Primary care in the US is segregated by racial/ethnic identification. What are the implications?
Most people in the US are aware that our neighborhoods are often highly segregated by race and ethnicity. Racism — historical and current, structural and individual — plays a role in neighborhood demographics. The same forces also result in segregated workplaces, schools, and more. Since most people see doctors close to home, school, or work, it’s not surprising that primary care is also segregated.
80% of people of color were seen by just 35% of PCPs, 2006-16
New research from Medical Care, led by a team from NYU, found that 35% of primary care providers (PCPs) see 80% of the non-White patients across the US. The study, titled Racial and Ethnic Segregation in Primary Care and Association of Practice Composition With Quality of Care, used data from 2006 to 2016 from the National Ambulatory Medical Care Survey, an excellent source of national information on primary care. The results are little-changed since 2001–2003, based on research published in Medical Care in 2011.
Were there differences in quality?
The immediate next question addressed by the author team was, “What is the regression-adjusted relationship between the racial/ethnic composition of PCP practices and measures of the quality of care delivered?” In short, the authors found little association between the racial/ethnic composition of a PCP’s panel and the quality of care, either before or after the passage of the Affordable Care Act in 2010.
Prior research supports the authors’ findings. For example, disparities in the quality of hospital care have been largely explained by the choice of hospital. Research on PCPs has also suggested that disparities in care experiences between Black and White patients were mainly attributable to differences in which physicians were seen by these groups, rather than differences in treatment within a practice.
What are the implications?
According to a 2021 paper incorporating the latest Census data, segregation of Black individuals from all other racial/ethnic groups declined from 1990 to 2020. However, Black people remain highly segregated from White and Asian people in many cities. In addition, segregation of Hispanic and Asian individuals from White individuals and from each other increased over the same time period.
Racial and ethnic segregation persists in primary care, as well. With the ACA’s expansion of health insurance coverage, more Black, Indigenous, and other People of Color (BIPOC) gained access to care. Yet, the dominance of Medicaid coverage in many BIPOC communities means that PCPs who accept Medicaid are caring for the majority of people of color.
On average, Medicaid pays physicians two-thirds of the rates Medicare pays (this varies by state and type of care). Meaning, PCPs who accept Medicaid get less money per patient, but are still expected to provide the same level of high-quality care. Based on the study we are highlighting today, it appears that they have been largely successful.
Yet, the segregation of primary care is driven by policies as much as anything else. The ACA may have increased the resources available to practices that treat a disproportionate share of racial and ethnic minority patients, but there is still much more room for improvement.
Lisa M. Lines