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Racial inequities in health care narrowed, then widened, over last six decades

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Study examines visits and expenses from Civil Rights era to after Affordable Care Act.

With racial inequities in health care visit rates and expenditures widening, policy changes are needed to address entrenched racial inequalities in the U.S. health care system, a new study said.

After 1963, the difference narrowed between the numbers of White and Black patients’ ambulatory care visits, then widened. Health care expenditures followed a similar pattern and White patients’ overall health care use, measured in dollars per capita, exceeded that of Black patients every year from 1963 to 2019, the study said.

“Trends in Health Care Use Among Black and White Persons in the U.S., 1963-2019,” was published June 14 in the journal JAMA Network Open. It analyzed data for 154,859 Black patients and 446,944 White patients, children, adults and seniors, from surveys dating from 1963, 1970, 1977, 1980, 1987 and continuously from 1996 to 2019. Researchers counted visits to ambulatory medical practitioners, to dentists, to emergency departments and hospitals, measured by inpatient days.

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Although the findings did not prove causation, the changes in disparities in health care use after 1963 coincided with the implementation of Medicare and Medicaid, which outlawed segregation in medical facilities, said the study, led by corresponding author Samuel L. Dickman, MD, at the Texas Policy Evaluation Project at the University of Texas at Austin. That era brought new community health centers and civil rights protections “that improved Black individuals’ access to housing, jobs, education, and the ballot box,” the study said.

The figures on health care use began diverging in the 1980s, coinciding with waning civil rights enforcement, increasing incarceration – especially for Black men – and stagnating Medicaid enrollment. In 2014, the Affordable Care Act (ACA) narrowed racial differences in insurance coverage and self-reported access to care, but gaps persisted, the study said.

“The current White-Black gap in ambulatory care visit rates is larger than ever before, and differences in expenditures are wider than in the pre-ACA period and at an all-time high measured by real (inflation-adjusted) dollars,” the study said.

Insurance coverage could be a factor, but the disparities remained when analyzing patients with private insurance, or Medicaid enrollees, or older adults. Other hurdles could be insurance copayments and deductibles, lower incomes, lack of transportation, inability to take time off work, lack of trust in the health care system and lack of Black medical practitioners, the study said.

“The persistence of large racial gaps in the amounts of medical care delivered to White and Black patients in the U.S. suggests that structural racism is ingrained in the health care system,” the study said. Solutions could include addressing shortages of Black health care professionals and managers, investing in Black-serving medical facilities, increasing community outreach and rebuilding Black patients’ trust in the health care system.


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