Where Are America’s Greatest Black-White Inequities — Not Where You Think
Education, housing, employment, law and justice, civic participation, and health care are among the powerful social determinants of long term health and mortality. Access to these determinants is, in turn, partly determined by both federal and state laws, policies, and programs. This analysis examines the distribution among U.S. states of Black people’s access to social determinants and of Black-White inequity in access to social determinants.
Determinants were selected to cover diverse facets of social life from data available by race at the state level: high school non-completion, incarceration, unemployment, poverty, non homeownership, and voter non-registration. Inequity in each state was determined by assessing the difference in access rates for each determinant between Black people and White people. For each determinant, states were ranked in terms of access and inequity, and ranks were summed across determinants for each state. The two indices developed here to examine the distribution among states of social determinants and of determinant inequities between Black and White people are conceptually independent; greater Black access and low or high inequity are possible as are low access and low or high inequity.
Five basic hypotheses are assessed:
1. Because of the history and legacies of the South, Black social disadvantage is highest in southern states and lowest in northern states.
2. Similarly, among U.S. states, Black-white inequity in social determinants is highest in southern states and lowest in northern states.
3. Social determinant access and access inequity are associated with self-rated Black health in states — the greater the access, the greater the self-rated health; in addition, the greater the inequity, the lower the self-rated health. Self-rated health is an established index of longterm morbidity and mortality.(Jylhä 2009) This is a test of the validity of the measures selected and combined in this analysis.
4. Social determinant access and access inequity are associated with Black age-adjusted mortality rates in states — the greater the access, the lower the Black mortality; in addition, the greater the inequity, the higher the Black mortality.
5. States with greater proportions of Black residents will have greater determinant access and equity, and vice versa. A greater proportion of Black residents in a state might be expected to be associated with a greater proportion of Black legislators (or legislators supporting the Black population), and thus greater access to determinants and greater equity.
Combined determinant access for Black people ranged from a high, i.e., greatest access, in Maryland to a low, i.e., least access, in Wisconsin (Map 1). The ranks for Black-White social determinant access inequity ranged from a low, i.e., least social determinant inequity, in Georgia to a high, i.e., greatest inequity, in Wisconsin (Map 2). For both indices, lowest, most favorable rates were found among southern states (Maps 1 and 2). Lower access to determinants was found in western central and midwestern states. Greatest inequity was found in central and midwestern states. Limited access and access inequity are closely related to each other; greater access is associated with lower inequity, and lower access is associated with higher inequity.
Hypothesis 1: Black social disadvantage is highest in southern states, lowest in northern states: Evidence contradicts this hypothesis. Overall, access is greatest in southern states (with the exceptions of Oklahoma and Louisiana) and lowest in northern states.
Hypothesis 2: Black-White inequity in social disadvantage highest in northern states, lowest in southern states: Evidence contradicts this hypothesis. Overall, inequity is lowest in southern states (with the exceptions of Oklahoma and Louisiana) and highest in northern and western states.
Hypothesis 3: Association of indices and self-rated Black health: Evidence supports this hypothesis. Lower social disadvantage is associated with lower rates of poor or fair self-assessed health; greater social disadvantage inequity is associated with higher rates of poor or fair self-assessed health. This association suggests that the determinants chosen and their combination are a reasonable measure of social determinant access and access equity.
Hypothesis 4: Association of indices and Black age-adjusted mortality: Evidence contradicts this hypothesis. There is no apparent association between either index and Black mortality in states.
Hypothesis 5: States with greater proportions of Black residents will have greater determinant access and equity, and vice versa. This hypothesis is confirmed. Higher proportions of the Black population in a state are associated with greater determinant access and lower inequity; lower proportions of the Black population are associated with lower determinant access and greater inequity. It is also reported that the proportion of Blacks among legislators is greater in southern than in other regions.(National Conference of State Legislatures.)
The Black population in the U.S. has been notoriously subjected to centuries of systematic deprivation, with devastating, pervasive, and lasting health consequences.(Reskin 2012, Williams and Mohammed 2013) Since the Civil War, substantial progress has been made, with substantial resistance, and with counter-resistance and sacrifice. On average, Black health and access to societal resources for health in the U.S. have improved enormously, though they are still far from equal to that of U.S. White people. State histories have been affected by socio-economic and socio-political forces that have led to the evolving characteristics and relative positions of their populations. While all U.S. residents are subject to federal law and policy, states may each enforce federal laws and implement programs and policies in different ways. In addition, each state has its own laws, policies, and programs, commonly determined by elected officials and, in turn, affecting the welfare and the distribution of resources for its population.
Some results of this analysis run contrary to common expectation, namely that access and equity are least in southern states — historically slave states and supporters of segregated institutions — and greatest in northern and western states. Examination of the association of proportions of Black people in each state indicates that higher proportions of Black people in states are associated with both greater access and less inequity. It is plausible that states with larger proportions of Black people have greater electoral representation and the power to control policies, programs, and their enforcement and execution, resulting in greater Black access and less inequity.
This analysis yields a rough picture. Indices may be inherently imperfect measures. They combine characteristics of differing dimensions and metrics. Determinant counts do not indicate the quality of what is counted. For example, that one state has a lower high school graduation rate than another gives no indication of the quality of education achieved in the one state versus the other. Rates of homeownership do not indicate the quality of the housing or its location. It is plausible that simple counts underestimate the gap between the social determinant access of Black people and White people. Poverty may have different consequences in a state with high versus lower costs of living, a state with or without state income taxes, a state with more or fewer low-income assistance sources, e.g., Medicaid Expansion. Thus, determinant counts are imprecise indicators. Ranks compress this imprecision, and rank summaries combine data over diverse units. Ranking is undertaken on the assumption that the benefits of summary across dimensions outweigh the sacrifice of precision.
The index of social determinant access indicates where the U.S. Black population has greater and less access to societal resources for health. The index of social determinant inequity indicates where access differences between U.S. Black and White populations are greater and less. The summary of Black-White inequity may be regarded as an index of the cumulative consequence of structural racism. Given a focus of public health on population welfare and equity, both indices roughly point to geo-political regions for intervention for the betterment of the lives of the Black population.
What are the roots of these distributions, what are their consequences, what should and can be done to address social disadvantage for the Black population and Black-White inequities? Even if logically possible, it is unlikely that health equity could be achieved in the absence of greater equity in access to the social determinants of health.
Many evidence-based policy and program prescriptions for the reduction of determinant inequities are available.(https://www.policylink.org/, https://www.thecommunityguide.org/topic/health-equity; (Smedley, Stith et al. 2003, Williams and Mohammed 2013).
This report is a summary of a more comprehensive published study:
Hahn RA. Access to Social Determinants of Health and Determinant Inequity for the Black Population in US States in the Early Twenty-First Century. Journal of Racial and Ethnic Health Disparities. 2020 Jun 29:1–6.
Atlas, N. E. (2017). Homeownership United States.
Foundation, K. (2017). Poverty Rate by Race/Ethnicity.
Galea, S., M. Tracy, K. J. Hoggatt, C. DiMaggio and A. Karpati (2011). “Estimated deaths attributable to social factors in the United States.” American Journal of Public Health 101(8): 1456–1465.
Hahn, R. A., B. I. Truman and D. R. Williams (2018). “Civil rights as determinants of public health and racial and ethnic health equity: health care, education, employment, and housing in the United States.” SSM-population health 4: 17–24.
Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Social science & medicine. 2009 Aug 1;69(3):307–16.
Link, B. G. and J. Phelan (1995). “Social conditions as fundamental causes of disease.” Journal of health and social behavior: 80–94.
Nellis, A. (2016). The color of justice: Racial and ethnic disparity in state prisons, Sentencing Project.
Reskin, B. (2012). “The race discrimination system.” Annual Review of Sociology 38: 17–35.
Smedley, B. D., A. Y. Stith and A. R. Nelson (2003). Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treatment: confronting racial and ethnic disparities in healthcare, Washington, DC: National Academies Press.
Snyder, T. D., C. De Brey and S. A. Dillow (2018). “Digest of Education Statistics 2016, NCES 2017–094.” National Center for Education Statistics.
Williams, D. R. and S. A. Mohammed (2013). “Racism and health II: a needed research agenda for effective interventions.” American behavioral scientist 57(8): 1200–1226.