Pinpointing one all-encompassing reason why healthcare disparities between racial groups in quality and access persist is as unrealistic as waving a magic wand to find a solution. Examining this phenomenon requires us to consider social determinants of health, the historical structures of racism, and the intersection of several public systems.
Last month, the American Public Health Association led this sort of examination in a webinar about systemic racism and assessing inequitable health outcomes. In the discussion, panelists from the University of Illinois School of Public Health, the National Collaborative for Health Equity, and the Mayo Clinic School of Medicine noted that although the Affordable Care Act has increased insurance coverage within racial groups, disparities between groups remain. The tide of healthcare coverage is rising, but individual social determinants of health (age, race, socioeconomic status, place, gender, disability status, etc.) often overlap to keep folks from being able to “float” to the same level of access and quality.
The intersections of disadvantage in health care outcomes across income, race, and place, for example, are not only social and systemic, but also plagued by the psychology of implicit biases. Healthcare professionals, like the rest of us, are human beings with their own set of internalized beliefs about the world. Acting according to implicit bias built from our own identity and experiences is efficient and effortless; our tasks are easier when we rely on this readily-available knowledge-set. But this tendency is dangerous if something as crucial as healthcare provision is largely concentrated in the hands—and therefore the implicit biases—of one segment of the overall population: that is, the white segment of the population.
For example, a study released by the American Association of Medical Colleges shows that from 1980-2004 white physicians have largely dominated the medical field, while black and Hispanic populations are underrepresented. More recently, the Texas Department of State Health Services published data showing that white healthcare professionals in Texas are more likely to hold higher-paying positions such as primary care physicians and less likely to act as community health workers, while the inverse is true for African Americans and Hispanics. The study shows us that even in states where people of color make up a large portion of the population, white people are in more powerful positions in disproportionately large numbers. The faces, experiences, and knowledge-sets of Texas’ healthcare providers, then, cannot truly be reflective of the wide array of needs of the patients requesting care—an argument of provider-patient disconnect that could be extended to other Southern states with similar demographics.
Providing quality healthcare for individuals with an array of identities and experiences should involve an unbiased approach to health assessment and treatment, thoughtfully addressing the realities that lead patients to require the care they’re seeking. Knowing and understanding patients and approaching them as partners in addressing health issues is a valuable framework for equitable treatment. For example, an anonymous article published in the Annals of Internal Medicine last month graphically describes how doctors with privileged identities (e.g. male, white) have acted inappropriately towards patients with less privileged identities (e.g. female, Latina), partially due to a lack of understanding and empathy towards those whose identities and experiences are different from their own. Such a testimonial reveals the necessity for increased representation of the wide range of people—across race, socioeconomic background, gender, etc.—that seek quality healthcare. The author described the need for his piece in the journal as a “silence to break.”
But something else must also be broken: a cycle that perpetuates a relationship between high wealth and better health outcomes. Increasing diversity at all levels of healthcare professions in order to improve health outcomes for people of color becomes rather daunting if you consider that getting the necessary education to hold such positions is influenced by an individual’s health outcomes, and various other interrelating social factors. If we want to address racialized health disparities, we have to look at the whole picture—what our regular readers know we like to call the infrastructure of opportunity. Addressing health disparities within such a framework means asking what public policies, community supports, and social structures are in place to address the ties between health outcomes and other social determinants of health. What is the relationship between upward mobility into quality jobs and the accessibility of quality healthcare?
To address the socially harmful association between wealth and health, we have to understand that access to quality healthcare, as well as housing and transportation, isn’t inevitably set along lines of race and wealth advantage/disadvantage, but is rather intentionally embedded into our society via an economic system that turns rights into privileges. Indeed, focused and justice-oriented action within to change the systemic cycle of low opportunity equating with poor health outcomes can generate hope: we have the power to do better, because we are the architects of the faulty system. A problem-solving lens that focuses on an infrastructure of opportunity allows us to not only address cycles of inequity, but also to build better pathways to equity for future generations. Such a view surely must take healthcare access and quality into account in order to build a (literally) healthy platform for future mobility.
Anna Ormond is MDC’s 2015-2016 Autry Fellow.