Unequal Health Care Access and Quality Contribute to U.S. Racial Health Disparities Among Older Adults
Older Black adults are less likely than their white peers to have private insurance and more likely to rely on Medicaid or Medicare as their only health insurance.
May 28, 2021
This article is an excerpt from issue 41 of Today’s Research on Aging
Older Black adults are less likely than their white peers to have private insurance and more likely to rely on Medicaid or Medicare as their only health insurance. Black adults under age 65 who do not qualify for Medicare are also less likely than their white peers to have employer-provided health insurance, creating barriers to care. Black adults who are beneficiaries of Medicare are also more likely than their white peers to receive care in emergency rooms and nursing homes and report fewer doctor’s office visits.1
Although disparities in health care access persist, the quality of hospitals treating mainly Black patients for heart attacks has improved over the past 20 years. Amitabh Chandra, Pragya Kakani, and Adam Sacarny examined data on Black and white Medicare patients treated for heart attacks.2 Black patients received care at lower-performing hospitals more often than did white patients, even when they live in the same ZIP code or hospital service area, they report.
Although the performance gap between hospitals treating mainly Black patients and those treating mainly white patients shrank by more than two-thirds over the past two decades, these gains are a result of performance improvement at the hospitals treating mainly Black patients rather than reallocation of Black patients to better hospitals. Chandra, Kakani, and Sacarny find that improved hospital performance is linked to hospitals adopting use of beta-blocker medications. They suggest that the diffusion of similar low-cost but high-impact technologies may help further reduce disparities.
Many older Black adults mistrust the health care system because of a history of mistreatment and exploitation by health care providers and more recent experiences of family and friends. For 40 years, the Tuskegee Syphilis Study monitored but did not treat hundreds of unsuspecting Black men suffering with syphilis.3 Calling the study an “egregious example of medical exploitation,” Marcella Alsan and Marianne Wanamaker document that the study’s health toll extended far beyond the test subjects. They find evidence that the 1972 public disclosure of the study led to heightened medical mistrust, decreased health care use, and increased mortality before age 75 among Black men, particularly among those living in areas near the study’s subjects.
Alsan and Wanamaker estimate that life expectancy at age 45 for Black men fell by up to 1.4 years in direct response to the study’s 1972 disclosure. This decline in longevity could explain approximately 35% of the life expectancy gap between Black and white men and 25% of the gap between Black men and women in 1980. They argue the disclosure of the Tuskegee study may have stalled, or even reversed, pre-1972 gains in narrowing the racial gap in health care use and mortality.
More diversity in the physician workforce may help close racial health gaps by encouraging use of preventive health services. Older Black male patients assigned to a Black doctor have a much higher take-up of screening services than those assigned to a non-Black doctor.4 Alsan, Owen Garrick, and Grant Graziani estimate that having more Black doctors could reduce the Black-white gap in men’s cardiovascular mortality by 19% and in male life expectancy by 8%.
The research team points to examples of past abuse and neglect such as the Tuskegee Syphilis Study to help explain why Black men have higher levels of mistrust of the medical establishment. Whereas older Black adults represent 9% of the population ages 65 and older, Black doctors make up only 4% of U.S. physicians. “Given the current supply of Black doctors, a more diverse physician workforce might be necessary to realize these gains,” they conclude.
A February 2021 survey by the Pew Research Center shows that a majority of Black Americans (61%) plan to get a COVID-19 vaccine or have already received one, a sharp rise from November 2020, when 42% told interviewers that they planned to get vaccinated. Over the three-month period, differences in vaccination plans shrank among Black, white, Hispanic, and Asian American adults.5 In January 2021, about 37% of non-Hispanic Black participants reported in a U.S. Census Bureau survey that they will “probably” or “definitely” not get a vaccine, a higher share than among Hispanic, non-Hispanic white, or Asian participants.6
Older Americans with dementia, functional limitations, or other disabilities rely on unpaid family caregivers who enable them to live independently or in settings other than nursing facilities. Compared with their white peers, older Black care recipients are more likely to have dementia and incomes below the federal poverty line, report Chanee D. Fabius, Jennifer L. Wolff, and Judith D. Kasper.7
Using data from the National Study of Caregiving of the National Health and Aging Trends Study, Fabius, Wolff, and Kasper show that older Black care recipients are more likely than their white counterparts to receive care from an adult child or other relative rather than a spouse. Black caregivers are more likely than white caregivers to report financial strain and receive help from community organizations but less likely to report emotional difficulty related to caregiving. These findings underscore the importance of paid family leave and expanding faith- and community-based programs to better support older Black adults and their unpaid caregivers, the researchers suggest.
- National Research Council, Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda, ed. Rodolfo A. Bulatao and Norman B. Anderson, Committee on Population, Division of Behavioral and Social Sciences and Education, Panel on Race, Ethnicity, and Health in Later Life (Washington, DC: National Academies Press, 2004).
- Amitabh Chandra, Pragya Kakani, and Adam Sacarny, “Hospital Allocation and Racial Disparities in Health Care,” working paper 28018, National Bureau of Economic Research (NBER) working paper series, October 2020, https://www.nber.org/papers/w28018.
- Marcella Alsan and Marianne Wanamaker, “Tuskegee and the Health of Black Men,” The Quarterly Journal of Economics 133, no. 1 (2018): 407-55, https://doi.org/10.1093/qje/qjx029.
- Marcella Alsan, Owen Garrick, and Grant Graziani, “Does Diversity Matter for Health? Experimental Evidence From Oakland,” American Economic Review 109, no. 12 (2019): 4071-111, https://doi.org/10.1257/aer.20181446.
- Cary Funk and Alec Tyson, “Growing Share of Americans Say They Plan to Get a COVID-19 Vaccine—or Already Have,” Pew Research Center, March 5, 2021, https://www.pewresearch.org/science/2021/03/05/growing-share-of-americans-say-they-plan-to-get-a-covid-19-vaccine–or-already-have.
- U.S. Census Bureau, “Around Half of Unvaccinated Americans Indicate They Will ‘Definitely’ Get COVID-19 Vaccine,” January 27, 2021, https://www.census.gov/library/stories/2021/01/around-half-of-unvaccinated-americans-indicate-they-will-definitely-get-covid-19-vaccine.html.
- Chanee D. Fabius, Jennifer L. Wolff, and Judith D. Kasper, “Race Differences in Characteristics and Experiences of Black and White Caregivers of Older Americans,” The Gerontologist 60, no. 7 (2020): 1244-53, https://doi.org/10.1093/geront/gnaa042.