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Recent efforts by various groups to shift the U.S. health care system to one that provides health coverage for all should be of vital concern to African Americans, other racial and ethnic minorities, and lower income families.  After all, it is in the area of healthcare where we can clearly see evidence of the “separate and unequal” philosophy still at work. 

Although only 29 percent of the U.S. population, African Americans, Hispanics and Asian Americans were a majority (52 percent) of the nation’s 45 million individuals who were uninsured year-round in 2003.  In that same year, 20 percent of African Americans, 33 percent of Hispanics, and 19 percent of Asians were without health insurance year round compared to 11 percent of Whites.  In 2003, 24 percent of those in households that made less than $25,000 were uninsured compared to 8 percent of those in households making more than $75,000.

Health disparity statistics reinforce that lives are unnecessarily cut short each year largely due to preventable chronic diseases.  According to the National Center for Health Statistics, the age-adjusted death rate for African Americans was higher than that of whites by 41 percent for stroke, 30 percent for heart disease, 25 percent for cancer, and more than 750 percent for HIV disease in 2002. 

It could be tempting to place the blame for these disparities squarely within the realm of personal responsibility, since many of these death-inducing chronic conditions are exacerbated by the common condition of overweight and obesity.  Yet, there is ample evidence to suggest that personal behaviors cannot fully explain why the low-income, African Americans and other racial and ethnic minorities end up with the short end of the health stick.

Structural Bias in the U.S. Health Insurance System

The U.S. health insurance system is largely employer-based, meaning that the quality of health insurance one receives or whether health insurance is received at all is primarily dependent upon the type of employer an individual has.  According to the Census Bureau, 60 percent of non-elderly Americans were covered by health insurance related to employment in 2003.  Yet within this group, a recent article in Health Affairs reported that 70 percent of whites received health insurance through their employer compared to only 49 percent of African Americans and 41 percent of Hispanics. 

Conversely, the government is the second largest provider of health insurance, providing coverage for 27 percent of Americans through Medicaid, Medicare, and military health care.  Yet of those 65 and under in this group, it is low-income racial and ethnic minorities that are most heavily reliant on government plans.  Twenty five percent and 21 percent of African Americans and Hispanics respectively received Medicaid as their source of health insurance coverage in 2003 compared to only 9 percent of Whites.

From employer-based to government-provided health coverage, racial and ethnic minority populations are ill served by the current structure of the U.S. health care system.  According to the U.S. Census Bureau, the likelihood of employer provided health coverage increases if an individual is a high wage earner, employed full time, and/or works in certain business sectors known for providing coverage such as the financial services industry.

Put another way, it can also be said that structural racism, ethnocentrism and classism are inherent in the U.S. employer-based health care system since it stacks the deck heavily in favor of higher income, better educated individuals who are able to get and hold on to the white-collar or union protected full-time jobs that are most likely to provide their employees with quality health coverage. 

Indeed, the data shows that racial and ethnic minorities have higher unemployment rates, are more likely to work in part-time jobs, and/or are in those sectors that are not prone to provide health coverage such at the construction, service, and wholesale and retail trade industries.   As a result of this labor market conundrum (which is also a function of where you grew up and what type of education you received), racial and ethnic minorities comprise a majority of the nation’s year round uninsured, meaning that they are unable to afford access to a doctor either for regular check ups or for emergency care services.  The combined effect of this lack of access contributes to their poorer health status and higher rates of disability and early death.

Unfortunately, a 2003 study by the National Institutes of Medicine found that minorities were more likely to receive a poorer quality of care even when they had the same level of health insurance access as Whites.  The report concluded that this could be a result of stereotyping and bias as well as the negative effects of financial and institutional health system arrangements.

On the flip side of the coin, racial and ethnic minorities disproportionately benefit from Medicaid.  But as a health insurance coverage program of last resort for those who are very poor, the quality of care Medicaid provides is compromised because services are limited in scope, providers often do not accept its patients due to low reimbursement rates, and benefit levels and the number of people served are subject to be cut at the whim of policymakers seeking to close federal and state budget deficits. 

To make matters worse, a new study from the Center on Budget and Policy Priorities demonstrates that adult Medicaid beneficiaries spend more than three times as much of their income on out-of-pocket health care costs than do middle class adults with private health insurance.  So, those who are least able to afford it pay more: go figure.

Towards a New HealthCare Paradigm

Where can vulnerable populations turn to help them escape the current trap called the U.S. health care system?  Ironically, these groups could actually benefit from the health care crisis currently brewing.  Skyrocketing health care costs, growing concern about health care quality, and the increasing number of uninsured are taking a heavy financial toll on employers, hospitals, providers, state and federal governments, and American families.

In their desperate attempt to save corporate profit margins, small and large businesses are cutting back on health care benefits and some are also joining with nontraditional allies to seek new ways of insuring the American public.  It is becoming increasingly clear to many that traditionally championed coverage measures, such as ad hoc efforts to enhance smaller employers’ ability to provide coverage and the provision of health insurance tax credits for unemployed individuals, are not sufficient for offsetting the magnitude or nature of the uninsured problem in America.  A total paradigm shift is now necessary in the way U.S. health care is financed and administered.

Throughout the years there have been a number of legislative initiatives and studies calling for universal health care.  The effort with the highest recent profile was led by then First Lady Hillary Clinton circa 1994.  Since that time legislators have introduced bills such as the “Health Security for All Americans” Act (H.R. 2133) and the “United States Health Insurance Act” Act (H.R. 676), offered by Rep. Tammy Baldwin and Rep. John Conyers respectively, which call for quality health coverage for all.  Within the past month, two additional voices have joined the chorus with the release of separate reports by the National Coalition on Health Care and The Century Foundation detailing proposals for structuring a universal health plan for America.

Civil Rights groups and other concerned organizations must begin to add their voices to this debate so as to address the factors that cause us to have less access and poorer health outcomes.  Measures that should be embraced by these groups include:  pursuing aggressive minority health worker recruitment efforts, de-linking health insurance from employment, encouraging physician diversity training and expanded data collection based on race, income, and other important variables, and providing administrative incentives for the promotion of equal health outcomes among other valid proposals.


Ultimately, we must all be concerned about improving the health care system as current inefficiencies are costing the country dearly not only in terms of higher costs for low quality health care services, but also in terms of lost productivity and wages and increased social insurance and welfare costs due to poor health, disability and higher mortality rates experienced by American workers who lack consistent access to quality care. 

Of course, this issue also has a direct impact on the Social Security debate since improving health care for all will increase life expectancies for African Americans and others who are presently more likely to die before receiving retirement benefits.

For a new generation of Americans who believe that there are no civil rights issues left to be addressed:  think again.  A lack of access to quality health care is one of the biggest and most egregious civil rights issues of our time and it is hidden in plain view.

Maya Rockeymoore, PhD., is of Research and Programs at the Congressional Black Caucus Foundation.  She is the author of The Political Action Handbook:  A How To Guide for the Hip Hop Generation and co-editor of Strengthening Communities:  Social Insurance in a Diverse America.


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June 9 2005
Issue 141

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