Abstract

At the dawn of the 21st century, structural racism helps explain disparities in U.S. health insurance coverage among diverse communities. By definition, structural racism is also systemic, where racist premises and policies are built into the housing, urban planning, and infrastructure designs that shape daily American life. The consequences that result from structured, systemic racism in the United States can be divided into three major categories: social, political, and economic. These outcomes affect each other in many complex ways, and can interlock tightly, causing a multitude of synergistic effects. These outcomes result in the often implicit bias that hinders opportunities for people of color in many ways, including adequate access to healthcare coverage. 

The synergistic effects of structural racism cannot continue to be overlooked by those trying to address healthcare inequity in the U.S. As history proves, doing so risks short-sided or misguided solutions. A prime example of such policy failures is the COVID-19 pandemic. In the USA, the pandemic affected people of color through entangled social, political, and economic mechanics much more than it affected White U.S. citizens. During the pandemic, racial minorities were highly under-reprensented when it came to healthcare coverage: In 2017, 10.6% of African Americans were uninsured, compared to 5.9% of white Americans. In addition, only 44.1% of African Americans had full health care coverage, compared to 93.7% of white Americans. Furthermore, 12.1% of Africans Americans under the age of 65 reported having no health insurance coverage (Carratala and Maxwell). Unfortunately, this situation continued to devolve. While White individuals faced a problematic 6% rise in the loss of coverage in the first year of the pandemic, Black and Hispanic individuals suffered a 13% rise in the loss of health insurance coverage, more than double the rate of loss compared to Whites (Hackett). 

While it is a common belief that there are no racist ideals built into our system in the 21st century, these statistics show how naive those beliefs are and how crucial it is that the consequences from the history of layers of structural racism are analyzed closely. 

Social Factors

Tolerance of Racial Hate Crimes

As the Black Lives Matter Movement of 2020 has demonstrated, police brutality, lynchings, and other forms of targeted violence brutalize African Americans in the U.S.A. Such incidents often remain unnoticed, unreported, or insufficiently investigated. “Past lynching combined with a sizeable black population largely suppresses (1) police compliance with federal hate crime law, (2) police reports of hate crimes that target blacks, and in some analyses (3) the likelihood of prosecuting a hate crime case” (King, Messner, and Baller). When government institutions fail to address hate crimes through justice, there is little to no chance that those very institutions will illuminate the struggles that minority groups face in securing adequate healthcare. 

Moreover, these failures of justice cause African American and other immigrant groups to experience reluctancy while seeking help for their injuries. “African Americans and recent immigrants report that they hesitate to seek health care, given their historical experience with substandard care, unethical human experimentation, and disproportionate reporting of patients to agencies such as Child Protective Services and Immigration and Customs Enforcement. African Americans, Latinos, and Native Americans may experience mental health services as entwined with law enforcement, given that the nation’s largest provider of mental health care is now the jail and prison system, and that members of these groups are two to six times as likely to be incarcerated” (Hansen, Riano, Meadows, and Mangurian). Not only are minority groups targeted in their day-to-day lives, but once they finally muster the courage to seek counsel, they again tend to be treated inhumanely by institutionalized authority figures. 

Even after centuries of battling the matters of inequality in the U.S., minority groups are forced to endure horrible hate crimes, where no sufficient action is taken to relieve their trauma. If action is taken, it tends to occur under worse conditions than what their White counterparts would experience. To improve health outcomes, racism must not only be addressed by those whose work directly pertains to racialized health disparities or those who are racial/ethnic minorities themselves, but by all public professionals (Garcia and Sharif).

 Urban Planning of Inner Cities

Poor urban planning and housing conditions are associated with a wide range of health conditions, including respiratory infections, asthma, lead poisoning, injuries, and mental health. “Studies have found that changes in nutrition, physical activity, and safety within communities can be achieved through urban planning and community development, which might also improve health behaviors” (Thornton, et al.). These health implications of urban planning pertain to both the interior components of residences as well as their surrounding area. With respect to the interior aspect, dead spaces in walls, for example, permit entry of cockroaches and rodents. Moreover, leaking pipes often contain contaminated water that can harm their inhabitants. Exposure to toxic, airborne pollutants within residences can lead to asthma and lung damage. Inadequate construction and management of properties in the inner city directly contribute to increased unwellness and disease (Higgins and Krieger). 

Outside of these dwellings, there are a number of environmental factors related to urban planning that can adversely affect disenfranchised inhabitants. One such manifestation of this includes access to healthy physical activity initiatives. For example, Project U-Turn in Michigan addressed this glaring need by creating designated bicycle lanes within its current inner city infrastructure and an increased number of walking paths. As a result, the “...project was associated with an increased proportion of children walking to school and an estimated 63 percent increase in active transportation citywide” (Thornton, et al.). Unfortunately, the preponderance of alcohol outlets in many disadvantaged communities have a number of adverse effects on their population. “Interventions that address the distribution and density of alcohol outlets in low-income communities can affect substance abuse–related morbidity, crime, and neighborhood safety” (Thornton, et al.). In response, The World Health Organization (WHO) has issued a global strategy for municipal policies to reduce the harmful use of alcohol (Anderson et al.). Although there is limited data to implement WHO’s recommendation, cities across the world can begin documenting and acting upon policies that address this systemic issue. Doing so would be a major step towards mitigating the racial disparities in healthcare because it would reduce the likelihood that minority groups visit a health office and are exploited due to the current lack of initiatives towards equality.

Barriers to Homeownership

Racial steering, a common practice, takes place when real estate agents deliberately direct African Americans away from desirable neighborhoods, and toward areas featuring larger concentrations of people of color, higher poverty levels, and lower housing quality, as compared to White neighborhoods. As a consequence of this segregation, African Americans receive proportionally fewer, more costly, and riskier home mortgage loans, and remain constrained in their residential investment options, where their property assets fail to appreciate as do those under White ownership (Zonta). By being more likely to live in disadvantaged neighborhoods and to have inadequately resourced schools (which yield lower educational attainment and quality), Black and Latino adults experience higher rates of chronic and disabling illnesses, infectious diseases, and higher mortality than white Americans (Health-Care Utilization as a Proxy in Disability Determination). 

This vicious cycle positions African Americans at a structured disadvantage in their ability to build equity and accumulate wealth. Indeed, low-income neighborhoods do not receive as much governmental funding, leading their school staff to be ill-equipped to provide quality educational opportunities for this population. After years of struggling to matriculate into an excellent college and ultimately obtain gainful employment, these individuals often have to raise their families in those same neighborhoods, forcing their children to endure these same obstacles. 

Political Factors

Underrepresentation in Government and Healthcare

After emancipation from enslavement, African Americans received healthcare in segregated facilities in northern hospitals created by local governments. The end of the plantation system of medical care heralded the beginning of the Freedmen's Bureau “...by the federal government to provide assistance to former slaves. The medical department of the Bureau established nearly 100 hospitals for freed slaves, however, by 1868 only one - the Howard University Medical Center - remained” (Smith, 1999). In the south, where most African Americans resided, local municipalities and states began to provide payments to hospitals to subsidize care for the underserved, which included segregated care for the poor (Smith, 1999). American Indians, who experienced displacement and high mortality, had little contact with health systems until the second half of the 19th century. This healthcare, administered by the government, was also “...poor, inadequately funded, and not sensitive to culture” (Byrd & Clayton).

The frustrations of Southern citizens at this level of mistreatment is evident in recent voter turnout trends. After being a staunch Republican state for almost 50 years, Georgia voters turned Georgia into a blue state during the 2020 presidential election. Furthermore, Raphael Warnock, a Democrat, became the first Black senator from Georgia (Smith). A break in underrepresentation is absolutely necessary in order for the basic needs of African Americans, such as health insurance coverage, to be accurately represented.

Not only is representation crucial in government, but there is a persistent lack of diversity among healthcare professionals. “Most active physicians today are white men and more nursing and rehabilitative positions are held by women—in turn, people of color are still vastly underrepresented in these areas” (Diversity in Healthcare and The Importance of Representation). According to the Association of American Medical Colleges, only about 5% of physicians identify as Black or African-American and fewer than 6% of physicians identify as Hispanic. However, 28% of physicians and surgeons in the United States are immigrants, with doctors from India and China making up the largest groups (Diversity in Healthcare and The Importance of Representation). These trends illuminate systemic oppression: people from minority groups that have a history of being oppressed in the U.S. are less represented as physicians than are immigrants. In turn, this phenomenon can lead to uneven promotion opportunities. For every 100 men who are promoted to managerial positions, only 85 women are promoted; for Black women and Latinas, it is only 58 or 71, respectively (Diversity in Healthcare and The Importance of Representation). With less people representing those who they are serving, impartial treatment is less likely to be achieved. This can result in implicit racial biases, causing a significant proportion of the population to not receive welcoming or satisfactory service at healthcare offices. 

Gerrymandering of Medical Services

Medicaid is a public program that provides health insurance to low-income Americans, children, disabled people, and the eldery. Nationwide, approximately 75 million people are enrolled in Medicaid, including nearly 13 million who gained eligibility through the ACA’s Medicaid expansion (Tausanovitch and Gee). Additionally, more than two-thirds of Americans report that they have either been covered by Medicaid themselves or have had a close friend or family member who was a Medicaid beneficiary (Tausanovitch and Gee). Unsurprisingly, then, Medicaid is popular with voters across both major political parties. Nationally, 74 percent of Americans have a favorable view of Medicaid—including 82 percent of Democrats and 65 percent of Republicans—while only 20 percent of Americans have an unfavorable view (Tausanovitch and Gee). Even in states that have not expanded Medicaid, 59 percent of respondents in a 2018 poll favored expanding Medicaid to cover more low-income uninsured people (Tausanovitch and Gee). Despite Medicaid’s popularity, some state government officials are still refusing to include Medicaid in their policies.

While Medicaid enjoys strong public support, many states have failed to expand Medicaid because of partisan gerrymandering, the practice of drawing district lines to unfairly favor particular politicians or political parties. Officials are prioritizing staying in power -- even if they lose voter support -- over serving the best interests of the citizens. At least once every decade, politicians redraw the lines of their electoral districts in order to adjust for the changes in population so that each official still represents roughly the same number of people. However, politicians frequently take this opportunity to draw lines that benefit themselves and hurt their opponents by spreading out supporters of their own party to secure a majority vote in as many districts as possible while isolating the opposing party in fewer districts. This practice is sometimes referred to as “cracking and packing” -- if one party’s supporters are packed into few enough districts, the other party can sometimes win a majority of districts even with a minority of the votes (Tausanovitch and Gee).

Two leading efforts to limit health care access to minorities include: (1) policies that refuse to expand the state Medicaid program to provide low-income adults access under the Affordable Care Act (ACA) and (2) initiatives that take coverage away from beneficiaries who do not meet burdensome work requirements. As a result of states’ refusal to incorporate Medicaid into their programs, more than 2 million uninsured citizens are stuck in the coverage gap: they do have enough to qualify for subsidized private coverage through the ACA but have an income that is too high to qualify for Medicaid (Tausanovitch and Gee). The specifics of the work requirements vary by state, but most require applicants to work 20 hours per week or 80 hours per month in full- or part-time employment, have attended job training programs, have secondary or college education, have attended technical school, and participate in caregiving and community service activities in order to receive Medicare benefits. This is an extremely worrying approach taken by the Trump administration because it makes healthcare an object to be earned, not to have as a right. Although such work requirements are meant to target adults, the policy hurts the children of those whose parents lose coverage. “When parents lack health coverage, children are also more likely to go uninsured. Children also benefit directly when their parents can access the health care they need and have greater financial security, which is why parents losing coverage hurts children’s health and long-term development” (Tausanovitch and Gee).

There are severe consequences from such policies. North Carolina, Wisconsin, and Georgia are three states that have not expanded Medicaid. In these states, “...1 million more people would have been insured and roughly 3,000 deaths would have been prevented in 2019 alone if the expansion had been fully implemented (Tausanovitch and Gee). Michigan is another state with heavily gerrymandered districts. In this state, conservatives in the Legislature repeatedly try to limit beneficiaries’ access to Medicaid by imposing onerous work requirements (Tausanovitch and Gee). “Evidence shows, however, that Medicaid work requirements not only result in low-income people losing health coverage but also fail at their purported objective of boosting employment” (Tausanovitch and Gee). Refusing to fully expand Medicaid prevents the ability to significantly increase coverage at a low cost to state taxpayers and fails to close the coverage gap.

Gentrification

Health care executives argue that the shift from hospitals to smaller, specialized facilities will improve care as new technologies limit the need for overnight hospital stays. “But for lower-income individuals, the loss of a hospital can mean the difference between being treated or not” (Franzosa). Freestanding Emergency Departments are not recognized as certified Medicare providers and do not bill Medicare or Medicaid for services. Medicare generally only reimburses EDs that bill under the National Provider Identifier of a Medicare-participating hospital. Therefore, although Freestanding EDs may provide care to Medicare beneficiaries, reimbursement for services provided in such facilities is generally limited to the reimbursement provided to physicians or other professionals for their services (DiVarco, Cook, and Reigart). Those who can afford a free-standing, local ER can be treated in minutes, and at lower costs. For minority groups, however, this can mean both loss of a full-service community hospital, and physical and financial inaccessibility to the new urgent care centers. 

A prime example of how gentrification affects access to healthcare in minority neighborhoods is shown from an incident in the South Side of Chicago. In 2010, 18-year-old Damien Turner was caught in the crossfire of a drive-by shooting. His death was not an immediate result of the shooting, but rather of the fact that he needed to be driven over nine miles to the nearest Level 1 Trauma Center. His death spurred a movement for residents to hold the University of Chicago Medical Center accountable for the inadequate services available in their neighborhood, ultimately leading to the opening of a new area hospital in 2018, the first trauma center to open in the neighborhood in nearly 30 years (Franzosa).

Today, someone may choose to visit a free-standing ER at a local shopping center and be treated in minutes, rather than waiting for hours in a hospital ER. Those who are wealthier may pay an annual fee, plus medical costs, for a service that provides immediate ER access whenever it is required. However, the poorer citizens of America -- who are forced to live in neighborhoods without a full-service hospital due to the cycle of discrimination in housing -- may not reach an ER in time, even if they are lucky enough to be fully insured. 

Economic Factors

Workplace Racial Discrimination

Insurance status is a fundamental predictor of the quality of care that a patient receives. For example, a private insurance company will generally provide higher-quality and more consistent care than publicly funded programs like Medicaid. “Racial disparities in health coverage account for barriers to healthcare access faced by many Black, Indigenous, and people of color (BIPOC). These inequalities result in disproportionate gaps in coverage, inconsistent access to services, and poorer health outcomes” (Bittker). As discussed in other sections, minority populations experience illnesses at higher rates with a lower life expectancy than other racial groups. Nevertheless, they continue to be paid less than their white peers while doing the same work, which plays a significant role in the coverage gap.

Job-based insurance coverage rates vary widely across race, income, citizenship status, and age groups. For example, among California working adults ages 19 to 64, “...the percentage who had employer-based coverage was lower for Latino and black workers, low-wage workers, non-citizen immigrants, and young adults than for other workers in 2018” (Lee, Lucia, Graham-Squire, and Dietz). The level of job-based coverage disparities is even greater when accounting for race, income, and citizenship status among Latino workers. Among this population in California, “... more than half (56 percent) are low-income workers, earning less than $14.35; only 31 percent of this group received insurance through their employer” (Lee, Lucia, Graham-Squire, and Dietz).

Since lower-income BIPOC workers pay lower tax rates, they reap smaller benefits from employer-sponsored health coverage than do higher-pay employees; that is, if they are offered employer-sponsored health coverage in the first place. Approximately one-third of employees in the lowest-income quintile are offered employer-sponsored health coverage with an acceptance rate of only 20%, whereas over 80% of employees in the highest-income quintile are offered, and accept, employee-sponsored health coverage (Bittker). Over time, the value of these benefits for the higher-paid employees will likely accelerate at a faster pace than the value of benefits for lower-paid employees.

The current U.S. healthcare system prioritizes healthcare delivery hierarchically. In short, it identifies who receives care by how much money they have, rather than by more equitable metrics. Since private-insurance companies -- not run by the federal or state government -- are for profit, the corporate profit-motive always risks an unresolvable tension with the ethical principles that drive healthcare. In turn, this phenomenon often results in a lack of transparency, fairness, and even efficiency. From this lens, healthcare is primarily treated as a commodity, instead of as a basic human right. 

Gender Discrimination Pay-Gap

Women of color tend to experience the nation’s gender wage gap most severely in the United States. While it is true that all women are paid less than their male peers, women of color generally face a more dire economic situation than White women. As of March 2021, White, non-Hispanic women were typically paid 79 cents for every dollar that a White, non-hispanic man was paid (Quantifying America’s Gender Wage Gap). Meanwhile, Black women were paid 63 cents to the dollar, Latinas were paid 55 cents to the dollar, Native American women were paid 60 cents to the dollar, and Asian American/Pacific Islander women were paid 52 cents to the dollar (Quantifying America’s Gender Wage Gap). 

If the annual wage gap were eliminated, a typical African American or Native American woman working in the United States would likely have enough money to pay for more than 16 additional months of premiums for employer-based health insurance (Quantifying America’s Gender Wage Gap). In addition, a typical Latina would likely have enough money to pay for nearly 20 additional months of premiums for employer-based health insurance (Quantifying America’s Gender Wage Gap). Moreover, a typical Asian American/Pacific Islander woman would likely have enough money to pay for more than five additional months of premiums for employer-based health insurance (Quantifying America’s Gender Wage Gap). Based upon these findings, it is clear that the U.S. economic policies systematically devalue women of color and their work. This then contributes to the flawed notion in the U.S. that healthcare is earned, not provided.

Not only are women paid less, but they also tend to utilize healthcare resources at a greater rate than men. Women generally require more primary care visits, screening services, diet and nutrition counseling, and sexual health care than men on an annual basis (Health-Care Utilization as a Proxy in Disability Determination). This is true not merely during child-bearing years for reproductive health or during menopause for cardiovascular disease and osteoporosis. In fact, women are more likely to have 10 or more visits to the doctor in one year, and more likely to have a hospitalization or ED visit (Health-Care Utilization as a Proxy in Disability Determination). Additionally, among ages 18-64, women have higher rates of disability and self-reported poor health status. Despite needing more medical care, among all adults (ages 18 and older), women are more likely to delay or not receive care, or not receive prescription drugs because of cost (Health-Care Utilization as a Proxy in Disability Determination). 

Overall, women tend to have a higher health-care utilization than men and are forced to work harder for less money. These factors contribute towards blocking women from adequate healthcare coverage. Critics may question the validity of the statement that women work harder for less, but it is unfortunately true. While the work-load may be the same in theory, women have to work harder to earn their male peers’ respect in the office, biased questions about their capabilities to juggle their home and work life, or even starting out with menial tasks. In light of such obstacles, the least the U.S. government can do is provide women with wages commensurate with those of men and adequate healthcare resources.

Red-lining by Corporate Banks

Racial discrimination in the 1930s regarding mortgage-lending set the wealth patterns of African Americans today. In 1933, faced with a housing shortage in the aftermath of the Great Depression, the federal government began a program where realtors would mark black or immigrant-filled neighborhoods as “hazardous” in red ink on maps drawn by the federal Home Owners’ Loan Corp (Jan). These neighborhoods were therefore deemed undesirable and loan programs for these areas were unavailable or overly expensive. As a result, it was exceedingly difficult for low-income minorities to buy homes (Jan). “Anyone who was not northern-European white was considered to be a detraction from the value of the area,” said Bruce Mitchell, a senior researcher at the National Community Reinvestment Coalition (Jan). Nationally, nearly two-thirds of “hazardous” neighborhoods contained black and Latino families while 91 percent of the “best” areas in the 1930s remained middle-to-high income and 85 percent of them were predominantly White (Jan). “Homeownership is the number-one method of accumulating wealth, but the effect of these policies that create more hurdles for the poor is a permanent underclass that’s disproportionately minority,” said John Taylor, president and chief executive of the NCRC (Jan). This again traps minority groups in the cycle mentioned before, where they are unable to accumulate wealth due to banks refusing to give loans to minorities. In turn, such oppressed individuals are forced to move into these underdeveloped neighborhoods where the next generation will likely live the same way. “If the bank’s not loaning, then things deteriorate,” says Torey Edmonds, an African-American woman who has lived in the same house in Richmond, Va. for 61 years, “We have a lot of our neighbors that have health challenges” (Godoy).

Although red-lining was banned in 1968, the effects of the practice are still evident over 50 years later. Since these neighborhoods were designated for minority groups and immigrants -- therefore, undesirable -- they were also extremely underdeveloped in comparison to the predominantly white neighborhoods. Residents of these neighborhoods are more likely to experience shorter life spans and suffering, at times as much as 20 to 30 years shorter lifespans than found in White neighborhoods in the same city (Godoy). As already noted, these neighborhoods also feature higher rates of chronic diseases, including asthma, diabetes, hypertension, obesity and kidney disease. “These once-redlined neighborhoods are also more likely to have greater social vulnerability, meaning they’re less able to withstand natural and human disasters because of their more limited resources” (Godoy). Due to this history of structural racism in the United States, minority groups have the highest need for medical care, but also struggle the most in order to acquire sufficient healthcare coverage. It is appalling to see how this sad irony is consistently being overlooked by government officials and it must be urgently addressed. 

Conclusion

The current U.S healthcare system is in an abysmal state that disenfranchises vulnerable citizens. Government officials thereby must enact solutions to close the gap between races in U.S. healthcare coverage. To this end, there are multiple steps that can be implemented, as follows:

- Expanding the racial/ethnic diversity of healthcare professions - It is vital to recruit a diverse workforce that reflects the population being served. This would also help to close the wage gap between gender and race, allowing more people of color to be able to afford adequate health insurance coverage. 

- Increasing awareness of the racial and ethnic disparities in healthcare amongst the general public - Currently, the underlying causes of these racial healthcare disparities in the U.S. are unknown to most, making it extremely difficult for change to occur. In order to gather support for placing every racial group on equal footing in healthcare coverage, the general public should be educated about the history of structural racism in the U.S. In turn, this can allow them to better appreciate the synergy of social, political, and economic factors that are costing millions of people of color their rights to sufficient healthcare. 

- Developing provider training programs and tools in cross-cultural education - Creating such programs would allow healthcare professionals to become more knowledgeable about structural racism in the U.S. It would also better equip these individuals to help those in need, and to strengthen patient-provider relationships in publicly funded health plans. Moreover, such programs must advocate for designating specific leaders that address disparities reduction and tying compensation to the reduction of this issue.

- Applying the same managed care protections to publicly funded Health Maintenance Organizations as to private HMOs - This remedy can allow citizens to receive proper treatment in a short amount of time, without needing to worry about expenses being too high since their ERs would be properly funded.

- Creating voter-determined district lines - Having districts drawn by independent parties that accurately depict voter preferences would ensure representation for minority groups and amplify their voices on critical issues like health care disparities. 

There is a stark difference in how racial/ethnic minorities in the U.S., who have persistently experienced social disadvantages and discrimination, experience greater health risks and worse healthcare services than their White counterparts. At least half of all Black, Hispanic, and Native American citizens of the U.S. have discontinuous insurance coverage, and with the population of people of color rising, it is imperative that these issues are addressed as soon as possible. The implicit bias in the system can easily cause many kinds of failure, as the COVID-19 pandemic has made very clear. There is also an economic motive for eliminating this disparity. “Dying in America is an expensive process, with about one in four Medicare dollars going to care for people in their last year of life. But for African-Americans and Hispanics, the cost of dying is more than it is for whites” (Gavin). Statistics from a University of Michigan team study in 2016 show that the cost of the last six months of life is $7,100 more expensive to the Medicare system for black people, and $6,100 more expensive for Hispanics, or 35 and 42 percent higher respectively than for whites (Gavin). 

Overall, the interlocking social, political, and economic factors that contribute to healthcare inequality in the U.S. must be addressed imminently. Had these inequalities been addressed sooner, millions of Americans could have been relieved of, at the least, a financial burden in the midst of a long-lasting pandemic, where loved ones were lost and the economy collapsed. Instead, the current state of our healthcare system forces over 40 million citizens to suffer at the hands of systemic racism every day. In light of this, it is imperative to implement the remedies addressed herein and save the lives of America’s most underserved citizens.

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