In light of recent events, many Americans are taking a hard look at how racism pervades virtually every aspect of American life. This is a critical moment for our country.
In healthcare, it’s impossible to ignore the jarring racial inequities that exist. The Department of Health and Human Services explains that racial disparities in healthcare arise in three ways:
- Differences in access to healthcare services
- Differences in the quality of care available
- Differences in underlying health status as a result of differences in life opportunities, exposures, and stressors
Black Americans, for instance, face disproportionately poor health outcomes, limited access to healthcare, and low-quality healthcare, even when controlling for factors like insurance type, income, and neighborhood. Latinx communities face the highest uninsured rates in the country, and Asian Americans are less likely to receive necessary prenatal care. These disparities only scratch the surface of racial inequities in our healthcare system.
Since passage of the Affordable Care Act, the US healthcare system has focused mainly on decreasing costs and increasing a very generic definition of quality, relying on metrics like infant mortality and readmission rates to judge the effectiveness of care. While useful, in isolation these metrics fail to account for the broader range of social determinants like education, housing, and transportation that feed into lower health outcomes for Black, Latinx, and other underinvested communities. In particular, they ignore the significant impact of structural racism on those social determinants.
Social determinants and racial disparities
Social determinants of health are the conditions in which people are born, grow, live, work and age; and they play a large role in determining health status and disparities. They include such factors as environment, access to healthy food and clean water, and availability of safe and secure housing. They also include language and culture, which impact communication between patients and providers; and socioeconomic status, which impacts the ability to afford health insurance and solve other important, health-related social needs.
It’s important to understand that social determinants of health do not act in isolation, but rather interact with each other in complex ways. For instance, good health is influenced by proper nutrition, which in turn depends on a person’s access to healthy food. But whether a person has access to healthy food is affected by a number of social determinants, including socioeconomic status. Socioeconomic status, in turn, impacts other social determinants (such as education and housing), as well as health status itself.
Structural racism—the “policies, institutional practices, cultural representations, and other norms” that perpetuate inequities—impacts access to a number of social supports and needs, as well as negatively affects interactions with existing social services. For minority populations, job loss, homelessness, and financial and food insecurity are more frequent. Structural racism also restricts access to higher quality schools and non-polluted neighborhoods, and increases the likelihood of negative interactions with public safety. All of these are social determinants of health and they play a large role in health status.
On top of it all, there is the real impact that prolonged exposure to racism has on a person’s mental and physical health, be it microaggressions, taunts, threats, or worse. The psychosocial impact of prolonged stress makes racism itself a social determinant of health. One study found that the impacts of racism on a pregnant mother contribute to an increased risk of premature birth and low birth weight in infants, resulting in Black babies being more than twice as likely to die in their first year of life than a White baby.
For healthcare providers seeking to address racial disparities in health outcomes, they cannot ignore the social conditions that play into health outcomes—nor can they ignore that racism doesn’t just impact social conditions, it is itself a social condition.
Addressing racial inequities requires addressing social determinants
Healthcare providers cannot single-handedly eliminate racial inequities in healthcare; too many changes are needed that are outside their scope. But, by taking the time to understand how racism impacts social determinants, and working to alleviate their effect on health outcomes, they can play a critical role.
We’ve already seen providers working to address the social determinants of health in their everyday work. Some hospital systems and insurers pay for housing for patients experiencing homelessness, and many health systems will offer free transportation to and from appointments. But providers and health systems can also establish ways to address social determinants in their daily practices in a manner that also incorporates an understanding of the impact of racial inequities.
For example, Oak Street Health develops processes to identify and integrate specific community needs into the care they provide. One way they do this is by hiring outreach specialists directly from the communities they serve, since they know more about their community’s needs than anyone else. Health Leads is another example of a health organization specifically targeting causes of inequity. They work with communities and health systems to design and implement social needs strategies and ongoing programs, and provide patients with on-site referrals to community organizations that can address their social needs. It’s programs like these that will gain momentum in addressing racial disparities in healthcare.
Healthcare does not exist in a vacuum. The real lived experiences of racism and inequity play a significant role in the health outcomes of many people in America. Healthcare providers who want to improve outcomes for all of their patients have a responsibility to address racial inequity in whatever way they can.