Racial, ethnic disparities persist in U.S. health care access, spending
Recent studies looked at differences by race and ethnicity in quality of ambulatory care for patients with Medicare Advantage versus traditional Medicare, health status and health care access, and health care spending over time.
Three studies published in the Aug. 17 JAMA looked at racial and ethnic disparities in health care in the United States.
The first study compared differences in enrollment in Medicare Advantage and traditional Medicare, as well as access to and quality of ambulatory care, according to race and ethnicity, using a nationally representative sample from the Medicare Current Beneficiary Survey. A total of 45,833 person-years involving 26,887 patients were included. Main outcome measures were patient-reported measures of ambulatory care access (having a usual source of care in the past year, having a primary care clinician as a usual source of care, or having seen a specialist) and care quality (receiving influenza vaccination, pneumonia vaccination, and colon cancer screening).
Data were included from 2015 to 2018. In the final sample, 6,023 patients and 9,816 person-years were from minority groups and 20,864 patients and 36,017 person-years were from White or multiracial groups. Patients from minority groups with Medicare Advantage had significantly better access to a primary care clinician as a usual source of care, influenza vaccinations, pneumonia vaccinations, and colon cancer screenings than minority patients with traditional Medicare. However, minority patients had significantly lower rates of access to a primary care clinician as a usual source of care (adjusted marginal difference, 4.7% [95% CI, 2.5% to 6.8%]), specialist visits (adjusted marginal difference, 10.8% [95% CI, 8.3% to 13.3%]), influenza vaccinations (adjusted marginal difference, 4.3% [95% CI, 1.2% to 7.4%]), and pneumonia vaccinations (adjusted marginal difference, 6.4% [95% CI, 3.9% to 9.0%]) when compared with White or multiracial beneficiaries across both Medicare Advantage and traditional Medicare. The authors concluded that while Medicare Advantage was associated with better access and quality in minority beneficiaries, they had a higher likelihood of worse access and quality than White or multiracial beneficiaries across both insurance programs.
The second study looked at trends in self-reported measures of health status and health care access and affordability by race and ethnicity among U.S. adults over 20 years, using National Health Interview Survey data from 1999 to 2018. A total of 596,355 adults with a mean age of 46.2 years were included. Just over half (51.8%) were women, 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. Low income was reported by 28.2%, 46.1%, 51.5%, and 23.9% of Asian, Black, Latino/Hispanic, and White individuals, respectively.
Poor or fair health in 1999 and 2018 was most likely to be reported in Black persons with low income (29.1% and 24.9%) and least likely to be reported in White persons with middle and high income (6.4% and 6.3%). Racial and ethnic gaps in poor or fair health status did not change significantly from 1999 to 2018, other than a significant decrease in the difference between White and Black persons with low income, which was no longer statistically significant in 2018. In 2018, Black persons and Latino/Hispanic persons were significantly more likely than White persons to report being uninsured. The authors concluded that while racial and ethnic differences in self-reported health status, access, and affordability improved over time for some subgroups, they largely persisted over this 20-year period.
The third study looked at national and Medicare survey data to determine differences in health care spending by race and ethnicity in the U.S. from 2002 to 2016. The main outcome measures were total and age-standardized health care spending per person by race and ethnicity for each year from 2002 through 2016, according to type of care. The researchers found that an estimated $2.4 trillion was spent across six types of health care in 2016, with an estimated age-standardized total health care spending per person of $7,649 for American Indian and Alaska Native (non-Hispanic) individuals; $4,692 for Asian, Native Hawaiian, and Pacific Islander (non-Hispanic) individuals; $7,361 for Black (non-Hispanic) individuals; $6,025 for Hispanic individuals; $9,276 for multiracial individuals (non-Hispanic); and $8,141 for White (non-Hispanic) individuals. The last group accounted for an estimated 72% of health care spending and, after adjustment for population size and age, received an estimated 15% more spending on ambulatory care than the all-population mean.
Black (non-Hispanic) patients received an estimated 26% less spending than the mean on ambulatory care but 19% more (P=0.02) on inpatient care and 12% more (P=0.04) on ED care. Hispanic patients received an estimated 33% less (P<0.001) spending per person on ambulatory care than the mean. Asian, Native Hawaiian, and Pacific Islander (non-Hispanic) patients received less spending than the mean on all types of care except dental care (P<0.001 for all comparisons), while American Indian and Alaska Native (non-Hispanic) patients had an estimated 90% more spending on ED care than the mean (P=0.04) and multiracial (non-Hispanic) individuals had an estimated 40% more spending on ED care than the mean (P=0.006). The study authors called for additional research on current health care spending according to race and ethnicity, including that related to the COVID-19 pandemic.
An editorial accompanying all three studies said they show that access to and use of services is not always linked to health insurance and availability of health care, as indicated recently by disparities in vaccination rates during the COVID-19 pandemic. “The elimination of health care inequities will require effective integration of health care systems with communities and the social safety net. Moreover, health equity can only be achieved through attention to the needs and perceptions of the communities served and to the elimination of racism and biases deeply imbedded in the system,” the editorialists wrote.
The editorialists also stressed the need for improving cultural competency among physicians and expanding the diversity of the physician workforce so that it more closely represents the populations served. They pointed out that while Black and Latino persons make up 13.4% and 18.5% of the U.S. population, percentages of Black and Latino physicians are approximately 5.0% and 5.8%, with even lower proportions for American Indian and Alaska Native physicians and Native Hawaiian or other Pacific Islanders. “Ending structural racism and inequities in the US health care system has proved to be a challenge,” the editorialists wrote. “What has become clear is that there needs to be much more intensified and multifaceted approaches that by necessity will require a much larger and committed investment in research, training, clinic practice, and community engagement.”