Report measures sharp health care disparities by race, ethnicity and geography

Black, Hispanic and Native Americans have poorer health care than white people, even in states with health care systems that do better than in most of the rest of the country, according to a new national study.

Wisconsin ranks right in the middle for its overall health care system’s performance — worse than 24 states and the District of Columbia, but better than 25 states. For Black residents, however, Wisconsin’s health care system has the fifth-worst overall performance in the country, according to the study released Thursday by the Commonwealth Fund.

“We find that health equity does not exist in any state in the U.S., not even in  states with historically stronger health systems,” said David Radley, a Commonwealth Fund senior scientist and one of the study’s authors.

The nonprofit Commonwealth Fund researches and recommends policy to improve health care access, quality and efficiency, particularly for the most vulnerable, including people of color, people with low incomes and the uninsured.

The report, “Advancing Racial Equity in U.S. Health Care,” confirms what many public health professionals and researchers have observed for years — that persistent disparities in health care and in health outcomes have left Black, Hispanic and indigenous people in the U.S. worse off than white people.

“We’ve long  known  that  racial  and  ethnic  disparities  in  health  and  health care  have  existed  in  our  country,” said Dr. Joseph Betancourt, the Commonwealth Fund’s president, at a media briefing Wednesday. “Quite simply and on average, our report shows that disparities exist in every  state in our nation. Even in states that have strong overall health systems, racial and ethnic health disparities can be dramatic.”

Health care mirrors the “systematic inequalities that plague all facets of American society,” he said. Local, state and federal policies as well as “underinvestment and inequity” in local health care systems have all contributed to discrimination against people of color and contributed to poorer health outcomes for many, he added.

Health outcomes, access and quality

For the study, researchers assembled data on 25 separate indicators to assess health and health care as it’s delivered in the U.S.

The indicators included measures of health outcomes, access to care and the quality and use of health care services. Among metrics used were deaths under the age of 75 from preventable and treatable health conditions; deaths from treatable conditions such as breast cancer; health insurance coverage; the use of primary care providers and access to preventive health care services such as vaccines.

The metrics were applied to state population data and logged by race and ethnicity for five population groups: Black, Hispanic, white, American Indians and Alaska Natives, and Asian Americans, a group that also includes native Hawaiian and Pacific Islanders and their descendants.

With the data the researchers calculated a score up to 100 that they called “health system performance” for each of the five racial and ethnic groups in each state. They ranked the states by their scores for each group, comparing them against the average for the entire U.S. population, set at 50.

Wisconsin’s health system performance score was 82 for white residents. For Hispanic residents it was 30 — below the national average for all people — and for Black residents it was 14. Despite Wisconsin’s tribal population, the report said there wasn’t enough data to calculate the health system performance for American Indian and Alaska Natives in the state.

In most states, the health system performance was best for white people, although in about a dozen, the health system performance score was even higher for Asian Americans. The scores showed that health systems in each state performed less well for Black and Hispanic people and for American Indian and Alaska Native populations.

In four states — West Virginia, Oklahoma, Mississippi and Arkansas — the combined health indicators for white people were below the national average, but still above those for Black or Hispanic residents of those states.

Six states — Rhode Island, Massachusetts, Maryland, Delaware, Connecticut and New York — had health performance scores for Black people that were above the national average for all groups. Even in those states, however, Radley said, “Black people are faring substantially worse than the top-performing group” in their state.

Wisconsin, Illinois and Minnesota are among states where the gap was largest between Black people’s experience of the health care system and that of white people or Asian Americans.

In eight states where Hispanic people’s health care experiences were better than the national average, they were still well below the group in their state that was doing the best, according to the report.

Reasons and recommendations

Poverty, pollution, higher crime rates and fewer green spaces all contribute to poorer health conditions in communities where people of color live, according to the report.

In addition, access to health care is also a barrier. That can be due to the lack of health insurance or coverage that requires higher out-of-pocket payments from patients as well as a lack of health care providers, the report said. It is also due to a paucity of medical providers to serve those communities.

The report recommends a wide array of policies to expand health care coverage but also to address broader problems such as the need for affordable housing, child care and public transportation — identifying all of those as contributors to health disparities.

Insurance coverage is “the floor in terms of ensuring that everyone has access to health care,” said Dr. Laurie Zephyrin, a report coauthor and the vice president for advancing health equity at the Commonwealth Fund. “And it is really critical when we look at the data — about 25 million people in the United States are still uninsured, and they’re disproportionately people of color.”

As many as 25% of working adults are underinsured, Zephyrin added — with “high out-of-pocket costs and deductibles relative to their income” that lead many to forgo medical care “because they can’t afford it.”

In calculating Wisconsin’s score, the study found that for Black residents, health care quality was above the national average, but access and outcomes were below the national average.

“Wisconsin is one of the 10 states that hasn’t fully expanded their Medicaid program,” said Sara Collins, a vice president and scholar for the Commonwealth Fund. “That is always a telltale sign of a state having access issues.”

Federally subsidized Medicaid expansion — which the Legislature’s Republican leaders have rebuffed despite repeated attempts by Democratic Gov. Tony Evers to accept — would enable Wisconsin residents with incomes up to 138% of the federal poverty guideline to enroll in the state’s BadgerCare health coverage plan.

The report also recommends expanding the workforce of people who can provide primary care in communities lacking those providers.

“Primary health care is a key foundation of any health care system,” Zephyrin said. “Black and Hispanic communities have fewer primary health care providers, and we are in a primary health care crisis.”