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A Framework to Understand Systemic Racism in Health

Summary: Juneteenth commemorates an 1865 US army order to end slavery in Texas. Emancipation was the first essential step to offer Black Americans the opportunity to live a free and healthy life. But even today, 157 years later, the well-being of people of color is compromised by numerous post-emancipation policies that disadvantage them. We offer a framework to understand these issues and advocate for change.

Comment by: Jim Kahn and Susan Rogers

Systemic racism in health is the constellation of policy decisions taken within health care as well as in other policy domains that affect health, regardless of the purported mindset of decision-makers and practitioners. Overt racist intent (e.g., denying Black individuals the same rights as White individuals) is unacceptable and deeply harmful, but is not required for racist consequences. Indeed, many broadly harmful policies derive from racist perspectives dressed up to appear beneficent (e.g., providing inferior public services when the likely users are people of color). What makes racism “systemic” is that structural features foster unequal treatment and outcomes.

Our framework for understanding systemic racism in health starts with health care, including insurance and delivery of care. It then proceeds to broader domains that less obviously, but indeed powerfully, influence health. Our effort in this post is broad, with a few citations. It should not be taken as a definitive academic review on the topic. Instead, we hope it helps clarify the challenges we face in order to reduce and end systemic racism in health.

A note on terminology. Observed differences are often described as “disparities,” which has a neutral tone. We prefer “inequities,” which highlights that these differences are unjust and unfair.

Health insurance: Black and Latino Americans are less likely to be privately insured, and more likely to be uninsured or Medicaid-insured. This is the insurance structure that predisposes them to health care access problems. Our public policy tolerance of low payment rates and poor access under Medicaid differentially harms people of color, and in so doing reveals a fundamental and unacceptable disregard for their welfare.

The Affordable Care Act reduced uninsurance inequities, via the Medicaid expansion. However, the 13 non-expansion states have high Black and Hispanic Medicaid participation, including five of the ten highest states by this metric. Thus state refusals of federal money to expand Medicaid disproportionally hurt people of color.

Inequities in coverage worsened during COVID.

Historical Origins: 20th century health insurance expansions, including the lack of universal coverage, were shaped substantially by the linked issues of states’ rights and racism. Medicaid design and implementation compromises were similarly influenced.

Access to care: Blacks and Latinos are more likely to experience financial barriers to care. This derives from higher rates of uninsurance and Medicaid. In the Medicare program, lower income and race interact to create higher rates of skipped or delayed care. In addition, there are geographic barriers: often no hospitals, clinics, or pharmacies in poor and rural neighborhoods.

Health workforce: People of color are under-represented in the most prestigious professional group in medicine – physicians. Even worse, they remain under-represented among medical students, so the physician mix is not evolving. The American Medical Association excluded blacks until the 1965 passage of Medicare, which desegregated hospitals. A wide variety of racist attitudes and behaviors continue in clinical practice.

Pain management: One often-mentioned issue is different attitudes and use of narcotic pain relief for Black patients, with an example here. This problem is especially difficult to read about for sickle cell anemia, with its excruciating sickle crises.

Quality of care: The literature on race and quality of care is massive. A PubMed search turned up 1,700 systematic reviews, and 200,000 articles. The issue pervades medicine.

Now we discuss issues apparently outside the health realm. Yet they influence health care and health in profound ways.

Law enforcement & incarceration: Our criminal justice system is biased against people of color at all steps: stops, arrests, convictions, and severity of punishment. Blacks and Latinos are vastly over-represented in prisons. The high rate of incarceration creates a “prison penalty” which impairs employment. This, in turn, reduces access to private insurance, among other harms.

Living in areas with concentrated poverty: Blacks are more likely to be poor than are whites. However, the elevated risk of living in areas of concentrated poverty – with scarce resources like supermarkets, well-funded schools, and health care, and greater environmental toxicity – is even greater. Blacks are five times more likely than whites to live in concentrated poverty, 10 times in some cities, and even non-poor Black families are 1.5 times as likely as poor White families to live in concentrated poverty.[1] 

Public funding to get ahead: The GI bill after World War II paid for higher education for returning soldiers – if white; black soldiers were mainly excluded. Federal mortgage guarantees were “red-lined”: excluding high risk (read: mainly black) neighborhoods. As a result, Black families were denied the leg up needed to establish family financial stability. Wealth differences are massive by race. This contributes to a greater medical debt burden.

Health effects: Life expectancy is >3 years greater for White than Black babies. At age 60, the difference is 1 year. Both differences increased with COVID, which had much higher death rates among Black than White individuals.

We’ve said it before, and we’ll keep saying it: single payer universal health care will help end inequity in health insurance and thus largely in access. The phrase “health insurance program for the poor” will no longer have meaning. Being Black or Hispanic will no longer feed an “algorithm” to rank health insurance attention to underserved populations. Instead, it will mean that person deserves excellent universal health insurance, just like everyone else.    

We should rejoice that the federal government has designated Juneteenth as an official holiday. We have a lot more work to do.

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Susan Rogers is president of Physicians for a National Health Program.

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