Author of ‘The Death Gap’ talks about health care inequities

Scientific racism and lack of access to quality health care hurts low-income families and people of color.

Protesters gather across the Chicago River from Trump Tower to rally against the repeal of the Affordable Care Act Friday, March 24, 2017 CREDIT: Charles Rex Arbogast

Although the Affordable Care Act has expanded health care access for millions of people, unequal access to treatment is still shortening the lives of many Americans. David Ansell, who has worked as a doctor in low-income Chicago communities for nearly four decades, focuses on these health care disparities in his new book, The Death Gap.

ThinkProgress interviewed Ansell on some of the health disparities he documents in his book, as well as possible solutions to these health care inequities.

Half of your book is devoted to issues of economic inequality that contribute to health disparities. Who is your book’s intended audience?

I’m actually aiming the book toward a reading public who might be interested in the question, “Why are things the way they are?” Because I’ve been a doctor in Chicago for over 30 years and have worked in three hospitals on one street. I call it “one street, two worlds” because the lives people live in one neighborhood are so different than the lives people live in another neighborhood, and sometimes they are juxtaposed next to each other.

While I think medical personnel and students will read [the book], it’s really aimed for people to understand how inequality itself leads to people dying early, and that that is an unacceptable proposition from a human rights perspective.

Most of the patients you mentioned in your book were people of color. As white people die at greater numbers, media outlets are taking notice, but does it ever disappoint you that the health issues of people of color appear to get less attention?

On the loop in Chicago, you can live to be 85 years old. Yet my hospital was just three stops away, and that life expectancy plummets to 69. As a problem, it’s not what people are doing, it’s due to the conditions in their neighborhoods. The conditions in black neighborhoods, especially urban black neighborhoods…these are conditions that have led to this neglect for hundreds of years, plus the exploitation and structural racism.

When this disadvantage is concentrated in neighborhoods and families, people die earlier.

But the income equality, inequality in educational achievement, and other things are impacting white folks in the country as well, and what is underlying this is cumulative disadvantage, and sometimes generational disadvantage. When this disadvantage is concentrated in neighborhoods and families, people die earlier. So people are calling deaths in white people “diseases of despair,” and people are saying “About time you noticed this, because it’s been going on in black communities.”

I think it should bring us all pause and really to begin to bring solutions to neighborhoods that are actually quite straightforward. It’s redistribution of our wealth into investments, into good-paying jobs, free education, and health care for all without co-pays and deductibles. And it will benefit folks in Appalachia and rural California as well as Chicago.

You mention examples of scientific racism, such as the discredited theories about slavery and hypertension, and that researchers rely on so-called racial and ethnic evidence to excuse health disparities. Can you explain how those findings might distract people from acknowledging and doing something about these death gaps?

There is scientific racism because we use race in this country as as a biological category. We need to distinguish race from racism. Racism is a form of structural violence that actually harms people of color and black people in particular, disadvantaging them in so many different ways from economic exclusion, to exclusion from neighborhoods, educational opportunities, and from jobs. And it’s important we distinguish that.

But of course, the medical community has been all too happy to conflate race and racism, and then ascribe biological phenomena that are really results of exploitative conditions to the melanin concentration in skin. And it doesn’t make any sense. Human beings are 99.9 percent alike. That isn’t minimizing that diseases have biological manifestations, but to ascribe a condition to race is inherently racist in my opinion, and it deflects from solving the real problem. Because if the problem is within the individual, we need to fix the individual. But if the problem is the way we design and structure society, concentrating wealth into the hands of people in certain communities to the exclusion of others, then we need to reorganize the world through taxing and other processes to create opportunities for those who are systematically exploited.

Since you cited research showing that doctors have given different medical workups to patients of color — such as black people getting less angiograms to evaluate chest pain symptoms — I’m wondering what you think the medical establishment should do to reduce racial bias.

One, people’s reaction to black patients is different, and they’ve done tests on bias in nurses and doctors, so we have to acknowledge implicit bias in health care. Two, as a result of implicit bias, differential care is provided, so the way one deals with that is to check in within oneself, to make sure reactions are not out of bias, and to look at data through a race and gender and age lens to identify areas where there is differential care. If there is differential care, if we want to improve it, we have to measure it and put it out in front of quality boards in institutions and design projects to mitigate this.

What is necessary is for health care institutions to look at their performance on quality measures through an equity lens — by race, age, gender, and insurance for example — to ensure that care is being provided equitably to all. The only way to improve is to measure and share the data within the hospital quality structure, up to and including the [hospital’s governing] board.

But the biggest gap on top of all this is that health care institutions supporting minority patients are different than institutions serving white patients, in terms of overarching quality. The health care system we have is almost the opposite of equitable, because those who have more — and this tends to weigh in our society by skin color and gender — have better insurance cards and have better hospitals that tend to be in white communities.

“On three different levels, people can get bad care based on race.”

[These hospitals] have higher star ratings by Centers for Medicare and Medicaid Services, and those hospitals serving black and brown people have lower quality. This correlates with mortality rates, so on three different levels, people can get bad care based on race.

One is implicit bias, two is people not looking at quality overall through an equity lens, so you could be providing worse care. We know black people are less likely to receive angiograms, and breast cancer treatment varies. The third part is the structure of the health care system, which allows those who have more to get better insurance cards, and they get their care in better organized hospitals and health systems.

How does the neighborhood of the hospital affect the care patients receive?

Every city has a street like Ogden Avenue in Chicago, where you have great life expectancy gaps. A hospital in a poor community tends to be taking care of more uninsured patients and patients on Medicaid. I worked at Mount Sinai, which dedicated itself to serving Lawndale and poor communities on West Side. Because there were fewer people who could pay the bills, you couldn’t buy equipment or hire a specialist. After 17 years at [Hospital of Cook County] and 10 years at Mount Sinai, not once did a patient that I had who needed a transplant ever get one, and yet there were two trauma centers. There was a transplant center literally down the street.

But it also has to do with how capital is needed to improve care, so if you want to build a new facility or if you need fancy diagnostic equipment, hospitals that serve poor minority communities are under-capitalized, and therefore patients don’t have access to the best technology. As a doctor, I thought all I had to do was show up in a safety net setting and take care of patients. When I got to Rush University Medical Center, a shiny new medical center, I found that it wasn’t enough if the if availability for patients wasn’t there for me.

But when I showed up, what I found was that there wasn’t enough equipment, and the availability of patients wasn’t there for me. It is really an apartheid medical system. We can fix if we want to, but we haven’t yet, and all this debate about health care in DC is missing the point when it comes to equality and equity.

You say you want a single-payer system because there is a lot the ACA can’t achieve, particularly after the Supreme Court allowed states to opt out of Medicaid expansion. Do you think that under the current conditions, with Republicans pushing their own health care bill, we will get to return to a conversation about a single-payer system?

The ACA did some tremendous things, and 20 million people are insured who were uninsured. For every million uninsured, that is 1,000 additional deaths each year, so that means there are 20,000 fewer people dying each year. That is a wonderful thing, but the downside is that people were still left uninsured. And most of all, it propped up a flawed health insurance system that depends on profit-making health insurance companies and pharmaceutical companies that have basically raised rates for people — not only those buying health care on health care marketplaces but for those getting insurance as employees.

Those buying on the marketplaces, most of it is subsidized, but they’re also facing high co-pays and deductibles. And that actually deters people from seeking the care they need, so it is inherently flawed when you use insurance companies. Premiums have have not gone up under the ACA as fast as they were going before, but they’re still going up faster than wages … If you’re poor and uninsured, there is no worse thing than not having a Medicaid card, but the next less worse thing is having a Medicaid card, because one out of three doctors does not take Medicaid. It’s much harder for people with Medicaid to get specialty care and not all doctors take Medicaid plans.

So the ACA was good, but not good enough from a health equity perspective. The best and cheapest way is to take insurance companies out of it, get rid of co-pays under Medicare, and expand it for all.

I think Republican attempts to repeal are getting into the dilemma that the ACA was essentially a Republican conservative idea. Let the free market solve it. What they’re running into is that they can’t solve the problem without throwing 20 million people off of insurance, so they’re going to face opposition from both Republicans and Democrats. But the opportunity now is to do what other developed countries have done and have a single payer system.

How do you think activism is playing a role in forcing people to take notice of these death gaps?

We haven’t gotten rights in this country without being publicly vocal and being part of larger social movements. I gave examples of local things in Chicago, but it’s also true nationally. It’s not enough just to resist. We need to present a vision of what the world should be and get the political power to make it happen, and this will only happen with larger social movements.

This interview has been edited and condensed for clarity.

Author of ‘The Death Gap’ talks about health care inequities was originally published in ThinkProgress on Medium, where people are continuing the conversation by highlighting and responding to this story.