor health outcomes with chronic illnesses like heart disease, diabetes, and cancer.

Mental Health

Amidst the numerous challenges that low-income African Americans face with housing, lack of healthcare coverage, low-quality healthcare providers, pollution, and chronic disease, the least discussed and yet among the most dangerous is mental health.

Historically, mental health has not been part of overall health for families across all demographics, but African Americans are among the last and fewest to acknowledge and seek mental health treatment. Despite the massive challenges and struggles facing the African American community, reports show that only one- third of African Americans who need mental health treatment receive it. Much of that is because nearly two-thirds of the black community perceives mental health conditions as a sign of weakness.12

Additionally, in a mental health crisis, most African Americans in low-income areas go to the nearest emergency room due to a lack of mental health providers nearby.

The concept of living the daily life of a black man or woman in America has never been safe or comforting since long before the country was founded in 1776. Every day, the trauma of potential danger or death that has always and continues to follow each African American is enough to necessitate mental health care.

This trauma is further exacerbated by seemingly endless stories of police brutality and misconduct toward black Americans, and housing segregation in communities where poor education, poverty, and crime are daily challenges.

There is little accurate data on the mental health status or treatment for African Americans because of the black community’s stigma on mental health issues. Why there is such a negative stigma is arguable, but the most robust running theory is that, since being captured and brought to this country, black people have been forced to survive the constant barrage of assaults launched upon them, whether physical or institutional, or economic – leaving little opportunity to focus on mental health. While much progress has been made, it may yet take more time before mental health takes its place as an integral part of improved health outcomes in America for African Americans. An ideal healthcare system is still unrealized, but implicit bias and racism challenging African Americans and other people of color must be acknowledged and confronted to work for all Americans.

1. Supreme Court of the United States, National Federation of Independent Business v Sebelius
2. Center on Budget and Policy Priorities “Closing Medicaid Coverage Gap Would Help Diverse Group and Narrow Racial Disparities“,
3. KFF, Health Coverage by Race and Ethnicity, 20120-2019
4. National Academy for State Health Policy, State Proposals for Medicaid Work and Community Engagement Requirements
5. US Bureau of Labor Statistics, Labor Force Characteristics by Race and Ethnicity
6. USDA, Characteristics and Influential Factors of Food Deserts
7. USA Today, US Doctor Shortage Worsens as Efforts to Recruit Black and Latino Students Stall
8. AAMC, The Complexities of Physician Supply and Demand
9. National Library of Medicine, Fine Particulate Matter constituents and cardiopulmonary mortality
10. Asthma and Allergy Foundation of America, Asthma Disparities in America
11. Center for Disease Control and Prevention, African American Health
12. NAMI, The Effects of Racial Trauma on Mental Health

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