When Racial and Rural Disparities Collide

By Katie Keith, JD, MPH
March 8, 2022

Katie Keith is the director of the Health Policy and the Law Initiative at the O’Neill Institute at Georgetown University Law Center. Katie is also an associate research professor at the Center on Health Insurance Reforms, a regular contributor to Health Affairs Forefront and a member of the 2022 Tradeoffs Research Council. She focuses on providing technical assistance for policymakers and public education on health policy legal issues with an emphasis on access to coverage, affordability, transparency and equity.

“[T]he problem of the Twentieth Century is the problem of the color line.” – W. E. B. DuBois 

A recent Health Affairs study led by Jan M. Eberth opens with this quote from W. E. B. DuBois, co-founder of the NAACP, who used the phrase “color line” to describe widespread discrimination and exclusion of Black people. After pointing out that an array of racist policies have shaped where people live in the U.S., the study’s authors proceed to show how the color line remains today when it comes to access to health care.

Eberth and colleagues first identified zip codes with the highest concentrations of minoritized racial and ethnic populations. They then used data from the American Hospital Association and CMS to calculate the distance to the nearest hospital that provided emergency services, trauma care, obstetrics, outpatient surgery, intensive care and cardiac care, respectively.

They found the nearest hospital was significantly farther from rural zip codes with a high share of Black or American Indian/Alaska Native people compared to areas with high white representation. They found the opposite in urban areas: Hospital services were farther from people living in urban areas with a greater share of white people.

Two caveats: The researchers used straight-line distance, which might not reflect true travel time. An urban hospital might appear closer but actually be less accessible due to travel barriers such as the need to use public transportation. The study also did not look at the quality of nearby hospitals, which can be lower at less-resourced hospitals serving communities of color.

Racial and rural disparities in access to care are not new. But this study does the important work of documenting structural inequalities and furthering our understanding of where people of color do and don’t have access to health care. (If you want to dig deeper, I highly recommend the “StoryMap” the authors produced, which includes several interactive maps, and Health Affairs’ full issue on racism and health.)

The authors also outlined numerous policy actions to increase rural access to care including Medicaid expansion, state oversight of hospital system mergers, expanded use of telehealth and increased broadband internet access. They also called on CMS to better ensure geographic equity in access to care through improved network adequacy standards for Medicare and Medicaid. The Biden administration recently proposed enhanced network adequacy standards for Affordable Care Act plans, but this study suggests even stronger standards may be needed.

As Eberth and colleagues put it, “the color line does not have to be the future.”

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