Measuring Magnitude of Disparities in US Healthcare over Decades

Michelle Odlum, EdD, MPH

The disparity in health between adults of color and White persons in the US, particularly apparent in the course of the coronavirus 2019 (COVID-19) pandemic, has persisted and increased in the 20-year period since major Congressional funding was allocated to address and reduce it, according to a study of multiple health indicators in minority groups.

"Our findings add to the literature documenting that policy choices have not resulted in the sought after reductions in Black-White health disparities in the United States," declared Michelle Odlum, EdD, MPH, assistant professor of Nursing, Columbia University School of Nursing, and colleagues.

In 1999, Congress charged the Institute of Medicine (currently the National Academy of Medicine) to systematically assess US health inequities and prepare policy statements to address their findings.

In the period of 2000-2019, $35 billion in federal funds were allocated to this effort which, the investigators note, dwarfed the $12 million that had been marked for this purpose in the preceding 15 years.

The funds were targeted more for researching the problem than for direct intervention, however—serving to support over 16,000 research projects on racial/ethnic health disparities.

"Several possible reasons (for continued disparities) include the fact that the National Academy of Medicine projects were funded primarily to assess the consequences of health disparities and to draft policy statements," Odlum and colleagues observed. "Interventions were less emphasized."

The investigators undertook what they characterize as "among the first and largest studies" to quantify multiple indicators of health in the Black and Hispanic populations over time and compare these in the White population.

The study used a repeated cross-sectional study design with anonymized, nationally representative data from the Behavioral Risk Factor Surveillance System (BRFSS). The studied period of 1999-2018 followed the Minority Health and Health Disparities Research and Education Act of 2000.

The age of the studied population of 4,856,326 individuals (60.9% women) was 45 years or older, the investigators explained, to capture the chronic diseases which typically emerge in middle age after long-term exposure to harmful behavioral, genetic environmental, and/or low socioeconomic conditions.

The investigators reported that over the 2 decades, Black adults had an overall improvement in uninsured status, but an overall deterioration in rates of hypertension, diabetes, asthma, and stroke. The gap between Black and White populations was reduced with improvements in the Black population in the categories of being uninsured and in physical inactivity, but the gap widened with higher rates in the Black population of diabetes, hypertension, coronary heart disease and asthma.

Hispanic adults showed improvements in physical inactivity and perceived poor health, but had overall deterioration in hypertension and diabetes. In comparison to the White population, the gap was reduced for Hispanic adults in coronary heart disease, stroke, kidney disease, asthma, arthritis, depression, and physical inactivity. There was a widening of the gap, however, in more Hispanic adults having diabetes, hypertension and more without insurance.

Odlum and colleagues characterize the patterns of poor health in Hispanic adults as "complicated.” Relative to Black adults, the Hispanic population showed worsening patterns in diabetes prevalence; but in contrast to Black adults, Hispanic adults showed lower prevalence in hypertension and stoke, and the lowest prevalence of COPD.

The Hispanic population also showed trend patterns of gradually eliminating the disparities between their White peers in most indicators of poor health.

Odlum and colleagues pointed out that several of the chronic diseases that showed the worst trends were eligible for screening through ACA policies, "suggesting that promoting screening alone will be insufficient to reduce disparities." They remarked that progress can be challenging and slow, but encouraged researchers to look to the successes achieved in such areas as physical inactivity and in arthritis.

"Researchers and policy makers should continue to propose targeted, culturally sensitive, multilevel interventions that can be widely implemented and sustained," they advised.

The study, "Trends in Poor Health Indicators Among Black and Hispanic Middle-aged and Older Adults in the United States, 1999-2018" was published online in JAMA Network Open.