Academic institutions, civil society, and nonprofit institutions are increasingly identifying systemic racism as an impediment to good health.1 Many racial and ethnic minorities and people living in rural, underserved communities or low-income households do not have equal access to high-quality healthcare in the United States; as a consequence, they often experience worse health outcomes, according to the American Medical Association.2
But while these racial disparities in health access and outcomes have been well documented, less is understood about people’s perceptions of their healthcare across different races and ethnicities. To learn more about consumer sentiment on factors that influence health equity, we analyzed McKinsey’s Consumer Health Insights Surveys and listened directly to consumers.
Analysis of previous research and our 2020–21 insights examines underlying sentiment, experiences, and attitudes for Black and Latino consumers that, if better understood, could help to shape more effective consumer engagement.3 These insights, in addition to other data on disparities across the healthcare ecosystem, provide a perspective on the role healthcare stakeholders could play in improving, and potentially transforming, health equity for Black and Latino communities.
Within the healthcare system, we identify four areas to improve health outcomes: quality of care, access to care, affordability, and meeting health-related basic needs, including economic and social risk factors. In each area, we identify potential ways in which healthcare stakeholders may want to address consumer sentiment and perceptions, create wide-ranging impact, and begin to chip away at the root causes of healthcare inequity.
Quality of care: Black and Latino consumers are more likely to perceive that they receive lower quality of care due to their race
Consumer perceptions of quality of care are typically informed by patient experience and health outcomes. Healthcare quality is often defined as how healthcare services for individuals and populations increase the likelihood of desired health outcomes and reflect current professional knowledge.4
Across outcome metrics, many Black and Latino community members said they have had a negative experience, which may dampen their perceptions of the healthcare system. For mental healthcare, perceptions may reflect differences in the quality of care that patients receive based on criteria such as medication recommendations, comorbidities, or mortality. For example, 23 percent of White adults reported receiving some form of mental-health treatment and 19 percent reported taking medication for mental health within the past year in 2019. Comparatively, 11 percent of Black adults and 10 percent of Hispanic adults reported taking medication.5
Intermediate diabetes outcomes, such as glycemic control, are poorer for Black patients than for their White counterparts.6 In maternal health and child health, Black women are 3.2 times more likely to die from pregnancy or childbirth-related causes than White women.7
When evaluating behavioral health, McKinsey’s 2020 Behavioral Health Survey showed that Black and Latino respondents had a lower perception of their quality of life, rating it “very low” on a ten-point scale, at about 5.1 and 3.1 times the rate of White respondents, respectively.8
Black and Latino consumers were more likely than White respondents to report that the quality of care they received was influenced by their race, whereas White respondents were most likely to report that race had no impact on their quality of care (Exhibit 1). Black and Latino respondents also were more likely than their White counterparts to report receiving lower-quality care as a result of their race: 6 percent of White respondents felt that they received lower-quality healthcare based on their ethnicity or race (one to three on a ten-point scale) versus 12 percent for Black and 8 percent for Latino respondents.9
Survey respondents who identified as underrepresented minorities highlighted perceived and actual disrespect within the healthcare system because of their race as an influencing factor in their care. One respondent remarked, “African-Americans are treated unfairly. From [providers] belittling me with slight comments to making assumptions about my lifestyle to not comprehending my concerns, my ethnicity and race influences everything in my life.” The influence of race was not limited to providers, with another respondent stating, “Being a person of color may make me a second-class citizen in the eyes of the health insurance industry.”
Healthcare institutions may be able to increase customer satisfaction among Black and Latino patients by gathering data and providing culturally relevant care. To support these goals, potential actions may include the following:
- Use metrics from patient surveys that assess patient experience in accessing and receiving care to better inform opportunities to improve the experience (for example, network design or journey redesign).
- Add quality ratings from underrepresented minorities to ensure that providers engage patients consistently to deliver high-quality care to all patients.
- Ensure better representation of care staff to align with the populations they serve.
- Promote culturally relevant care, both in medical training and beyond, including clinical education with antibias trainings and clinical policy standardization.
- Work with medical schools to encourage increased focus on culturally competent care.
Access to care: Coverage, services, and feasibility
To understand consumer perceptions regarding access to care, we looked at three dimensions: coverage—the ability for patients to gain entry into the healthcare system and navigate it without barriers to care; services—the ability to receive appropriate preventative, specialist, and emergency care; and feasibility—the ability to acquire medical services without major hurdles soon after a need has been identified. Outcome data and consumer sentiment show that across all three dimensions, Black and Latino populations fare worse.
- Coverage: While insurance coverage has increased since the passage of the Affordable Care Act of 2010, discrepancies remain. Among elderly populations, Black (20 percent) and Latino (14 percent) consumers are less likely to have supplemental insurance coverage from employer-sponsored plans to cover the full cost of their care compared with White consumers (32 percent).10 Black and Latino Medicare beneficiaries are 2.5 and 2.0 times more likely, respectively, to rely on Medicaid to supplement their insurance than White beneficiaries, according to research from the Kaiser Family Foundation (KFF).11 KFF also reports that nonelderly Latino Americans are more than 2.5 times as likely to be uninsured as White Americans, and Black individuals are nearly 1.7 times more likely to be uninsured.12 McKinsey’s Health Institute found that Black and Latino Americans were 3.0 and 2.0 times more likely to report losing health insurance during the COVID-19 pandemic than White respondents, respectively, further limiting access to testing and treatment. Variations in network and insurance coverage contribute to differential use of routine care across populations.
- Services: A KFF analysis found that 25 percent of Latino adults reported having no usual source of care and no healthcare visit in the past 12 months compared with 15 percent of White adults.13 Roughly 53 percent of Black consumers and 44 percent of Latino consumers said they had visited a primary-care provider in the past 12 months, compared with approximately 60 percent of White consumers.14
Differential access influences how patients seek care; for example, Black patients were more likely than White patients to report they would go to the emergency room (32 versus 23 percent) when told to see a doctor immediately.15 It also has an impact on how individuals gather medical advice before even seeking care. While White respondents were most likely to say that they prefer to call the doctor’s office if they weren’t feeling well, Black and Latino respondents were more likely than White respondents to research online and speak to friends and family members instead (Exhibit 2).
Among Medicare Advantage enrollees, Black and Hispanic beneficiaries reported worse experiences than White beneficiaries with getting appointments and care quickly and had lower rates of vaccination for the flu.16
Feasibility: In addition to encountering obstacles when trying to access care, some patients may feel discouraged from seeking care because of cost and other factors. According to KFF, 24 percent of Black adults and 25 percent of Hispanic adults delayed care for reasons other than cost. In comparison, 19 percent of White adults delayed care.17 Fifty-two percent of Black and 49 percent of Hispanic workers said they postponed care because it would take too long.18 Other considerations in delaying care included lack of transportation, an expectation of not getting treatment, and uncertainty about what to do when feeling unwell (Exhibit 3).
Access remains an important factor in how Black and Latino individuals evaluate healthcare quality. While 79 percent of Latino and 78 percent of Black respondents reported that access to healthcare facilities has an impact on the healthcare they receive, only 68 percent of White respondents said they felt similarly (Exhibit 4).19 One possible factor is that Black and Latino adults are more likely to be in occupations that limit their ability to get time off during working hours for medical appointments, such as the service industry.20 Access to transportation for routine medical care for Black and Hispanic groups may also be a factor. For example, a 2007 study found that Black Americans and other minorities in urban settings were substantially more likely to report a trip for medical or dental care lasting more than 30 minutes compared with their White counterparts.21 When controlling for the mode of transportation, community, and personal characteristics, Black Americans were still more likely than White Americans to face a longer travel time for medical or dental care.22
Stakeholders may consider the following to increase options for care and representation in the workforce.
Increased options for care: Expanded physical locations in underserved communities may be a place to start. This could include forming partnerships with community organizations and offering more virtual care via hubs for telehealth. It also may mean offering weekend and evening hours of service for patients who are unable to visit a provider during the weekday hours of 9:00 a.m. to 5:00 p.m.
Payers also may want to examine network access for Black and Hispanic members to ensure that they have access to care. Both payers and providers also could consider expanding access through linguistic and translation services. These services should include in-person, digital, and written options.
Employers may also have a role to play by ensuring their employees understand their benefits, including what services are covered and how. According to McKinsey research, approximately 80 percent of employees use few if any medical services in a typical year, yet American workers are substantially less healthy than their counterparts in other countries. Employers could play a role in promoting engagement with the healthcare system, not only to avoid injury but also to potentially improve employees’ overall health through preventive-health measures, behavioral-health programs, well-being initiatives, and social determinants.
Representation: A more diversified workforce could help providers and payers improve patient service. While roughly 5 percent of White respondents said they cared about the race of their physician, race was a consideration for 13 percent of Black respondents; of those, 85 percent indicated a preference for a Black physician.23 This preference is not reflected in the demographics of active physicians in the United States. In 2018, approximately 6 percent of active physicians in the United States were Latino and 5 percent were Black,24 despite these groups representing 19 percent and 13 percent of the US population, respectively.25
Health systems could support and develop educational programs and scholarships that support and advance Black and Latino healthcare personnel in training.
Affordability: Among both the insured and uninsured, Black and Latino consumers report higher cost burdens to obtain care
The cost of care is a critical lever in health equity, as many patients say they may defer care because it is unaffordable or out of network.26 Approximately 22 percent of White survey respondents stated they had deferred care due to not being able to afford the costs, compared with 49 percent of Black and 51 percent of Hispanic adults.27 Other outcomes of the inability to afford care may include skipping medication doses to expand the length of time until a refill is needed.
Among participants surveyed, billing and the cost of care were listed as the greatest sources of frustration among all races.28 In addition to affording care, many patients report facing difficulty determining the cost of care, with only 39 percent of Black and Hispanic respondents reporting high satisfaction determining the cost of care from their health insurers (compared with 55 percent of White people).29 Poverty, medical debt, and insurance coverage are among the factors that affect affordability.
Poverty: Twenty-one percent of Black and 17 percent of Latino respondents live at or below the poverty line, compared with 9 percent of White Americans.30 Additionally, there is a persistent wealth gap between Black and Latino families and their White counterparts—the median family income for White families is tenfold that of Black and Hispanic families. Black Americans are expected to earn up to $1 million less than White Americans over their lifetimes, reflective of social factors including unequal access to quality schooling, differential treatment in the criminal justice system, wage disparities, and lower rates of professional advancement and compensation.
Medical debt: Black and Latino groups are more likely to be burdened by medical debt, which can stem from high out-of-pocket-cost maximums, noncovered prescriptions, or catastrophic or chronic illnesses. Black and Latino groups are around 1.7 times more likely to have more than $1,000 in medical debt.31 Medical debt is exacerbated by limited financing and banking solutions available to build savings and prepare for financial shocks.
Coverage: More than 40 percent of Black, Hispanic, and White respondents reported that health expenditures had a slight or severe impact on their financial welfare. However, Latino and Black survey respondents cited a higher desire for more lower-cost health plans, even if those plans had high deductibles (Exhibit 5).32
Addressing pain points in affordability of care and transparency in the cost of care may help improve consumer perceptions.
- Healthcare stakeholders have a role to play in improving access to affordable care (for example, understanding the populations that are least able to afford care and providing information on how to find affordable care and treatment).
- Payers could evaluate potential racial disparities in denials and benefits coverage to identify potential policy and procedural flaws and consumer pain points. They could assess healthcare usage patterns to understand where there may be racial differences in claims for the same disease or condition.
- Health technology could help providers estimate the cost of services to increase transparency and allow patients to shop for the lowest cost services and make affordable choices. This may reduce unexpected medical costs.
- Employers could make care more affordable for employees through tiered premiums based on income to ensure that those with lower incomes can still afford employer-sponsored coverage.
The cost of care is a critical lever in health equity, as many patients say they may defer care because it is unaffordable or out of network.
Economic and social risk factors: Beyond the healthcare system, Black and Latino populations have more unmet health-related basic needs
Health outcomes and health equity expand beyond the healthcare system and are influenced by basic needs that affect physical and mental health, including food security, housing, employment, and financial mobility. Black and Hispanic populations are more likely to report multiple unmet health-related social needs, at 28 percent of Black and 31 percent of Hispanic respondents, respectively, compared with 19 percent of White respondents.33
Food insecurity: Sixteen percent of White respondents reported high food needs compared with 25 percent of Black and 24 percent of Latino respondents in a McKinsey 2020 Consumer Health Insights Survey.34 These figures are reflected in national trends. Between April and June 2020, the US Census Household Pulse Survey showed that Black households were 1.8 times more likely to report being food insecure than White households ( Latino households were around 1.6 times more likely to report the same), with 41 percent of Black households, 37 percent of Hispanic households, and 23 percent of White households considered food insecure.35 These rates have continued to rise throughout the COVID-19 pandemic.36
Lack of housing: Around 10 percent of White respondents reported high housing insecurity in 2020, compared with almost 20 percent of Latino respondents and 13 percent of Black respondents. Latino respondents were 1.8 times more likely than White respondents to say they were worried about losing their house. Roughly 2.8 percent of White respondents said they did not have housing, while 3.8 percent of Black and 7.1 percent of Latino respondents reported experiencing homelessness.37
The COVID-19 pandemic exacerbated many Americans’ ability to pay their rent or mortgage, or to keep secure housing. By late September 2020, almost a fourth of Black and 20 percent of Hispanic adults were behind on their rent payments, compared with 10 percent of White adults, per a US Census Bureau analysis.38 Seven percent of White homeowners were behind on mortgage payments in late September 2020, compared with 17 and 18 percent for Black and Hispanic adults, respectively.39
Additional analysis has found that even when median household incomes are roughly the same, Black-led households pay more for identical housing than their White counterparts, with the rent gap increasing the more White-led households there are in a neighborhood.40
Unemployment and financial mobility: Amid record unemployment numbers in 2020, Black and Latino groups were among the hardest hit and the slowest to recover. As of September 2020, 53 percent of Latino adults said they or someone else in their household had either been laid off or had taken a pay cut due to the COVID-19 pandemic, compared with 43 percent of Black adults and 38 percent of White adults.41 As of June 2021, the unemployment rate for Black (9.2 percent) and Hispanic (7.4 percent) workers remains 1.8 and 1.4 times higher, respectively, than for White adults (5.2 percent).42 Even before the pandemic, only half of the top ten occupations that Black Americans typically hold pay above the federal poverty guidelines for a family of four.
Economic and social risk factors that influence health are vast and diverse. Understanding an individual’s unmet basic needs is a critical first step to understanding broader consumer needs and sentiments.
- By identifying these needs, providers may connect patients to more appropriate resources. Providers may screen individuals and understand the needs and contexts of the communities they serve by using available data on food insecurity, educational attainment, community violence, and other relevant metrics. Providers prepared to engage with patients about their social needs could more readily connect their patients and enhance consumer trust in the system.
- Payers and providers may enlist resource coordinators to better manage communication and coordination of resources for individuals with unmet needs.
- Payers and other healthcare companies may be well positioned to increase awareness and expand workplace support to better meet employee behavioral-health needs. These stakeholders could strengthen prevention efforts, analyzing data and tech to identify patients who may benefit most from targeted prevention and treatment efforts, while integrating behavioral and physical health services.
Potential steps for stakeholders to close the equity gap
While there are several ways to build trust and strengthen Black and Latino engagement with the healthcare system, these changes will likely rely on an ability to address structural barriers and experiences that underlie consumer sentiment.
Organizations that wish to move the needle on these issues could show leadership and embed health equity into their business strategy through the following potential steps:
- Create a position statement on health equity, including a clear definition of the term and an expressed commitment or pledge.
- Incorporate diverse representation in all governance structures (for example, leadership, board, and staff positions) and ensure a breadth of perspectives are considered in decision making. Ensuring that leadership includes those with lived experiences of disparities is pivotal to a sustainable, community-driven solution.
- Establish patient advisory committees or ensure that existing ones have representative voices to ensure diverse consumer perspectives are incorporated in important elements of operations. Incorporate these insights to inform policies and practices that are patient-centric from inception to implementation.
- Standardize processes to routinely collect patient-experience data (for example, operational measures, surveys), review racial and ethnic disparities, identify gaps, and assess organizational policies and practices. Ensure data is robust and representative of all populations (for example, surveys should be accessible to patients in multiple languages).
- Invest time and resources in assessing community health needs. Provide community stakeholders the opportunity to meaningfully engage in a process of informing hospitals about consumer needs. Meeting these needs will ultimately enhance consumer perceptions of the systems serving them.
All stakeholders in the healthcare system have a role and responsibility to advance health equity. As the US population continues to diversify, addressing these disparities benefits not only consumers but also employers and the broader business community, allowing a more equitable healthcare framework for all.