Last Updated Aug 10, 2022
This guide is intended to help donors gain a deeper understanding of the issues related to the U.S. healthcare system and outlines opportunities to address the root causes of inequitable outcomes. See the entire series. By Lucy Brennan-Levine
Public health programs and policies aim to keep a community and the population healthy and increase positive health outcomes. Public health programs also work to prevent long-term and chronic health issues within communities.
In the U.S., public health disparities run along racial and class lines and often fail to center the needs of BIPOC people. A few examples:
Although the goal is to ensure wellness across populations, U.S. systems do not coordinate efforts well enough to capture data sets that accurately portray community health, especially for communities of color. For example, ethnicity data is often not disaggregated within Asian Americans and Pacific Islanders communities making it difficult to understand disparities. At the same time, communities of color are impacted by racism, which research has shown causes health disparities and gaps in accessing healthcare.
Sexism, ableism, and homophobia also contribute to health inequity, particularly affecting LGBTQ+ individuals, women of color, and people with disabilities, who may struggle to access public health programs. While public healthcare programs such as Medicare and Medicaid aim to help expand coverage and affordability for communities that are most vulnerable, it’s not without its issues.
By investing in public health, donors can support more equitable healthcare and reduce burdens on our economic system. Consider that indirect costs associated with preventable chronic diseases related to workplace productivity can exceed $1 trillion dollars.
But, every $1 invested in public health yields improved health outcomes equivalent to as much as $88 in expenditures saved by county public health departments.
Because so many public health issues intersect with race and class, it’s important to put social justice at the forefront of your giving approach. Public health programs that aren’t tackling poverty and public health simultaneously can’t stop cycles that families and children continue to be caught in. Inherited and generational poverty and trauma can negatively impact an individual’s environment and health outcomes. For instance, children living in high-poverty areas are exposed to adverse experiences, which can impact and slow brain development. And, access to housing and healthy food is more difficult for the 1 in 10 people living in poverty.
Meanwhile, the physician workforce remains racially unbalanced.
There is evidence to suggest that seeing racial and ethnic representation in the healthcare workforce can improve shared decision making between doctors and patients, reduce wait times for patients, and increase the patient’s understanding of cancer risks. Creating representative pipelines for healthcare workers can help improve outcomes for BIPOC patients seeking comprehensive care.
Indigenous peoples experience health disparities such as higher rates of suicide and diabetes, among other chronic diseases. Indigenous peoples are also among the populations at highest risk of being impacted by environmental pollutants. An estimated one in 10 Indigenous Americans lacks access to safe drinking water.
Despite these problems, Indigenous people in federally recognized tribes only have one major source of public healthcare: Indian Health Services (IHS). It receives significantly less funding compared to other U.S. departments.
Approximately 2.8 million Native peoples live in urban settings around the country. While some urban Indigenous people are in federally recognized tribes, there are 109 tribes that were “terminated” in the 1950s. These individuals can not receive healthcare from IHS. Meanwhile, urban Indigenous people that are part of federally recognized tribes face barriers to receiving care because they do not live on reservations.
Only 1% of the Indian health budget is currently reserved for urban populations and remains in flux.
The expansion of the Centers for Medicare and Medicaid Services within IHS offers public healthcare programs to Indigenous people but many opted out of enrollment. Because of a long history of broken treaties, underfunding, and displacement, many Indigenous people do not trust the U.S. government.
Native reservations are not able to make money from land taxes like other cities and towns to improve their land issues and tribal voices are often not included in government approaches to help address these public health issues.
Immigrants tend to have lower rates of health insurance, use fewer healthcare services, and receive lower quality of care than U.S.-born populations, according to one study. Language barriers can make it difficult for individuals to understand treatment options, instructions, and medical treatment regimens and research shows there’s a need for language assistance in healthcare.
Culturally-competent care could help to end some racial and ethnic health disparities by reducing barriers to patient care and encouraging more comfortable preventative care visits. Some of those practices include:
Despite millions of Americans gaining health insurance coverage under the Affordable Care Act, there are still two million individuals within the coverage gap. Individuals that are uninsured are largely from low-income families and people of color are more likely to be uninsured than their white counterparts. From 2018 to 2019, the number of uninsured children grew by more than 327,000 and this increase was seen most in Hispanic communities.
Both institutional and interpersonal racism affect people of color, especially Brown and Black communities and have a significant negative impact on their health outcomes. Black Americans are less likely to get adequate treatment or be seen by specialists. Moreover, United States government health agencies have an atrocious history of experimenting on Black communities and people of color.
In an October 2020 poll, “seven out of 10 Black Americans say they’re treated unfairly by healthcare systems and 55% say they distrust it.”
LGBTQ+ populations have faced a long history of discrimination and bias. According to a 2017 Center for American Progress study, “8% of lesbian, gay, and bisexual respondents and 29% of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity in the past year.”
Additionally, 9% of LGBTQ respondents said that their physicians used harsh or abusive language during their visit. LGBTQ+ populations face higher rates of suicide, violence, and psychiatric disorders, prompting the need for high-quality healthcare options. Additionally, training for medical professionals is not always LGBTQ+ inclusive and does not prepare medical staff to operate at a comprehensive level that treats all patients equally and with care.
Transgender populations specifically have difficulty accessing gender-affirming care or preventative and primary care due to insurance exclusions.
Specific data collection on transgender populations and broader LGBTQ communities is still rare and should be a public health priority.
Racism is considered a public health crisis in some U.S. cities. Discrimination in the form of housing segregation, police brutality, and employment bias all jeopardize health outcomes for people of color or disrupt access to adequate healthcare. Racism along the lines of the social determinants of health also prevent positive health outcomes.
Classism is another barrier for positive health. People living in poverty tend to have more difficulty finding consistent employment, having jobs that offer high-quality health insurance, and experience financial instability.
How can we make change? One way is to increase voter participation which can help advance equitable health policies through more diverse representation. However, voter suppression tactics, such as strict voter ID laws that disproportionately impact communities of color, continue to be a barrier.
The public health workforce declined by 20% since 2008 and more than 60% of local health departments report flattened budgets. A recent report found that there is a shortage of 10,000 public health physicians.
At a state and local level, public health programs depend on whether elected officials prioritize community-based health programs that are traditionally underfunded.
Grant funding from the CDC provides some states with public health prevention dollars for diabetes, heart disease, and tobacco use, while others may only receive funding for one public health issue, despite chronic conditions prevalent in that state. Donor investment in community-based programs that tackle preventative care for vulnerable communities is lacking and community organizations are working with small budgets that impede expansion and longevity.
Public health research can help inform policy, however, research is not always accountable to BIPOC communities and often leaves out voices that should be heard. Even as recently as 2020, more than half of U.S. health departments did not report demographic data on morbidity mortality rates during COVID-19. In some cases, populations do not share information based on medical distrust and history of medical abuse against minority patients.
Additionally, standard data collection processes lack the nuances to adequately collect information on health outcomes for specific populations. For instance, race and ethnicity reporting is informed by the Office of Management and Budget which includes only five categories for data on race. Populations that are varied such as Native Hawaiians, Asian Americans and Pacific Islanders (NHAAPI) encompass individual backgrounds of more than 40 countries. These gaps prevent policymakers from seeing all racial health disparities and hinder responses that focus on sub-groups of communities.
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