Birmingham’s skyline includes prominent medical facilities, such as UAB, Children’s of Alabama and St. Vincent’s Hospital. Within sight of those buildings, however, are neighborhoods with the worst life expectancy and disability rates in Jefferson County.
Socioeconomic factors affect health, notably poverty, lower education and poor access to amenities such as grocery stores and sidewalks. But Black Americans also face barriers within the medical field itself, which lead to worse care and worse health outcomes.
“Even when you are physically close to a health care facility (that) doesn’t mean that you actually have access to that facility,” said Dr. Monica Baskin, a professor of preventative medicine at UAB and the Department of Medicine’s vice chair for culture and diversity. That access may be barred by lack of medical resources, no or limited insurance coverage or lack of what Baskin calls “culturally competent” care.
Alabama overall has a health care shortage. Much of the state is considered as being in a medically underserved area by the federal Health Resources and Services Administration.
Medically underserved areas are determined by the number of health care providers per 1,000 residents, the percent of the population that live at or below the federal poverty level, the population over age 65 and the infant mortality rate.
Every Alabama county has at least one underserved area, and some are entirely underserved. In Birmingham, some individual census tracts have medically underserved populations, based on characteristics such as low income levels, Medicaid eligibility and homelessness.
Geographically, much of Alabama qualifies for federal designation as medically underserved areas, shown in pink. (Source: Alabama Office of Primary Care Rural Health)
Seventeen hospitals have closed in the state in the past decade, according to the Alabama Hospital Association, and only one has reopened, making it harder for people to find care close to home.
The Rural Health Medical Program runs eight affordable health care clinics in Dallas, Marengo, Monroe, Perry and Wilcox counties, and about 80% of its patients are Blacks. Rural Health CEO Keshee Dozier-Smith said the clinics are often the only treatment option for miles around. This is particularly true for specialty care such as dental, vision or pediatrics.
“Rural Health is essential in these areas,” she said. Even where private practices do exist, Dozier-Smith said, they often don’t have the staff and capacity to accept the number of patients who need primary care physicians. The patient-to-provider ratio can be “astronomical,” even as much as 2,000 to 1, she said.
“You see that the providers are unable to accept new patients as quickly” as needed, she said. As a result, Dozier-Smith said, many of Rural Health’s patients did not get regular medical care or did use emergency rooms as their primary source of care before they started going to a Rural Health clinic.
Part of the problem for Alabama’s underserved areas is that it can be difficult to persuade medical professionals to move to the areas where they are most needed, Dozier-Smith said. Small rural towns have little to entice doctors or medical staff and their families, such as entertainment, good schools and job opportunities for spouses.
There also isn’t as much earning potential in treating low-income patients, whether urban or rural. After spending years obtaining a medical degree — and the student loan debt that comes with it — Dozier-Smith said, most professionals are lured away by larger or more prestigious opportunities.
“It’s close to impossible” to draw doctors to the area, she said.
The result is that the doctors in many underserved communities are either people with a passion for those communities or people who stay only a short time as part of a loan forgiveness program.
According to a 1996 study published in the health care journal Inquiry, minority and female physicians “are much more likely to serve minority, poor, and Medicaid populations.” The Association of American Medical Colleges reported in 2018 that 56.2% of physicians are white and only 5% are black. About 35.8% of physicians are women. In a state already marked by a shortage of health care providers, this further limits the pool of physicians likely to work in Alabama’s minority communities.
The Kaiser Family Foundation, a nonprofit focused on health care research and news, published a study in November 2019 about reproductive care in Dallas County. The study relied partly on a focus group of women in the area and the challenges of taking care of their reproductive health.
The study noted: “Providers in Dallas County, one of the poorest counties in the state, reported that it is hard to recruit qualified employees — from front desk staff to physicians — because many people living in the area do not have the required education or work experience, and those who are qualified leave for better opportunities elsewhere. Interviewees reported that the number of Ob-Gyns providing the full range of obstetric and gynecological services in the region has declined to just two.”
Adequate insurance coverage can open doors for patients. Without it, patients are limited to choosing among health care providers who will accept them without insurance. The price tag of prescriptions and procedures means the choice between crushing medical debts or no treatment at all.
In 2018, the U.S. Census Bureau reports that approximately 10% of Alabamians were uninsured, slightly above the national average of 8.9%. Among those insured in the state, about 37.2% used some form of public insurance, either as their sole source or in addition to private insurance. Lack of coverage — or inexpensive insurance plans that cover care only in catastrophic circumstances — cause people to delay care or seek out only emergency care, since emergency rooms can’t turn away patients.
“If someone doesn’t have insurance, they may wait until they absolutely have to go to the (emergency department)]. And that’s the case for any health condition. So you get people who are sicker because they’ve been waiting,” said Dr. Allyson G. Hall, a professor and the director of graduate programs in health care quality and safety at UAB.
After the passage of the Affordable Care Act in 2010, uninsured rates dropped across all races: 13.1% in 2010 to 7.5% in 2018 for white non-elderly adults, 19.9% to 11.5% for black adults and 32.6% to19% for Hispanic adults, according to a Kaiser Family Foundation analysis of data from the Census Bureau’s American Community Survey. However, every minority group except for Asian Americans continues to have higher uninsured rates than white Americans, and Black uninsured rates have risen slightly since 2015.
The Kaiser analysis also noted that uninsured Black adults were more likely than uninsured white adults “to fall in the coverage gap in states that have not expanded Medicaid,” including Alabama.
The Trump administration’s efforts to remove parts of the ACA, such as the mandate requiring coverage, or to strike down the law entirely, could cause loss of insurance for millions of Americans.
For low-income families who can’t get insurance through their employer and can’t afford a private insurance plan, there is the option to apply for Medicaid. Residents can qualify for partial or full Medicaid services based on income levels for children, senior citizens, people with disabilities and certain categories for other adults, such as parents or caretakers of those covered by Medicaid, pregnancy care and family planning services.
However, Alabama chose not to expand Medicaid coverage eligibility as part of the Affordable Care Act, which would have provided additional federal funding for the program. The Alabama Medicaid Agency’s 2018 annual report states: “In almost all cases, Alabama’s financial eligibility limits are at the federal minimum level.”
The annual report showed 1,020,972 people in Alabama had a service covered by Medicaid during at least one month of 2018.
“We have a segment of the population who are working and paying taxes, but they cannot get Medicaid. They make too much money to qualify for Medicaid in the state of Alabama. So we have a chunk of people in our state, for whom they’re in this hole where they don’t make enough money to buy it themselves and they make too much money to qualify, so they will not get (Medicaid). … So, there are a lot of working poor people who cannot get insurance coverage and that’s a huge problem,” Hall said.
Dr. Monica Aswani, an assistant professor for the School of Health Professions at UAB, says the complications of rejecting Medicaid coverage for many go deeper than political stances, in part because many insurance companies chose to exit marketplaces in states that did not expand Medicaid eligibility, creating monopolies.
“Yet many policy debates surrounding decisions such as Medicaid expansion or Medicaid work requirements perpetuate myths of welfare fraud to vilify those in need, even though employer-provided health insurance is also subsidized,” Aswani said.
In its 2019 focus group study of women’s reproductive care in Dallas County, the Kaiser Family Foundation found that many women felt Alabama’s Medicaid eligibility limits blocked access to health care.
“Women with dependent children who earn more than 18% of the federal poverty level, or roughly $3,800 a year for a family of three, exceed the state’s eligibility threshold, which is the second lowest in the United States,” the study reported. Pregnant women are eligible if they earn up to 146% of the federal poverty level, but that coverage ends 60 days after childbirth. Adults who are not pregnant or parents are not eligible at any income level, unless they have a disability or are over age 65.
Even with Medicaid eligibility, Dozier-Smith said that coverage doesn’t necessarily mean patients can get all the care they need. The program limits coverage to 14 medical visits per year, with some exceptions such as family planning or mental health care, and it has caps on prescription coverage.
For people with chronic conditions that require multiple appointments, specialty care or maintenance prescriptions, Dozier-Smith said those coverage limits are insufficient. It means many low-income patients can’t afford to treat their chronic illnesses or conditions once they’ve reached their annual cap.
Another impact of not expanding insurance coverage is on the state’s rural hospitals. The Kaiser study on Dallas County reproductive care reported that those they interviewed, including health care providers, mentioned “lack of Medicaid expansion and low reimbursement rates” as “contributing factors to hospital closures in smaller towns across southern and central Alabama.”
Trust and Implicit Bias
Even after hurdles of finding medical care and getting coverage, black patients may find that the care they receive inside the exam room looks different from what white patients receive.
“Sometimes people are feeling like, ‘If I go to this particular facility, they’re not going to see me and they’re not going to treat me the same,’” Baskin said.
The Association of Black Cardiologists interviewed 159 physicians in 2018 and found that 70% or more of them agreed that white patients were more likely to receive higher-quality care, specialized procedures and newer treatments than minority patients. While nearly 60% said patients with similar health issues receive different care based on race, only a quarter acknowledged that it happened in their own hospitals.
Trust is a critical element in medicine, and it’s a two-way street: patients need to trust their doctors’ care decisions, and doctors need to trust patients’ knowledge of their own health problems. Without that, treatment and overall health suffers.
A 2006 focus group study in Chicago found that black patients made trust decisions based on their perception of a doctor’s personal and technical competence, as well as expectations of racism or experimentation in care. Those patients who trusted their physicians were more likely to seek out care in the first place and then comply with their treatment plan.
“You want to make sure that you have some kind of trust. So we do know that people of color often have a sense of distrust around the health care system,” Baskin said, which can stem from prior bad experiences, fear of judgment or discrimination and racial or socioeconomic differences between patients and physicians.
Baskin said doctors still need to learn about implicit, or unconscious, bias and ways to provide “culturally competent” care. Even unintentionally, doctors’ preconceived notions can change their treatment decisions based on the race of their patient.
Sometimes those implicit biases perpetuate stereotypes that can harm Black patients.
A 2016 study, published in the Proceedings of the National Academies of Science, surveyed 418 medical students and residents about whether they believed false stereotypes, such as that Black people have thicker skin or are less sensitive to pain than white people. About half of the medical students believed at least one of the false statements presented to them.
Those who believed more of those stereotypes were more likely to rate Black patients as experiencing less pain than white patients, and they made less accurate treatment recommendations for Black patients. Students who believed fewer of these statements were likely to rate pain levels as higher for Black patients than white ones.
“Greater racial bias in pain ratings was associated with greater racial bias in the accuracy of treatment recommendations,” the study reported.
In 2007, a research paper from the University of Tennessee College of Medicine similarly reported that, by comparing patients’ ratings of their own pain levels with doctors’ ratings of those patients’ pain, “physicians are twice as likely to underestimate pain in black patients compared to all other ethnicities combined.”
Lack of diversity in medicine can also be a major trust factor for patients.
In 2018, a research team from the National Bureau of Economic Research paired Black male patients with doctors of different races and studied their likelihood to receive preventative health services such as the flu shot, body mass index measurement, cholesterol screening, diabetes screening and blood pressure measurement.
After the consultation appointments with their doctors, the patients assigned to Black doctors were 18 percentage points more likely to choose additional preventative services than those assigned to doctors of other races.
This effect was especially pronounced when considering only invasive services that included an injection or a blood draw.
For “those (procedures) that carry more risk and thus likely require more trust in the person providing the service, only subjects assigned to black doctors responded: increasing their take-up of diabetes and cholesterol screenings by 20 and 26 percentage points (49% and 71%), respectively,” the study reported.”
In an additional survey of Black and white male patients, the NBER research team found that “for questions regarding communication, in particular which doctor would understand your concerns,” 65% of Black survey respondents and 70% of white respondents chose a doctor of their own race.
“The health care field is not paying as much attention to the need to diversify that workforce,” Baskin said.
This is one aspect of that cultural competency: the belief by patients that their doctors understand their background and “are hearing all of what you have to say,” Baskin said. While more diversity among medical professionals can be a straightforward way to create more immediate trust, ongoing education and training can create cultural competency across ethnicities.
Dozier-Smith said trust for Rural Health patients is often less about race and more about being embedded in the community. The revolving door of doctors in rural areas causes many patients to have their guard up until a doctor can prove that they are there for the long haul.
She said patients want to know: “Are you invested in our community and really making a change?”
Despite having grown up in Perry County, that’s something Dozier-Smith experienced herself when she returned to the area to work with Rural Health.
“Returning home as an adult versus a child, there was some trust that had to be reestablished,” she said.
Baskin said being able to “move the needle” on health care disparities for minorities will require a combination of choices by hospitals or private practices and policy changes on the state and federal level.
Baskin pointed to several efforts by the Health Action Partnership, a group of Jefferson County organizations that created 2013 and 2018 reports on health equity in the county. The members of the team have worked with the Cover Alabama Coalition on insurance reform initiatives, worked with the Jefferson County Department of Public Health on access programs and other projects. Baskin said they would also like to see schools become outlets to disseminate health resources to people outside the doctor’s office.
Dozier-Smith said the state’s health care could be improved through a “systematic approach” of recruitment and incentives to bring medical professionals to underserved areas. She also believes an integrated network across many hospitals and private practices to track an individual patient’s care would make it easier for doctors to treat patients in a coordinated way. The current fragmented system can cause unintentional gaps in care, especially when patients don’t have a regular physician who understands their case history.
The Rural Health program continues its own efforts to reach more patients, including the planned launch of a mobile clinic and working with county governments and organizations to find their way into new communities.
Tracking health outcomes and patient demographics needs to be a priority for Alabama’s hospitals, Baskin said. By measuring, “you’re better able to see where you might need intervention to improve things … and I don’t think that’s happening on a regular basis.”
“Things that get measured actually get action,” she said.