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Original Investigation
August 17, 2021

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

Author Affiliations
  • 1Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
  • 2Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 3Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
  • 4Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
  • 5Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 6Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 7Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 8Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 9Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 10Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
  • 11Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
JAMA. 2021;326(7):637-648. doi:10.1001/jama.2021.9907
Key Points

Question  How have racial and ethnic differences in self-reported health status, access, and affordability among US adults changed between 1999 and 2018?

Findings  In this serial cross-sectional study that included 596 355 adults, there were marked racial and ethnic differences in measures of health status, access, and affordability, with evidence of improvement in some subgroups but persistence overall. In 2018, Black individuals with low income had the highest estimated prevalence of poor or fair health (24.9%), while White individuals with middle or high income had the lowest (6.3%).

Meaning  Between 1999 and 2018, some estimated racial and ethnic differences in measures of self-reported health status and health care access improved, but many differences persisted.

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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