U.S. Racial and Ethnic Health Disparities Widespread, New Report Shows

A report from The Commonwealth Fund finds disparities in health outcomes, healthcare access, and quality and use of healthcare services.

A new report from The Commonwealth Fund finds that racial and ethnic health disparities exist in every state of the country.

Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.

The new report is based on data collected for 24 indicators of health system performance, and the data was stratified by state and by race and ethnicity. The indicators were grouped in three areas: health outcomes, healthcare access, and quality and use of healthcare services. The report examines data for five ethnic and racial groups: Asian American, Native Hawaiian, and Pacific Islander (AANHPI); American Indian/Alaska Native (AIAN); Black; Latinx/Hispanic; and white.

In a teleconference yesterday, the report's lead author, David Radley, PhD, senior scientist at The Commonwealth Fund, summarized the state scorecard data.

"Six states stand out for having higher-than-average performance for all ethnic and racial groups that we measured. These states include Massachusetts, Connecticut, Rhode Island, New York, Hawaii, and Oregon. They also tended to have some of the smallest—albeit still evident—within-state disparities between the groups with the best and the worst performance. In other states such as Minnesota, Michigan, and Wisconsin, health system performance was particularly strong for white residents but lacking among Black, Latino, and Native Americans. These states had some of the largest within-state disparities. Finally, there were a number of states including Oklahoma and Mississippi where performance was weak overall for all racial and ethnic groups. In these states, despite low scores for even the highest performing groups, there were still sizeable inequities in each state," he said.

Health system performance scores by state and race/ethnicity show a stark health inequity between Black and white Americans. Health system performance for Black Americans was above the all-group median in only five states: Rhode Island, Massachusetts, Maryland, Connecticut, and New York. Health system performance for white Americans was below the all-group median in only three states: West Virginia, Oklahoma, and Mississippi.

Health outcomes findings

Even states that have scored high on overall healthcare performance can have significant racial and ethnic disparities, the report's co-authors wrote. "For example, Minnesota, which ranked third in The Commonwealth Fund’s most recent State Scorecard on Health System Performance, has some of the largest disparities between white and Black, Latinx/Hispanic, AANHPI, and AIAN communities."

Health outcomes, which were measured mainly by mortality rates and the incidence of health-related problems, vary significantly by race and ethnicity, the report's co-authors wrote. "In most states, Black and AIAN populations tend to fare worse than white, Latinx/Hispanic, and AANHPI populations. While enduring lower life expectancies for Black and AIAN individuals in the U.S. can be attributed in large part to generations of structural racism, oppression, and other factors beyond healthcare delivery, the healthcare system nevertheless has a crucial and often unfulfilled role in mitigating disparities."

Racial and ethnic disparities exist for treatable conditions, the report's co-authors wrote.

"Diabetes is an example of a disease that can often be effectively managed—for example, with consistent blood glucose monitoring and proven medications—but is nonetheless associated with profound racial and ethnic disparities in outcomes. Black and AIAN individuals are much more likely to die from diabetes-related complications than people of other races and ethnicities. Health systems striving for equity should bolster disease management resources among these communities to achieve better outcomes," they wrote.

Healthcare access findings

There are significant disparities in access to care between white and most nonwhite populations, according to the report.

Health insurance plays a crucial role in access to care, the report's co-authors wrote. "A key contributor to these access inequities is lack of comprehensive insurance coverage, or any coverage at all. Insurance alone cannot guarantee access, but it is necessary for getting needed healthcare without incurring substantial or even catastrophic financial risk."

In 2014, expansion of insurance coverage under the Affordable Care Act through the creation of an individual marketplace and the expansion of Medicaid in many states improved the uninsured rate for all ethnic and racial groups, but insurance coverage disparities persist, the report's co-authors wrote. "In nearly all states, uninsured rates continue to be higher for Black, Latinx/Hispanic, and AIAN people than they are for whites."

The lack of Medicaid expansion in 12 states negatively impacts two racial and ethnic groups, the report's co-authors wrote. "Black and Latinx/Hispanic communities are disproportionally represented in states that have not expanded Medicaid: 43% of Black and 36% of Latinx people live in the 12 nonexpansion states."

Insurance disparities have profound care access implications for people of color, the report's co-authors wrote.

"When people are uninsured, experience gaps in coverage, or are in private plans that do not provide comprehensive coverage, they often avoid getting care when they need it or pay high out-of-pocket costs when they do seek care. This is particularly burdensome for individuals with lower income and little wealth—disproportionately people of color. Because of these costs, Black, Latinx/Hispanic, and AIAN people are more likely to avoid getting care when they need it, more often have higher out-of-pocket costs, and are more prone to incur medical debt at all income levels," they wrote.

Quality and use of healthcare services findings

Disparities in the quality and use of healthcare services are widespread, the report's co-authors wrote. "Across and within most states, white populations overall receive better care than Black, Latinx/Hispanic, American Indian/Alaska Native (AIAN), and, often, Asian American, Pacific Islander, and Native Hawaiian (AANHPI) individuals."

Primary care disparities have a significant impact on the quality and use of healthcare services, the report's co-authors wrote.

"Primary care clinicians play an especially critical role in providing people with high-value services, including preventive care like cancer screenings and vaccines, as well as chronic disease management. … Expanded access to primary care improves health outcomes. And given the relatively lower use of primary care by Black, Latinx/Hispanic, and AIAN people, these groups in particular are likely to see a greater health impact from improved access and quality," they wrote.