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

Educational Objective
To learn the trends in self-reported health status and health care access and affordability by race and ethnicity and income level among US adults.
1 Credit CME
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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Harlan M. Krumholz, MD, SM, Yale New Haven Hospital Center for Outcomes Research and Evaluation, 195 Church St, Fifth floor, New Haven, CT 06510 (harlan.krumholz@yale.edu).

Accepted for Publication: June 1, 2021

Author Contributions: Drs Caraballo and Mahajan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mahajan and Caraballo contributed equally as co-first authors.

Concept and design: Mahajan, Caraballo, Valero-Elizondo, Massey, Onuma, Nunez-Smith, Herrin, Krumholz.

Acquisition, analysis, or interpretation of data: Mahajan, Caraballo, Lu, Annapureddy, Roy, Riley, Murugiah, Forman, Nasir, Herrin, Krumholz.

Drafting of the manuscript: Mahajan, Caraballo, Annapureddy, Riley.

Critical revision of the manuscript for important intellectual content: Mahajan, Lu, Valero-Elizondo, Massey, Annapureddy, Roy, Riley, Murugiah, Onuma, Nunez-Smith, Forman, Nasir, Herrin, Krumholz.

Statistical analysis: Mahajan, Caraballo, Herrin.

Administrative, technical, or material support: Mahajan, Massey, Annapureddy, Krumholz.

Supervision: Nunez-Smith, Krumholz.

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.

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