Editor’s Note: In a new primer developed for the Blue Cross Blue Shield of Massachusetts Foundation, Manatt Health creates a foundational resource to broaden the collective understanding of racial and ethnic health inequities and disparities in the Commonwealth, with lessons that can benefit other states. The primer, summarized below, presents a data-informed reflection of the racial and ethnic health inequities and disparities Massachusetts residents confront today. The evidence of racial and ethnic disparities in the health care system is clear and disturbing and compels collective action and accountability. Achieving health equity is a moral imperative, and it is only through all of us working together that we can begin to fully understand and address the societal systems, structures and policies that must be changed. Click here to download the full primer.
The COVID-19 pandemic laid bare long-standing racial and ethnic health inequities and disparities across America, including in Massachusetts. Black and Hispanic people in Massachusetts have been disproportionately impacted by COVID-19 relative to White and Asian people.
Specifically, they have been two to three times more likely to contract COVID-19, twice as likely to be hospitalized for it, and three times more likely to die from it than White and Asian people of similar age as the pandemic has unfolded. On a national level, the impact of the pandemic has had a similarly adverse impact on the lives of Black and Hispanic people. While average life expectancy declined by 1.36 years for White Americans between 2018 and 2020, it fell by 3.25 years for non-Hispanic Black people and 3.88 years for Hispanic people. The pandemic was singularly responsible for eliminating the nation’s progress since 2010 in reducing the life expectancy gap between Black and White people.
The root causes of health inequities among racial and ethnic groups in Massachusetts and nationally, exemplified by the pandemic experience but not limited to it, are multifactorial, complex and persistent. Structural racism is historical and pervasive through our society and social systems, such as housing, education, employment and the criminal legal system.1, 2, 3, 4 These systems and policies have a direct effect on social conditions that impact health and well-being, such as poverty, lack of economic opportunity, discrimination, unstable and unsafe housing and neighborhoods, and poor access to and poor quality of education.5
Nearly one in three Hispanic children and one in four Black children in Massachusetts live below the poverty level. Black and Hispanic people in Massachusetts are three to four times more likely to access food support benefits (e.g., SNAP) than are Asian and White people. And Hispanic and Black people in Massachusetts are less likely to own their homes than White and Asian people. Homeownership is a key source of household stability, as well as a primary pathway for building wealth. Black people are incarcerated at five times the rate of White people, and Hispanic people at 1.4 times the rate.6 Like housing, justice involvement impacts people’s—and their families’—ability to maintain stable and healthy lives.
Further, America’s health care system, designed by those in historical positions of authority, itself has a history of racism that must be acknowledged and addressed to better understand present health inequities, resulting disparities in health outcomes, and the continued distrust that people of color have toward its diagnoses and treatments. Structural racism and barriers to accessing health-determining and health care resources lead to direct adverse health impacts and outcomes for people of color. While disparities in health outcomes across racial and ethnic groups are often narrower in the Commonwealth than they are in the nation as a whole, clear disparities persist across many key outcome measures in Massachusetts, including:
- White people are more likely to report having “excellent or very good” health than are Black and Hispanic people.7
- Black and Hispanic people are more likely to report having “fair or poor” mental health than are White people.8
- Rates of both pregnancy-associated mortality and severe maternal morbidity are higher for Black women compared to White, Hispanic and Asian women.9
- Black and Hispanic people have substantially higher infant mortality rates than White and Asian people.10
- Black and Hispanic people report higher rates of diabetes and asthma than do White people.11
Additionally, race and ethnicity are only two of many factors that influence the barriers and opportunities people may face in pursuing a healthy life. Structural barriers—historical and present-day—also exist for people of various genders and sexual orientations and according to their disability status, economic status, immigration status and geography, and these could have similar or compounding influences.
Structural Racism and the Implications for Health
On April 8, 2021, Rochelle Walensky, director of the U.S. Centers for Disease Control and Prevention (CDC), declared racism a “serious public health threat that directly affects the well-being of millions of Americans.” She noted:
Racism is not just the discrimination against one group based on the color of their skin or their race or ethnicity, but the structural barriers that impact racial and ethnic groups differently to influence where a person lives, where they work, where their children play, and where they worship and gather in community. These social determinants of health have life-long negative effects on the mental and physical health of people in communities of color.23
American society and its systems for supporting the public good have often been designed or evolved to tilt in favor of those historically in power, including White men and their families, people who are affluent, and others favored by social and cultural norms. While there is no consensus definition of “structural racism,” most definitions speak to the historical structural bias embedded in societal systems—economic, educational, justice, political and health, among others—which, deeply ingrained and compounded over generations, results in divergent access to opportunities for individual and familial advancement and to the goods and services that support health and well-being. Examples of systemic or structural racism that directly and indirectly influence health disparities include:
- American financial structures and systems that preserve and perpetuate the wealth gap between people (or communities) of color and White people. Black and Hispanic families in America are less likely than White families to own assets such as homes and businesses or to have financial savings and retirement assets, and those who do have, on average, less valuable assets.24, 25 Divergent financial endowments are a product of historical and residual structural and societal barriers to wealth accumulation.
Today, Black people make up 13 percent of the American population but hold only 2 percent of American wealth, and the average net worth of a White family ($171,000) is nearly ten times greater than that of a Black family ($17,150)37, 38, 39. Hispanic families and families of recent immigrants face similar barriers to wealth accumulation—including structural racism and discriminatory housing and immigration policies—though quantitative evidence of these barriers is still emerging.40, 41 Financial resources and stability allow families to invest in better lives, including homes in safer communities with better schools, better jobs, healthier foods and better health care.
- Structurally unequal treatment in the American justice system that undermines familial and community stability, and the health, of Black people. Racial and ethnic bias has been well documented across America’s criminal legal system, with Black people “experiencing harsher outcomes in relation to police encounters, bail setting, sentencing length and capital punishment” than White people.42 Black people are incarcerated at five times the rate of White people and Hispanics at 1.4 times the rate.43, 44 Research suggests that disparities in incarceration rates and sentence lengths in Massachusetts are largely driven by differences in charging decisions (i.e., Black and Hispanic people tend to be charged with more serious offenses than White people). These differences are not entirely explained by contextual factors.45 Like housing, justice involvement impacts people’s—and their families’—ability to maintain stable and healthy lives.
- Access to quality health care that is not equitably available to all Americans. America’s health care system has a history of racism that must be acknowledged and addressed to better understand present inequities in the health care system and disparities in health outcomes.48 Early leaders in American medicine—almost exclusively White males—have shaped a health care system designed to sustain existing governance structures and positions for people of similar backgrounds; promote false claims of innate differences in intelligence, disease susceptibility and character between White people and people of color; and provide the best access to high-quality health care services to predominantly White communities.49, 50 Racism in medical practice is evident in numerous trials and experiments that the medical community conducted on Black people through the 20th century, the most notorious of which may be the Tuskegee experiments, in which Black people were denied treatment for syphilis without their consent as part of a medical study.52 But research also documents that Black people continue to face implicit bias, prejudice and stereotyping by medical professionals.
Social Drivers of Health
Social drivers of health, also known as social determinants of health, are conditions in the environments in which people are born, live, learn, work, play, worship and age that affect health, functioning, and quality-of-life risks and outcomes. Research demonstrates that such socioeconomic factors, physical environments and health behaviors drive health outcomes more than medical care.58 Social drivers such as food and housing insecurity, jobs that do not provide paid family or medical leave, and limited access to transportation are also associated with emergency department overuse and higher rates of missed medical appointments.59 Black and Hispanic people in Massachusetts are also more likely to have one or more unmet social needs than are White people, adversely impacting their health and well-being. Black and Hispanic residents are also more likely than White residents to be food insecure, to live in rented units (as opposed to owner-occupied units) and to work in low-paying jobs. Understanding these social drivers of health—and the social and economic structures, policies, and practices that shape social circumstances—is critical to understanding health and health care inequities and disparities in Massachusetts and, ultimately, addressing the broader societal factors that contribute to our health and well-being.
Access to Coverage and Care
Access to health care coverage and services, along with other social factors and the structures, systems and policies that drive them, can have a significant impact on health outcomes. While Massachusetts has one of the lowest uninsured rates in the country, uninsured rates for Black and Hispanic people remain twice as high as for Asian and White people, and Black and Hispanic people are more likely to experience disruptions in health insurance coverage. On average, Black and Hispanic people have a harder time accessing health care services than do White people, potentially due to the types of jobs they have, the type of health insurance they possess and the transportation barriers they face. Hispanic people are less likely than White or Black people to have a usual source of care, potentially stemming from lower rates of insurance due to immigration status. The treating health care professionals in Massachusetts, including physicians and registered nurses, are also disproportionately White and Asian, suggesting that Black and Hispanic residents—even those who are insured—may struggle to access culturally appropriate care in the Commonwealth.85
Differences in how racial and ethnic populations use the health care system may reflect clinical need, which may be impacted by the social drivers of health previously discussed, such as the person’s job, the flexibility in their work schedule, and access to transportation to and from appointments. The differences may also relate to differences in populations’ insurance coverage, the availability of culturally appropriate care, and diagnosis rates, among other factors. Black and Hispanic people in Massachusetts are less likely to use routine or specialist care, are more likely to use the emergency department for care (including for non-emergency conditions), and are more likely to have elevated levels of unmet need for specialist care relative to White people. Black people in Massachusetts are also less likely to have received recommended immunizations, with higher rates of concern about flu vaccine side effects and safety, potentially stemming from a long history of medical system distrust, contributing to vaccine hesitancy.
Quality and Consumer Experience
Inequities in the quality of care received by Black and Hispanic people relative to White people have been well documented in the medical literature over the past several decades. The most recent national data suggests that these inequities persist. National data from 2019 shows that Black and Hispanic people reported receiving “worse” care across four times as many health care quality measures as did White people; Asian people were also more likely than White people to report that their care was not appropriately person-centered. While inequities may be partially explained by the structural contributors to health care access and use—such as differences in income, the neighborhood in which a person lives, underlying health status, and health insurance type—research finds that inequities remain even after controlling for these factors, particularly for Black people.127
Black and Hispanic people bear a disproportionate burden of preventable disease, death and disability relative to White people, driven by many of the social factors—and policies, practices and structures associated with those—that have been previously discussed. While the Commonwealth often has narrower disparities in health outcomes across racial and ethnic groups than the nation as a whole, disparities persist across many key outcome measures. White people are more likely to report “Excellent or Very Good” health in Massachusetts than are Black and Hispanic people, while Black and Hispanic people report higher rates of “Fair or Poor” mental health. Black and Hispanic people in Massachusetts report higher rates of diabetes and asthma than White people do, while White people report higher rates of angina and coronary artery disease. Despite these adverse clinical conditions, life expectancies for Massachusetts residents across race and ethnicity categories—but particularly for Black and Hispanic people—exceed national averages. Both nationally and in Massachusetts, Hispanic life expectancies exceed those of all other reported racial and ethnic groups, though that advantage declines the longer the people have resided in America.134 Furthermore, recent data suggests that life expectancy for Black and Hispanic people may have been disproportionately impacted by the COVID-19 pandemic relative to White people.135
Disparate Impact of COVID-19
Long-standing health inequities and disparities were laid bare during the COVID-19 pandemic, with Black and Hispanic populations shouldering the largest burden of disease and mortality in Massachusetts as well as nationally. Massachusetts data shows that Black and Hispanic people are more likely than Asian and White people to have been diagnosed with COVID-19, to have been hospitalized with COVID-19, and to have died from COVID-19. The causes of these disparities are numerous. Research suggests that Black people admitted to a hospital with COVID-19 early in the pandemic were more likely to die than White people, and that such difference is partially attributable to differences in the hospitals to which individuals were admitted.162
The inequities, both nationally and in the Commonwealth, also result from significant socioeconomic differences between Black and Hispanic people and White and Asian people.163 Black and Hispanic people are more likely than White people to live in multigenerational households and rely on public transportation, and they are less likely to be able to work remotely, increasing the odds that they will be exposed to COVID-19 during the course of day-to-day activities and that they will infect members of their household. Black and Hispanic people have also been more hesitant than Asian and White people to get vaccinated, likely the result of barriers to access among Black and Hispanic populations as well as greater levels of vaccine hesitancy.
Despite important limitations around the availability and robustness of data on racial and health disparities in Massachusetts, existing data does paint a clear picture that Black and Hispanic people in Massachusetts face persistent disparities in access to health care coverage, access to routine medical care, quality of care, and health outcomes, including experiences with the COVID-19 pandemic. Black and Hispanic people are significantly more likely to be uninsured and face cost-related barriers to care relative to White people, and they are unlikely to have access to racially and ethnically diverse providers. Black and Hispanic people receive worse care across a broad range of quality measures and experience higher rates of many adverse health outcomes, including infant/neonatal mortality, diabetes, asthma, HIV mortality and heart disease. Black and Hispanic people are also significantly more likely to be hospitalized or die as a result of COVID-19. These disparities are driven by a host of intersecting factors—including socioeconomic drivers of health such as food insecurity, housing instability, language barriers and exposure to toxic stress—many of which are rooted in long-standing racist structures, policies and practices in Massachusetts and the United States more broadly.
We must not wait to take action. Stakeholders and policymakers across state and local governments; health care organizations; and public health, social services and community-based organizations must act collectively and in partnership with the communities and people harmed by structural racism and inequities in health care, elevating their voices and ensuring they are equal participants in the effort to craft and implement solutions that advance and achieve health equity for all residents. Achieving health equity is a moral imperative, and it is only through all of us working together that we can begin to fully understand and address the societal systems, structures and policies that must be changed.
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