Despite some progress, Black Americans continue to have worse health outcomes than other racial groups. KFF Health News senior correspondent Renuka Rayasam joins host Krys Boyd to discuss why we’re failing to close the health gap – especially for rural, low-income African Americans – and why access to quality care is sometimes blocked by the states. Her article, written with Fred Clasen-Kelly, is “Black Americans Still Suffer Worse Health. Here’s Why There’s So Little Progress.”
The Black American fight for proper healthcare
By Madelyn Walton, Think Intern
The lives of Black Americans continue to face racial disparities in health care due to historic and recent government policies. The racial health gap is compounded by difficulties finding employment that does not put them at risk of illness, a lack of health providers in low-income areas, and an inability to access affordable treatments.
Renuka Rayasam is a KKF Health News Senior correspondent. She joined host Krys Boyd to discuss how the past plays a role in modern day health care decisions, why the government struggles to provide resources for low-income households, and how this system threatens the lives of patients of color. Co-written with Fred Clasen-Kelly, her article is “Black Americans Still Suffer Worse Health. Here’s Why There’s So Little Progress.”
Nationwide, data shows Black Americans have trouble accessing quality health care, but in the South, policies make the problem especially glaring. Rayasam spoke with family physician and clinic owner, Morris Brown, who aids the lives of many in Kingstree, South Carolina.
“The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation,” Rayasam says.
The area is poverty stricken and the small population of Black Americans often feel powerless.
“The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease,” Rayasam says.
Many of them live in public housing that does not provide a good standard of living, or they work in areas with greater exposure to life-threatening situations.
“Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems,” she says.
Healthcare issues stem back to racial segregation, civil rights, and slavery, says Rayasam.
“The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year.”
Although the federal and state governments have tried their best with the Affordable Care Act and other health policies, South Carolina happens to be one of the few states where Medicaid hasn’t been expanded.
“All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life,” she says.
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Transcript
Krys Boyd [00:00:00] Researchers have long been aware that health outcomes are broadly worse for black Americans than for white Americans. Modern science has laid to rest the myth that race makes bodies of people of different races very different from one another. But that doesn’t mean health care systems or other important institutions treat everyone the same. From Kera in Dallas, this is Think. I’m Krys Boyd. A big part of the problem comes down to who receives quality health care in a timely manner early enough to catch and treat potentially serious illnesses comprehensive enough to manage chronic disease. As my guest will tell us, the question of access is often about money. And there are still states like South Carolina that have chosen not to take the federal government up on its offer to help expand state access to Medicaid. Renuka Rayasam is senior correspondent at KFF Health News, where she and her coauthor, Fred Clasen-Kelley, published the article “Black Americans Still Suffer Worse Health. Here’s Why There’s So Little Progress.” Renuka, welcome to Think.
Renuka Rayasam [00:01:01] Thanks for having me.
Krys Boyd [00:01:03] You centered this article around a region of South Carolina that has sometimes been referred to as the “Corridor of Shame.” What does that name refer to?
Renuka Rayasam [00:01:12] Well, that name actually originally came from the lack of investment in rural schools in South Carolina. So it was directly related to education and lack of investment. But over time, it just also became a reference to poor health outcomes and poor outcome outcomes generally in this area. And it’s an area that has just historically not had the levels of investment as the wealthier parts of the state. And you can see that.
Krys Boyd [00:01:43] Although poverty and black poverty in particular are unusually concentrated, they’re in that place called the “Corridor of Shame.” A lot of the lessons from the region could apply to other parts of the country.
Renuka Rayasam [00:01:54] Absolutely. We undertook this project on race and health this year, and it was really looking at what’s driving these health disparities. And there is one very clear outcome, and that was, historical government decisions and decisions even today. And, you can go as far back as, say, reconstruction and look at the ways in which Black Americans were excluded from the health system and why today we are one of the only high income nations that doesn’t have universal health care coverage. And that’s very much related to the fact that a lot of policymakers didn’t think that Black Americans should have equal access to health care. And you see that today. And I think that it’s very clear when you’re looking at policies like redlining that concentrated Black Americans into neighborhoods that did not receive the same levels of investment as their wealthier white counterparts. And you see those disparities persist even today and even despite efforts to close the gap. I mean, they’re they’re persistent. They’re chronic. And that’s it’s really hard to do without a more concerted effort.
Krys Boyd [00:03:08] I mean, it’s bad for one’s health to be poor no matter where one lives. Why is it often worse to be poor in places with a high concentration of poverty?
Renuka Rayasam [00:03:17] You have fewer resources. Right. So this is you know, you’re talking about the “Corridor of Shame.” And so you don’t have hospitals, you don’t have doctors, you don’t have the types of health facilities that you’d have in in other parts of the country. And and it becomes a cycle. People don’t get good health care. They’re in schools that don’t have equal investment and then they’re more likely to get sick. And that becomes a cycle. And then there’s nowhere for them to go. And so they become sicker. And so it becomes hard to access preventative care. It becomes hard to access care once you get sick. And so you see people kind of kind of muddle along with really poor health. And that’s something, you know, we kind of we don’t talk about enough like, what does it mean to not have access to health care? What does it mean to have access, not have access to doctors and health insurance and an ability to pay people? People find a way to carry on, but it means that they die more quickly than they would otherwise die. It means that they live in poorer health than they should otherwise. And so it often is a hard to to see. Sometimes it’s hard to measure in statistics. It does come up when you look at excess deaths or excess lives. But I think some of that is people just living in worse health. Covid, I think, made the pandemic made a lot of that there when we saw how many more Black Americans were dying and how they were disproportionately dying from, you know, lack of access to care. And because a lot of them had already had these underlying conditions that were going untreated, you know, you saw those excess deaths.
Krys Boyd [00:04:56] Yeah. The Covid example is really poignant. You. We know we’ve heard the explanation that many Black Americans were more likely to work in jobs that didn’t allow them to stay home and sort of ride out the pandemic behind closed doors. You mentioned, you know, preexisting health conditions. You also discovered that in some parts of the country, there just weren’t a lot of easily accessible test facilities sited in majority black neighborhoods.
Renuka Rayasam [00:05:21] Yeah, My colleague, Fred, who is in North Carolina, he did some work about about kind of North Carolina’s Covid response and and found that Mandy Cohen, who is now the director of the Centers for Disease Control and Prevention, failed to get Covid testing to vulnerable black communities where people were getting sick and dying. And that was true across the country. It’s a lot of the communities that were hardest hit by Covid, the communities where people were sick, where they were dying, where it was hard for people to shelter in place. Those are the communities that weren’t getting testing. And so even in 2020, we saw these disparities continue.
Krys Boyd [00:06:01] This is particularly ironic given that the Centers for Disease Control has declared racism a serious health threat.
Renuka Rayasam [00:06:08] Absolutely. And I think, you know, I think the Biden administration has taken steps to kind of at least recognize that, hey, this is the problem. But it also shows how hard it is to to address the problem and address the problem at scale. And there’s still a lot of resistance around the country to to addressing these issues. I mean, we’re seeing that now with the election of former President Donald Trump. He, in his last time in office, did a lot to cut the Affordable Care Act and and outreach andsubsidies and things that helped people get health insurance. And if his administration does that, again, you’re going to see a lot more people who don’t have health insurance, who can’t go to the doctor and who are going to get sick and die.
Krys Boyd [00:06:56] Since our primary example for this story is South Carolina, for folks who don’t know the state well. Can you explain the ways it tends to be divided geographically by race and by income?
Renuka Rayasam [00:07:08] Well, you have, you know, wealthier coastal areas and Charleston and then you have you have, you know, the kind of rural areas kind of in other parts of the state. And so like, you know, if you visit Charleston, you visit Myrtle Beach, you see a very different South Carolina than if you were going to King Street where the story is centered. And and so in King Street or in Williamsburg County, which is the the city that contains King Street, which is in this corridor of shame, 23% of residents live below the poverty line. That’s twice the the national average. And and this is a county where there’s one primary care physician for every 5000 residents. And you compare that to urban, wealthier counties in the state. That’s there’s Richland, Greenville, Beaufort. And, you know, that’s just far, far less than what you have in those in those communities. And, you know, you do have big medical centers in South Carolina, but those tend to be clustered in urban areas. And in in these rural parts of South Carolina, you just just don’t have nearly as many resources.
Krys Boyd [00:08:14] So this dearth of physicians that’s possibly related to the lack of insurance coverage or money to fund care in certain parts of the state, like health professionals aren’t necessarily willing to locate in those areas.
Renuka Rayasam [00:08:26] Yeah, I think it’s like I said, it’s sort of a vicious cycle when you have people living in poverty and they don’t have health health insurance and they don’t have access to health insurance. Then you just have fewer physicians. And the other thing that happens is you have more people who are covered by Medicaid, which in these states, in South Carolina, a lot of other states, the payment rate for Medicaid. So what Medicaid pays doctors versus what commercial insurance pays doctors is a lot less. And so when you have a lot of people who are uninsured or who are on Medicaid, you just have fewer doctors that are willing to go to those areas and practice in those areas. And so so you see this, you see this across the country, you see this in Dallas. I mean, in Dallas, you had a lot of, for example, freestanding emergency centers located in suburban, wealthy communities, even though those are the communities that already have access to care. And that’s true in South Carolina. It’s true across the country. You see a lot of doctors locating in places where people have commercial insurance, where where they have money, where they can go to the doctor. And primary care in particular, there’s a lot of concierge medicine these days. A lot of primary care doctors will just charge a fee and they’re going to go to places where they can get that fee. And if this is a rural county with a lot of poverty, people can’t just pay those pay that kind of money. And a lot of physicians aren’t willing to practice in areas where their payment rates are going to be lower.
Krys Boyd [00:09:55] This doesn’t come up in the in the piece. So forgive me if I’m putting you on the spot, but most people. All are aware that a significant percentage, perhaps most physicians, are happy to accept Medicare payments. Are the reimbursement rates for Medicaid very different?
Renuka Rayasam [00:10:12] Yes, Medicaid is set by states. And and, you know, Medicare, too. There’s there’s sort of there’s just so many different parts of this. You can get, you know, private, private Medicare plans. Medicaid rates are set by the state and every state does something a little different. They pay a little bit differently. But in general, those rates tend to be much lower.
Krys Boyd [00:10:33] Okay. This term preventable deaths comes up in the piece. Will you just explain what that refers to exactly?
Renuka Rayasam [00:10:40] I recently I went to a GI doctor and he told me colon cancer is a preventable disease. And I thought that was really striking. I never thought about that. But if you go to a doctor, you get regular health checkups, you do all the things that you need to do to to to track that. Then you don’t have to die from colon cancer. But let’s say you don’t have insurance. Let’s say you don’t have access to a GI doctor. Let’s say you don’t have access to time off to go and get a colonoscopy or, you know, all the procedures you need to to prevent colon cancer or you’re going to die of colon cancer. And I think, you know, when we’re talking about preventable deaths, we’re talking about there’s a lot of diseases and diabetes is a good one. Nobody in 2024 should die from diabetes. We have medications to treat diabetes, not just insulin. But now we have all these GLP one agonists like Ozempic. There’s so many different ways to treat this disease. Nobody, nobody should die from diabetes. And yet you find people dying from diabetes and it’s disproportionately black Americans, people living in poverty, people living without access to care. And that’s you know, that’s what I mean by a lot of this is a little bit more hidden in that in that in that you don’t necessarily see that in person can live with diabetes for a while before they die, but they’re going to die 20, 30 years before, before they would have if they had had proper care.
Krys Boyd [00:12:06] And what you found just to draw a line under this is that these counties in South Carolina include higher than average numbers of preventable deaths.
Renuka Rayasam [00:12:14] Absolutely. In these counties, you see these health disparities where people are dying from things they shouldn’t necessarily be dying from if they had had proper care, proper access to care, they wouldn’t be dying. And, you know, I want to say another thing, too, which is that it is much cheaper for a health care system to treat, to treat things, chronic illnesses early in their progression and to and to deal with that early as opposed to when it gets later, it’s easier to kind of deal with a lot of cancers when they’re earlier diabetes as opposed to kind of when they progress and worsen, then that’s very expensive care. And so what you see happen is a lot of people are not getting that preventative care. They’re not getting care early, and then they end up let’s say you’re uninsured. You end up in the emergency room because of some complication from diabetes, for example, and that ends up being a lot more expensive for health care system. And it’s one of the reasons you see, you know, the U.S., as you know, has it’s one of the most expensive health care systems with some poor outcomes. And that’s one of the reasons you see that.
Krys Boyd [00:13:29] It is understandable that people would be reluctant to visit a doctor regularly or even when they’re feeling sick, if they’re uninsured and worried that medical bills could bankrupt them. You note that South Carolina is among the ten states, mostly in the South, that have not accepted the federal government’s offer to help expand Medicaid access. How does that deal work for states that do expand the program.
Renuka Rayasam [00:13:53] So most states around the country have have accepted this. And so, you know, for a little history, the Affordable Care Act, when it passed, it included this sort of mandatory expansion of Medicaid. A lot of conservative states led by Texas fought to make that expansion voluntary and then chose not to expand Medicaid. And this is to populations that are, you know, that are a little bit that earn a tiny bit more than than otherwise and sort of bridges the gap between private insurance so people can go to the Affordable Care Act, to the federal marketplace, excuse me, through the Affordable Care Act. And you can get insurance and you can. And if you’re a low income, you can get subsidies that cover a lot of that cost of that care. But there’s this gap between people who qualify for traditional Medicaid and people who can go on the exchange and get subsidies. And expansion was meant to cover that gap, to cover the people who are in that gap, sort of called the coverage gap. And so that’s for most states, that’s that’s what they do. And that’s a way to extend insurance to people who otherwise wouldn’t have access. Us to it.
Krys Boyd [00:15:00] Okay, so it’s possible to be working, but still find it incredibly hard to pay for health insurance through the health exchange if your employer doesn’t provide it. But also in these ten states not qualify for Medicaid because of where the levels are set.
Renuka Rayasam [00:15:17] Yes. And I mean, the levels are extremely low. So if you’re like a part time worker working in a restaurant, for example, your hours fluctuate. You’re going to earn too much to qualify for Medicaid. And you know, in Georgia, where I’m located, if you’re a single adult without kids, there’s basically no way. You know, if you don’t have a disability, there’s almost pretty much no way to qualify for Medicaid. Georgia did. I should say that’s a bit of a caveat. They did a small expansion with work requirements and that that targeted some people. But in South Carolina you you really don’t qualify for for any assistance. And so what are you going to do an expansion kind of covers people who are in that gap and and yeah I think that’s and you’re talking about people who are working we’re talking about the working poor. So they are working, but low income.
Krys Boyd [00:16:11] How much does it cost the state to take the federal government up on that Medicaid expansion offer?
Renuka Rayasam [00:16:19] States tend to actually make money when they expand Medicaid. So the federal government provides states, you know, billions of dollars to expand Medicaid as a bonus and then covers most of the costs of that care. For many years it’s changed over time. But that, you know, federal legislation, it’s like, you know, if you if the state expands Medicaid and most of their costs end up being paid for, a large majority of their costs are paid for by the federal government. So states South Carolina’s Republican governor, for example, said that, you know, he wouldn’t even create a committee to consider Medicaid expansion, saying that it wasn’t fiscally responsible. But the reality is South Carolina would make money expanding Medicaid, not just from federal subsidies for health care. But one research estimate said that South Carolina would get $4 billion in additional economic output from an influx of federal funds in 2026 if they were to expand Medicaid.
Krys Boyd [00:17:27] It’s also, according to some estimates, a job creator, something that tends to be very popular in the very same states that have turned down this expansion offer.
Renuka Rayasam [00:17:36] Yeah, absolutely. I mean, hospitals tend to really want this because as opposed to people going uninsured and showing up to ERs, they actually have insurance and can go to the doctors. And of course, there’s you know, there’s issues with Medicaid networks and the availability of doctors. Like I said earlier, you know, payment rates are low, so not a lot of doctors will take it and there can be waiting lists. It’s it’s not perfect by any stretch, but it’s better than being uninsured. And and like I said, going to the for care which is which is what some people do. And in states that didn’t expand Medicaid, the federal government will give them money to cover the cost of what they call uncompensated care. So you show up to the E.R., you don’t have insurance and you can’t pay your bill, and the hospital just has to eat that costs. And so it’s far more sort of, I think, fiscally responsible to have people have insurance and go to the doctor before they get sick rather than ending up really sick and saddling up a hospital with an bill that can’t be paid.
Krys Boyd [00:18:38] Okay. Back to this geographic and social divide in South Carolina. Would a greater percentage of black South Carolinians qualify for Medicaid under the kind of expansion we’ve been talking about than white South Carolinians?
Renuka Rayasam [00:18:52] That’s a good question. So I think it would be about 50,000 black South Carolinians that would that would benefit from Medicaid expansion. I think it’s more than half black and and Latino and people of color who would who would benefit. So a lot of white Americans would benefit from this, too. You know, so I think if the state of South Carolina expanded Medicaid, I’d think it’s like 360,000 people statewide that would gain coverage. And some of that is like shifting of coverage and things like that. And so and so I think, you know, look, you have to kind of look at the numbers, but you have a large a large percent of of people from all races, but more than half, I think people of color would benefit.
Krys Boyd [00:19:40] So I’m struggling to understand the numbers that South Carolina’s governor looked at in turning down the Medicaid expansion and deciding that it was not fiscally responsible.
Renuka Rayasam [00:19:53] I have absolutely no idea. If you look at all the numbers, it makes absolutely no sense. So you’re asking the wrong person that question.
Krys Boyd [00:20:01] All right. So you note in the article in the headline that the U.S. has made little progress toward narrowing the racial gap in health care outcomes. This is for over the last 20 years. Had there been gains before that time?
Renuka Rayasam [00:20:19] So, you know, it’s hard to say because the U.S. didn’t even really start tracking health outcomes for black Americans until the 1980s. There was a report called The Heckler Report, and that was the first time that the federal government said, hey, let’s start tracking these. And what they found was that there were 60,000 excess deaths among black American people each year from from a bunch of different preventable diseases. So that’s deaths that could have been prevented. And I think before that, this wasn’t really studied, which is really which is really a shame because you’re talking about, like I said, you know, you can trace this back to reconstruction when there was when there were kind of decisions made not to expand health coverage to keep black Americans, you know, in separate hospitals and absolutely kind of deny them access to sort of basic health care that white Americans were getting at the time. And like I said, that kind of grew over time. And here in Atlanta, you know, we have Grady Hospital and there’s, you know, a time, a black hospital and a white hospital and and a, you know, a black entrance and a white entrance. And and they just got different care. And it was very, very stark. And it was very clear. And you could see that kind of day to day. But it wasn’t tracked, though. That data wasn’t tracked in a comprehensive way, I should say.
Krys Boyd [00:21:48] Randall, I do want to address a couple of things here. Many people might have heard the old conventional wisdom sometimes passed down, even in medical schools, that health differences between people of different races might somehow be related to physiological differences between different races. Do scientists studying these outcomes still believe this?
Renuka Rayasam [00:22:08] No, absolutely not. I mean, I think I think we know health outcomes are related to so many environmental factors diet, lifestyle, whether you have mold in your walls and proper living conditions and and clean water. I mean, these are these explain a vast majority of health outcomes. And and there’s sort of nothing really talking about biological differences that’s a pretty outdated concept.
Krys Boyd [00:22:37] There’s also this question of personal responsibility. What do researchers know about how financial resources can make it easier for people to make what doctors consider wise choices in taking care of their bodies?
Renuka Rayasam [00:22:51] Yeah, I mean, that’s if you have a job that that allows you to buy healthy food, for example, or you only have to work one job, you don’t have to work two jobs to pay rent. You can go to the grocery store. You can cook. You can spend money on on high quality food. You have time to exercise and to make and to make different decisions, to go to the doctor, to get preventative checkups. I mean, there’s so many kind of things that go into that. So, for example, like if I if I find mold in my walls, I can move, you know, I have the resources, the resources to pick up and move in to say, you know what? Like, I’m not going to I have young kids. I don’t want to live here with mold in the walls. A lot of people, if you don’t have income, I mean, it’s very expensive to move. You just don’t have that kind of income. And where are you going to go write rent? Rent is so expensive and so and so. There just all of these myriad aspects of our daily lives that affect our health. And in every single one of them, almost always, if you have more money, if you have higher incomes, you can you can address them in a different way than you can if you just don’t have those resources.
Krys Boyd [00:24:05] How does investment in public housing play into this or lack of investment?
Renuka Rayasam [00:24:11] Yeah. So that’s you know, that’s one of the stories we did in this series looking at at public housing. And and Fred and I traveled to Savannah. We went to a public housing complex called Yarmouk Village. And it was I mean, it was in such disrepair. It was hard. It was hard to see people living in conditions. I mean, there are bullet holes and windows that were not that were not patched up, people with just mold all along the walls, roaches, rats. I mean, it was hard to see. And these are like and again, these are working poor. These are people who have jobs who who work in retail stores or, you know, in restaurants. And and they go home, you know, after working. And it’s in these unlivable conditions. And and like I said, that that is again, these are not like these are not accidents of history. These are very clear choices to to not invest in public housing. And so, again, if you’re sort of looking at historical trends, you have to look at how the federal government created redlining and pushed a lot of black Americans into neighborhoods that did not get investment. And and then over time, you know, public housing actually when it started was was, you know, were white Americans. But over time, you know, what we found when we did that story, when we’re doing the research for that story and looking back at the history, you know, white Americans were getting subsidized mortgages in suburbs that were not available to black Americans. I mean, it’s just like that’s just the way it was. And when you think about the American dream and all of that, like, you know, white Americans were getting these subsidized FHA mortgages and to go buy a house in the suburbs, and black Americans were not getting those and they were sort of left in public housing complexes. And over the years, the federal government cut investment in public housing complexes, especially as a majority of the residents were black and became black. And as more white people moved out and as sort of more black people concentrated in those developments, you saw the value cut investment. And at some point during the Clinton administration, there was an amendment passed, a law that was passed that capped the construction of new public housing. And so you have this situation where you see lawmakers say, well, public housing is a failure. Well, why is it a failure? Because they didn’t invest in it, because they didn’t put money in it, because they capped the amount of units that could be available for people. And so you have you know, you have some progressive politicians today, including Alexandria Ocasio-Cortez and others. They’re calling for a lift on that moratorium and that are calling for it’s like $80 billion or billions of dollars in a backlog of repairs to public housing that’s needed.
Krys Boyd [00:27:04] So the other thing that comes up in this piece it’s very interesting is gun laws, given that many researchers believe we ought to frame gun injuries as a public health problem rather than just a criminal justice issue. What did you learn there?
Renuka Rayasam [00:27:18] We’re working on another story that’s going to be a follow up that’s going to focus more specifically on gun deaths. But again, gun deaths are tend to be concentrated in small areas in any city. So you think about in any city, you can look at the pattern of gun deaths and it’s usually concentrated to a few streets, you know, not just within a few neighborhoods, but in in really specific areas. And those deaths and I should say not just gun deaths, but gun injuries. So if you get shot but you don’t die also, again, very concentrated and those are very much concentrated again. And I’m sorry I keep repeating myself, but it’s sort of the same story over and over again, which is that these are areas that have historically lacked investment and have been sort of structurally underinvested in over time. And, you know, and one other thing I sort of want to talk about, we’re talking about kind of like these structural barriers and what makes it so hard to fix. One of the things I think a lot about is how in this country we fund so much of our public investment through property taxes. And what does that do if you are in a community with a lot of big and expensive houses, you have more resources at your disposal. And if you’re in a community where you don’t have high property values, you have less resources at your disposal. So all that does is solidify and ingrain these existing disparities. And and so I think that’s, you know, one of the things I point to when we talk about what things don’t have to be this way. We’re talking about schools. When you’re talking about housing, when you’re talking about gun deaths, which is related to all of that, it doesn’t have to necessarily be that way. And I sort of want people to think about kind of these structural aspects of their lives that they don’t always necessarily that you take for granted that you don’t think about and how that kind of reinforces these patterns. But yeah, gun deaths, I mean, it’s very much about these root causes of structural disinvestment. And then, you know, during the pandemic, one of the things that happened is, you know, just because an area is been disinvested in for decades doesn’t mean it’s going to necessarily have a lot of gun deaths. But you take an area that’s been decent, that hasn’t had investment in decades, that that has been ignored for resources and all of that and were starved of resources, I should say. And then you add into that like a sense of hopelessness, a sense of a sense of despair. And it doesn’t take much to have an argument that escalates and turns into a gun death. And that’s what we found in our work on on gun violence. And and there’s a lot more research that needs to be done. Of course, you know, there hasn’t been a lot of federally funded research into into gun violence. Not to say there isn’t any, but there hasn’t been enough. And so there’s still a lot that needs to be looked at in terms of how do you reverse the pattern of gun deaths, given that the causes have been so structural over time?
Krys Boyd [00:30:01] We all understand Rainier, that chronic stress takes a toll on human health. What makes stress sometimes more pervasive for many black Americans than for their white neighbors?
Renuka Rayasam [00:30:15] You know, I. Yeah, I think, I think when you’re dealing with the impact of racism on a daily basis and, you know, I think, that can be very stressful and that’s what research has found. So if we have a research side, we did a survey about racism, discrimination and health and found and found a lot of Americans, black Americans, who felt like that sort of every aspect of in health care settings that, you know, kind of experienced a lot of racism and a lot of discrimination. And and I think that that is one thing that takes its toll and increases levels of chronic stress, I think throughout in a person’s life.
Krys Boyd [00:31:05] You found that even health monitoring systems might fail black Americans at higher than average rates. How do tools meant to detect health problems and time to treat them sometimes fail people of color?
Renuka Rayasam [00:31:18] So, you know, you have I think I think blood pressure monitoring, sorry, blood oxygen monitoring is a good example. And and we recently did a story about this where, you know, during Covid people bought these sort of pulse pulse oximeters you could measure your blood oxygen level. Well, those weren’t a lot of those devices weren’t tested properly among people, people of color. And so you got different readings and less accurate readings among people of color. And we see that again throughout algorithms meant to meant to kind of solve for different health, health things over and over again. You see a lot of those things are not properly tested among people of color and then they don’t work among people of color. And there’s not really a requirement necessarily to do that. And so, you know, we saw that, like I said, in the case of Pulse Oximeters, that people were getting inaccurate readings and in some of these devices meant to monitor blood, oxygen levels and and yes, suffering worse outcomes are getting sicker because of because of that or getting sicker than necessary not getting the care that they should have. Otherwise.
Krys Boyd [00:32:29] You share something in this piece that I cannot stop thinking about. What did the social justice and public policy scholar Luke Schaefer tell you about this correlation that he discovered?
Renuka Rayasam [00:32:40] I mean, that was that was that was really amazing. I mean, he said that you can take facts from a hundred years ago about segregation and lynchings for a county and predicts that the poverty rate and life expectancy with extraordinary precision. And again, I think that just speaks to how segregation in this country has become embedded and ingrained and translated into into outcomes that we see today.
Krys Boyd [00:33:11] I mean, many people this has come up in different interviews on this show before. Many people don’t feel as if they are contributing to living in a segregated society, but they might look around themselves and realize that they live in a neighborhood where most people look like them. Now that redlining is illegal and, you know, apartment buildings aren’t allowed to discriminate. Why did these effects persist?
Renuka Rayasam [00:33:36] I think it’s just it’s I think it’s a cycle, right? If you grow up in a wealthy neighborhood, it going to a quote unquote good school and you you know, you then get a good education and you can get a high paying job and then you can buy a house in a neighborhood that’s richer and have kids and they go to that good school and that continues. It’s hard to break out of that cycle. Right. And and, you know, and let me be clear, we’re sort of talking about we’re using the word disproportionate a lot. And and there are a lot of poor white people who are affected by a lot of these things, too, that face these same barriers. You’re finding the lack of universal health care in the U.S., the lack of Medicaid expansion that affects a lot of people but affects a lot of of poor people across different groups. But it disproportionately impacts black Americans. And I think the reason that we don’t have those sorts of things can be directly traced back to a very specific intention to deny black people health coverage. And now it’s affecting, you know, a lot of people. And so now, of course, you know, that’s not to say that there are communities where there are that are that are more mixed or you have wealthy people of all races. What you continue to see and in certain neighborhoods is if you have this area that for decades and decades has just not had good schools or not had investment in its schools or well-resourced schools, how are you going to ever break out of that cycle? It’s very hard to do.
Krys Boyd [00:35:28] What has the Biden administration done and failed to do about these health inequities, racial health inequities?
Renuka Rayasam [00:35:38] I think, you know, they have acknowledged that. They have acknowledged that these disparities exist. And I think that’s no small thing. It’s no small thing to say. We acknowledge that these that these that these disparities exist. And, you know, the American Rescue Plan Act and the Inflation Reduction Act, I mean, that had a lot of money to address some of these disparities that give money to communities to address these disparities. You know, sometimes what they did with it was was a little different. But it is like I said, it is very hard when you have a lot of these things that are baked into the structure of how we live. It’s hard to to reverse that. It’s hard to reverse that. In three years or overnight.
Krys Boyd [00:36:30] Have you been able to see what the incoming Trump administration might be planning? I don’t know how explicit the campaign has been about what they’re looking at in terms of health.
Renuka Rayasam [00:36:43] With RFK Jr potentially being the health secretary. It’s a real wild card to know, you know, what the incoming administration might do. They have not been. And former President Donald Trump on the campaign trail this year hasn’t been super clear on his health goals. What he wants to do in terms of health care. And we’ve had we’ve heard a lot of mixed messages from different Republicans on what they want to do. But what you know what? So so what do we have? You have what happened in the last previous Trump administration And and you’re just kind of looking at some of the policy documents that have come out on the conservative side. And almost uniformly, there have been ways to chip away at access to Medicaid. I you know, I covered health care in Texas for a long time. A lot of people who worked and conservative people who worked in health care in Texas are sort of part of the Trump administration were or will be. And over and over again, people said to me and I and I was sort of shocked by the statement, but this belief that health care, health insurance doesn’t equal health access and that health insurance wasn’t important. You know, I don’t agree with that. I think the system that we have now that health insurance is very important. But, you know, there is a lot of there’s an effort to really to really get the protections that were built into the Affordable Care Act, to trim to trim access to Medicaid through, for example, like work requirements, which is, you know, people, which is that’s a conservative name for said people have to in a medicaid expansion population, somebody has to prove that they have a job. This is something Georgia has done over the past year. They’re the only state that’s doing this, for example. And all that’s really done is it’s created an enormous paperwork burden on the states and on individual enrollees. You know, people who are working have to submit their paystubs all the time to kind of keep getting their health insurance. It’s just created an enormous amount of red tape and expensive red tape, I should say, without actually giving people benefits. Cut wouldn’t cuts their benefits because a lot of people might be working or might be doing other things, but just, you know, can’t. You know, like forgot to upload their documents or don’t have the bandwidth to upload their documents or don’t have the technology to upload their documents. And so you see a lot of ways that that conservative lawmakers believe in sort of chipping away at access to health care. And and and like I said, I think, you know, we’re not I’m not entirely sure because they haven’t been clear. And there could be some pretty big things that they do or could be, like I said, a lot of chipping away at access. And you know what the Affordable Care Act did is it created kind of a it created a floor for the amount of coverage that people should get. And, of course, that made. Premium’s a little bit more expensive because there’s a lot like Preventative Care’s cover. There are other things that are covered, but you’re not you’re not left with a big bill if something goes horribly wrong. At least that’s sort of the intention, that you weren’t supposed to be left with a big bill if something goes wrong. You know, of course that still happens all the time. And you see some of those protections being being chipped away at. And and a lot of a lot of conservative lawmakers saying that, you know, people should have plans or they get less coverage and pay less. But of course, what happens when you then have a serious health situation? And so so like I said, I think it’s a really hard question to answer in this moment. We just kind of have some some guesses. But but yeah, that’s kind of that’s kind of what we’re that’s kind of what we’re expecting. So, so yeah, I think, like I said, sort of bottom line, I think you’re going to see a lot of funding cuts in, in, in public health and safety net programs, cuts and housing programs which affect health. Like we’ve talked about cuts in SNAP benefits, which is food stamps, which of course will affect health. And so I think you’ll expect to see a lot of those programs significantly cut.
Krys Boyd [00:41:07] People listening Renuka might assume now that expanding Medicaid seems like it could narrow some of these racial inequities in health outcomes. It turns out that expanding access can have beneficial effects beyond just the person who gains coverage this way. Tell us about that.
Renuka Rayasam [00:41:23] We talked to a woman. She she works at a at a place called Maximus. And they have a contract with the federal government to help people sign up for Medicare and Affordable Care Act plans. This is a workforce that is disproportionately women, people of color. And, you know, they kind of call people and help them sign up for these programs. But she said her own health care is so expensive, she cannot afford for her son to be on her health plan. So he’s on Medicaid. And the situation for kids in the country is a little different. There’s a lot more options if you’re a kid, There’s it’s you can get on Medicaid and you can get on. There’s a children’s health insurance plan. And so she you know, she said she has she has a job. She has private insurance through her job. But that insurance, again, is so expensive, she can’t she has to pay a higher premium if her son’s on there and she can’t afford that. And she said that even with insurance, she’s had a 4500 medical bill that she couldn’t pay because, you know, you first have to meet a certain amount, minimum amount, your deductible, pay that out of pocket before you are fully covered. And the deductible or her plan was what, you know, kind of left her with this bill and she couldn’t pay it. And I think that’s, you know, that’s kind of some of the some of the things that we’re seeing there.
Krys Boyd [00:42:36] In states that have expanded access to Medicaid. Have they also documented a narrowing of racial gaps in health outcomes?
Renuka Rayasam [00:42:48] Yes. And like I said, there’s sort of you know, there’s I think there’s these things are complicated. So Medicaid expansion is absolutely one step that could narrow health disparities. You know, with like I said, not that much cost to the state, but it is not a panacea. We had a somebody who said that it’s not going to solve all of the structural inequities in a state. And, you know, it’s not going to solve all the health care provider shortages we’re seeing in these rural areas. But I think, you know, the way we look at it and the reason that most states have expanded Medicaid is that it’s it’s a no brainer. Right? It’s one way to narrow disparities without, you know, if the federal government picks up most of the cost. And so most of the tab of that. And so that’s why you’ve seen so many states actually do it.
Krys Boyd [00:43:44] Renuka Rayasum is senior correspondent at KFF Health News, where she and her co-author, Fred Clasen-Kelly, published the article “Black Americans Still Suffer Worse Health. Here’s why there’s so little progress.” Renuka, thank you for the conversation today.
Renuka Rayasam [00:43:59] Thank you so much for having me.
Krys Boyd [00:44:01] Think is distributed by PRX the public radio exchange. You can find us on Facebook and Instagram and wherever you get your podcasts, just search for KERA Think. Our website is think.kera.org. When you go there, you can find out about upcoming shows and sign up for our free weekly newsletter. Again, I’m Krys Boyd. Thanks for listening. Have a great day.
