Joseph Dieleman researches where the $3 trillion the U.S. spends on healthcare goes each year. His team’s analysis of more than a decades worth of data demonstrates that a disproportionate share of the money is spent on white Americans. What’s more, the research determined that white Americans tend to get more outpatient care, compared to other groups who tend to receive more care in emergency settings.
“Structural racism and discrimination impact access to care and what kind of care is received when different populations access services,” says Dieleman, an associate professor in the department of health metric sciences at the University of Washington and the lead author of the study published in JAMA on Tuesday. “The types of care that are being provided to each race or ethnicity are fundamentally different.”
The fact that more money is spent on white Americans than those who identify as Black, Asian or Hispanic shouldn’t come as a shock given a growing body of research around health equity. But what is unique about this study is the amount of data analyzed — more than 7.3 million survey responses from 2002 to 2016 — as well as the breakdown among race and ethnicity across different types of care. The researchers also accounted for age differences among the populations.
In 2016, average healthcare spending for a white patient was $8,141, nearly double the average $4,692 spent per patient who identified as Asian, Native Hawaiian or Pacific Islander. The average spending was $7,361 per Black patient and $6,025 per Hispanic patient. White people made up 61% of the population yet accounted for 72% of healthcare spending. Hispanic patients, who made up 18% of the population, accounted for only 11% of healthcare spending.
While the most recent data included in the study is from 2016, these issues are particularly relevant to the Covid-19 pandemic, as the virus has only intensified existing healthcare disparities. Differences in the hospitals Black and white patients were admitted to can explain why Black Covid-19 patients are more likely to die, according to a study published in JAMA Network Open in June. One possible reason could be that “more hospitals located in disadvantaged neighborhoods may have worse finances and provide care of lower quality as a result of differences in payer mix or community resources,” the researchers suggested.
While spending on Black patients was roughly equal to their 11% share of the population, the study offered insight into where they were receiving care. Black patients saw 12% more spending in the emergency room and 26% less spending on outpatient care than the average person. White patients, on the other hand, saw 15% more spending on outpatient care than the average person. While the study didn’t measure the quality of care received, outpatient care generally suggests a person is getting earlier and more preventative care, rather than using the emergency room for issues that may have gone untreated and are more severe.
“We find that hospital care and emergency department care are the types of care that are most associated with people of color,” says Dieleman. “Moving forward, it seems like timely access to high quality primary health care is not only critical for improving health outcomes across the country, but also may lead to a more equitable distribution of healthcare resources.”
“Latinos and other communities of color are less likely to regularly go to a doctor and seek preventive care and are more likely to only go when it’s deemed necessary such an emergency.”
While the most recent census data shows the U.S. population under 18 is now a majority people of color, there are several big challenges. First, these communities are more likely to be uninsured, says Amelia Ramirez, who directs the Institute for Health Promotion Research at University of Texas Health San Antonio and wasn’t involved in the study. “As of 2019, only 8% of white Americans under the age of 64 are uninsured. But when you compare that to 11% for Black Americans to 20% for Hispanic Americans and 22% of our American Indian and Alaskan Native populations, those differences are large,” she says.
One of the key solutions is enrolling eligible people in Medicaid or directing them to health plans available through the marketplaces established by the Affordable Care Act. It is a combination of both lack of access and cost, says Ramirez. “Latinos and other communities of color are less likely to regularly go to a doctor and seek preventive care and are more likely to only go when it’s deemed necessary such an emergency.”
It’s a shift that requires change both on behalf of patients through community engagement and education about preventative care, but also about educating physicians and building a pipeline of new doctors from within these communities. “I really see our study, despite it being about healthcare spending, to be about access to primary healthcare,” says Dieleman.
His team plans to look at geographic variation and breakdown issues of race and ethnicity and access at the county-level, as well as update the data set through 2020 and the start of the Covid-19 pandemic. The hope is that access to primary care could not only lead to improved health outcomes, but also to “move some of the spending away from inpatient care and emergency department care to where the services can actually be most effective in preventing and managing diseases before they become so severe.”