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. 2021 Aug 17;326(7):637-648.
doi: 10.1001/jama.2021.9907.

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018

Shiwani Mahajan  1   2 , César Caraballo  1   2 , Yuan Lu  1   2 , Javier Valero-Elizondo  3   4 , Daisy Massey  1 , Amarnath R Annapureddy  1   2 , Brita Roy  5   6 , Carley Riley  7   8 , Karthik Murugiah  1   2 , Oyere Onuma  5 , Marcella Nunez-Smith  9 , Howard P Forman  10   11 , Khurram Nasir  3   4 , Jeph Herrin  2 , Harlan M Krumholz  1   2   11
Affiliations

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018

Shiwani Mahajan et al. JAMA. .

Abstract

Importance: The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades.

Objective: To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US.

Design, setting, and participants: Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults.

Exposures: Self-reported race, ethnicity, and income level.

Main outcomes and measures: Rates and racial and ethnic differences in self-reported health status and health care access and affordability.

Results: The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification.

Conclusions and relevance: In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lu reported grants from the National Heart, Lung, and Blood Institute (K12HL138037) and the Yale Center for Implementation Science outside the submitted work. She was a recipient of a research agreement, through Yale University, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion. Dr Roy reported being a consultant for the Institute for Healthcare Improvement. Dr Riley reported receiving personal fees from Heluna Health and the Institute for Healthcare Improvement outside the submitted work. Dr Murugiah reported working under contract with the Centers for Medicare & Medicaid Services to support quality measurement programs. Dr Nunez-Smith reported receiving speaker fees from Genentech outside the submitted work. Dr Nasir reported serving on advisory boards of Amgen, Novartis, and The Medicines Company; and his research is partly supported by the Jerold B. Katz Academy of Translational Research. Dr Krumholz reported receiving personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Siegfried & Jensen Law Firm, Arnold & Porter Law Firm, Martin/Baughman Law Firm, National Center for Cardiovascular Diseases in Beijing, and F-Prime; contracts from the Centers for Medicare & Medicaid Services, through Yale New Haven Hospital, to develop and maintain measures of hospital performance; and grants from Medtronic, the US Food and Drug Administration, Johnson & Johnson, Foundation for a Smoke-Free World, State of Connecticut Department of Public Health, and the Shenzhen Center for Health Information outside the submitted work. He is a co-founder of Refactor Health and HugoHealth. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Population
The 4 mutually exclusive racial and ethnic subgroups were created based on the primary race and ethnicity combinations. aSmall sample size defined as less than 1% of the surveyed population. Individuals in these categories did not identify as Latino/Hispanic.
Figure 2.
Figure 2.. Trends of Self-reported Poor or Fair Health Status, Functional Limitation, and Severe Psychological Distress by Race and Ethnicity, 1999-2018
Data source is the National Health Interview Survey from years 1999 to 2018. Rates are adjusted for age, sex, and US region using logistic regression, with 95% CIs shown with error bars. Definitions of each outcome are shown in Study Outcomes in the Methods section. The median annual number of adults included in the study by race and ethnicity were 1301 (IQR, 911-1815) non-Hispanic Asian, 4355 (IQR, 3843-4589) non-Hispanic Black, 5325 (IQR, 4212-5603) Latino/Hispanic, and 20 290 (IQR, 16919-20961) non-Hispanic White. The annual number and weighted proportion of individuals included in the study population are shown in eFigure 1 in the Supplement. The income-stratified results for these measures are presented in eFigure 4 in the Supplement.
Figure 3.
Figure 3.. Trends of Self-reported Health Care Access, Utilization, and Affordability Measures by Race and Ethnicity, 1999-2018
Data source is the National Health Interview Survey from years 1999 to 2018. Rates are adjusted for age, sex, and US region using logistic regression, with 95% CIs shown with error bars. Definitions of each outcome are shown in Study Outcomes in the Methods section. The median annual numbers of adults included in the study by race and ethnicity were 1301 (IQR, 911-1815) non-Hispanic Asian, 4355 (IQR, 3843-4589) non-Hispanic Black, 5325 (IQR, 4212-5603) Latino/Hispanic, and 20 290 (IQR, 16 919-20 961) non-Hispanic White. The annual number and weighted proportion of individuals included in the study population are shown in eFigure 1 in the Supplement. For these measures, rather than assuming a monotonic relationship between time and outcome rates, time was modeled as a linear spline with knots at 2010 and 2016 (dotted vertical lines) to reflect the observed inflection points of foregone or delayed medical care due to cost and health insurance coverage. Of note, the Affordable Care Act was enacted in March 2010. The annualized rate of change of each outcome during each of the 3 time periods is presented in eTable 8 in the Supplement. The income-stratified results for these measures are presented in eFigure 6 in the Supplement.
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