Elucidating the Role of Place in Health Care Disparities: The Example of Racial/Ethnic Residential Segregation

Despite a substantial literature documenting persistent disparities in health and health care utilization by race/ethnicity (Smedley, Stith, and Nelson 2008; AHRQ 2010), our understanding of the cause of these disparities is incomplete. Although health insurance coverage, individual socioeconomic position, provider bias, and discrimination have all been demonstrated to impede access to care, there is increasing interest in elucidating the role of place in shaping observed health care inequities (Zaslavsky and Ayanian 2009). Recent evidence suggests that health care resources often reflect the geographic distribution of race/ethnicity. As a prominent organizing feature of American society, we focus on racial/ethnic residential segregation, to elucidate a framework for investigating the role of place in disparities in health care. Racial/ethnic residential segregation refers to the degree to which two or more groups live separately from one another in a geographic area (Massey and Denton 2003). Levels of racial/ethnic segregation (hereafter segregation) in the United States are higher than economic segregation (Massey, Rothwell, and Domina 2010). The segregation of blacks is distinctive and remains higher in comparison with other racial/ethnic groups. Competing explanations of the cause and persistence of segregation such as personal preference, socioeconomic status (SES), and prejudice have been theoretically articulated and empirically tested and suggest that personal preferences have not substantially contributed to endemic levels of segregation (Charles 2002). Although overt discriminatory policies and institutional practices promoting segregation are now illegal, segregation continues to have lasting implications for both individual and community well-being (Massey and Denton 1988). Considered a spatial manifestation of institutionalized discrimination, segregation policies protected whites from residential contact with blacks and fostered racial inequality (Massey and Denton 1988). Segregation continues to perpetuate racial disparities in educational and employment opportunities, concentrate poverty, and shape social and physical features of neighborhoods (Williams and Collins 2011). These mechanisms also have serious consequences for individual and community health (Acevedo-Garcia et al. 2003; Kramer and Hogue 2005). The excess burden of poorer health resulting from segregation may be further exacerbated by disparities in health care. Similar pathways affecting health status may also present barriers to accessing and utilizing health care resources in segregated neighborhoods. The purpose of this paper is to synthesize findings from the health services research literature and present a framework that extends a seminal model of segregation and health disparities (Williams and Collins 2011) to address segregation as a fundamental cause of racial disparities in health care. We identify gaps in the understanding of segregation and health care disparities, discuss methodological and conceptual challenges, and outline needed research to advance the understanding of how segregation contributes to the inequitable provision of health care.