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A new analysis of health care spending in the United States found stark disparities across racial and ethnic lines in how medical resources are divided.
Non-Hispanic white Americans, who made up 61 percent of the nation's population at the time of the study, accounted for 72 percent of the $2.4 trillion spent in 2016 on ambulatory, inpatient and emergency care; nursing facilities; prescribed pharmaceuticals; and dental care, according to a recent study published in JAMA.
No other single racial or ethnic group received an outsized piece of the health care pie:
- Hispanics (then constituting 18 percent of the population) got 11 percent
- African Americans (then representing 12 percent of the population) received 11 percent
- Asian, Native Hawaiian and Pacific Islanders (then at 6 percent of the population) got 3 percent
- American Indians and Native Alaskans (then at 1 percent of the population) got 1 percent
The researchers analyzed data collected on 7.3 million health system visits, admissions or prescriptions from 2002 through 2016 totaling an estimated $29.9 trillion in spending across six types of care. The racial and ethnic disparities in health care spending that the analysis revealed persisted after adjusting for differences in age or health conditions among racial and ethnic groups.
"This study provides evidence of spending and utilization differences across race and ethnicity groups that cannot be explained by differences in the age or notified health status of the individual,” the researchers wrote.
Instead, they suggest that myriad causes that have been previously identified are at play, including “how physicians respond to patients,[...] bias that exists in the algorithms that assess health needs and determine appropriate interventions,” and “residential segregation that precludes easy access to health care services."
Inside the numbers
Although health care spending by African Americans was roughly in proportion with their population size, the researchers say, a closer look at the numbers suggest they do not receive care until they are experiencing advanced illness.
African Americans accounted for 26 percent less spending on outpatient care but 12 percent more spending on emergency department care per person than average, a finding that “reinforces previous research showing unequal access to primary care,” the study authors observed.
In contrast, non-Hispanic white Americans received 15 percent more spending per person on outpatient care than average, suggesting they have better access to routine and preventive care. They also spend more on dental care and pharmaceuticals than other racial or ethnic groups.
"This study provides a clear picture of who is benefiting from and who is being left behind in our health care system,” lead study author Joseph L. Dieleman, an associate professor in the Department of Health Metric Sciences at the University of Washington School of Medicine, said in a statement.
Hispanics received about 33 percent less spending per person on outpatient ambulatory care than average. Asian, Native Hawaiian and Pacific Islanders received less spending per person than average on all but dental care, according to the researchers.
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Spending on Asian, Native Hawaiian or Pacific Islanders was an estimated 73 percent lower than average for nursing facility care. Among the other categories, spending was 46 percent lower than average for prescribed pharmaceuticals, 44 percent lower for emergency care, 40 percent lower for ambulatory care and 29 percent lower for inpatient care, according to the study.
"Latinos in particular often lack access to high-quality health care and are among the least likely of any racial or ethnic group to visit the doctor when they have a medical issue,” Amelie G. Ramirez, director of the Institute for Health Promotion Research and the Salud America! program at UT Health San Antonio, said in a statement. “As a result, they suffer from poorer health outcomes on a range of measures. This study highlights the urgent need for new investments in Latino health."
The study also considered a “multiple-race” group that then represented 2 percent of the population, which had more estimated spending on all types of care (save nursing facility care) than the average.
About the study
The study included data from 7.3 million health system visits, admissions or prescriptions captured in the “Medical Expenditure Panel Survey” between 2002 and 2016 and the “Medicare Current Beneficiary Survey” between 2002 and 2012. The data were combined with insured population estimates from the “National Health Interview Survey” (2002, 2016) and health care spending estimates from the Disease Expenditure project (1996–2016).
Researchers from the Institute for Health Metrics and Evaluation at the University of Washington School of Medicine, Johns Hopkins University in Baltimore, and the University of Michigan, Ann Arbor contributed to the study.
The researchers noted that their study had some limitations; in particular, they did not consider how health services were paid — a factor that would have made it possible to better understand the role insurance plays in racial and ethnic disparities.
"Access to private insurance is not equitable across key race and ethnicity groups, and insurance coverage is known to drive differences in utilization,” they wrote.
The researchers also suggested that further study is needed to consider the impact of the COVID-19 pandemic on health care disparities, noting that it “will be important for understanding utilization and treatment,” given that the pandemic “has already been shown to exacerbate already existing health inequalities."
JAMA's closer look
An accompanying editorial noted that the study results are “important reminders that even with considerable research and policy efforts to address them, health inequities persist” and suggested that achieving health equity will require engaging patients, physicians, health care organizations, payers, government programs, community-based organizations and community members in designing and implementing change.
Average Per-Person Spending on Health Care Services (2016)
- $8,141 for non-Hispanic whites
- $7,649 for American Indians and Native Alaskans
- $7,361 for Blacks
- $6,025 for Hispanics
- $4,692 for Asian, Native Hawaiian and Pacific Islanders
"How to achieve this and make these efforts translatable, transformative, and sustainable continue to be challenging,” wrote Alexander N. Ortega, a professor of health policy at Drexel University, and Dylan H. Roby, a faculty associate at the UCLA Center for Health Policy Research.
The study was one of three research papers published in the latest issue of JAMA examining racial and ethnic inequities in medicine.
A second report found a decreasing percentage of uninsured among all racial and ethnic groups after the passage of the Affordable Care Act in 2010, but disparities remain. In 2018, Blacks had a 3.0-point higher prevalence and Latino/Hispanics had a 12.2-point higher prevalence of being uninsured than whites.
A third study found inequities in access to and quality of care by race and ethnicity in Medicare Advantage and traditional Medicare plans from 2015 to 2018, with non-whites having lower rates of access to a primary care clinician as their usual source of care.
Average Per-Person Spending by Age Group in 2016
| Racial/Ethnic Group | (20-44) | (45-64) | (65-plus) |
| Whites (non-Hispanic) | $5,425 | $10,419 | $18,532 |
| Blacks | $4,287 | $9,168 | $17,905 |
| American Indian, Alaskan Native | $5,150 | $10,746 | $15,518 |
| Hispanic | $3,522 | $7,000 | $14,403 |
| Asian, Native Hawaiian, Pacific Islanders | $3,496 | $5,381 | $9,602 |
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