Racial Concentration as a Determinant of Access to Health Care in Georgia

IntroductionDespite the implementation of the Affordable Care Act (ACA), disparities in access to health care still exist today in the United States. Many Americans remain uninsured and dissatisfied with their personal access to healthcare. There are many possible reasons for this disparity in access, including socio-economic, environmental, behavioral, biological, and genetic factors. One of the most significant contributors, however, is Racial Residential Segregation (RRS). RRS today is the concentration of personal residence, based on race, into certain geographic areas (1). In the past, this included legally restricted residence in some areas of the country. The possible mechanisms through which RRS could affect health include racial bias in medical care, low access to health insurance, and poor access to health care facilities. The Affordable Care Act attempts to expand access to care primarily at the individual-level, though efforts like the expansion of Medicaid. In targeting the individual, however, it does not address neighborhood-level problems like RRS, and could therefore allow racial disparities in access to care to persist.Segregation has been prevalent in Georgia since 1900, when majority of the black community moved into urban areas (2). There were also several segregation laws implemented in the past. A majority of Southeast American states enforced segregation through "Jim Crow" laws (3-6), examples of which include prohibition of interracial marriages and racial segregation of public schools (7). These laws created de jure segregation by race, and further regulated social, economic, and political relationships between whites and African-Americans (8,9). Segregation was not only common in the southern United States, but also present in a de facto sense in the north (10). Blacks could not buy houses in the same neighborhoods as whites and economic and educational opportunities for black Americans were greatly restricted (11). This illustrates the institutional foundation for how RRS arose in the United States and how it could persist even after the Jim Crow laws were repealed (12). Evidence of racial disparities in access to health care is well established in the United States. Majority black communities have experienced discrimination in relatively depressed housing policies, bank loans, labor markets, and real estate transactions (13). Furthermore, as late as 1995, primarily black communities have suffered more from environmental degradation than primarily white ones (14), Residents face disparities in quality of education, educational attainment, employment opportunities, income and health insurance status; all of which contribute to disparities in access to health care (15). Blacks are more likely than whites to be uninsured or covered by Medicaid (16). The result is that blacks utilize health services at lower rates than whites (15, 17, 18), even when comparing individuals with similar health needs (19). Blacks living in more segregated areas have less comprehensive health insurance coverage compared to blacks living in less segregated areas (20). Low private health insurance coverage, and the resulting poor reimbursement rates, could create difficulties for those health care facilities and providers serving black communities. Poor access to care has, in turn, contributed to increased incidences of asthma and cardio-vascular disease (17). The pattern is also observable in infant health, where "there were 1.12 excess infant deaths per thousand live births among black infants due to living in a segregated city compared with a non-segregated city" (21). Taken together, the evidence suggests that segregation is a potentially important variable in explaining persistent racial disparities in access to health care.The fact that a neighborhood is partly defined by its individual residents creates challenges in estimating the impact of neighborhood-level racial concentration on access to health care. …