Disclosures: Dieleman, Johnston, Mahajan, Mensah, Ortega and Ramirez report no relevant financial disclosures. Please see the studies for all other financial disclosures.
August 25, 2021
6 min read

Disparities in health care spending, outcomes persist in US, studies show

Disclosures: Dieleman, Johnston, Mahajan, Mensah, Ortega and Ramirez report no relevant financial disclosures. Please see the studies for all other financial disclosures.
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Health care spending and outcomes vary across racial and ethnic groups in the U.S., with underrepresented populations often having higher rates of ED spending and poor or fair health, according to three studies published in JAMA.

“Black and Indigenous individuals and other people of color face significant barriers to obtaining quality health care services in the U.S.,” Joseph L. Dieleman, PhD, a professor in the department of health metric sciences at the University of Washington, and colleagues wrote. “Inequalities by race and ethnicity in access to care have been attributed to variation in insurance coverage; socioeconomic and geographic inequities that affect health and access to health care; and structural, institutional, and interpersonal racism within the health care system. These barriers to health care utilization and treatment reflect and perpetuate structural racism in U.S. society more broadly.”

Estimated prevalence of poor or fair health
Dieleman JL, et al. JAMA. 2021;doi:10.1001/jama.2021.9937.

Health care spending

Dieleman and colleagues conducted an exploratory study to estimate health care spending from 2002 to 2016. It is the first study of its kind that “disaggregates health care spending in the United States across six key race and ethnicity groupings,” Dieleman said during a press briefing held by the Institute for Health Metrics and Evaluation (IHME). These included American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, Black, Hispanic and white patients.

The analysis was based on data from 7.3 million health system visits, admissions or prescriptions, which the researchers collected from the Medical Expenditure Panel Survey and the Medicare Current Beneficiary Survey. They combined the data with insured population and notified case estimates from the National Health Interview Survey, and health care spending estimates from the IHME’s Disease Expenditure project.

The findings revealed that health care spending among Black patients was roughly equal to population levels. Black Americans accounted for about 12% of the U.S. population and received an estimated 11% of spending, according to the researchers. However, that spending was largely connected to emergency and inpatient care, suggesting that Black Americans do not receive care until they experience advanced or emergent illness, according to the IHME.

Overall, from 2002 to 2016, $29.9 trillion was spent on health care services across six types of care: ambulatory, dental, emergent, inpatient, nursing facility and prescribed pharmaceuticals. In 2016 alone, about $2.4 trillion was spent on health care, 72% of which was on white patients despite this group accounting for 61% of the U.S. population.

Dieleman and colleagues reported that Hispanic individuals accounted for about 11% of spending in the same year while representing 18% of the population. Also, Asian and Native Hawaiian or Pacific Islander individuals received about 3% of spending and made up 6% of the population; multiple-race individuals received 2% of spending and made up 2% of the population; and American Indian or Alaskan Native individuals received about 1% of spending and made up 1% of the population.

Unequal spending geared toward white individuals persisted throughout the study, and the differences “could not be explained simply by rates of insurance coverage,” according to Dieleman and colleagues.

Underrepresented populations are more likely to be uninsured or have restrictive insurance policies, Amelie Ramirez, DrPH, MPH, director of the Institute for Health Promotion Research and the Salud America! program at UT Health San Antonio, said during the press briefing.

“As of 2019, only 8% of white Americans under the age of 54 are uninsured. When you compare that to 11% for Black Americans, 20% for Hispanic Americans and 22% for American Indian and Alaska Native populations, those differences are large,” Ramirez said.

However, in the health care spending study, the driving force behind differences in spending among racial and ethnic groups was the type of care, Dieleman noted.

“Types of care connected to primary care — ambulatory care, dental care and prescribed pharmaceuticals — tended to have more spending for white non-Hispanics, while inpatient care has more spending on Black non-Hispanics, and emergency department care has more on American Indian and Alaska Native,” he said during the press briefing.

White individuals received about 15% more spending on ambulatory care than the all-population average, while Black individuals received about 26% less spending than the all-population mean for this care category. However, Black individuals received 19% more on inpatient care and 12% more on ED care (P = .04). Also, Hispanic individuals received about 33% less spending per person on ambulatory care. Asian and Native Hawaiian or Pacific Islander individuals received less spending overall on all types of care except dental (P < .001), while American Indian and Alaska Native individuals received more spending on ED care (P = .04). Multiple-race individuals also received more spending on ED care (P = .006), according to Dieleman and colleagues.

“Further research is needed to assess these disparities and the drivers and structural forces that produce them,” they wrote.

Insurance coverage and outcomes

In a different, exploratory observational cohort study, researchers found that Medicare Advantage improved access to ambulatory care and quality among underrepresented populations. However, they still experienced worse outcomes compared with other beneficiaries.

Kenton J. Johnston, PhD, MPH, an associate professor in the department of health management and policy at Saint Louis University, and colleagues investigated racial and ethnic differences in rates of enrollment, access and quality of care from 2015 to 2018 using a national representative sample of 26,887 Medicare Advantage or traditional Medicare beneficiaries.

According to the findings, enrollment in Medicare Advantage compared with traditional Medicare was significantly associated with better outcomes for access and quality among Black, Hispanic, Native American or Asian/Pacific Islander individuals. The researchers noted that these individuals were significantly more likely to enroll in Medicare Advantage. However, in both the Medicare Advantage and traditional Medicare programs, beneficiaries belonging to underrepresented groups were still significantly less likely to have a primary care clinician as a usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%) and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%) compared with white or multiracial individuals, Johnston and colleagues wrote.

“It is possible that these differences in access contribute to worse outcomes observed for racial and ethnic minority populations with chronic diseases such as diabetes, CVD and stroke,” the researchers wrote. “This study did not examine whether differences in access and quality were directly tied to outcomes, such as contracting influenza. This is an important area for future study.”

Access and affordability

Many racial differences in health status and health care access have persisted over the past 2 decades, according to a separate, serial cross-sectional study of 596,355 adults.

Shiwani Mahajan, MBBS, MHS, a postdoctoral fellow at Yale School of Medicine, and colleagues determined 20-year trends in racial and ethnic differences in health status, access and affordability in the U.S. using National Health Interview Survey data.

The analyses revealed that Black individuals with a low income had the highest estimated prevalence of poor or fair health in 1999 (29.1%) and 2018 (24.9%), while white individuals with a middle or high income had the lowest estimated prevalence in 1999 (6.4%) and 2018 (6.3%).

The rates of uninsured individuals have decreased significantly across all racial and ethnic groups since 1999, according to the researchers. Still, significant disparities remain, with Black individuals having an uninsured rate 3 points higher than white individuals, and Latino and Hispanic individuals having an uninsured rate 12.2 points higher than white individuals in 2018 (P < .001).

While there were some improvements in racial and ethnic disparities in access to care, Mahajan and colleagues reported that health care affordability did not substantially improve since 1999, despite the implementation of the Affordable Care Act.

Eliminating health care inequities

In a related editorial, Alexander N. Ortega, PhD, a professor in the Dornsife School of Public Health at Drexel University, and Dylan H. Roby, PhD, an associate professor and chair of health policy and management at the University of Maryland School of Public Health, discussed structural racism in the U.S. health care system. Despite efforts at the organizational, local, state and federal levels, inequities in health and health care remain, they wrote.

The studies conducted by Dieleman, Johnston, Mahajan and colleagues “show that access to

and utilization of services is not merely predicated on health insurance or the availability of health care,” Ortega and Roby wrote.

“The elimination of health care inequities will require effective integration of health care systems with communities and the social safety net,” they added. “Moreover, health equity can only be achieved through attention to the needs and perceptions of the communities served and to the elimination of racism and biases deeply imbedded in the system.”

Role of PCPs

There are several actions that primary care physicians can take to reduce disparities in spending and care, according to Ramirez and George Mensah, MD, director of the Center for Translation Research and Implementation Science in the National Heart, Lung and Blood institute at the NIH. Mensah recommended using personalized, individual reminders for patients of underrepresented groups. Tackling misinformation is another key area.

“There is a general misinformation that you don’t need to go see the doctor if you’re not sick. You could go for 4 or 5 years without your blood pressure or blood cholesterol known,” Mensah said during the press briefing.

Ramirez suggested altering practice hours to be more conducive to patients who have limited availability during the day, such as those who work multiple jobs and are only available during the evening or weekend.

“Many of our PCPs want to do more, but they’re limited based on the number of patients that they have to see,” she said. “We’re trying to come up with new and creative ideas on how we can use our electronic medical records to help us better identify key areas of our community that might need that help.”


Dieleman JL, et al. JAMA. 2021;doi:10.1001/jama.2021.9937.

Institute for Health Metrics and Evaluation. New study shows U.S. healthcare dollars disproportionately spent on white Americans. http://www.healthdata.org/news-release/new-study-shows-us%C2%A0health-care-dollars-disproportionately-spent-white-americans. Accessed August 17, 2021.

Johnston KJ, et al. JAMA. 2021;doi:10.1001/jama.2021.10413.

Mahajan S, et al. JAMA. 2021;doi:10.1001/jama.2021.9907.

Ortega AN, Roby DH. JAMA. 2021;doi:10.1001/jama.2021.11160.