Disparities in Healthcare Access for American Women of Color
By Ramya Prabhakar
The 2020 primary season has whittled down the impressive field of Democratic presidential contenders to a mere eight candidates. With the exit of Kamala Harris in early December, the field lost its only woman of color, and with the suspension of the Castro and Booker campaigns, the field became entirely white.
Simultaneously, the platform of the Democratic party has centered around healthcare—and for good reason. Polling continues to show that voters rank healthcare as the most important issue in elections, and Democratic focus on Republican efforts to repeal the Affordable Care Act helped them win back the majority in the House of Representatives. And healthcare disparities negatively affect women—particularly women of color. This article lists some of the major risks and causes of disparities between women of color and white women, and then discusses the effects of Obamacare.
Higher Risks of Illnesses
Women of color, particularly Black and Latina women, face higher risks of diabetes, heart disease, hypertension, and certain types of cancer. Latina women are particularly susceptible to cancer, heart disease, stroke, and diabetes, and are 50% more likely to die from liver disease and diabetes. Asian women, particularly Indian women, also face higher risk for cardiovascular disease.[i]
Neighborhoods and living environments also significantly impact health and are greater risk factors for women of color. Communities of color are also more likely to live in neighborhoods that are more affected by air pollution, causing higher rates of respiratory issues, lung cancer, and heart disease. These neighborhoods, often lower-income, also are less likely to have access to supermarkets, limiting access to fresh produce and lean proteins. And residents of these neighborhoods are also less likely to have access to primary care physicians, let alone medical specialists.
Among other conditions, living in such neighborhoods in such conditions can cause obesity, which is one of the most common roots of higher health risks. Obesity has been linked to heart disease, stroke, high blood pressure, cancer, diabetes, and other potentially fatal illnesses. Furthermore, many of these diseases are hereditary, meaning that having close relatives with these conditions can increase the likelihood of incidence in future generations.[ii]
In general, women of color in poverty face significant challenges in prioritizing and affording healthcare, particularly for family planning and abortion services.
Women of color are particularly susceptible to cervical and breast cancer, unintended pregnancies, and pregnancy-related complications. Black women have the highest rates among all women of breast cancer, while Latinas are most likely to develop cervical cancer.
Black, Native American, and Alaskan Native women are three times more likely than white women to die of pregnancy-related causes. This number has actually increased in recent years, but studies have shown that 60% of these deaths could be prevented with better access to healthcare as well as anti-poverty measures such as stable housing and transportation. This is staggering when one considers the fact that though maternal death rates fell globally from 2000 to 2015, rates actually increased for women in America during the same time period.[iii]
Women of color living in states that are hostile to abortion rights face greater challenges, as they are more likely to be denied coverage for abortion and other contraceptive measures. Without insurance, these women—particularly black women—often cannot afford contraceptive care. Relatedly, studies have found a disparity in rates of sexually transmitted illnesses (STIs), particularly for Hispanic women. This is mostly linked to difficulties in accessing sexual health services, securing a hygienic living environment, and distrust of healthcare institutions, as well as social and cultural discrimination and language barriers.[iv]
Insurance and Healthcare Access
This problem is compounded by the fact that a large percentage of women of color are unable to properly access quality medical care. Compared to white women, 8% of whom were uninsured in 2017, women of color are on average far more likely to be uninsured. 19.9% of Latina women, 13.9% of black women, and 21.1% of Native American women ages 18-64 do not have health insurance. And this number goes up when considering only women of reproductive ages. While the uninsured rates for white women remained the same, 17% of women of color (all races) do not have coverage.[v]
There are geographic disparities as well. Many women of color who do have health insurance rely on Medicaid for their coverage, but states in the South and the Midwest in particular chose not to expand Medicaid coverage, limiting health insurance options for women of color in those states. Still other women fall within the “coverage gap,” where higher salaries render them ineligible for Medicaid coverage but insufficient for private insurance. As a result, 28% of Latinas and 16% of Black women in the South do not have health insurance, and 30% of Hawaiian and Pacific Islander women and 25% of Native American women are also uninsured.[vi]
The reasons for coverage disparities vary widely. For some, particularly immigrant women, language barriers result in an inability to properly access and evaluate care. Legal barriers, particularly for undocumented immigrant women, can also prevent women from accessing insurance.
Cultural barriers also contribute to lower rates of coverage. Some Asian and Latin American cultures emphasize family decisions when regarding healthcare, which can sometimes clash with the American medical system or prevent women from accessing care. In particular, some cultures expect women to endure a certain amount of pain, resulting in inaccurate assessments (whether by the woman or by the doctor) of pain levels and insufficient treatment. Many Black women in particular also found that their concerns of pain or questions about their health were dismissed by medical professionals, and that their complaints were often disregarded.[vii]
Social and Historical Factors
Besides insurance rates, societal factors and history also play a large role in determining healthcare access. A few studies have shown links between the stress of dealing with discrimination and health problems such as increased cortisol levels, inflammation, and premature aging—not to mention mental health issues.[viii]And medical providers often succumb to unconscious biases about women of color, penalizing women who are more passionate in getting care and disbelieving women of color who say they are in pain. Black women, in particular, face the challenge of avoiding the “angry Black woman” label when advocating for themselves in medical settings.[ix]
Mistrust of institutions, particularly for Black, Native American, and undocumented immigrant women, also contributes to lower access to care. In a study published in 2019, researchers interviewed women in communities of color in Selma, Alabama; Tulare County, California; St. Louis, Missouri; the Crow Tribal Reservation in Montana; and Erie County, Pennsylvania. They found that communities of color were still aware of the legacies left by the medical establishment, particularly abuses such as forced sterilization on Native American women and the Tuskegee syphilis study close to Selma.[x]
The Effects of Obamacare
In March 2010, President Obama signed the Patient Protection and Affordable Care Act, which gave communities of color and low- and middle-income households access to new health insurance options. Primarily, the bill prohibited insurance companies from charging higher rates or denying care for pre-existing conditions, and also prohibited insurers from classifying pregnancy as a pre-existing condition.
The ACA also protected against caps for chronic diseases and, most significantly, offered coverage to uninsured adults who had been excluded from care previously. It also expanded Medicaid coverage to include individuals and families whose incomes up to 138% less than the national poverty line. This particularly helped women of color with chronic diseases such as HIV, as they could afford housing, childcare, and nutritional support along with prevention methods such as regular screenings and counseling, and the lack of any co-pay.
At first glance, the bill seems to have worked. From 2013 to 2015, coverage rates for women of color grew at more than double the rate of coverage for women overall.[xi]Among Black, Latina, Asian American, and Pacific Islander women, uninsured rates have sharply decreased, and doctor’s visits have increased. Though some women of color questioned the ACA’s affordability and availability, many eventually signed up thanks to community outreach efforts in person, by phone, and at community events.
Unfortunately, however, the bill did not solve all the problems. The 2015 Supreme Court ruling on the ACA gave states the ability to decide whether or not they could expand Medicaid, and as of January 2020, fourteen states have chosen not to. The ACA also has weathered—and will continue to weather—legislative efforts to weaken its provisions, most significantly evidenced by the AHCA and the BCRA plans that failed in the Senate in 2017. These states—mostly in the South and Midwest—host 38% of Latinos and 23% of Asians, along with 55% of African Americans.[xii]
Furthermore, large populations of low-income women remain uninsured. Along with racial disparities, single mothers are also more likely to be uninsured, and women of color are less likely to receive coverage from their employers or be claimed as a dependent on someone else’s insurance. Even those receiving health insurance must also pay cost sharing through high copays and large deductibles.
The ACA definitely has not enabled all women of color to fully access quality healthcare, but it is a step in the right direction. It remains to be seen whether proposals for healthcare, as well as public health and anti-poverty measures, from any of the Democratic candidates can succeed where the ACA has failed. With Medicare For All and a public option emerging as the two primary plans, it looks like the ACA was simply the first step in America’s long-overdue journey to healthcare for all.