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The Century Foundation | tcf.org

Racism, Inequality, and Health Care
for African Americans
DECEMBER 19, 2019 — JAMILA TAYLOR

The Century Foundation | tcf.org 1

Racism, Inequality, and Health Care
for African Americans
DECEMBER 19, 2019 — JAMILA TAYLOR

The American health care system in beset with inequalities
that have a disproportionate impact on people of color and
other marginalized groups. These inequalities contribute to
gaps in health insurance coverage, uneven access to services,
and poorer health outcomes among certain populations.
African Americans bear the brunt of these health care
challenges.

African Americans comprise 13.4 percent of the U.S.
population.1 Over the span of several decades, namely since
the Civil Rights Acts of 1964 and 1968, they have been able
to make notable strides in American society. According to
the Economic Policy Institute, educational attainment has
greatly increased, with more than 90 percent of African
Americans aged 25–29 having graduated from high school.2

College graduation rates have also improved among
African Americans. When it comes to income, gains have
been made as well, but African Americans are still paid less
than white Americans for the same jobs and lag significantly
behind when it comes to accumulating wealth. And as for
home ownership, just over 40 percent of African Americans
own a home—a rate virtually unchanged since 1968.3

African Americans are also living longer, and the majority of
them have some form of health insurance coverage. However,

African Americans still experience illness and infirmity at
extremely high rates and have lower life expectancy than
other racial and ethnic groups. They are also one of the most
economically disadvantaged demographics in this country.

This report will examine the state of health care coverage
for African Americans and shed a light on important social
factors that uniquely impact their health outcomes. In an
effort to draw implications from leading health care reform
plans, recommendations are made for the way forward in
ensuring that the physiological and social impacts of racism
are not omitted in efforts to secure truly universal health
care coverage in America. African Americans are one of
the most politically engaged demographics in this country.
Addressing their unique challenges and perspectives,
including the pervasive impacts of racism, must be included
in health reform efforts.

Coverage Gains—and Obstacles—for
African Americans Under the ACA

The Affordable Care Act (ACA) has helped to ensure
health care coverage for millions of Americans. The
uninsured rate among African Americans declined after the
law was implemented: of the more than 20 million people

This report can be found online at: https://tcf.org/content/report/racism-inequality-health-care-african-americans/

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who have gained coverage under the ACA, 2.8 million of
them are African-American.4 Yet, this population is still
more likely to be uninsured than white Americans: as of
2018, the uninsured rate among African Americans was
9.7 percent, while it was just 5.4 percent among whites.5

African Americans were more likely to be covered through
employer-sponsored or private health insurance: 55 percent
of African Americans used private health insurance in 2018,
while 41.2 percent were enrolled in Medicaid or some other
type of public health insurance.6

While coverage expansions under the ACA have hastened
the progress toward universal coverage, the continued
high cost of many coverage options means that access
to affordable health care is still a challenge for many
Americans—particularly African Americans.

The average family spends $8,200 (or 11 percent of
family income) per year on health care premiums, and
out-of-pocket costs for things such as office visit copays,
prescription drugs, and surprise or out of plan medical
bills continue to wreak havoc on the financial security of
families.7 For African Americans, the average annual cost for
health care premiums is almost 20 percent8 of the average
household income—a major cost to bear, when taking into
account income inequality and other economic challenges
for this demographic.

The high cost of coverage has kept the number of uninsured
and underinsured unacceptably high: of the 27.5 million
people that still lack health insurance coverage,9 45 percent
cite cost as the reason for being uninsured.10 Furthermore, the
Commonwealth Fund estimates that an additional 87 million
people (adults aged 19 to 64) are underinsured; that is, they
have coverage, but their plan leads to unusually high out-
of-pocket costs relative to income that can lead to a strain
on personal finances or even debt. Of these underinsured
adults, 18 percent are African-American.11

Systemic Health Care Challenges
That Reform Must Address

Despite coverage gains, remaining health care challenges
exist that have a disproportionate impact on African
Americans. The lack of Medicaid expansion in key states,
health disparities, and health care provider shortages make
it incredibly hard to address America’s health care needs in a
comprehensive way. And while these challenges are factors
that touch many Americans in various parts of the country,
the gravity of them is uniquely seen in the South, and among
the African-American population.

The South’s Stubborn Approach to
Medicaid Expansion

The Medicaid program has been a lifeline for low-income
Americans, pregnant people, the elderly, and people with
disabilities. It is jointly funded by states and the federal
government, and has been operating for fifty-four years.12 As
of August 2019, the program covered 68 million people, with
African Americans making up about 20 percent of Medicaid
enrollees.13 Because African Americans tend to be poorer
than other demographic groups on average, public health
insurance programs such as Medicaid are vital to ensure
affordable health care and healthier outcomes. In states
that have not expanded Medicaid under the Affordable
Care Act (ACA), African Americans and other people of
color are most likely to fall within a coverage gap—meaning
they earn too much to qualify for the traditional Medicaid
program, yet not enough to be eligible for premium tax
credits under marketplace plans.14

Under the ACA, Medicaid eligibility was expanded for adults
with incomes up to 138 percent of the federal poverty level
(FPL).15 This expansion was originally written into the ACA
as a requirement for all states, but due to a 2012 Supreme
Court ruling in National Federation of Independent
v. Sebelius,16 it is now just an option for states. To
date, thirty-seven states (including the District of Columbia)
have expanded Medicaid, either through traditional means
or the Section 1115 waiver process.17 The states that have not
expanded Medicaid are largely concentrated in the southern
region of the United States. (See Map 1.)

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In the South, African Americans are disproportionately
represented. According to the U.S. Department of Health
and Human Services Office of Minority Health, 58 percent
of the African-American population lived in the South as
of 2017.18 They are also more likely to be uninsured, with
Texas, Florida, and Georgia being home to the largest
shares of uninsured African Americans.19 Some states
have also proposed draconian work requirements20 as a
condition for the participation in the Medicaid program.
These requirements can only serve to stigmatize enrollees,
deny coverage, and discourage low-income people from
the support they desperately need. In Arkansas—one
of nine states to date with 1115 waivers approved by the
Trump administration allowing fully implemented work
requirements—18,000 low-income people lost health care
coverage as a result.21 This coverage loss comes as no
surprise, because the use of work requirements for other
safety-net programs, including Temporary Assistance for
Needy Families (TANF), has proven them to be ineffective

in their stated goal—promoting employment—yet highly
effective in reducing program eligibility.22 Medicaid wok
requirements for three states have been struck down by the
courts. Due to the failure to expand Medicaid, the South is
now home to the nation’s sickest people, and is where health
disparities between whites and people of color are the most
pronounced.23

Disparities in Health Outcomes

Increases in health insurance coverage under the ACA
have improved access to medical care and have been
linked to better outcomes for African Americans, such
as earlier diagnosis and treatment of certain cancers.24

However, disparities still exist across health conditions
when comparing African Americans and whites, including
maternal mortality, infant mortality, heart disease, diabetes,
cancer, and other health issues. Social factors, including
economic disadvantage, inequities in education, and lack

MAP 1

STATUS OF STATE ACTION ON THE MEDICAID EXPANSION DECISION

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FIGURE 1

MATERNAL MORTALITY RATE

FIGURE 2

INFANT MORTALITY RATE

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Health Care Provider Shortages

Due to residential segregation, majority African-American
and Hispanic areas are more likely to lack hospitals and other
health care providers.30 Therefore, place matters. When
health care providers are located within majority African-
American and Hispanic neighborhoods, they tend to offer
lower-quality care.31 Often, people of color find themselves
relying heavily on community health centers, emergency
rooms or outpatient care, and community-based providers
due to the lack of available primary care and mental health
providers in a given geographic area. Traveling outside of
the immediate geographic area to access health care may
be an option for some people, yet this can be a challenge
due to lack of access to transportation for those with limited
incomes or for those living in rural areas.

It is not difficult to locate where—and for whom—provider
shortages are a serious concern. The Health Resources and
Services Administration (HRSA) defines Health Professional
Shortage Areas (HPSAs) as geographic, population, or

of access to health care, impact a person’s ability to lead a
healthy and productive life. For people in American society
that experience racism and inequality in their daily lives,
and throughout the lifespan, the impact of social factors on
health are the most grave.

Even with improved access to medical care under the
ACA, the disparities in health outcomes between African
Americans and whites are stark. African-American women
are three times more likely to die of pregnancy-related
causes than white women (see Figure 1).25 The African-
American infant mortality rate is twice the rate for white
infants (see Figure 2).26 African Americans are more likely
to die from cancer and heart disease than whites, and are
at greater risk for the onset of diabetes.27 However, death
rates for African Americans with cancer and heart disease
did drop over a fifteen year period.28 Across many chronic
illnesses, however, African Americans are still more likely to
die compared to other racial and ethnic groups. Homicides
are also a leading cause of death for African Americans. In
fact, African American children are ten times more likely to
die by gun violence than white children (see Figure 3).29

FIGURE 3

CHILD FIREARM MORTALITY RATE

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facility-based designations that are indicative of health
care provider shortages.32 Designations are made by the
following health disciplines: primary care, dental health, and
mental health. Federal regulations dictate the threshold for
shortages by calculating the ratio of population to provider
in order to identify high need areas.33 In 2018, there were
17,657 geographic areas, populations, and facilities identified
by HRSA as not having enough health care providers.34

Mental health and primary care were the disciplines in the
shortest supply.

Medically Underserved Areas and Populations (MUA/ Ps)
are another designation by HRSA. They are geographic
areas and populations that lack adequate access to primary
care providers.35 MUA/ Ps identify specific populations that
are likely to experience barriers to health care including the
homeless, low-income people, people eligible for Medicaid,
Native Americans, and migrant farmworkers. Designations
are made by calculating the population-to-provider ratio,
percent of population below the federal poverty level,
percent of population over the age of 65, and the infant
mortality rate.36

Important Considerations for Health
Care Specific to African Americans

Certain social factors, also referred to as social determinants
of health, have important implications for health risk and the
ability to attain health insurance coverage. Poverty, income
inequality, wealth inequality, food insecurity, and the lack of
safe, affordable housing are just a few. Another important
social factor leading to poor health outcomes and economic
disadvantage among African Americans is racism, because
not only is it a stressor, but it impacts who gets what in
America, particularly health care.

Racism’s Wear and Tear on African Americans

African Americans have endured racism within American
society for hundreds of years. Studies conducted over time
have been consistent in proving that racism not only impacts
social stratification, but also the ability of African Americans
to be healthy—both mentally and physically.37 This

burden—a burden that is indeed inescapable for black and
brown people in this country—causes African Americans to
die prematurely and experience chronic illnesses and mental
health challenges at higher rates than white Americans.

According to a study published in the journal of
Psychoneuroendocrinology, racist experiences bring on an
increase in inflammation in African Americans.38 This increase
in inflammation raises the risk of becoming chronically ill.
The researchers of the study assert that, because the body’s
response to stressors—such as the adversity of racism—
results in compromising systems that are critical in fending
off disease, exposure to racism over long periods of time
caused the health of African Americans to suffer greatly
with chronic illness as the body’s defenses were down
due to inflammation.39 Chronic illnesses associated with
experiencing racism include heart attack, neurodegenerative
disease, and metastatic cancer.40 The study participants
had similar socioeconomic backgrounds, which eliminated
poverty as a stressor—a social factor that has also been
linked to the onset of illness.

Similar findings were yielded in some of the earliest
studies looking at the impact of racism on the health of
African Americans by University of Michigan public health
researcher Arline Geronimous. After looking at biological
factors associated with exposure to stressors, Geronimous
hypothesized, in what is also referred to as the weathering
hypothesis, that African Americans experienced health
deterioration because of those stressors.41 Geronimous
examined the allostatic load scores—that is, the cumulative
wear and tear on the body’s system brought on by the
repeated adaptation to stressors42—for adults aged 18–64.
African Americans were found to have higher scores
than white Americans. Once again, poverty was ruled out
as a factor, due to the fact that the higher allostatic loads
existed among African Americans of various socioeconomic
backgrounds. Geronimous concluded that racism, and
the burden of coping with it across the lifespan, leads to
differences in health among African Americans and white
Americans—including the onset of chronic illness and
premature death.

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and are less likely to have a full-time worker in the household.46
The poverty rate among African Americans was 20.8 percent
in 2018, higher than for any other racial or ethnic group in
the United States, and more than twice the poverty rate of
white Americans.47 Growing up in poverty is also associated
with toxic stress,48 of which the impact can reach crisis levels
when a person is also grappling with the toxic stress brought
on by racism. When African Americans are able to attain
work, they are more likely to work in low-paying jobs that
lack important benefits, including health insurance and paid
leave. The African-American poverty rate also shows how
critical public programs such as Medicaid are to helping
ensure access to health care for this population. Because
of these factors, Medicaid expansion helps more African
Americans gain coverage than any other group.49

Household Income Inequality

African-American households have significantly lower
household income than white households. The average
household income for African Americans in 2018 was
$41,361, while it was $70,642 for white households.50 (See

In addition to instigating poor health outcomes among
African Americans, racism also creates barriers to economic
opportunity and uneven access to health care. Even the
health care system itself perpetuates racism and bias43

toward African Americans. This has been well documented
with examples, including differences in pain management
and treatment of African Americans when compared to
whites experiencing the same health conditions, use of
African Americans’ bodies in medical experimentation, and
racial bias in health algorithms for the purpose of guiding
health decisions and assessing health care costs.44 Actions
like these have led to a general distrust of the health care
system within the African American community.45 Racism
cannot be divorced from the other social factors outlined
in this report, which give reason to the fact that African
Americans are disproportionately affected by them.

Poverty

Across economic indicators, vast disparities exist between
African Americans and whites that mirror the proportions
seen in health disparities. Due to structural barriers, African
Americans are more likely to be poor than white Americans

FIGURE 4

AVERAGE HOUSEHOLD INCOME FOR AFRICAN AMERICANS AND WHITES

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Figure 4.) African Americans tend to make less than whites
for the same jobs, pointing to unequal pay as a contributing
factor in the gap in household income.51 Even when taking
into account similar education levels, workers of color are
consistently paid less than white workers.52

Income is a major factor in a family’s ability to access health
care, which can make up a significant share of household
spending in terms of insurance premium costs and out-of-
pocket costs.

The Wealth Gap

When it comes to accumulating wealth, the numbers are
even more grim—white families now have approximately ten
times the wealth of African-American families, on average.53

(See Figure 5.) Research shows that the wealth gap impacts
African Americans across the income and education
spectrum, making it harder for them to own homes or
build retirement savings.54 And while African Americans
on average have less total debt than whites, the wealth gap

means they are more likely to have costly, high-interest debt
obligations. High health care costs and surprise medical bills
can negatively affect an African-American family’s ability to
reduce or eliminate debt, and ultimately the ability to create
wealth—which could impact a family for generations.

Food Insecurity

Food insecurity is also an issue affecting many African
Americans and has important implications for health
outcomes and economic well-being. Food insecurity occurs
when a household or family lacks access to adequate
nutritious food.55 This happens due to the lack of financial
means to purchase healthy food or by living in impoverished
geographic areas void of grocery stores with whole, fresh
foods. Neighborhoods that lack access to nutritious foods
are also referred to as food deserts.56 The ten U.S. counties
with the highest food insecurity rates are all at least 60
percent African-American.57 African Americans experience
hunger at twice the rate of white Americans, including one
in four African-American children.58 Hunger can also lead

FIGURE 5

AVERAGE HOUSEHOLD WEALTH FOR AFIRCAN AMERICANS AND WHITES

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to chronic illness and has been associated with low-birth
weight, diabetes, cancer, pregnancy complications, and
mental distress.59

The Lack of Safe and Affordable Housing

Housing and neighborhood safety are also important
economic indicators that can impact health. Unfortunately,
far too many African Americans have to grapple with
neighborhood violence and environmental factors (such as a
lack of clean water, exposure to lead paint, and pollution) that
can negatively impact both their mental and physical health.
Additionally, a relative lack of affordable housing options
and home ownership continues to plague the African-
American community, largely due to longstanding racist
practices such as redlining and subprime mortgages. The
lack of affordable housing puts a financial strain on families
and can pull resources away from necessities like food and
medical care.60 For homeless and transient communities, it
can be almost impossible to access health care or maintain
adequate health regimens. Despite comprising just 13.4
percent of the total U.S. population, African Americans
make up 40 percent of the homeless population, and are an
overrepresented part of this group in every state.61

Overview of Health Care
Reform Plans

Several health care reform proposals62 have been introduced
by members of U.S. Congress and by 2020 presidential
candidates. In this section, the most widely known and
promising plans that have gained traction and media
coverage in recent months are highlighted.63

Medicare for All

Medicare for All is a signature single-payer plan originally
authored by Senator Bernie Sanders, setting forth a vision
for major structural change of the health insurance system. It
has since been endorsed and supported by Representative
Pramila Jayapal (who introduced the House version of the
legislation), Representative Alexandria Ocasio-Cortez,
Senator Elizabeth Warren, Senator Kamala Harris, Senator

Cory Booker, and a host of other progressive policymakers.64
It calls for a single federal program with comprehensive
benefits for all U.S. residents that would replace all private
insurance, Medicaid, Medicare, and the Children’s Health
Insurance Program (CHIP). The plan would be financed by
taxes and eliminate premiums and cost-sharing or out-of-
pocket costs, leading to major cost-savings for consumers
in the long run. Taking into account the vast economic
challenges for African Americans, savings in health care costs
could help lead to better economic outcomes. In turn, health
outcomes could also improve due to more comprehensive
coverage available to all.

Comprehensive health benefits under Medicare for All
include medically necessary services in thirteen benefit
categories, including home and community-based long-
term care, dental care, hearing, vision care, comprehensive
reproductive health care (including abortion services), and
transportation to health care appointments for people with
disabilities and low-income people.65 Drug prices would be
negotiated annually and a formulary would be established.
Medicare for All would also prohibit balance billing, also
known as surprise billing, which happens when health
providers bill patients for the difference in the total cost of a
health care service and the amount paid by an insurer.66

Public Insurance Option

Public option plans call for a federal insurance option. These
plans essentially build upon the ACA by adding a new option
available to those seeking coverage. Former vice president
Joe Biden has been an advocate for this plan and has
included it in his platform as a 2020 presidential candidate.
There are several versions of the public option—some that
would leave the marketplace subsidy structure unchanged,
and others that would enhance it for all plan participants.
Some public option proposals even go so far as to eliminate
individual heath insurance plans created by the ACA. A key
difference in the Biden plan, when compared with Medicare
for All, is that it retains current public and private insurance
sources. For people who like or prefer their private insurance,
they can maintain it under the Biden plan.

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The Biden plan would retain major components of the
ACA including protections for people with pre-existing
conditions, premium subsidies, and Medicaid expansion,
along with offering public insurance as an option to anyone
who wants it.67 A public insurance option was initially part
of the ACA as introduced in Congress but was taken
out of the legislation later in the negotiations process.
Biden’s public option plan also aims to reduce the cost of
prescription drugs by allowing importation of them from
other countries, empowering Medicare to negotiate drug
prices, and supporting the development of generic drugs.68
It would also offer tax credits to middle class families to help
lower the cost of health insurance and eliminate the 400
percent federal poverty level income cap. The plan would
eliminate balanced billing and be financed through capital
gains taxes on rich individuals. Biden’s plan also includes
protecting access to contraception and abortion rights, as
well as the promise to adopt California’s strategy of public–
private partnerships nationwide in addressing the U.S.
maternal mortality crisis as major steps in building upon the
ACA. Various versions of public insurance option legislation
have also been introduced in Congress by Senator Ben
Cardin, Representative Cedric Richmond, Senator Tim
Kaine, Representative Jan Schakowsky, and others.

61 percent of white respondents in a November 2019 Gallup
poll prefer the private health insurance system, whereas 57
percent of nonwhite respondents prefer government-run
insurance.69 The cost of health care is still of major concern
for those people with private health insurance, more so than
for those with public insurance sources.70

Ensuring Health Care Access
and Affordable Coverage for
African Americans

The single payer and public option insurance plans outlined
in this report were developed in a way to help fill coverage
gaps and get as many people insured as possible. The plans
aim to do this by emphasizing affordability—addressing the
high cost of insurance premiums and limiting out-of-pocket
costs, including surprise medical bills, prescription drugs, and
fees for direct health care services. Unfortunately, current

health reform plans fall short in adequately addressing
racism in the health care system. This stands in the way of
ensuring health equity, namely full insurance coverage and
quality health care access for African Americans.

Cost to the individual is certainly an important factor in the
conversation about health coverage and ensuring that people
can access the health care services they need. However, in
order for African Americans to attain meaningful insurance
coverage and access to quality health care, the health care
system must be transformed to better address the unique
social factors that cause African Americans to remain
in the coverage gap and how racism plays a role in their
health outcomes. Furthermore, the economic challenges
African Americans face serve as barriers to sustaining
comprehensive coverage which can lead to poor health
outcomes. It is simply not enough for insurance coverage
to be affordable or even “free”—it must also serve as a tool
in progress toward systemic change and equity that will help
African Americans get ahead.

To do this, getting to universal health care coverage will
require that the following steps be taken:

• Promote health equity by adequately addressing
racism, bias, discrimination, and other systemic
barriers within the health care system. To do this,
policymakers must acknowledge the historical
foundations of racism and ensure that health care
providers, personnel and staff are substantively
trained to recognize and eliminate all forms of bias
in the health care system. Accountability measures
at both the individual and systems levels should
be in place, including measures that link payment,
professional certification, and licensure to quality of
care.

• Incorporate evidence-based tools to adequately
address health disparities that focus on quality
of care that extend beyond health insurance
coverage, including the impact of racism on the
health of African Americans throughout the life
course. In health reform efforts, policymakers must

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take into account the social determinants and
address how they impact health by working across
sectors, including social support agencies …