The De-Facto Segregation of Health Care

Last week, over 8,000 people lined up to be treated by medical volunteers at the Forum stadium in Inglewood, California. It was a rare moment of visibility for the hidden faces of the health-care debate -- the 46 million Americans without health insurance, who have largely been obscured by the rage and fear expressed at town hall meetings and rallies. The majority are nonwhite and live in segregated neighborhoods without access to quality health care. It was the first time the organization, Remote Area Medical, had arranged this kind of an event in an urban area, the teeming crowds a reminder of the ongoing health-care crisis plaguing people of color. "This need has existed in this country for decades and decades," RAM founder Ed Brock told the Associated Press. "The people coming here are here because they are in pain."

They are in pain because of an inadequate health-care system exacerbated by the ongoing legacy of racial segregation, which limits access to quality care. "Segregation is still a profound problem in the United States," says Brian Smedley, a health-care expert with the Center for Joint Political and Economic Studies. "We've made a lot of progress in the past 50 years, [but] in many U.S. cities, we have segregation levels that are not far below apartheid South Africa."

That ongoing de-facto segregation has a profound effect on the quality of care to which people of color -- insured or otherwise -- have access. While the health-care bills being debated in Congress would expand access to and quality of care for people of color, ultimately racial health disparities can't be eliminated without better distribution of health resources. That doesn't just mean more and better primary-care providers in minority neighborhoods; it also means environmentally safe living conditions, access to fresh and healthy foods, and safer and more exercise-friendly neighborhoods.

Racial disparities related to health care can be broken down into two categories: access and outcomes. Nonwhites are 52 percent of the uninsured population, the largest proportion of which is Hispanic, at 30 percent -- but those numbers don't tell the whole story about access. Even when people of color are covered, their access to quality care is diminished heavily by ongoing segregation and poverty; in nonwhite neighborhoods, it's simply harder to find a primary provider than it is in white neighborhoods. The facilities that exist are often of lower quality and lack the resources institutions located in primarily white areas have.

What this means is that even when minorities are covered by health insurance, they're less likely to have quality care and less able to afford the associated out-of-pocket expenses -- and the results are staggering. Children born to black women are more than twice as likely to die within their first year of life as are children born to white women. This disparity is unaffected by income or education level. According to the Kaiser Family Foundation, the mortality rate for infants of college-educated black women is 11.5 deaths for 1,000 live births, more than twice that for infants of similarly educated white women, 4.2 for 1,000 live births.

It's not just infant mortality. According to a 2004 analysis published in the American Journal of Public Health, if the mortality rate of blacks had been the same as that of whites between 1991 and 2000, 880,000 deaths could have been avoided. People of color are more likely to suffer and die from chronic diseases such as diabetes, cancer, and cardiovascular disease, they're less likely to get the kinds of life-saving treatments that whites get, and they're more likely to receive the kinds of treatments you would avoid if you could -- such as limb amputation for diabetes.

African Americans made up almost half of the new cases of HIV infection recorded in the 2000 Census. People of color are less likely to have seen a dentist. Only 27 percent of African Americans and Hispanics, 36 percent of Asian and Pacific Islander Americans, and 41 percent of Native Americans and Alaska Natives reported seeing a dentist in the past year, compared to nearly half of whites who had. A fifth of black adults report being in poor or fair health, slightly more than Hispanic adults and nearly twice as many as white adults. Some of these conditions are due to disparities in employment, education, and wealth. Language and cultural barriers also hinder effective care, preventing patients and doctors from communicating effectively about medical problems and treatments. But disparities persist even when controlling for income and education levels, the most reliable indicators of quality coverage.

"The reasons why many racial and ethnic minority groups have poorer health literally from the cradle to the grave are many and varied; they're primarily related to socioeconomic differences," Smedley says, "but they're also profoundly related to living conditions."

Given the harrowing public-health crisis facing people of color, it's easy to understand why thousands of people would line up in Inglewood looking for quality care. The House version of the health-care reform bill, America's Affordable Health Choices Act, would help reduce barriers to health insurance access by expanding Medicaid, prohibiting discrimination against people with pre-existing conditions, capping out-of-pocket expenses, and subsidizing the purchase of health insurance below 400 percent of the poverty level. But while both the Senate and the House bills expand community health centers, when it comes to addressing issues like geographic barriers to quality health care stemming from ongoing de-facto segregation, the bills are less aggressive than some health-care policy advocates would like.

Some health care experts argue that in addition to expanding coverage, the key to reducing racial health disparities lies in prevention measures. "They're putting more focus on prevention and quality services, wellness care as opposed to sick care," says Dr. Willarda V. Edwards of the National Medical Association. "That's what we need to be focused on."

Both the House's and the Senate's proposals offer funds for community-based programs that focus on prevention by addressing issues like obesity and smoking -- things that contribute to the onset of such chronic diseases as diabetes and cancer later in life. "Ensuring that the final legislation includes prevention could actually be one of the most important steps [in] decreasing if not eliminating some of these disparities," says Judith Bell, president of Policylink, an advocacy organization focused on social and economic equality. But prevention has so much to do with living conditions -- like living in a polluted area or one without access to fresh food -- that health-care reform can only do so much.

During the presidential campaign, President Barack Obama avoided making the case for health reform in racial terms. This has continued, with the administration reluctant to point out racial disparities in access to or quality of care for people of color, preferring to make the case for health-care reform in race-neutral terms. An argument for how health-care reform would benefit the poor has also been absent. Opponents of reform haven't been as shy about invoking race, particularly when it comes to whether the bill covers undocumented immigrants. An Investor's Business Daily editorial called health-care reform "affirmative-action on steroids" and argued that it was a form of reparations for slavery, a description echoed by Fox News personality Glenn Beck. Much of the rage at town hall meetings across the country has been fueled by the misperception that the reform proposals would extend health coverage to undocumented immigrants. None of the current versions do -- a politically convenient decision that ignores the cost incurred by not covering everyone.

Melissa Harris-Lacewell, a professor of politics and African American studies at Princeton University, believes the administration's decision to avoid race may not have been a wise one. "Obama really does believe that the best way to pass good social policy that has a beneficial effect for people of color is by never mentioning race," she says. "They were trying to do what they did in the campaign, which is focus on similarities rather than differences. … It’s not like the opposition isn't capable of bringing this up anyway."

"I think they fumbled the ball on this one," she adds.

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