Persistent Inequalities in Health and Access to Health Services: Evidence From New York City
| Author | Michael K. Gusmano,Victor G. Rodwin,Daniel Weisz |
| DOI | http://doi.org/10.1002/wmh3.226 |
| Date | 01 June 2017 |
| Published date | 01 June 2017 |
Persistent Inequalities in Health and Access to Health
Services: Evidence From New York City
Michael K. Gusmano , Victor G. Rodwin, and Daniel Weisz
In Manhattan, the rate of hospital discharges for avoidable hospital conditions (AHC), a measure of
access to timely and effective ambulatory care, fell by nearly 50 percent between 1999 and 2013.
Despite this remarkable improvement, there has been virtually no change in racial, ethnic, or
neighborhood-level differences in rates of AHC. This is surprising given New York City’s emphasis
on public health and its efforts to reduce health and health-care inequalities. We discuss the policy
implications of these findings and argue that growing income and wealth inequalities have limited
the ability of New York City to address inequalities in population health and health-care access.
Unless there are substantial changes in federal and state policy, designed to reduce economic
inequalities, it will be difficult to achieve the goal of eliminating health and health-care inequalities.
KEY WORDS: New York City, health inequalities, avoidable hospital conditions
Introduction
Since 2000, New York City (NYC) has made remarkable gains in its
population health status and access to health-care services. Despite increases in
the prevalence of obesity, high blood pressure, diabetes, and asthma, and poorer
self-reported health status—life expectancy at birth has increased, infant mortality
has declined and the percentage of people who report having a regular source of
care has increased (Table 1) (NYC Health, 2014; Roberts, 2013).
These improvements reflect, in part, what Thorstein Veblen called the
“advantages of backwardness,” for in comparison to other global cities—Paris
and London for example—life expectancy at birth for NYC’s population was
significantly lower in the early 2000 period and access to primary care was far
worse (Gusmano, Rodwin, & Weisz, 2010). Since then, the administration of
former Mayor Bloomberg emphasized the importance of improving NYC’s
population health status and reducing disparities in access to health services; his
successor, Mayor De Blasio, continues this focus. In spite of these efforts, racial,
ethnic, and neighborhood-level inequalities in health and access to health-care
services persist within the city.
World Medical & Health Policy, Vol. 9, No. 2, 2017
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doi: 10.1002/wmh3.226
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These persistent inequalities are acknowledged by the NYC Department of
Health and Mental Hygiene (DOHMH) and reducing them remains a goal of the
city’s recently published Take Care New York 2020 report (NYC Health, 2016). In
this paper, we update an analysis of Manhattan, in 2000, with respect to an
important dimension of health system performance—access to community-based
ambulatory care as measured by hospital discharge rates for avoidable hospital
conditions (AHC), to which we refer henceforth as AHC rates. Over the 2000–12
period, we find that overall AHC rates fell by nearly 50 percent; yet racial, ethnic,
and neighborhood-level inequalities hardly declined. Our analysis highlights the
challenge of addressing health-care inequalities at the local level in the context of
large and growing income and wealth inequalities shaped by national policies.
Racial, Ethnic, and Spatial Inequalities in Health and Health Care
The existence of racial, ethnic, and neighborhood-level inequalities in health
and health care are a long-standing problem in the United States. They are not
unique to New York City. Racial differences in health status, for example, were
documented in the earliest records of U.S. vital statistics (Williams & Sternthal,
2010). Scientific studies and government reports document racial, ethnic, and
neighborhood-level differences in mortality, in the incidence of acute and chronic
illness, and access to health care (CDC, 2011). Healthy People 2020, a set of
objectives with 10-year targets, produced by an advisory committee to the U.S.
Department of Health and Human Services (HHS), calls for the elimination of
these, and other health disparities (US DHHS, 2011). Despite these goals set forth
by the federal government, as Deborah Stone (2006) noted over a decade ago, “no
policy reforms have significantly reduced disparities.”
What accounts for racial and ethnic health disparities? Some analysts focus
on biological and genetic factors, but they account for less than 1 percent of
excess deaths in the Black population in the United States (Cooper & David,
1986). More complete accounts invoke the concept of intersectionality and
examine the complex interactions among class, ethnicity, gender, and race
Table 1. Changes in Health and Access to Care: NYC, 2002–10
Self-reported health status (% reporting
fair or poor health)
19.5% 20.9%
Life expectancy at birth 77.9 (2001) 80.9 (2010)
Infant mortality 5.83/1,000 live births 4.48/1,000 live births (2012)
Do you have one person or more
than one person you think of as
your personal doctor or health-care provider?
73.6% 83.7% (2014)
Obesity (CI) 18.2% (17.2–19.2) 24.2% (22.8–25.5)
High blood pressure ever 25.9% (24.9–26.9) 27.8% (26.6–29.0)
Diabetes ever 8.0% (7.4–8.7) 10.7% (9.9–11.9)
Asthma ever 12.1% (11.3–12.9) 12.5% (11.5–13.7)
Sources: Life expectancy: New York City Department of Health and Mental Hygiene; Infant
mortality: Wang, Schoen, & Melnik (2013); Personal doctor or health-care provider: NYC
Community Health Survey, 2002 and 2014.
Gusmano/Rodwin/Weisz: Persistent Inequalities 187
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