Racial health inequities occur when racial minorities experience an increased presence and severity of certain diseases, poorer health outcomes, and greater difficulty in obtaining healthcare services compared to more advantaged social groups (Center for Medicare Advocacy, 2017). For example, Black, Latinx/Hispanic, and American Indian/Alaska Native populations are less likely to have health insurance, more likely to face cost-related barriers to obtaining health care, and more likely to experience medical debt compared to White populations (Radley et al., 2021). The issue of racial health inequities stems from the structural racism that has occurred for centuries in the United States; this discrimination is not the deviant behavior of a few, but is backed by institutional policies and racial bias. Addressing and learning about these inequities is crucial to the pursuit of health equity and justice for marginalized groups.

1. Patients of color lack trust in the healthcare system because of historical and current discrimination.

Medical mistrust is rooted in long-held practices and events that have shaped racial communities’ views of the U.S. healthcare system. It stands in the way of patients seeking the care they need or being adequately treated when they do seek care, perpetuating ongoing health disparities (Ranowsky, 2022). The infamous 1932 Tuskegee study, officially called the “Tuskegee Study of Untreated Syphilis in the Negro Male,” targeted the Black community and serves as a classic example of unethical research and a historical atrocity. In this study, 600 Black men in Alabama were told they were being treated for “bad blood,” a local term describing various ailments, including anemia, fatigue, and syphilis. Instead, they were being observed for the natural course of syphilis without their knowledge or consent (Centers for Disease Control and Prevention, 2022). When the syphilis treatment penicillin became readily available in the 1940s, the researchers withheld the drug from the men. They stood by as 128 died, 40 of their wives were infected, and 19 babies were born with congenital syphilis (Urell, 2022). 

Tuskegee is just one example of a long history of abuses and prejudices against people of color. Now, medical distrust has contributed to Black patients’ hesitancy toward COVID-19 vaccine trial participation and uptake (Thompson, 2021). Mistrust in the healthcare system is not just related to past legacies of mistreatment but also stems from contemporary experiences of discrimination that persist. Every day, Black Americans have their pain denied, their illnesses misdiagnosed, and necessary treatment withheld. A meta-analysis of 20 years of studies revealed that Black patients were 22% less likely than white patients to receive any pain medication (Meghani et al., 2012). Moreover, a study showed that half of the medical student and resident participants held false beliefs about Black patients having a higher pain tolerance than white patients (Hoffman et al., 2016). Thus, the U.S. healthcare system still struggles to gain the trust of marginalized populations when it comes to medication education and health care delivery (Bridges).

2. States’ decisions to not expand Medicaid under the Affordable Care Act (ACA) have disproportionately pushed racial minority groups into the coverage gap.

The ACA is a health care reform law enacted in 2010 aimed to make affordable health insurance available to more people, support innovative care delivery methods, and expand Medicaid (United States Department of Health and Human Services, 2022). Under the ACA’s guidelines for Medicaid expansion, Medicaid eligibility extended to adults under the age of 65 with incomes up to 138% of the federal poverty level (HealthCare.gov). By expanding Medicaid, the ACA paved the way for many uninsured adults of color to become eligible for the program, potentially increasing their access to care and advancing health equity. However, 12 states have not implemented the ACA’s provision, creating a coverage gap. The two million people that have fallen into this gap are ineligible for premium subsidies in the ACA’s marketplace with an income under the poverty level, and are also ineligible for Medicaid due to their state’s decision. Within the coverage gap, racial minorities are disproportionately represented, where six in ten people in the gap are people of color (Garfield et al., 2021). This disparity echoes the economic, educational, and housing inequities that create higher rates of poverty for people of color and over-representation in low-paid jobs without employer-sponsored health coverage. 

In the states that did adopt the ACA’s call for Medicaid expansion, coverage increased across all racial groups between 2010 and 2016. The Hispanic population had the largest drop in their uninsured rate within that time span, falling from 32.6% to 19.1%. However, even though the coverage expansion helped narrow these disparities, people of color are still more likely to be uninsured compared to their White counterparts. Moreover, the individual mandate elimination in December 2017 increased the number of uninsured, facilitating a broken system (Artiga et al., 2021).

3. Systemic racism in employee-sponsored health insurance persists.

Private insurance, the dominant form of coverage, is primarily provided by employers. However, the gaps in employee-sponsored health coverage highlight the cracks in our fragmented healthcare system. Workers of color are overrepresented in low-wage jobs. This is because many historical policy decisions and institutional practices concentrated workers of color in undervalued occupations. For instance, the legacies of slavery and Jim Crow have led to people of color remaining overrepresented in the lowest-paid agricultural, domestic, and service vocations (Solomon et al., 2023). In 2017, 8.6% of white workers were paid “poverty wages” - hourly wages making them below the federal poverty guideline for their family size if they are the sole earner in the family, even if they work full-time, year-round. On the other hand, 19.2% - nearly one in five - Hispanic workers and 14.3% - roughly one in seven - Black workers were paid poverty wages. Asian or Pacific Islander workers also had higher poverty-wage rates than white workers at 10.9% (Cooper, 2018). With this, compared to employees with higher-paying jobs, employees with lower incomes reap fewer benefits from their employer-sponsored health coverage system. Moreover, some lower-income workers are not offered employer-sponsored health coverage at all (Boucher, 2022). Some of these workers may be eligible for Medicaid or the ACA’s marketplace subsidies, or they could fall into the coverage gap based on their state. Insufficient insurance benefits or the lack of insurance altogether puts low-wage workers at higher risk for out-of-pocket costs or health care access barriers, adding to existing disparities (Garfield et al., 2020). 

4. Racial segregation creates worse access to and lower quality health care for people of color.

People of color in racially isolated neighborhoods have more difficulty accessing medical care and receive lower quality care when they do use health care services. Racially isolated neighborhoods have resulted from policies and practices of racial exclusion and disinvestment that primarily targeted people of color. In the early 20th century, restrictive covenants barred African Americans from owning, leasing, or occupying homes in designated communities, thus designing a legal framework for systematic racial segregation (Turner). “Redlining,” where government surveyors in the 1960s deemed areas of majority racial groups “hazardous” and credit risks, still shapes the demographic and financial patterns of neighborhoods today. Specifically, these same areas are today much more likely than other areas to comprise of lower-income, minority residents and be under-resourced (Jan, 2021). Because of this, majority Black and Hispanic areas are more likely to lack hospitals and experience health care provider shortages. Additionally, in comparison to Whites, African Americans and Hispanics are more likely to be uninsured or covered by Medicaid (Gaskin et al., 2012). Therefore, people of color often find themselves depending on community health centers, emergency rooms or outpatient care, and community-based providers because of their insurance status and the unavailability of primary care, surgeons, and mental health providers within their geographic area. Although safety-net providers play a role in reducing health inequities by caring for underserved populations, these institutions and other largely Medicaid-receiving facilities are often under-resourced and face financial scarcity, lowering their quality of care delivery. They tend to report low patient satisfaction surveys and have higher rates of adverse safety complications (Yearby et al., 2022).

5. Addressing the social drivers of health (SDOH) is fundamental to improving health outcomes and reducing health inequities.

The SDOH include non-medical factors that affect one’s health, such as education, housing, food insecurity, or unemployment. These influences unfairly disadvantage some individuals and communities, particularly minority groups, and create racial disparities (World Health Organization). Right now, the U.S. healthcare system does not take into account patients’ SDOH enough, even though studies have shown that greater social care spending relative to health care is associated with improved health outcomes, lower health care use, and reduced costs. Some present examples of social care within U.S. health care include hospice, family planning services, case management, and transportation to medical care (Lyons, 2022). Innovative efforts focused on the SDOH are also happening on a state level. California Advancing and​ Innovating Medi-Cal (CalAIM) concentrates on reducing health disparities and addressing the social drivers of health through whole-person care approaches, which involve the coordination of health, behavioral health, and social services (Department of Health Care Services, 2022). The North Carolina Healthy Opportunities Pilot is the United States’ first comprehensive program to test and evaluate the impact of providing non-medical interventions for housing, food, transportation, interpersonal safety, and toxic stress for high-needs Medicaid enrollees (North Carolina Department of Health and Human Services, 2022). Initiatives like CalAim and the Healthy Opportunities Pilot are steps in the right direction, but there needs to be more integrated, comprehensive care implementation across the nation to further address social needs for patients as a part of their health care services.

To achieve health equity, we must change the institutions and policies that give rise to racial health disparities. If change doesn’t happen soon, these generational injustices will only continue - compromising the health and well-being of minority communities. Thus, dismantling these structural inequities requires policymakers, medical professionals, public health officials, and community advocates to work together to implement sustainable policy change - and the time to act is now.