*11 II. Racial Disparities in Access to Health Care: Structural and Institutional Racial Bias
Ruqaiijah Yearby , Sick and Tired of Being Sick and Tired: Putting an End to Separate and Unequal Health Care in the United States 50 Years after the Civil Rights Act of 1964, 25 Health Matrix: Journal of Law-Medicine 1 (2015) (155 Footnotes)
African Americans' access to health care is limited by structural and institutional racial bias. Structural racial bias operates at the societal level, privileging Caucasians, while denying African Americans many important resources. This racial bias affects African Americans' length and quality of life. It also restricts African Americans' educational, housing, and economic opportunities. Often relegated to racially segregated neighborhoods, African Americans attend low-quality schools, keeping them unemployed, underemployed, or in jobs without health insurance.
Structural racial bias within the health care system, which provides health care based on ability to pay, not need, denies many African Americans without money or insurance access to medically necessary health care. This is compounded by institutional racial bias which operates through organizational structures within institutions *12 which “establish separate and independent barriers” to health care services. Institutional racial bias within the health care system is best demonstrated by hospital closures in African American communities, which leaves predominately African American neighborhoods without access to quality health care services.
A. Structural Racial Bias
1. Racial Bias in the United States
Racial bias persists in the United States, resulting in increased stress for African Americans that impairs their health status. The *13 effect of this racial bias on health is captured by the “constrained choice theory,” which describes the ways that inequity within institutions and social structures affects an individual's biology and shapes his or her health status as well as opportunities to pursue healthy choices. In their article, “Understanding and Addressing the Common Roots of Racial Disparities: The Case of Cardiovascular Disease & HIV/AIDS in African Americans,” Drs. Martha E. Lang and Chloe E. Bird use the constrained choice theory to explain how racial bias affects African Americans' health.
*14 Studies have shown that both U.S. born and foreign born African American women who have experienced racial bias were more likely to have hypertension or hypertension events. In fact, African American women who had experienced racial bias and had chosen not to object to it were 4.4 times more likely to have hypertension than those who stated that they took action or talked to somebody about it. Moreover, research suggests that there is a higher positive correlation between perceived racial prejudice and increased cigarette and alcohol use among African Americans as compared to Caucasians. The increased stress from perceived racial bias also affects birth outcomes by increasing African Americans' rates of infant mortality. Finally, research has shown that experiencing racial bias accelerates the biological aging of African American men, which may lead to their lower life expectancy.
In addition to the biological effects of racial bias, Drs. Lang and Bird note that racial bias limits African Americans' opportunities to pursue health. For instance, because American cities are nearly as hypersegregated as apartheid era South African metropolitan areas *15 and have only made slight gains towards desegregation in the past twenty years, African Americans have higher rates of disability and death. In particular, racially hypersegregated neighborhoods usually have less economic investment, and thus they have fewer resources such as healthy food, places to exercise or play, and health care, but they have more stressors such as pollution, noise, overcrowded housing stock, and high rates of crime. This translates into poorer health for African Americans.
Indeed, researchers have found that the presence of one or more health clubs as well as lower crime rates were both directly associated with lower cardiovascular disease risk for the African American women in their study. Furthermore, in racially hypersegregated neighborhoods, “residents do not have access to healthy food due to a lack of supermarkets and a preponderance of convenience stores and fast food restaurants as the primary food outlets,” all of which have been shown to lead to obesity, a risk factor for cancer and cardiovascular disease.
Racial segregation also affects the place that African Americans receive care. In highly racially segregated areas, African Americans are more likely to undergo surgery in low-quality hospitals, whereas in *16 areas with low degrees of racial segregation, African Americans and Caucasians are likely to undergo surgery at low quality hospitals at the same rate. This is significant because among Medicare patients, most of the racial disparities in risk-adjusted death rates for major surgery are a result of the site of care.
Wealth inequality also directly affects health by leaving African Americans without the money they need to pay for medically necessary health services. Following the same households for over twenty-five years (1984-2009), researchers found that the total wealth gap between Caucasian and African American families nearly tripled, increasing from $85,000 in 1984 to $236,500 in 2009, a difference of $152,000. For instance, a 2009 survey showed that the median wealth of white families was $113,149 compared with $5,677 for African American families, a difference of almost $108,000. Researchers found that approximately 66 percent of the wealth gap between African Americans and Caucasians was a result of racial bias which caused racial inequalities in homeownership, income, employment, education, and inheritance.
During his symposium presentation, Dr. David Miller noted that, “as of February 2014, 12.9% of African American men were unemployed compared to 5.5% of Caucasian men.” A college education does not equalize employment; indeed, in 2009, the Bureau of Labor Statistics showed that the unemployment rate for African American male college graduates was 8.4 percent compared to 4.4 percent for Caucasian college graduates. Studies show that African *17 Americans seeking employment have a harder time obtaining employment because non-African American managers tend to hire more Caucasians. Also, African Americans with non-Caucasian names received 50 percent less callbacks than African Americans with Caucasian sounding names. Thus, racial bias in the United States results not only in African Americans' poorer health status, but it also prevents African Americans from being able to access health care.
2. Structural Racial Bias: Rationing Health Care Based on Ability to Pay
Health care in the United States is rationed on ability to pay, and although this seems race neutral, it is not. As the wealth inequities discussed above show, because of structural racial bias, African Americans do not have equal wealth compared to Caucasians, and thus they are often unable to pay for health care. Specifically, African Americans and Hispanics are more likely than Caucasians to work in low-wage jobs, and they tend to have reduced access to employer-sponsored health care coverage relative to their higher-wage counterparts. Consequently, minorities are more likely than Caucasians to be uninsured or be covered by Medicaid. In fact, of the 45.7 million non-elderly Americans who were uninsured in 2008, more than half (55 percent) were minorities and, as of 2009, 23 percent of African Americans were uninsured.
In addition to health insurance, minorities disproportionately live in poverty. In 2007, the U.S. Census Bureau reported that 24.5 percent of African Americans were living at the poverty level compared to 8.2 percent of Caucasians. By 2008, over 50 percent of *18 African Americans were poor or near poor compared with 27 percent of Caucasians. As a result of their lack of employer-sponsored health care insurance and poverty, minorities are disproportionately unable to afford insurance or to pay for health care, which results in racial disparities in access to health care.
Professor Rene Bowser discusses the disproportionately harmful effects of rationing on African Americans in his article “Race and Rationing.” Uninsured and unable to afford health care, African Americans “lack a usual source of care, have substantially higher unmet health needs, and have higher out of pocket costs.” In 2005 and 2006, “[t]he largest difference in doctor visits between insured and uninsured populations was seen among African-Americans and individuals of two or more races.” This racial difference in physician visits is not new. In 1986, a national survey of the use of health care services found that “even after taking into account persons' income, health status, age, sex, and whether they had one or more chronic or serious illnesses, blacks have a statistically significantly [sic] lower mean number of annual ambulatory [walk-in] visits and are less likely to have seen a physician in a year.” Thus, African Americans often forgo care leading to diagnosis at more advanced stages of disease. Indeed, government data shows that African American women were 10 percent less likely to have been diagnosed with breast cancer; however, they were 34 percent more likely to die from breast cancer, as compared to Caucasian women.
Professor Bowser also notes that the U.S. health care system is rationed based on physician status and power, which determines who gets to see a renowned specialist or added to an organ transplant waiting list. While Caucasian “patients cared for by ‘high status' *19 physicians have privileged access to health care services and can more easily push their patients to the head of the queue,” African Americans are often treated by African American physicians who “report greater difficulties accessing high-quality specialists, diagnostic imaging, and nonemergency admission of their patients to the hospital than physicians serving predominantly nonminority patients.”
An example of the deadly effects of rationing based on physician status and power was shown in a 2013 study on surgery mortality. The study showed that African Americans patients were more likely than Caucasian patients to die from coronary artery bypass grafting, abdominal aortic aneurysm repair, and resection for lung cancer. This disparity in survival rates was due to African Americans' separate and unequal access to quality hospitals. Even though African Americans live closer to high quality hospitals than Caucasians, they were more likely to undergo surgery at low-quality hospitals. A plethora of “decisions about where to go for major surgery [such as coronary artery bypass grafting, abdominal aortic aneurysm repair, and resection for lung cancer] are made by referring physicians, not by patients and their families,” and studies show that physicians serving African American patients have reduced access to specialists, suggesting that these patients will have trouble seeing and being treated by surgeons at high-quality hospitals. Thus, regardless of whether care is rationed based on ability to pay or physician status and power, African Americans are denied equal access to health care, which results in unnecessary morbidity and mortality for African Americans.
B. Institutional Racial Bias: Hospital Closures
In 1949, African Americans were either excluded from or were given restricted access to emergency care in hospitals, which resulted in higher death rates for African Americans from auto accidents in particular. In 2008, research showed that African Americans still had a higher death rate for trauma injuries, including those from auto accidents, because of “treatment delays, different care due to receipt *20 of fewer diagnostic tests, and decreased health literacy.” In fact, almost forty years of studies have shown that African Americans are still excluded from hospitals because of institutional racial bias.
Shortly after the passage of Title VI, hospitals in African American communities closed and relocated to affluent Caucasian neighborhoods. Similarly, in 1992, a report of 190 urban community hospitals between 1980 and 1987 found that the percentage of African American residents in the neighborhood was the most significant factor in hospital closures. As the percentage of African American residents increased in the neighborhood, hospital closures increased. In 2006, Alan Sager reported that as the African American population in a neighborhood increased, the closure and relocation of hospital services increased for every period between 1980 to 2003, except between 1990 and 1997.
In fact, while speaking at the symposium, Dr. Sager showed that 45 percent of hospitals open in 1970 had closed by 2010, and of these hospitals, 60 percent were in neighborhoods that were predominately African American. St. Louis and Detroit are poignant examples of these race-based hospital closures. St. Louis had eighteen hospitals in predominately African American neighborhoods. By 2010, all but one had closed. In 1960, Detroit had forty-two hospitals open in predominately African American neighborhoods; by 2010 only four were open.
*21 This reduction of hospital beds in African American communities, which generally have the greatest need for care, further compromises African Americans' health by decreasing their access to health care, thereby increasing health care costs. As hospitals leave predominately African American neighborhoods, the remaining hospitals are left to fill the void. This often strains the remaining hospitals' resources and their ability to provide quality care. Consequently, the hospitals that do remain to provide care to African Americans gradually deteriorate and provide substandard care.
Not only is access to health care diminished because of a reduction of hospital services, but care also suffers because of physician departures. Once a hospital has closed or relocated, the physicians practicing in the area often follow the hospital to more affluent neighborhoods, thereby further disrupting the health care services in predominately African American neighborhoods. Evidence shows that primary care physicians often leave after the closure of a neighborhood hospital because the hospital provides a critical base for their practice. This disruption in care is significant because many predominately African American neighborhoods already suffer from physician shortages prior to hospital closures and physician flight. Additionally, as the number of primary care physicians decreases, African Americans are forced to seek care in emergency rooms and public hospitals, which are often understaffed and not adequately maintained. Thus, even if African Americans are granted access to hospitals, they still receive less than the *22 medically necessary care, which is compounded by interpersonal racial bias against African Americans.
