Health Equity: Inequitable Access To Healthcare's Racist Roots

Centuries of racism in the United States have altered migration patterns and impacted access to resources, including healthcare. One component of health equity is accessible proximity to hospitals. The Hospital Survey and Construction Act of 1946, known as the Hill-Burton Act, provided funding to construct hospitals throughout the country and allowed for racial segregation in hospital access. This engrained overt healthcare segregation for nearly twenty years before passage of the Civil Rights Act of 1964 and Medicare legislation in 1965. Hospital access remains unequal because socioeconomic factors such as wealth, insurance coverage, educational attainment, and trust of healthcare providers are influenced by systemic racism and curtail the likelihood of hospitals locating in historically marginalized communities.

Although gaps in healthcare access have well understood causes, much of the research exploring these inequities focuses on national or regional trends and does not provide detailed information about particular communities. A lack of local data is often cited by policymakers as an impediment to health plans and providers taking action to improve health equity. Recent research in Health Affairs titled “The Problem Of The Color Line: Spatial Access To Hospital Services For Minoritized Racial And Ethnic Groups” demonstrates a method of identifying inequities at a granular geography and may serve as a model for health plans seeking to understand healthcare access gaps in their service areas.

Study: Inequitable access to healthcare & systemic racism

To understand the impact of systemic racism on inequitable access to healthcare, this study used accessible methods to precisely identify communities with people from racial and ethnic groups located farther from hospital resources than comparable communities with significant White populations. 

First, the health equity researchers identified ZIP Code Tabulation Areas (ZCTAs) with shares of their populations belonging to each racial and ethnic group ranked in the ninety-fifth percentile and above for that racial or ethnic group. Race and ethnicity data were drawn from the American Community Survey’s 2015-2019 estimates. Separate ninety-fifth percentile cutoffs were used for urban and rural ZCTAs because of their differing demographics. 

Then, the study team used data from the 2019 American Hospital Association (AHA) Annual Survey to identify hospitals offering emergency, trauma, obstetrics, outpatient surgery, intensive care, and cardiac care services. Researchers calculated straight-line distances between the population-weighted center of each ZCTA and the location of the nearest hospital of each type. 

Finally, the study employed multivariable analysis to explore the association between ZCTAs having a high proportion of people from racial and ethnic groups and access to hospital services. The analyses held constant community characteristics that influence healthcare access such as vehicle ownership, employment, elderly population, poverty, insurance coverage rates, and racial segregation in the counties each ZCTA is located within. 

Results: Health equity study on racism & inequitable access to care

The health equity study revealed concerning differences in access to hospital care by racial and ethnic group. Key findings include:

• Among high-minority ZCTAs, communities in the northern border of Arizona, southwest Alabama, and areas in South Dakota, New Mexico, and Texas were the furthest from emergency and ICU care.
• Distances to intensive and cardiac care were often longer than thirty miles for rural high-minority communities. This lack of access was especially severe for American Indian/Alaska Native and Hispanic communities.
• Trauma care was the most inequitably distributed services. Rural communities with large subpopulations were frequently 20 or more miles from trauma care. The difference in distance to the nearest hospital offering trauma care between communities with large racial and ethnic groups and White communities was larger than the comparable difference for any other service type.
• In regression analysis, rural communities with large Black and/or American Indian/Alaska Native populations were, on average, the furthest from hospitals.
• Rural Black communities, all measured variables held constant, were located farther from emergency services, outpatient surgery, ICUs, obstetric care, and cardiac care than rural communities with large White populations.
• Rural communities with large populations of multiple racial and ethnic groups had about two times higher odds of needing to travel more than thirty miles to obtain care relative to communities with large White populations.

Overall, these findings confirm that even holding socioeconomic factors constant, communities with large racial and ethnic groups have to travel farther to hospitals than majority-White communities. Travel distance inequities become even more glaring when considering that the socioeconomic factors the study holds constant are themselves influenced by racial prejudice. 

Healthcare inequities even in closer proximity for urban ethnic communities

Exorbitant travel distances have been exacerbated by hospital closures driven in part by political resistance to expanding Medicaid or covering subpopulations. While travel distances to hospitals were less severe for racial and ethnic residents residing in urban areas, these facilities may be less well-resourced or still require long journeys (measured in minutes). Underfunded public transportation networks and the way that interstate highways bisect racial and ethnic communities means that although hospitals may be relatively nearby, they can nonetheless be challenging to access.

Promoting equal access to hospitals: Potential state & federal health equity solutions

Unequal access to hospitals will not be corrected without significant investment in building new hospitals and correcting the underlying reasons hospitals close. State-level policy levers include altering hospital licensing requirements; increasing oversight of hospital system mergers and closures with a focus on maintaining service in disinvested areas; promoting increased coordination between hospital systems, professional associations, and community organizations; and expanding Medicaid in states that have thus far neglected to do so. 

Federal policy options include improving transportation systems, expanding broadband internet access, directly investing in building new hospitals, and altering Medicaid incentives to encourage covering more subpopulation beneficiaries.

Hospital access one facet of broader health inequity issues

Access to hospital services is only one objective criteria by which people of racial and ethnic groups are disserved by the healthcare system. Other notable health inequity examples include:

Insurance coverage

According to the Kaiser Family Foundation, American Indian/Alaska Native, Hispanic, and Black people are significantly more likely to lack health insurance relative to White peers. Elevated uninsured rates largely reflect reduced access to private coverage that are not fully compensated for by Medicaid and CHIP. While gaps in coverage began closing following the passage of the Affordable Care Act, they began expanding again in 2017.

Disparities in outcomes

Data predating the COVID-19 pandemic demonstrated that people of color experience increased infant mortality, pregnancy-related deaths, prevalence and severity of chronic conditions, and mental health risks relative to white peers. Many outcome gaps appear to have grown worse as a result of COVID-19. American Indian/Alaska Native, Black, and Hispanic people were over three times as likely to die prematurely in 2020 than White or Asian people, reflecting longstanding inequities in working conditions, transportation, and the risk of experiencing severe illness in addition to the impact of COVID-19. Additionally, the pandemic has had disproportionately adverse financial impacts on historically marginalized people.

Increased incidence of dementia

Black people are significantly more likely to develop dementia later in life, perhaps driven by increased risk for long-term hypertension. This research suggests that healthcare inequalities lead to decreased quality of life in addition to shorter lifespans.

Food insecurity

Results from the National Poll on Healthy Aging showed food insecurity disparities by age, health status, race, ethnicity and education that were potentially worsened by the pandemic. People from racial and ethnic groups are less likely to have access to food that helps them manage underlying health conditions.

Telemedicine access

Given the hope for telemedicine to counteract insufficient health care access in disinvested communities, recent reports are discouraging: Black patients are less likely to use telemedicine than White patients. Telemedicine access inequities are rooted in many of the same individual, community, and structural factors that limit access to in-person care. However, given the recent surge in interest in telemedicine, tools are rapidly developing and could be designed in the future to increase uptake by subpopulations, particularly outside of young females where current uptake is highest. 

Identifying and acting on local health inequities

The research summarized here is a snippet of literature that establishes persistent health inequities in the United States. Despite widespread acknowledgment of this problem, many health plans lack detailed knowledge of healthcare inequities in their communities. The Health Affairs article reviewed in this blog demonstrates how to use granular datasets to spotlight inequities in fine detail. Health plans need this sort of localized data—or even more specific data about their individual members—to identify access gaps and plan comprehensive health equity strategies.

RTI Health Advance offers Health Equity consulting services to payers and providers. As a consulting organization with the expertise of an academic research organization, we have experience blending publicly available and proprietary data (such as our new RTI Rarity™ artificial intelligence tool which predicts life expectancy at the census block level) to identify areas with access and outcome gaps. After identifying historically excluded communities, we can partner with health plans to formulate targeted interventions or multi-layered approaches that allow health plans to improve the well-being of all populations in their service areas.