State of healthcare access in Houston: Medical apartheid?

In the US, there are two trains of thought regarding access to healthcare. One camp believes it is a right given to all people at birth regardless of any particular status. The other views healthcare access as a privilege to be earned via US citizenship, insurability, residency, etc. These two opposing views have created a reality where there exists a huge gap in access, especially for members of the Black and Latinx communities.

But how does this access or lack thereof play out for Black and Latinx members in the Greater Houston area? Is it “medical apartheid,” where access is almost totally denies to individuals on the basis of race, or is it something else?

CURRENT GRADE

When asked to grade that access for the Houston area’s people of color, Dr. Lorna McNeill, chair of the Department of Health Disparities Research in MD Anderson’s division of cancer prevention, she pulled no punches.

“Probably a D,” said McNeill. “On one level, much of access to healthcare obviously is governed by whether or not you have insurance, and the state of Texas has the highest uninsured rate in the country and the highest number of individuals without insurance. So, without Medicaid access and expansion of the Affordable Care Act, Texas leads the nation in uninsured rates. So that would probably be an F.”

According to the Commonwealth Fund, a health policy foundation in New York, the Lone Star State is in the bottom quarter of states regarding both access to and quality of care for Blacks and Latinos. These populations, when compared to their white counterparts, are also more likely to suffer worse healthcare outcomes.

For state health systems’ treatment of Blacks and Latinos, Texas ranked in the 22nd percentile (the bottom fourth)

For state health systems’ treatment of Blacks and Latinos, Texas ranked in the 22nd percentile (the bottom fourth), while ranking in the top 40%, or 63rd percentile, for treatment delivered to whites.

Cancer “survivor/thriver” Felicia Pichon, founder of Sisters Thrive, a nonprofit that supports Black women in various stages of their breast cancer journey, agrees with McNeill’s assessment of healthcare access in the Houston area.

“I think it is appalling when I found out that in Houston, every other woman that dies from breast cancer is Black, with the Medical Center down the street,” said Pichon. “During Breast Cancer Awareness Month I attended every event I could, saying, ‘Let me get out here and see what they got going on in the community.’ And I would see MD Anderson at every event with the same slideshow, just a different representative each time. And it’s like, ‘Y’all doing all this but where are y’all at the rest of the year? Where? Because I can’t get in contact. What are you doing to make a difference?’”

When accessing the current state of healthcare access, Dr. Munish Chawla, retired radiologist and current co-head of the nonprofit Peaceful Planet, names vastly different qualities of care as a reason for the divide.

“Receiving care for COVID, for example, at LBJ hospital is vastly different from receiving care at Methodist Hospital in the medical center, in terms of equipment, nursing, testing and treatment option resources,” said Chawla.

Chawla added poorer underlying health, “higher rates of obesity, diabetes, heart disease, etc., play a role in worse outcomes in communities of color.”

McNeill added that because healthy people equate to a healthier economy, fixing this access issue demands that solutions don’t get ignored or rejected based on partisan politics.

Texas has not accepted federal Medicaid expansion

• 5,355,045 – Number of Texans covered by Medicaid/CHIP as of March 2022
• 1,748,000 – Number of additional Texas residents who would be covered if the state accepted expansion
• 771,000 – Number of people who have NO realistic access to health insurance without Medicaid expansion
• $6 billion – Federal money Texas is leaving on the table in 2022 by not expanding Medicaid (source)

CHALLENGES

So, what are the challenges that lead to this disparate care? There are several.

It’s said everything’s bigger in Texas. Unfortunately, that includes the rate of uninsured where roughly one in five Texans lack insurance. About 20% of Blacks and 38% of Latinos are uninsured. For whites, that number stands at 15%.

This [the Texas Medical Center] is the largest medical center in the world… [but access] is still dominated by whether or not you have insurance, unfortunately,” said McNeill.

Another challenge is the cost of healthcare, an issue directly related to insurance.

About 20% of Blacks and 38% of Latinos are uninsured. For whites, that number stands at 15%.

When Pichon discovered a lump in her breast in June 2021, she said one of the reasons she almost talked herself into not going to get a mammogram was the cost. She also said dealing with the economically crippling costs for breast cancer treatment is one of the most common conversations members of her Sister Thrive nonprofit have.

But that’s not her only beef with healthcare-related fees.

“I love Jesus, so I’m trying not to cuss. But I’m appalled. First off, I’m pissed off that you’re over here making money hand over fist, just with the parking alone. It’s not right. And honestly, it is inhumane. You don’t need my 10 cents, but you’re going to take it from me just because,” she said.

And the cost of healthcare, or rather, what people can afford to spend on healthcare is impacted by the costs of other things required to live, like housing, for example.

People of color face housing challenges, compared to the white population, including: lower rates of home ownership, less access to transportation, and greater exposure to environmental pollution/toxins in and near their residences.

In Houston/Harris County, “people of color face housing challenges, compared to the white population, including: lower rates of home ownership, less access to transportation and greater exposure to environmental pollution/toxins in and near their residences” (“Health Disparity and Health Inequity: 2019 Trends and Data Report, Houston/Harris County;” Houston Health Department).

Economists and common sense says if families are spending more on housing, they will have less disposable income to devote to other things, including food, savings and healthcare.

Below is the percentage of income spent on housing by race/ethnicity in Houston, TX in 2015:

Cost as a factor in the Houston area’s disparate access to healthcare has been made worse by a growing area wage gap.

In 1980, whites in Houston earned $7 more per hour than people of color; by 2015, that gap had more than doubled, to $15 per hour (“Health Disparity and Health Inequity: 2019 Trends and Data Report, Houston/Harris County;” Houston Health Department).

And regarding costs, being classified as “low income” is one thing. But being classified as living in poverty brings with it even more challenges in general, and more challenges in one’s ability to pay for healthcare.

In Harris County, in 2004, approximately 20% of Hispanics, 20% of Blacks, and 5% of whites had incomes below the federal poverty level. In 2015, this percentage had not improved; 22% of Hispanics, 20% of Blacks and 5% of whites lived below poverty.

Poverty is measured by the proportion of people with incomes below the Federal Poverty Level (FPL) or twice/three times the FPL. The poverty threshold for a family with two adults and one child was $20,780 in 2018, and was $12,140 for a one-person household.

And in Harris County, poverty is concentrated in within the 610 loop, which is predominantly in Houston. These locations with the highest percentages of persons living below poverty are predominantly Black and Latinx.

These cost/economic factors directly affect healthcare access. In Harris County in 2017, the percentage of adults who reported they could not see a doctor due to cost are as follows: Hispanic/Latinx (30.4%), Black (21.6%) and white (13.6%). The percentage of all Harris County adults who said cost was the reason they could not see a doctor was 22.1%.

Another challenge: the location of care.

“Transportation is a roadblock for many as there are no hospitals in the Third Ward, and relatively few clinics, though that’s changing a bit with the recent opening of Legacy Health and CenterWell (senior care only),” said Chawla.

In Houston, 17% of Black households do not have access to a vehicle, compared to 5% of whites and 8% of Hispanics.

“Health Disparity and Health Inequity: 2019 Trends And Data Report, Houston/Harris County” Houston Health Department

McNeill counts partisan politics as a huge challenge to equal healthcare access.

With the ACA, states have the option to expand Medicaid eligibility to nonelderly people with incomes up to 138% of the federal poverty level. Only 12 states have not done so: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Wisconsin, Wyoming and Texas. All of these states have Republican governors and/or GOP-dominated state legislatures.

According to a July 2022 Robert Wood Johnson Foundation report, 11 of the 13 states with the highest uninsured rates nationwide have not expanded Medicaid. Moreover, if the 12 non-expansion states were to fully implement a Medicaid expansion in 2023, 3.7 million fewer people would be uninsured, a reduction of 29.1 percent.

Groups who would gain the most in coverage due to Medicaid expansion would be Blacks, young adults, and women, particularly women of reproductive age. 

if the 12 non-expansion states were to fully implement a Medicaid expansion in 2023, 3.7 million fewer people would be uninsured

“Our state representatives and our US representatives know these examples from across the country of the benefits and the improved health outcomes of residents in states that have expanded the ACA. So, these decisions to not expand, from my perspective, are more political, not focused on the health of the citizenry,” said McNeill. “Because to the extent that we’re concerned about people dying earlier than they need to be, people not having access to healthcare, this was the solution nationally to solve that problem. I think all of us are open to hearing what the other recommendations and suggestions are. If it’s not the Affordable Care Act, then what is it?”

Part of that political partisanship challenge is the idea that healthcare is not a human right. From McNeill’s perspective, it is the responsibility for Americans to take care of those in need.

“Good healthcare and healthcare access is a right. You don’t earn it. You are born. You are on this earth and we all get sick and we all have healthcare needs regardless of what kind of job you have or what neighborhoods you live in. Everyone should have access to that. Therefore, if everyone has a right to that, everyone has to share in the distribution of healthcare so that everyone has access to it.

“Those hospital systems within the greater Houston area have a responsibility to provide greater care for those that don’t. And we’re not all doing the best that we can,” said McNeill.

Another challenge is one members of the Black community must own—our distrust of the healthcare system.

“Go to the doctor, get a checkup,” said Dr. Alauna Curry, a Houston-area psychologist, when asked about what health practice Blacks need to engage in more. “We’re hesitant to do that, and understandably so, because we have been abused by so many elements of the system that we often don’t know who to trust. We don’t trust the people. We don’t trust that we’ll get the answers we need. And sometimes we will have bad experiences mm-hmm. But that cannot let you neglect your health. And that’s often what we use as excuses to not take advantage of the advances in medical science, like the COVID vaccine, a huge advance in medical science.”

McNeill adds that despite the criticisms and shortcomings, there are some bright spots regarding area Black healthcare.

“In Harris County, we have access to good, affordable healthcare through our county system, our Harris Health system, that is a safety net hospital system for those without access to insurance, those who are underinsured. Our residents of Harris County can access that system. And MD Anderson provides oncology care to all patients seen at LBJ Hospital. Whereas, for example, Baylor, UT Health provides that access at Ben Taub. That’s a bright spot in terms of the state of Texas,” she said.

According to McNeill, however, some neighboring counties don’t have similar systems.

“If you live in Fort Bend County, Brazoria County, you’re of on your own if you don’t have access to insurance.”

Moreover, the Harris County Harris Health System offers care to anyone who needs it, US citizen or not. There’s also an extensive healthcare system within Greater Houston made up of several low-income clinics, and federally-qualified health systems that provide wrap-around care to keep people in need from falling through the cracks.

“Legacy is one system, for example, where you don’t have to have insurance and you can get care on a sliding scale. The Houston area has a robust wraparound safety net system in general, for people that don’t have insurance. But it’s not free necessarily, although it can be depending on what service you are seeking,” added McNeill.

These challenges to equal access to healthcare make worse an already bad health situation. Consider these statistics:

SOLUTIONS

Solutions from those interviewed to bridge the healthcare gap include using the insurance we have, expanding insurance access beyond employment, producing more healthcare workers of color, increasing hospitals and clinics in Black and Brown communities and what McNeill sees as the first step, pushing Texas to accept ACA funding.

“We cannot be 50th in the United States in terms of people who have access to healthcare. And then, of course, it’s continuing to identify ways in which we can provide free preventative care to people in the state of Texas so that they don’t show up in emergency rooms with advanced stages of disease, though we have a robust screening program where we can detect cancers at earlier stages, do more preventative care around prediabetes and diabetes and hypertension, and get on the forefront of those things. You can’t get on the forefront of these conditions and diseases that are predominantly in African American and Hispanic communities if you don’t have access to preventative services.”

McNeill also wants Blacks to use what they have.

“While Texas has the highest uninsured rate and the most uninsured people, in the greater Houston area, particularly for African Americans, we have relatively high rates of insurance. I want people to take advantage of the insurance that they do have, for those that do have access. It’s a call to action, to figure out and learn about the insurance that you have, learn about the benefits that you do have. Seek that preventative care that you have access to and utilize what you have,” urged McNeill.

McNeill contends better access is just part of the solution.

“Once we’re talking about that access, it needs to be accessible, meaning in places where people live, work, and play and worship. Everyone doesn’t want to come to the Medical Center in order to get their healthcare.”

McNeill says lots of healthcare systems are expanding, including Memorial Hermann and Methodist with new locations popping up, but few in Black and Brown neighborhoods.

“We need to challenge our healthcare partners and the healthcare system to expand these services and locations where the people who need them the most,” she said.

And don’t forget, producing more healthcare workers of color.

McNeill pointed out, countless studies show that concordant care, where a patient sees a provider of the same background (racial, religious, gender, etc.), produces better patient outcomes.