When Melissa Creary talks about racism in health care, she has first-hand experience: As a public health expert at the University of Michigan with decades of research experience, she’s an expert on sickle cell disease, the disparities in its effects, and how discrimination and stigma feed into those outcomes. But she also lives with the disease, and, she told me, has learned to navigate racism in the health care system herself.
Sickle cell disease causes some red blood cells to transform into crescent shapes, increasing the risk of cardiovascular problems and organ failure, and often producing agonizing pain. The disease afflicts 100,000 Americans, most of them Black. Because it doesn’t affect the white majority the health care system was by and large built for, it’s long been under-researched and under-treated — in fact, life expectancy for sickle cell patients fell in recent decades, according to Kaiser Health News, even as life expectancy increased overall.
“The life-long consequences of living in a society that protects and values unequally, matched with the life-long physiologic burdens of disease, propel me to work towards ways to combat structural racism and increase the quality of life for this population,” Creary said.
These unbalanced outcomes are just one example of the racial disparities in health care that have fueled the Black-white life expectancy gap.
Based on data from the Centers for Disease Control and Prevention, around 70,000 Black people died prematurely in 2019 compared to their white peers — on average, 190 people dying prematurely every day for a year.
Covid-19 has likely made that worse. Due to a range of structural factors, Black people are disproportionately likely to get seriously ill and die from the disease. A recent study in PNAS found that the Black-white life expectancy gap grew by nearly a year and a half in 2020 due to the coronavirus, from 3.6 to 5 years.
That’s equal to undoing more than a decade of progress in closing the gap. The Black-white gap had been narrowing, partly due to improvements in access to health care (good) and drops in life expectancy among some white groups (bad). Covid-19 reversed part, though not all, of the improvements.
So I asked experts and researchers in this area: How does the US get back on track — and how does it finally erase this gap for good?
The overall goal, in short, is to make Black life a bit more like the better parts of white life. Today, it’s often challenging for Black people and their communities to make the healthy decision: Between lack of access to health insurance, food deserts with no healthy eating options, and inflexible family and work schedules that make time to exercise difficult to find, Black people have fewer opportunities than their white counterparts to do what’s best for their health.
“Race is not the risk factor,” Creary said. “Racism is.”
Policy could play a role in fixing this. Different levels of government could increase access to health care through an expansion of Medicaid (which serves populations with low incomes or disabilities) or other existing government health care benefits, and make the delivery of that health care more equitable and better suited for a diverse population. Lawmakers could try to address underlying socioeconomic gaps, which in turn can drive disparities in life expectancy by fueling poor social determinants of health. These policies can be targeted toward Black communities or be universal — even those that in theory benefit all Americans, like a child allowance that would send cash to parents every month, can in effect help lift Black people since they’re more likely to face impoverished conditions.
But there’s also an underlying cultural element to this. To the extent that much of what holds Black people back is simply discrimination by individuals, that will have to be alleviated in some way or another by a broader cultural and social shift. That’s not to say that policy can’t help — it can — but that there’s work to be done in less tangible realms of hearts and minds to help make American society less racist.
Ultimately, addressing the gap will require a truly systemic shift from both the policy and cultural levels. But America has made progress in this area, before Covid-19, and it can continue doing so in the aftermath.
Why there’s a big Black-white life expectancy gap
The Black-white life expectancy gap can be distilled to one fact: US society has, in many ways, made it easier for a white person to live a fully healthy life than a Black person.
This is personal for Jamila Taylor, the health care director at the progressive Century Foundation. Her father died of prostate cancer at just 44, and she has seen other Black people — aunts, uncles, cousins, and friends — in her life die prematurely as well.
“There are still these structural barriers — not only through the health care system but through broader society — that impact the ability of the African-American community to lead healthy and productive lives,” Taylor told me. “We see structural racism interwoven through institutions throughout this country.”
The average white person is more likely than the average Black person to have health insurance and access to care. The average white person is more likely to live near a grocery store with healthy options. She’s more likely to live in a good school district. She’s more likely to live in a neighborhood with better air quality. She’s more likely to live in a community that isn’t plagued by gun violence. She’s more likely to have flexible work conditions. And on and on.
That’s not to say every single white American has it great — that’s obviously not true. But, on average, Black people tend to face much bigger challenges for living the healthiest life possible. That shows up in the life expectancy gap: White people were expected to live nearly 79 years on average before Covid-19 and almost 78 years after, while Black people were expected to live nearly 75 years before Covid-19 and almost 73 after, according to the PNAS study. The Black life expectancy even before Covid-19 was equivalent to what the white life expectancy was in the 1970s — as though decades of progress in well-being and health care were suddenly erased.
There are many, many reasons for this. Throughout US history, outright discrimination has driven Black people into poorer communities with more pollution and less access to healthy food, while keeping access to good jobs, homes, and health care out of reach. The aftermath of Jim Crow and slavery, and insufficient action to repair the harms such policies afflicted on Black communities, left big socioeconomic disparities in place, including a very large racial wealth gap. Whether it’s explicit or implicit, there’s no part of Black life that systemic racism, past or present, hasn’t touched.
Meanwhile, America’s health care system in particular has an awful record on race. As one example, researchers in the Tuskegee study used Black people as unwilling test subjects — allowing them to languish with syphilis and even die. Black patients have also dealt with a health care system that has long dismissed their legitimate concerns, whether it’s regarding pain or maternal health. Surveys show that, as a result, Black people are less likely to trust the health care system, and perhaps use it even when it could help them.
“It’s a very intimate thing — your medical history — and there’s a lot of potential judgment involved and vulnerability involved,” Marcella Alsan, an economist and public health expert at Harvard Kennedy School, told me. “You have to have a belief in the person giving you the advice.”
All of that has, in some way or another, bled over to Black people’s health. Black people are more likely to suffer from health conditions that lead to a shorter life, like obesity, and report poorer health overall relative to their white peers. As a result, Black people also suffer from higher age-adjusted mortality rates in general but also are more likely to die by almost every major killer of Americans, including heart disease, cancer, and diabetes.
Covid-19 has exposed these harsh realities. The virus isn’t racist, but the society and the systems that it has spread in are, at the very least, racially biased. It’s that society and systems that have enabled a country in which Black people are more likely to suffer from conditions that make them more vulnerable to Covid-19. And it’s in that environment that Black people have disproportionately died from the coronavirus, undoing more than a decade’s worth of work in reducing the life expectancy gap.
Health care policies can help fix the life expectancy gap
The good news is this is an area where good policy changes can make a real impact — literally life or death for Black communities.
Part of this could be focused on the health care system, particularly through helping poor populations that are disproportionately likely to be Black. There are lots of specific options here:
- Bigger federal subsidies for health care plans. The federal government could boost subsidies for health insurance plans on Obamacare marketplaces, making them more affordable. About 11.4 percent of Black Americans were uninsured in 2019, compared to 7.8 percent of white Americans, according to the Kaiser Family Foundation. Based on surveys, the biggest reason for being uninsured is inability to afford it. Under Obamacare, the federal government already subsidizes health plans in the individual marketplace for lower-income families — but it could, as President Biden has proposed doing, pay for an even bigger chunk of those families’ health care costs. Congress is currently pursuing this as part of the Covid-19 relief bill.
- More states could expand Medicaid through Obamacare. Under the Affordable Care Act, states were encouraged to expand their Medicaid programs to include everyone up to 138 percent of the federal poverty level, with the promise that the federal government would pick up at least 90 percent of the cost. But 12 states, including populous Texas, Florida, and Georgia, haven’t expanded Medicaid. That’s disproportionately hurt Black people, based on a Kaiser Family Foundation analysis: “Uninsured Blacks are more likely than Whites to fall in the coverage gap in states that have not expanded Medicaid.” Congress is also considering boosting federal payments for Medicaid to encourage states to expand Medicaid.
- More generous Medicaid payments. Black people are more likely, due to worse economic conditions, to be on Medicaid than their white peers: About 15 percent of white people are on Medicaid, compared to 33 percent of Black people. But Medicaid plans generally don’t pay as much as private health insurance plans, leading some doctors to refuse Medicaid patients altogether. By making Medicaid rates and payments to doctors and hospitals more competitive with private plans, more doctors might be willing to accept Medicaid patients, and as a result serve this disproportionately Black population. These kinds of decisions are typically left to the states — meaning state lawmakers have most of the power here — but Congress could offer financial incentives to, say, boost primary care reimbursements.
All of these steps address an issue that comes up again and again in this space — what Taylor described as an unmistakable “divide” between Black and white Americans’ access to health care and ability to afford it.
There are also more targeted, innovative approaches. One study in the American Economic Review, from Alsan, found Black patients tend to do better with Black doctors — leading to the patients selecting more preventive services, including a flu shot. The researchers found Black doctors alone could cut the Black-white gap in cardiovascular mortality by 19 percent.
Alsan cautioned that we’re still figuring out why that is. One aspect is trust: If you don’t trust the health care system because you believe it’s racist, a Black doctor might be able to dispel some of those notions. It’s also possible that Black doctors, who are more likely to be part of the same communities as their Black patients, may already have earned trust and know how to communicate with their patients more effectively. Or Black doctors might be able to, in some cases, better address Black patients’ specific needs — particularly if the issue is a condition, like sickle cell disease, that disproportionately afflicts Black people and a Black doctor may be personally more aware of.
All of that and more could create the circumstances where diversifying the medical workforce could boost outcomes for Black patients. But as it stands, Black people are underrepresented in health care professions: Black people make up roughly 13 percent of the US population, but about 4 percent of doctors. Policymakers could move to address this gap by, for example, improving financial supports for Black people going to medical school.
“It’s about the opportunity,” Alsan said. “If I want to see a female gynecologist, I can do it. If you want to see a male urologist, you can do it.” The same, she explained, should be true for Black patients and doctors.
Policies outside health care could help too
Beyond health care, lawmakers could tackle the life expectancy gap through some of its underlying causes, particularly socioeconomic forces that limit Black people’s ability to live as healthy as they’d like. A stronger social safety net in general, whether it comes through universal basic income or a child allowance — which has already been introduced by federal lawmakers, including Sen. Mitt Romney (R-UT), and could get a boost in the coming Covid-19 relief package — could provide the financial support necessary to actually afford better food, preventive health care, a gym pass, and all the other keys to a healthier life.
All levels of government could address food deserts where there aren’t fully stocked grocery stores — by providing subsidies to encourage more companies to open shops or tapping into growing delivery services to ship healthier foods to underserved areas. Baltimore, for example, previously set up a system to let residents in food deserts order food online.
They could also take steps to clean up the environment. Some of these efforts have been going on for decades, from asbestos and lead abatement programs to clean energy initiatives that all levels of government have launched. But because they are more likely to live in poorer neighborhoods with outdated housing, Black people haven’t benefited from these efforts as much. Finishing the job here, through federal incentives or state and local measures, could address vast and remaining concerns about environmental inequity.
The idea is to make it so Black people have the resources and living conditions that enable a healthier lifestyle, aligning them a bit closer to the resources and living conditions that their white peers are currently more likely to have.
Policy approaches also don’t have to be explicitly targeted by race because policies that are in theory universal can have disproportionately beneficial effects for Black people since they’re likelier to fall toward the bottom of the socioeconomic ladder. Obamacare’s Medicaid expansion, for example, wasn’t framed as a racial policy. But it shrank disparities in both health care coverage and access to care.
It’s also easier to sell to a wider audience and get support in Congress. The Medicaid expansion, although it’s essentially socialist medicine, has won in Republican-dominated states.
That suggests a universal approach may be a more politically favorable path to shrinking the Black-white life expectancy gap. “Hopefully, that will make people more comfortable,” Taylor said.
Policy can’t fix everything
As much as policy can help, it probably can’t close the entire Black-white life expectancy gap on its own.
That’s because, to some extent, the gap is driven by outright discrimination in health care, jobs, housing, education, and more. Lawmakers have acted against such discrimination — that’s what laws like the Civil Rights Act tried to address — but it clearly persists.
What policy can’t achieve will need to be addressed by both individuals and society at large with social and cultural changes. Some of that is already taking place, as surveys find racial resentment has decreased over the past few decades. But a lot of work could still be done, whether it’s continuing to change media depictions of Black people, addressing racism in workplaces, or facilitating compassionate conversations in private spaces.
As that cultural work goes on in parallel, though, better policy could help. The US is poised to act on some of these issues, too: President Biden and Democrats in Congress, which swept into power over the past few months while voicing support for racial justice and Black Lives Matter, are currently working on an economic relief package that includes more generous subsidies for Obamacare marketplace health plans, more incentives for states to expand Medicaid, and other policies, like a child allowance, that could reduce some of the broader socioeconomic disparities between Black and white Americans.
But even that would only be the start. To really finish the job and close the full Black-white life expectancy gap, America will need to adopt more aggressive policies — like incentivizing primary care reimbursements — and address the racial injustices seeded in American life. After Covid-19, it’s all the clearer such systemic changes are truly needed.
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