Health care cost disparities between black and white adults vary greatly by local level of racial and economic integration, and tend to be low or nonexistent in highly integrated communities, according to a study led by researchers at the Johns Hopkins Bloomberg School of Public Health.
For their study, the researchers compared health care costs for a nationally representative sample of black and white adults in census tracts across the United States. They found that, given the same level of health care, health care costs for black adults were much lower than for white adults in areas with the lowest levels of racial integration, but were about the same in areas with the most integration. high. The researchers also found that more integrated areas also had signs of more equitable access to health care for black and white adults.
Individual health care expenditures are indicators of people’s health needs and the types of health care they can or cannot access. The findings add to evidence that health disparities between black and white adults are largely due to modifiable social factors.
The study was published online Nov. 3 in JAMA Health Forum.
“Fixing health care disparities can require both health and non-health solutions — making sure people have health insurance and that the resources they have based on where they live give them the best chance to be healthy.” , says lead study author Lorraine Dean, ScD, associate professor in the Bloomberg School’s Department of Epidemiology. “We already knew from previous research that health care disparities mostly disappeared when black and white adults lived in more equitable areas—now we know that’s also true for health care costs.”
Because of external factors—including different levels of exposure to poverty, economic opportunity, access to health care, and environment—it has long been known that life expectancy, risk of disease, health outcomes, and other health-related measures differ between whites and black Americans. On average, black adults have shorter life spans and higher rates of common diseases, including diabetes, hypertension, and kidney disease.
A 2011 study, also by Bloomberg School researchers, including new study co-author Darrell Gaskin, PhD, the William C. and Nancy F. Richardson Professor in the Bloomberg School’s Department of Health Policy and Management, described racial and socioeconomic integrated area of Baltimore, where disparities in rates of hypertension, diabetes and other health measures were much lower than the national average, and for some measures disappeared altogether. The study used the term “place, not race” to capture the findings.
In the new study, Dean and colleagues address the closely related question of whether health care costs vary by level of racial and socioeconomic integration.
For their analysis, the researchers used data from a 2016 US government survey called the Medical Expenditure Panel Survey (MEPS), which includes data on race, socioeconomic status, health status, access to health care, use of health care and health care costs (including insurance payments) for a nationally representative sample of Americans. The researchers also used data on the levels of racial and socioeconomic integration of each MEPS participant based on the US Census Bureau American Community Survey (ACS) 2013–17.
The analysis included a total of 7,062 adult MEPS participants age 21 or older — one-third of them black, two-thirds white — living in 2,238 census tracts where the population was at least five percent black.
For each of these census tracts, the researchers used census data to calculate a measure of socioeconomic and black/white integration called the Index of Concentration at the Extremes (ICE). They define this as the number of non-Hispanic white adults in high-income households (≥$100,000) minus the number of non-Hispanic blacks in low-income households (<$20,000) divided by the total population with known income in that census tract.
The analysis, which adjusted for potential confounders such as age, gender and education level, found that in communities where ICE was highest — many high-income white adults, few low-income blacks — racial disparities in health care spending were uttered. In these relatively unintegrated communities, black adults spend $2,145 less on health care per year than white adults. These differences could reflect undertreatment for black adults or overuse of health care by white adults. In contrast, in communities where ICE was in the middle range, indicating the highest level of racial and socioeconomic integration, these cost differences nearly disappeared—the estimated difference in total annual costs was only $79.
In the least integrated communities, where black adults have lower total health care costs, they still have levels of physical health similar to those of white adults. Their lower total costs are mainly due to lower costs for doctor’s office, prescription drugs and dental services. But in highly integrated areas, differences in individual expenditure categories were minimized. The most integrated areas also have relatively equitable access to health care, according to MEPS data.
Overall, the researchers say, the findings suggest that reducing the disparity in health care costs between blacks and whites is possible, although it may be much easier to achieve in areas where socioeconomic disparities and access to health care are minimized.
“Health Care Expenditures for Black and White US Adults Living in Similar Conditions” was co-authored by Lorraine Dean, Yuehan Zhang, Rachel McCleary, Rachel Dawit, Roland Thorpe, and Darrell Gaskin.
Funding for the study was provided by the National Institute on Minority Health and Health Disparities (U54MD000214) and the National Heart, Blood, and Lung Institute (R01HL164116).
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