Structural racism, slavery, discrimination, and colonial medicine have historically impacted access to healthcare in the United States. But other forms of historical discrimination disproportionally affect many groups, including people with low incomes, immigrants, people with chronic conditions, and people with mental health conditions (Corscadden et al., 2018). Historical discrimination is related to healthcare access, lack of health insurance, gender discrimination and violence, rural healthcare disparities, redlining, and gentrification.
Social Determinants of Health and Access to Healthcare Services
Social determinants of health are conditions in the environment that affect a person’s health, functioning, and quality-of-life. Resources that enhance quality of life, such as safe and affordable housing, access to education, public safety, availability of healthy foods, local health services, and environments free of life-threatening toxins can have a significant influence on population health outcomes (ODPHP, 2022). Social determinants of health affect people throughout the lifespan.
Social determinants of health are often grouped into the 5 domains illustrated above. Source: ODPHP. See References for citation and web address.
Most Americans are unaware of these social determinants, do not understand what causes them, and do not necessarily find them to be unfair. In 2008–2009, a national survey showed that 73% of respondents were aware of health differences between the poor and middle-class people, but less than half reported awareness of health differences between white and Black Americans. Many respondents placed the responsibility for poor outcomes on individual behaviors such as smoking, diet, and exercise, as well as access to clinical care, and less on the social determinants of health. Understanding how social determinants affect health equity has led healthcare organizations and providers to recognize the need to address persistently poor health outcomes that affect certain groups (Towe et al., 2021).
Access to Health Insurance
Health insurance—or being underinsured—is a key factor in whether, when, and where people get medical care. Uninsured people are far more likely than those with insurance to postpone or forego healthcare. Being uninsured can have severe financial consequences, with many unable to pay their medical bills, resulting in medical debt (Guth and Artiga, 2022).
Despite most people of color having a full-time worker in the family, they may be employed in low-wage jobs that are less likely to offer health insurance. While private insurance is the largest source of health coverage for people across racial and ethnic groups, people of color are less likely to be privately insured than white people (Guth and Artiga, 2022).
Rural Healthcare Disparities
Rural populations make up around ~19% of the U.S. population. These areas have heightened mortality rates from several chronic diseases compared to urban populations. A lack of rural hospitals and clinics, lack of access to specialty services, and high turnover rates among healthcare providers, create significant health discrepancies for rural communities. Additionally, higher rates of poverty, behavioral risk factors, larger proportions of older adults and people with disabilities, and lower rates of insurance and education create disparities (Nuako et al., 2022).
In Kentucky, nearly half of its 120 counties are listed as rural. Importantly, 61 counties are considered medically underserved and 85 are designated as health professional shortage areas.
Gender is an important and often overlooked social determinant of health and population health inequalities (Alcalde-Rubio et al., 2020). Factors related to gender include: health system discrimination and bias, inequitable societal norms and practices, differential exposure to disease, disability, and injuries, and biases in health research (UCL, 2020).
Women have been victims of bias and discrimination in medical diagnosis, treatment, and care throughout history. They are less likely to be diagnosed with a non-psychosomatic illness, have their pain treated, and have their symptoms taken seriously compared to men. Women were also excluded from clinical trials until the early 1990s (Luu, 2021).
There has been a long history of forced and coerced sterilization of women throughout the world. The practice has targeted marginalized populations, including people diagnosed with a mental illness, disabled persons, racial minorities, poor women, and people living with specific illnesses, such as epilepsy (Patel, 2017).
Throughout the early 20th century, countries passed laws authorizing the coerced or forced sterilization of those they believed should not be permitted to procreate. In the U.S., more than half of the 50 states passed laws permitting the sterilization of people diagnosed with a mental illness, disabled persons, criminals, persons with specific physical illnesses, such as epilepsy, and Native Americans, and African Americans (Patel, 2017).
Indigenous and non-white Hispanic women have been stereotyped as being non-compliant with clinical health recommendations, having risky health behavior, and difficulty understanding or communicating health information. Women are less likely than men to be referred for cardiovascular testing and Indigenous women in particular report perceived discrimination by clinicians as a reason for not seeking recommended cancer screening (Dirks et al, 2022).
Did You Know. . .
From the 1910s through the 1950s, and in some places into the 1960s and 1970s, tens of thousands—perhaps hundreds of thousands—of American women were detained and forcibly examined for sexually transmitted infections. The program was modeled after similar ones in Europe, under which authorities stalked “suspicious” women, arresting, testing, and imprisoning them.
Inside these institutions, the women were often injected with mercury and forced to ingest arsenic-based drugs, the most common treatments for syphilis in the early part of the century. If they misbehaved, or if they failed to show “proper” ladylike deference, these women could be beaten, doused with cold water, thrown into solitary confinement—or even sterilized.
Scott W. Stern, America's Forgotten Mass Imprisonment of Women Believed to Be Sexually Immoral, 2019
During 2007–2016, Black and American Indian/Alaska Native women had significantly more pregnancy-related deaths per 100,000 births than did white, Hispanic, and Asian/Pacific Islander women. Gaps in healthcare coverage and preventive care, lack of coordinated healthcare and social services, and community factors such as transportation and housing contributed to pregnancy-related deaths (Petersen et al., 2019).
Did You Know. . .
In 1970, the Family Planning Services and Population Research Act of 1970, led to nearly one in four Native American women of childbearing age being sterilized without their consent. This policy remained in effect until 1976 (Yellow Horse et al., 2020).
The recent Supreme Court ruling overturning Roe v. Wade has already affected pregnancy-related healthcare for many women. It has also impacted OB/GYN training in the 26 states that have restricted or are poised to restrict abortion services. This means hospitals will no longer offer vital training used to manage miscarriages and other pregnancy-related complications.
Redlining and Gentrification
Redlining and gentrification are historical social practices that we may not consider as contributing to gaps in health. Redlining is a practice in which lenders deny mortgages to eligible buyers solely because of their race. This practice, once widespread, assured that people of color were denied the right of home ownership and upward economic mobility that millions of white people enjoyed (Julian, Hardeman, and Huerto, 2020).
Redlining has been succeeded by gentrification, whereby wealthier middle-class people move into urban areas and displace people who have lived in a neighborhood for years. Both redlining and gentrification perpetuate poverty in communities of color. As such, many Black and low-income Americans live in communities where clean water isn’t guaranteed, and social distancing is nearly impossible in crowded homes. Redlining and gentrification greatly impacted the racial inequities seen during the COVID-19 pandemic (Julian, Hardeman, and Huerto, 2020).
Discrimination in LGBTQ+ Healthcare
LGBTQ+ individuals face significant disparities in physical and mental health outcomes. Compared to their heterosexual counterparts, LGBTQ+ patients have higher rates of anal cancer, asthma, cardiovascular disease, obesity, substance abuse, cigarette smoking, and suicide (Morris et al., 2019).
Sexual minority women report fewer lifetime Pap tests, transgender youth have less access to healthcare, and LGBTQ+ individuals are more likely to delay or avoid necessary medical care compared to heterosexual individuals. These disparities are due, in part, to lower healthcare utilization by LGBTQ+ individuals (Morris et al., 2019).
Perceived discrimination from healthcare providers and denial of healthcare altogether are common experiences among LGBTQ+ patients and have been identified as contributing factors to health disparities. Disparities in healthcare access and outcomes experienced by LGBTQ+ patients are compounded by vulnerabilities linked to racial identity and geographic location (Morris et al., 2019).