“Black people suffer from dramatic health disparities in life expectancy, maternal and infant mortality, chronic medical conditions, and outcomes from acute illnesses like myocardial infarction and sepsis,” stated a recent open letter signed by more than 1,200 public health experts and medical students supporting the George Floyd protests. “They result from long-standing systems of oppression and bias which have subjected people of color to discrimination in the healthcare setting.”
It is a widely held belief among healthcare policy experts that racism causes health disparities between black people and white people. In 2016, the prestigious New England Journal of Medicine ran an editorial that stated, “Most physicians are not explicitly racist. … However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals.”
Is that belief correct?
On its face, the data say yes. Life expectancy among black people is still more than three years less, on average, than among white people in the United States. According to the U.S. Department of Health and Human Services, black people are 60% more likely to be diagnosed with diabetes than white people. Heart disease and kidney failure are complications stemming from diabetes, and rates of both are higher among black people as well. The risk of kidney failure is 4 times higher for blacks than whites, and black people are 20% more likely to die from heart disease.
Yet Jonathan Klick and Sally Satel challenge the “idea that racial bias is a meaningful cause of health disparities” in their book The Health Disparities Myth. Klick, a professor of law at the University of Pennsylvania, and Satel, a physician and resident scholar at the conservative American Enterprise Institute, write that the idea is “sensational but unsubstantiated.” They make the case that factors such as physician quality and geography better account for the disparities.
Much research has examined whether physicians are guilty of “implicit bias,” that physicians make clinical decisions based on implicit assumptions about race and ethnicity. However, there is no definitive conclusion on implicit bias. For example, a research review from 2013 in the Journal of General Internal Medicine examined “implicit bias” among physicians and concluded that “implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics.” But a 2017 review in Academic Emergency Medicine stated that the “current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making.”
Klick and Satel point to research showing that black people are more likely to seek treatment from lower-quality physicians than white people. A study of Medicare patients found that 80% of physician visits by black people were made to only 22% of physicians. In general, those physicians were less likely to have passed a rigorous certification exam and had less access to high-quality specialists to which they could refer their patients. A similar pattern can be found among hospitals. Those that treat predominantly minority patients tend to offer lower quality healthcare.
A more important factor is geography — specifically where a patient lives. “Geographic residence often explains race-related differences in treatment better than even income or education,” Klick and Satel write. “As a rule, the quality of care received by blacks is inversely related to the concentration of black residents in the local population.” They point to research showing that the frequency of annual eye exams for black diabetic patients dropped in areas with a heavier concentration of black residents. But black residents who lived in areas with more white residents received eye care that was equal to that of whites. Research that examined the impact of geography on heart attacks and infant mortality found similar results.
However, if black people tend to live in areas with lower-quality healthcare, perhaps that in itself is evidence of “structural racism.” The same editorial in the New England Journal of Medicine defines structural racism as “a confluence of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups.” Perhaps structural racism is responsible for why black people are more likely to live in areas with inferior healthcare services. For example, an article in the Annual Review of Sociology concluded that “racial inequalities in health endure primarily because racism is a fundamental cause of racial differences in [socioeconomic status] and because SES is a fundamental cause of health inequalities.”
Proponents of the structural racism argument point to the practice of “redlining,” the denial of services such as mortgages and business loans in areas with heavy minority populations. The federal Fair Housing Act of 1968 outlawed redlining, but those making the structural racism argument point to research showing that black people still have a harder time than white people getting mortgages and small-business loans. Critics of the structural racism argument claim that credit scores determine whether people are approved for loans and that blacks and Hispanics tend to have lower credit scores than whites and Asians.
The question of whether racism or other factors account for health disparities between blacks and whites is far from academic. If racism is indeed the cause, then more policy measures aimed at reducing racial disparities are likely needed to reduce health disparities. But if racism is not the cause, then focusing on it, as Klick and Satel write, “siphons energy and resources from endeavors targeting system factors that are more relevant to improving minority health.”
