Healthcare Disparities in the United States

Created By

Catherine Sardo Weidner, Lake Forest College

  • World War II, 1939-1945: The Homefront
  • Post-World War II Domestic Confidence and Unrest: Fair Deal to Great Society
  • America into the 21st Century: Politics

Introduction & Context

Healthcare disparities in the United States stem from a complex web of factors based on unequal access to healthcare and health insurance; discriminatory and disparate treatment within the healthcare system; and the influence of the social determinants of health.

Unequal access to healthcare and health insurance are a legacy of slavery, legal segregation, the forced relocation of Native Americans onto reservations, and the surge of Hispanic migration to the United States during the twentieth century. The introduction of employer-based health insurance during World War II generally excluded low-wage workers and minorities. Compounding this divide, the Hill Burton Act of 1946 funded the construction of hospitals and long-term care facilities for the poor throughout the South while also codifying segregated and unequal facilities. Native Americans endured a similar fate. Although the federal government established the Indian Health Service in 1955, it was chronically underfunded, understaffed, short on specialists, and unable to deliver optimal health outcomes. Poverty, as well as cultural and language barriers, also left many Hispanics without access to quality medical care and health insurance.

By the time the Johnson administration launched the War on Poverty in 1964, addressing the health insurance gap was a priority. Although the majority of Americans enjoy private insurance coverage, Medicaid, a government program that provides health insurance to states for many adults and children with limited income and resources, and Medicare, public health insurance for the elderly, were both established in 1965. Medicaid became the largest source of funding for medical and health-related services for America's poorest people, but eligibility requirements, available services, and payment were complex and varied considerably, even among states of similar size or geographic proximity. By 2010, nearly 18% of the poorest Americans still lacked basic healthcare coverage.

The Patient Protection and Affordable Care Act (ACA), passed in 2010, sought to address this inequity. Although the percentage of uninsured Americans fell to less than 9% in 2021, the failure of many states to expand Medicaid under the terms of the ACA remains the primary explanation for the insurance gap in the United States today. The 2020 COVID-19 pandemic further amplified persisting healthcare disparities in the United States for people of color and other underserved groups: American Indians, Alaska Natives, Hispanics, and Blacks were hospitalized and died at disproportionate rates compared to whites.

Unequal experiences receiving healthcare persist regardless of insurance coverage or socioeconomic status. It is documented that non-white patients receive fewer cardiovascular interventions and fewer renal transplants. Black women are also more likely to die after being diagnosed with breast cancer, and their maternal mortality rates are nearly three times those of white women. Additionally, one in five Native Americans report experiencing discriminatory treatment in the delivery of healthcare services, which undoubtedly contributes to their shorter life spans and disproportionate disease burden relative to the white population.

Finally, the social determinants of health like poverty, neighborhood environment, lack of green space, food deserts, pollution exposure, and unsafe drinking water greatly impact health. Impoverished minority communities continue to face these challenges as do those living on remote reservations and tribal lands.

Read More +

Teaching Tips Download PDF

This set of video clips documents the history and causes of healthcare disparities in the United States, from the 1930s to the present. The sources ask students to consider the role of systemic racism and poverty in creating health inequities while also weighing the impact of government efforts to reform and expand access to healthcare. Firsthand accounts from impacted patients, healthcare providers and policymakers round out the collection.

Background Information

Before engaging with this resource set, students should be familiar with the following:

  • The history of medical racism/experimentation in the U.S.
  • The history of residential segregation in the U.S.
  • The history of healthcare reforms: Medicaid and the Affordable Care Act
  • The impact of the COVID-19 pandemic

Essential Question

What are the most important causes of healthcare disparities and health inequities in the United States, both historically and today?

General Discussion Questions

  • How did government policies and programs build distrust of the healthcare establishment among Blacks, Native Americans and Hispanic Americans?
  • Why didn’t Medicaid work as it was designed to do? What accounted for the large numbers of uninsured Americans even after its passage in 1965?
  • To what degree does physician bias impact the quality and experience of an individual’s healthcare?
  • How much does the neighborhood you live in affect your health, and what are the most critical determinants?
  • To what degree did the ACA succeed and to what degree did it fall short? How do you account for the failure of the ACA to expand access to healthcare and to improve health outcomes for all Americans?
  • What did the COVID-19 pandemic reveal about healthcare disparities in the U.S.?
  • Is it possible to be healthy in the U.S. if you are poor?

Classroom Activities

1) The History and Legacy of Medical Experimentation

Ask students to watch the following sources:

Lead a class discussion, asking students:

  • How were the experiences of Herbert Shaw and Roxanne Flammond connected?
  • What role did racial prejudice play in the design and longevity of both the Tuskegee syphilis study and state level programs of coerced sterilization of women of color?
  • To what extent does the history of medical experimentation on Black and Native Americans continue to shape how Blacks and Native American view hospitals and healthcare providers today?
  • How did this legacy of distrust undermine government efforts to distribute the COVID-19 vaccine to these groups?
  • What strategies have the Black and Native American physicians featured in the segments adopted to combat this frayed trust?

Follow-up Activity: Redressing the Wrongs

In 1974, the federal government settled with the survivors of the Tuskegee Syphilis Experiment, offering $10 million dollars and free medical care for them and their families. President Clinton’s apology on behalf of the U.S. government took another 22 years. For the 60,000 Native American, Black, and Latina women subjected to forced sterilization in 32 states, only California, North Carolina, and Virginia have seen fit to compensate the victims. Most female victims have gotten nothing.

Ask students to consider the following questions:

  • What, in your opinion, do state governments owe the women?
  • What is the proper form of redress: monetary compensation, free lifetime medical care, a formal government apology, or something else?

As an extension activity, show students Wicked Silence, a half-hour documentary about the North Carolina eugenics program, which led to the forced sterilization of 7,600 women between 1929 and 1975. Ask them to write a short response paper evaluating the fairness of the state’s 2013 compensation agreement with sterilization victims.

2) Healthcare Reform: Successes and Failures

Ask students to watch the following sources:

Lead a class discussion, asking students:

  • What groups comprised the population most in need of healthcare services in Orange County, California, in 1987 and what did they have in common?
  • How did the recipients of Medicaid change between 1965 and 1995, and why did this occur?
  • In your opinion, should government healthcare programs like Medicaid cover the spiraling costs of long-term care for retired construction workers like Tommy Varner or children with cerebral palsy, like Joshua Ghrist?
  • What are the tradeoffs? How did expanding eligibility for Medicaid after the ACA was passed improve the lives of poor Kentuckians?
  • Why were Kentucky Republicans critical of the Medicaid expansion, despite its successes?
  • What does the maternal and morbidity crisis in Texas reflect about the human cost of resisting Medicaid expansion?
  • What do the racial disparities in decreased life expectancy post-COVID suggest about the limitations of the ACA and Medicaid expansion?
  • Why do you think healthcare reform has been so incremental and controversial in the United States?

Follow-up activity: The Politicization of Healthcare

The two largest expansions of healthcare coverage occurred in 1965 and 2010, under Democratic presidents who had a majority in Congress. Not a single Republican in either the House or the Senate voted for the Affordable Care Act in 2010.

Show students this PBS clip, How "Obamacare" Became a Symbol of America's Divide, and ask them to write a brief response to this prompt: Why do you think healthcare reform became so politicized in the United States and what was the long-term impact? (Students should consider both the PBS clip and set resources.)

3) Social, Economic, and Environmental Determinants of Health

Ask students to watch or listen to the following sources:

Lead a class discussion, asking students:

  • Why do you think food deserts exist in the United States?
  • What makes it difficult for the residents of Lambert, Mississippi, to obtain fresh, nutritious sources of food?
  • How did the growth of commodity farming transform the communities in rural Mississippi, and what were the health impacts?
  • What connects the segment on the colonias, food deserts, and the Flint water crisis?
  • What do Pedro Ibanez, Jennifer Hoskins of Lambert, Mississippi, the residents of Flint, Michigan, and the New Orleans blues singer Otis Jenkins have in common?
  • How much does the community or neighborhood someone lives in determine health outcomes?
  • To what degree does physician bias perpetuate healthcare disparities or unequal outcomes?
  • To what degree are government or corporate decisions responsible for these problems?
  • After watching all the sources, do you agree with Phyllis Landry’s observation that “African American life is devalued” in the United States? Do you think this statement also could be applied to Mexican Americans living in colonias? Why or why not?

Follow-up activity: Mapping food deserts in the United States

Food deserts are often invisible to Americans — they exist in segregated urban neighborhoods, in isolated rural communities, or within Indian reservations. The United States Departments of Agriculture, Treasury, and Health & Human Services have defined food deserts as low-income census tracts with a substantial number or share of residents with low levels of access to retail outlets selling healthy and affordable foods. For research purposes, they have created a food desert locator mapping tool that allows you to identify food deserts in American cities, states, or regions.

For this exercise, assign students a census tract in their city or region and ask them to use the food desert locator to create a statistical profile of the residents. Then ask them to look up that same census tract in the USDA Food Environment Atlas to evaluate how environmental factors — such as store/restaurant proximity, food prices, food and nutrition assistance programs, and community characteristics — correlate with food deserts.

Finally, ask students to identify what steps are needed to eliminate food deserts in their city, state, or region.

Additional Resources

  • The Myths That Helped Fuel Inequality in Our Healthcare System, Smithsonian Channel
  • Healthcare Disparities, PBS NewsHour
  • Unnatural Causes, California Newsreel
  • Citation

    Weidner, Catherine. "Healthcare Disparities in the United States" WGBH and the Library of Congress.