How Has 20th Century Health Policy Affected Racial Health Disparities?

Landmark civil rights legislation that instituted Medicare and Medicaid was instrumental in closing racial health disparities in care utilization, according to new data in JAMA Network Open. But those improvements only lasted for a few years before gaps in care widened to historical levels, calling into question current health policy debates around health equity, researchers said.

Currently, White people typically receive more healthcare than Black people, a paradoxical trend, the researchers said, considering inequities in disease burden that disproportionately impact populations of color.

“Black people in the US have higher rates of chronic conditions, such as diabetes and hypertension, and shorter life expectancy than their White counterparts,” they wrote in the study’s introduction. “Hence, ambulatory medical care use, if allocated solely based on need, would be higher for Black people.”

But data shows that’s not the case, the researchers continued. Again, White people are more likely to access dental and ambulatory care than Black people. That trend has existed for centuries, they added, with healthcare access being particularly cost-prohibitive for Black people before Civil Rights-era programs like Medicare and Medicaid were passed into law.

“Before the passage of landmark civil rights legislation and the implementation of Medicare and Medicaid in the mid-1960s, access to medical care was sharply restricted, particularly for Black and poor people,” the researchers said. “Subsequently, de jure segregation in health facilities was outlawed, and gaps in insurance coverage narrowed.”

But continued institutional racism has led to persistent healthcare coverage inequities, the research team added. And through an analysis of 29 US surveys capturing self-reported race and healthcare utilization collected between 1963 and 2019, inequities in insurance coverage have lent themselves to inequities in healthcare access.

Importantly, the analysis showed that policy reforms like Medicare and Medicaid helped close the Black-White gap in healthcare access, at least for some time. From 1963 until the 1970s, the Black-White disparity in ambulatory care visits shrank from 1.2 visits per year to 0.8 visits.

That improvement was seen in healthcare spending, too. From 1963 into the 1970s, the Black-White expenditure ratio shrank from 1.96 to 1.26.

But those gains in health equity did not last long, the analysis showed. From the 1980s onward, the Black-White disparity in ambulatory care visits began to widen to historical levels; by 2019, that gap was 3.2 visits per year, larger than it was before Medicare and Medicaid came into existence.

The same was true for the Black-White expenditure ratio, although to a lesser extent. In the 1980s, the Black-White expenditure ratio reached 1.46. In the years after, the Black-White expenditure ratio hung between 1.31 and 1.39.

“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 said.

“The divergence starting 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).”

Racial disparities in healthcare utilization, particularly the expenditure ratio, could be attributed to under-use by Black people, overuse by White people, or both, the researchers said, although separate data has indicated that underuse is a heavy factor.

That underuse could be linked to high healthcare costs, uninsurance, structural racism, social determinants of health, implicit bias, limited medical workforce diversity, or any combination of these factors.

This assessment outlined the impact that healthcare policymaking can have on healthcare access and health equity; passage of Medicare and Medicaid, as well as other civil rights protections, helped close the gap between White and Black patients.

Further policymaking that could cut down on out-of-pocket patient costs and expand access to comprehensive payer coverage could help close the once-again widening disparities.

But the researchers emphasized cultural change will be central to achieving true Health equity.

“Addressing shortages of Black health care professionals and managers, investing in Black-serving medical facilities, increasing community outreach efforts, and enacting other measures that help earn Black patients’ trust in the health care system could also promote equity,” they concluded. “Healing the persistent racial divide in medical care in the US would contribute to and benefit from measures to mend the social and economic schisms of race.”