The Role of Black Primary Care Physicians in Reducing Health Disparities

Introduction

This study evaluates the links between Black representation among primary care physicians (PCPs) and health outcomes for Black individuals in the United States. It investigates whether having higher levels of Black PCP representation at the county level is linked to higher life spans and lower mortality rates of Black individuals; the study also explores whether Black PCP representation at the county level mitigates health disparities between Black and white individuals.

The study utilizes county-level data, including poverty rates, uninsured rates, and median home values, across three years – 2009, 2014, and 2019 – for evaluating the effects of Black PCP representation on Black life expectancy and mortality.

The study’s importance lies in its implications for health equity and public health policy. The authors mention past studies showing greater availability of primary care services in communities being linked to better population health outcomes, including longer lifespans and lower levels of mortality. However, differences in health outcomes still persist between Black and white individuals. Therefore, by focusing on the relationship between Black PCP access and Black health outcomes, this research increases the field’s understanding regarding the influence of a higher prevalence of Black PCPs on health outcomes for Black individuals within a respective geographic area.

The authors of this study include John E. Snyder, Director of the Office of Planning Analysis and Evaluation at the Health Resources and Services Administration within the U.S. Department of Health & Human Services (HHS); Rachel D. Upton, Senior Health Scientist at the Office of Planning, Analysis, and Evaluation at the Health Resources and Services Administration (HRSA); Thomas C. Hassett, Health Scientist at the Office of Planning, Analysis, and Evaluation at the Health Resources and Services Administration (HRSA); Hyunjung Lee, Health Equity Data Analyst at the Office of Health Equity at the Health Resources and Services Administration (HRSA) and Research Scientist at the Oak Ridge Institute for Science and Education; Zakia Nouri, Senior Research Analyst at Workforce Studies at the Association of American Medical Colleges; and Michael Dill, Director of Workforce Studies at the Association of American Medical Colleges.

Methods and Findings

Methods

This study uses a cohort design, meaning it observes a group of participants over a period of time. County-level data were collected for three years: 2009, 2014, and 2019. Data sources included: 

• The American Medical Association (AMA) Physician Masterfile which provides details about physician characteristics and where they practice;
• Databases from the Association of American Medical Colleges (AAMC) that contain self-reported race and ethnicity information about physicians; and
• County-level population data on race and ethnicity, which were derived from 5-year estimates from the Census Bureau’s American Community Survey.

Counties included in the study were required to have at least one Black PCP in one or more of the specified years. Out of the 3142 Census-defined U.S. counties, 1618 counties met this requirement and were included in the analysis while the rest were excluded due to the absence of Black PCPs. The main variable studied was the proportion of Black PCPs to Black population in each county, known as the community representativeness ratio. The study’s main measures were age-adjusted life expectancy, mortality rates for Black individuals, and disparities in mortality rates between Black and white individuals. 

To evaluate the association between Black PCP representation and the aforementioned outcome measures, the researchers utilized mixed-effects growth models. These models allowed the researchers to analyze data change over time and across different groups and include both fixed effects (consistent across all observations) and random effects (varying across different groups). The analysis controlled for factors such as poverty rates, uninsured rates, and rural or urban status among others.

Findings

The study found that having a greater representation of Black PCPs within a given county was associated with improved health outcomes for Black individuals. Specifically, a 10% increase in Black PCP representation was linked with an increase in life expectancy by approximately 31 days and a decrease in mortality rates by approximately 13 deaths per 100,000 Black individuals. In addition, higher levels of Black PCP representation were associated with a decreased disparity in mortality rates between Black and white individuals within a given county. Furthermore, the study’s analysis revealed that the association between Black PCP representation and life expectancy was even stronger in counties with higher poverty levels.

Ultimately, these findings show a positive association between Black PCP and improved health outcomes for Black people and suggest the need for strategies to increase the presence of Black primary care physicians to potentially reduce health inequities and improve overall public health.

Conclusions

The findings suggest that having higher ratios of Black PCPs within a given county is associated with better health outcomes for Black people. Specifically, the study demonstrates that a higher proportion of Black PCPs is associated with longer life expectancy and lower mortality rates among Black individuals. The Black-white mortality disparity reduces in counties with higher ratios of Black PCPs, as well. This beneficial effect is more pronounced in areas where poverty rates are higher, which suggests that the benefits of higher of Black PCPS are amplified more in socioeconomically disadvantaged areas.

Based on the study’s findings, the authors recommend targeted investments and policies aimed at increasing the number of Black PCPs, particularly in underserved and high-poverty areas. Strategies could include expanding support for medical education programs that recruit and train Black students, as well as implementing retention initiatives to ensure these physicians remain in practice within these geographic areas.

Racial Health Disparities in the US and the Potential Role of Reparations 

Introduction

This cohort study aims to identify, address and quantify the relationship between longevity ( “all cause mortality”) and wealth as it relates to Black individuals versus white individuals. Furthermore, the study then models how reparations payments to the black community could potentially affect the longevity ( “all cause mortality”) gap between Blacks and whites. The study adds to the currently growing academic literature about reparations payments and their potential effect on the well-being of the Black community. By further exploring the direct connection between reparations and health outcomes, the authors attempt to specifically describe the role of monetary resources in determining  health inequities across racial groups. 

Many of the authors of this study, including Dr. Kathryn Himmelstein, Dr. Michelle Morse, and Dr. Bram P. Wispelwey are research fellows or instructors at Harvard’s School of Medicine. They are joined by various other practitioners and professors in the field of Health Policy like Dr. Mary T. Bassett, a professor at the Harvard School of Public Health and Dr. Atheendar S. Venkataramani from the UPenn School of Medicine. Dr. Jourdyn A. Lawrence and Dr. Jaquelyn L. Jahn from the Drexel School of Public Health also co-authored the report and both have a focus on race and health inequity. Lastly, William A. Darity, Jr, is a professor of Public Policy and African-American studies at Duke University. Dr. Darity’s book, “From Here to Equality” makes the case for reparations as a way to close the racial wealth gap. 

Methods and Findings

This first part of this study evaluated data from the HRS – Health Retirement Study, which has been conducted at the University of Michigan via survey collection from respondents every two years, since 1992. The wealth component of HRS was an input variable, in addition to many other variables such as income, race, education level, sex, marital status and others. As an outcome variable, longevity was calculated month and year of death from postmortem interviews with the Family and the National Death Index. For the reparations modeling portion of the study, $840,900 was distributed to each participating Black household, and was calculated by the mean 2019 household wealth gap between white and Black families. 

The findings suggest that when reparations payments were distributed to Black households, the gap in median longevity curtailed from 4 years to 1.4 years. The results were even stronger, -0.1 years (Black longevity exceeding white longevity) in models that excluded income and educational attainment. The results of this study suggest that Black middle-aged and older adults have a median longevity that is 4 years shorter than their white counterparts. Additionally, the study emphasized that financial reparations —transferring payments to Black US residents— have significant health benefits for the Black community. 

Five Weibull survival models were conducted that adjusted for different variables within each model. There were some key similarities and differences among the models: 

• In all models, being male was associated with greater likelihood of mortality. In addition, being married or partnered was associated with lower rates of mortality.  
• When adjusting for wealth, the racial longevity gap between Blacks and whites was removed entirely. In all other models that did not adjust for wealth but adjusted for income or educational attainment, there was still a significantly higher likelihood of death for Black participants over white participants.  
• Overall, the hazard of death decreased with each higher wealth decile; however, the largest decreases in hazard of death occurred within changes in the bottom 7 deciles of wealth compared to changes in the higher deciles of wealth. 

Conclusions

While reparations alone do not reduce all the structural determinants of health outcomes, this research study shows reparations intervention produces an improved, meaningful effect on the longevity of Black people in the US. This change reveals other multiple causes, which includes increasing access to healthcare, removing economic stress caused by chronic illness, and boosting neighborhood and community-level resources that support long term health. It is important to note that this study only focuses on the association between wealth and mortality and not on causal implication that wealth may have upon health outcomes. Most importantly, this study provides reliable data on the relationship between racial, economic, and health inequalities to advance the public health case for reparations in the U.S.