Not everyone has the same access to healthcare resources.
You’ve probably heard some of the harrowing statistics about racial and ethnic disparities in health care. Many of the leading causes of death in the United States—namely heart disease, stroke, and diabetes—disproportionately affect African Americans, Native Americans, and Hispanic Americans, according to the Centers for Disease Control and Prevention (CDC).
What’s more, many of these health problems are considered preventable. “These are all really big problems that we have in our healthcare system,” says Sanjai Sinha, MD, internist at Weill Cornell Medicine. “It's often based on lots of structural barriers.”
That is to say, you can’t simply blame the health disparities on “bad lifestyle choices,” genes, or even blatant racism. Instead, public health experts have identified various obstacles that affect access and affordability to health care and healthy lifestyle needs.
Structural Barrier #1: Cost
Most notably, American health care is very expensive, even with health insurance coverage. In 2018, the CDC reported that 9.4 percent of all Americans were uninsured. However, the percentage without insurance was 26.7 percent among Hispanic Americans and 15.2 percent among African Americans.
The disparity in health insurance coverage may stem from a few factors, such as employment and socioeconomic status. The same CDC report states that 27.4 percent of low-income individuals lack health insurance, and racial and ethnic minorities are more likely to fall in this income bracket than white and Asian Americans.
Structural Barrier #2: Transportation
Transportation to good health care facilities can be lacking or not affordable. If your only option is a long bus ride to a hospital on the other side of town, you might have trouble getting to an appointment without taking time off work (another hidden cost).
In rural areas, there may not even be a bus available, and if you don’t have a car (or can’t afford to fill up on gas), you have to find a friend who can give you a lift.
Structural Barrier #3: Access to healthy food
Many racial and ethnic minorities live in neighborhoods that are considered “food deserts,” meaning an area where it is difficult to buy fresh and healthy food. When you live in these neighborhoods, you have to rely on convenience stores or fast food restaurants, or travel to another neighborhood (which is usually not cheap, fast, or easy) to go to a full-service supermarket.
Living in a food desert is a risk factor for many preventable diseases, including heart disease and type 2 diabetes. Convenient options that you can find in a food desert are often heavily processed, high in sodium and calories, and low in fiber, vitamins, and minerals—all of which may lead to high blood pressure, high cholesterol, and obesity.
Structural Barrier #4: Languages
“If there's a language barrier, sometimes physicians and their staff members discount the value of what patients are complaining about or what their needs are,” says Dr. Sinha.
While many hospitals have language-assistance services to help facilitate communication between providers and patients who speak other languages, this cannot always replace the immediacy of being able to express what you're experiencing to a doctor in your own words.
The Domino Effect of Structural Barriers
“There's a lot of problems that sort of lend themselves to people not availing themselves to the best that health care can give them,” says Dr. Sinha. “It turns into this sort of domino effect, [and] when you have that kind of fragmentation, there's a lot worse outcomes in general.”
For example, if you don’t have health insurance, you’re likely to visit the doctor less frequently, unless it’s an emergency. As a result, you might not have a primary care provider who knows you well and can detect concerning trends. If a doctor does catch something—like prediabetes—you might not have access to fresh fruits and veggies or even the appropriate information to change your diet, and you might not be able to attend follow-up visits with the doctor, allowing the condition to progress.
And ultimately, if you haven’t been able to be in touch with a healthcare provider, that can take a toll on your health literacy (or the capacity to understand healthcare information and incorporate it into your life). Having good health literacy is empowering: You’re able to understand your doctor and follow their instructions, make healthy lifestyle choices, and recognize the importance of treatment adherence or appointment attendance.
“The Department of Health and Human Services put out a statistic that only 12 percent of Americans have high health literacy,” says Dr. Sinha. “And that's still a problem that we have as physicians. It's not their problem. We're not doing a good job reaching out to them.”
Dr. Sinha specializes in internal medicine at Weill Cornell Medicine in New York.
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There's been quite a bit of research showing that
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ethnic and racial minorities have higher rates of chronic conditions
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like diabetes and cancer, but also acute conditions,
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like cold and flu and pneumonia.
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They are less likely to access preventive care,
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and they have poorer outcomes.
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What are some of the factors that contribute to this scandal, really?
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These are all really big problems
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that we have in our healthcare system,
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and it's not always just based on certain minority groups.
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It's often based on lots of structural barriers that people
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across the country have as more and more people
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have problems affording health care.
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It's obviously very expensive.
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There are structural barriers, we call them.
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Things like transportation, problems getting to offices on time.
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There's lack of access to doctors.
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So there's a lot of problems that sort of lend themselves
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to people not availing themselves to the best health care can give them,
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best quality health care.
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And so it turns into this sort of domino effect
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where you lose your continuity with your care provider.
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And so when you have that kind of fragmentation,
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there's a lot worse outcomes in general.
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I think that there's other kinds of bias that exist,
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both within the healthcare system and within physicians.
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For instance, if there's a language barrier.
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Sometimes physicians and their staff members discount the value
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of what patients are complaining about or what their needs are
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because the patient themselves can't communicate well.
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The Department of Health and Human Services put out a statistic
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that showed that only 12 percent of Americans have high health literacy.
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They can understand a graph, and a reduction in risk,
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for a cancer, for a death.
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We don't do a good job as physicians
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in communicating complicated information.
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If you have a lower education level, and potentially from an ethnic group
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that may have lower education attainment for a variety of reasons,
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you may not best understand what you should be doing.
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You may not truly be informed, and that's still a problem
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that we have as physicians.
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It's not their problem; we're not doing a good job reaching out to them.
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CDC health disparities and inequalities report - United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention, 2013. (Accessed on April 13, 2020 at https://www.cdc.gov/mmwr/preview/ind2013_su.html#HealthDisparities2013.)
What is health literacy? Atlanta, GA: Centers for Disease Control and Prevention, 2019. (Accessed on April 14, 2020 at https://www.cdc.gov/healthliteracy/learn/index.html.)