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Cited by 394Health disparities and outcomesHealthcare Policy and ManagementPublic Health and Social Inequalities

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999–2018

Open access
Mahajan, Shiwani, Caraballo, César, Lu, Yuan, Valero-Elizondo, Javier, Massey, Daisy, Annapureddy, Amarnath R., Roy, Brita, Riley, Carley +7 more·2021·JAMA
DOI 10.1001/jama.2021.9907PMC PMC8371573

Published version of a preprint

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Abstract

IMPORTANCE: The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades. OBJECTIVE: To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults. EXPOSURES: Self-reported race, ethnicity, and income level. MAIN OUTCOMES AND MEASURES: Rates and racial and ethnic differences in self-reported health status and health care access and affordability. RESULTS: The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification. CONCLUSIONS AND RELEVANCE: In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.

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  • Findingown data

    White-other racial/ethnic differences in severe psychological distress did not change significantly overall or within income strata (P>.05 for each group).

    “The estimated differences between White individuals and the other racial and ethnic groups did not significantly change, either overall or by income level (P > .05for each group)”
    Quote in the paperNot a substantial claim
  • Findingown data

    In 2018, Latino/Hispanic adults had a significantly higher estimated prevalence of lacking a usual source of care than White adults overall and in both income strata (P<.001 overall and middle/high income; P=.002 low income).

    “in 2018, a significantly higher estimated proportion of Latino/Hispanic individuals did not have a usual source of care compared with White individuals, both overall and by income level (P < .001among the overall and middle and high-income groups, and P = .002among low-income groups)”
    Quote in the paperSubstantial claim
  • Findingown data

    Most of the decline in uninsured prevalence occurred between 2010 and 2015.

    “This decrease occurred mostly between 2010 and 2015”
    Quote in the paperNot a substantial claim
  • Findingown data

    By 2018, the difference in poor or fair health between White and Black low-income adults was no longer statistically significant (P=.13).

    “the difference in 2018 was no longer statistically significant (P = .13)”
    Quote in the paperSubstantial claim
  • Findingown data

    The analysis included 596,355 US adults from the National Health Interview Survey for 1999 through 2018.

    “The final study population included 596 355 adults”
    • Also stated in: § Abstract · plain
      “that included 596 355 adults”
    Quote in the paperSubstantial claim
  • May combine two claims. 32
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 16

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    The weighted proportions of the sample were 4.7% Asian, 11.8% Black, 13.8% Latino/Hispanic, and 69.7% White.

    “of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Black adults with low income had the highest estimated prevalence of poor or fair health (29.1% in 1999 and 24.9% in 2018), while White adults with middle or high income had the lowest (6.4% in 1999 and 6.3% in 2018).

    “Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In 1999, estimated prevalence of lacking a usual source of care was 17.0% for Asian, 13.0% for Black, 20.3% for Latino/Hispanic, and 10.6% for White adults.

    “The estimated percentage of people reporting being without a usual source of care in 1999 was 17.0% (95% CI, 14.2%-20.2%)among Asian individuals, 13.0% (95% CI, 11.7%-14.6%)among Black individuals, 20.3% (95% CI, 18.8%-21.9%)among Latino/Hispanic individuals, and 10.6% (95% CI, 10.1%-11.0%)among White individuals”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    During the same period, White-Asian, White-Black, and White-Latino/Hispanic differences in uninsured prevalence decreased significantly (P=.001, .03, and <.001, respectively).

    “In the same period, the estimated difference between White and Asian, Black, and Latino/ Hispanic individuals also decreased significantly (P = .001,P = .03,and P < .001respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In 1999, estimated functional limitation prevalence was 19.0% for Asian, 29.4% for Black, 22.5% for Latino/Hispanic, and 29.7% for White adults.

    “In 1999, the estimated percentage of people reporting functional limitation was 19.0% (95% CI, 16.1%-22.4%)among Asian individuals, 29.4% (95% CI, 27.4%-31.5%)among Black individuals, 22.5% (95% CI, 20.9%-24.3%)among Latino/ Hispanic individuals, and 29.7% (95% CI, 28.9%-30.6%)among White individuals”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In 2018, low-income White adults had the highest estimated functional limitation prevalence (57.0%), while middle- or high-income Asian adults had the lowest (20.4%).

    “in 2018, White individuals with low income had the highest estimated prevalence of functional limitation (57.0%[95% CI, 54.8%-59.2%]),whereas Asian people with middle and high income had the lowest (20.4% [95% CI, 17.4%-23.8%])”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In 1999, estimated poor or fair health prevalence was 10.0% for Asian, 17.7% for Black, 14.3% for Latino/Hispanic, and 9.4% for White adults.

    “In 1999, the estimated percentage of people who reported poor or fair health status was 10.0% (95% CI, 7.9%-12.6%)among Asian individuals, 17.7% (95% CI, 16.1%-19.4%)among Black individuals, 14.3% (95% CI, 13.0%-15.8%)among Latino/ Hispanic individuals, and 9.4% (95% CI, 8.9%-9.8%)among White individuals”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In 2018, uninsured prevalence remained significantly higher for Black adults by 3.0 percentage points (95% CI, 1.7-4.3; P<.001) and for Latino/Hispanic adults by 12.2 points (95% CI, 10.1-14.3; P<.001) compared with White adults.

    “in 2018, there was still a significant difference in the estimated uninsured prevalence between White and Black individuals (3.0 points higher for Black individuals [95% CI, 1.7-4.3];P < .001)and Latino/Hispanic individuals (12.2 points higher for Latino/ Hispanic individuals [95% CI, 10.1-14.3];P < .001)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The estimated White-Asian and White-Latino/Hispanic gaps in functional limitation did not change significantly from 1999 to 2018 (P=.10 and P=.34, respectively).

    “Between 1999 and 2018, the estimated gap between White and Asian and Latino/Hispanic individuals did not significantly change (P = .10and P = .34,respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The estimated White-Black and White-Latino/Hispanic gaps in poor or fair health did not change significantly (P=.08 and P=.88, respectively).

    “no significant change in the estimated gap between White and Black or Latino/Hispanic individuals (P = .08and P = .88,respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In 2018, low-income Latino/Hispanic adults had the highest estimated uninsurance prevalence (27.3%), while middle- or high-income White adults had the lowest (4.2%).

    “In 2018, Latino/Hispanic individuals with low income had the highest estimated percentage of uninsurance (27.3% [95% CI, 24.0%-30.8%]),whereas White individuals with middle and high income had the lowest (4.2% [95% CI, 3.8%-4.7%])”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    White-Asian and White-Latino/Hispanic differences in lacking a usual source of care decreased significantly by 5.3 points (95% CI, -9.0 to -1.7; P=.004) and 3.2 points (95% CI, -5.6 to -0.7; P=.01), respectively.

    “The estimated difference between White and Asian and Latino/ Hispanic individuals significantly decreased (-5.3 points [95% CI, -9.0 to -1.7; P = .004]and -3.2 points [95% CI, -5.6 to -0.7; P = .01],respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    From 1999 to 2018, functional limitation prevalence rose significantly for Black, Latino/Hispanic, and White adults at all income levels (P<.001) and for low-income Asian adults (P=.03).

    “Between 1999 and 2018, the estimated prevalence of adults reporting functional limitation increased significantly for Black, Latino/Hispanic, and White individuals regardless of their income level (P < .001for all) and for Asian individuals with low income (P = .03)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In 1999, estimated prevalence of not seeing or talking to a health professional in the past year was 20.6% for Asian, 14.0% for Black, 21.9% for Latino/Hispanic, and 13.2% for White adults.

    “The estimated percentage of people who reported not having seen or talked to a health professional in the past year in 1999 was 20.6% (95% CI, 17.8%-23.7%) among Asian individuals, 14.0% (95% CI, 12.7%-15.5%) among Black individuals, 21.9% (95% CI, 20.5%-23.4%) among Latino/Hispanic individuals, and 13.2% (95% CI, 12.7%-13.7%) among White individuals”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    From 1999 to 2018, lacking a usual source of care decreased significantly for Asian and Latino/Hispanic adults (P=.001 and P=.002), but not for Black or White adults (P=.92 and P=.20).

    “Between 1999 and 2018, the estimated prevalence of people without a usual source of care decreased significantly for Asian and Latino/Hispanic individuals (P = .001and P = .002,respectively), but not for Black and White individuals (P = .92and P = .20,respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Between 1999 and 2018, most racial and ethnic gaps in poor or fair health did not change significantly, with or without income stratification, except that the White-Black difference among low-income adults decreased by 6.7 percentage points (95% CI, -11.3 to -2.0; P=.005).

    “From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among low-income adults, poor or fair health prevalence increased significantly for White individuals (P=.01), significantly narrowing the White-Black gap (P=.005).

    “in the low-income strata, the estimated prevalence of poor or fair health among White individuals increased significantly (P = .01),significantly narrowing their gap with Black individuals (P = .005)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In 1999, estimated severe psychological distress prevalence was 0.8% for Asian, 3.0% for Black, 3.2% for Latino/Hispanic, and 2.3% for White adults.

    “In 1999, the estimated percentage of people who reported severe psychological distress was 0.8% (95% CI, 0.4%-1.5%)among Asian individuals, 3.0% (95% CI, 2.5%-3.7%)among Black individuals, 3.2% (95% CI, 2.6%-3.8%)among Latino/Hispanic individuals, and 2.3% (95% CI, 2.0%-2.5%)among White individuals”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Estimated low-income prevalence was 28.2% for Asian, 46.1% for Black, 51.5% for Latino/Hispanic, and 23.9% for White adults.

    “The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In 2018, racial and ethnic differences in health care access and affordability were present, although some gaps improved over time.

    “Racial and ethnic differences in health care access and affordability were also noted in 2018, though there were some improvements in the racial and ethnic gaps over time.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Between 1999 and 2018, US racial and ethnic disparities in health status, access, and affordability narrowed in some subgroups but mostly remained.

    “In this US nationally representative serial cross-sectional study, from 1999 to 2018, racial and ethnic differences in health status, access, and affordability improved in some subgroups, but largely persisted.”
    • Also stated in: § Conclusions · plain
      “In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.”
    • Also stated in: § Discussion · plain
      “Despite a wide variety of health care and social policies and markedly increased health care spending, 31 health inequities persisted with modest evidence of progress.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    White-Asian, White-Black, and White-Latino/Hispanic differences in not seeing a health professional did not change significantly over the study period (P=.97, .68, and .69, respectively).

    “The differences between White and Asian, Black, and Latino/Hispanic individuals did not significantly change during the study period (P = .97, P = .68, and P = .69, respectively)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    During the study period, low-income Black and White adults had the highest estimated rates of foregone or delayed care due to cost (21.0% and 21.1% in 1999; 21.6% and 24.7% in 2018), while middle- or high-income Asian adults had the lowest (4.5% in 1999 and 5.9% in 2018).

    “During this time, Black and White individuals with low income had the highest estimated rates of foregone or delayed care due to cost (21.0%[95% CI, 18.7%-23.4%]and 21.1% [95% CI, 19.9%-22.4%] in 1999 and 21.6% [95% CI, 19.2%-24.3%]and 24.7% [95% CI, 23.0%-26.3%] in 2018, respectively), while Asian individuals with middle and high income had the lowest (4.5% [95% CI, 3.1%-6.5%]in 1999 and 5.9% [95”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    From 1999 to 2018, foregone or delayed care due to cost increased significantly among Black (P=.004), Latino/Hispanic (P=.01), and White (P<.001) adults.

    “From 1999 to 2018, the estimated prevalence of foregone or delayed care due to cost increased among Black, Latino/Hispanic, and White individuals (P = .004,P = .01,and P < .001,respectively)”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The mean conditional response rate for the Sample Adult Core survey over the study period was 81%.

    “The mean conditional response rate of the Sample Adult Core survey during the study period was 81%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Between Black and White individuals, age-adjusted death rates narrowed from 1993 to 2015, but the gap began widening after 2016.

    “Age-adjusted death rates by race and ethnicity between Black individuals and White individuals narrowed from 1993 to 2015, but since 2016 the gap began widening.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
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    Study design and conductown data

    The estimated prevalence of poor or fair health was minimally different when using the NCHS methodology.

    “The difference between the estimated prevalence of poor or fair health with the prevalence estimated using the NCHS methodology was minimal”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The mean final response rate for the Sample Adult Core survey, accounting for household and family nonresponse, was 64.8%.

    “The mean final response rate of the Sample Adult Core survey, which accounts for household and family nonresponse, 13 was 64.8%”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Missingness for each study outcome was below 2.5%.

    “the rate of missingness was less than 2.5% for each”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    In this serial cross-sectional survey of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups but largely persisted.

    “In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Racial and ethnic differences in some self-reported health care access measures decreased significantly, but differences in affordability did not, both overall and within income strata.

    “There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation

    The NHIS survey design is a complex multistage area probability sample that adjusts for nonresponse and supports nationally representative estimates, including for underrepresented groups.

    “The survey uses a complex multistage area probability design that accounts for nonresponse and allows for nationally representative estimates, including among underrepresented groups.”
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    Study design and conductown data

    A sensitivity analysis using an autoregressive error term with one-year correlation was conducted to address serial correlation in annual outcome rates.

    “we also performed a sensitivity analysis to account for the serial correlation of annual outcome rates, incorporating an autoregressive error term with 1-year correlation.”
    Quote in the paperNot a substantial claim

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    Premisecitation

    The United States has implemented numerous public health policies and programs aimed at reducing racial and ethnic health differences.

    “Since then, the US has implemented many public health policies and programs to address these racial and ethnic differences.”
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    Premisecitation

    Income can affect health and health care access in the United States.

    “Considering that income can influence health and health care access in the US”
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    Study design and conductown data

    Trends in racial and ethnic differences for health care access, utilization, and affordability from autoregressive models matched the main analyses.

    “The trends in race and ethnicity differences in these measures of health care access, utilization, and affordability using the autoregressive models were consistent with the main analyses (eTable 13 in the Supplement).”
    Quote in the paperNot a substantial claim

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    Premisecitation

    Odlum and colleagues' analysis of the Behavioral Risk Factor Surveillance System from 1999 to 2018 produced broadly consistent results, though it did not examine income.

    “Odlum and colleagues, 28 with a different analysis that used the Behavioral Risk Factor Surveillance System from 1999 to 2018, had results that were broadly consistent although they did not examine income.”
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    Study design and conductcitation

    The study focused on broad racial and ethnic groups and did not examine subgroups within non-Hispanic Asian and Latino/Hispanic populations, whose patterns could differ and whose distribution could have changed.

    “Fourth, the study primarily focused on large racial and ethnic group categories and did not examine subgroups within the non-Hispanic Asian and the Latino/Hispanic groups, in which patterns could differ and whose distribution could have changed during the study period.37”
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    Premisecitation

    Self-rated health status is associated with comorbidity burden, including physical functional status.

    “Self-rated health status is associated with comorbidity burden-including physical functional status-and lower selfrated health is associated with increased mortality.25,26”
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    Premisecitation

    Lower self-rated health is associated with higher mortality.

    “Self-rated health status is associated with comorbidity burden-including physical functional status-and lower selfrated health is associated with increased mortality.25,26”
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    Premisecitation

    Mojtabai et al found no significant trends in severe psychological distress prevalence between 2001 and 2012.

    “For example, Mojtabai et al 29 found no significant trends in the percentage of people reporting severe psychological distress between 2001 and 2012”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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    Study design and conductown data

    Nonresponse rates could bias the results, and the NHIS lacks race- and ethnicity-stratified nonresponse data.

    “Third, nonresponse rates could bias the results and the NHIS does not provide data on nonresponse rates stratified by race and ethnicity, though the NHIS has several strategies to mitigate the bias.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Black, Latino/Hispanic, and American Indian individuals have worse self-rated health.

    “Research has shown that Black, Latino/Hispanic, and American Indian individuals have worse self-rated health.27”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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    Study design and conductown data

    Rates were adjusted for age, sex, and US region using logistic regression.

    “Rates are adjusted for age, sex, and US region using logistic regression, with 95% CIs shown with error bars.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Olfson et al reported a significant decline in severe psychological distress between 2004 and 2015.

    “whereas Olfson et al 30 reported a significant decline in severe psychological distress between 2004 and 2015.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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    Study design and conductreasoning

    Given the number of statistical comparisons, some significant associations may be type I errors.

    “Fifth, considering the number of statistical comparisons in this study, some of the significant associations may represent type I error.”
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    Premisecitation

    Self-rated health has been shown to predict morbidity, health care utilization, and mortality well.

    “However, self-rated health has been shown to be a good predictor of morbidity, health care utilization, and mortality.15,36”
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    • cites [15] source

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    • cites [36]

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  • The paper relies on this without support.

    Prior research had not examined national long-term trends from the individual's perspective.

    “Prior studies have not evaluated national, long-term trends from the individual's perspective.”

  • The paper relies on this without support.

    Eliminating racial and ethnic differences in health status and health care access is a US goal.

    “The elimination of racial and ethnic differences in health status and health care access is a US goal”

  • The paper relies on this without support.

    The ACA became law in March 2010.

    “Of note, the Affordable Care Act was enacted in March 2010.”
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  • Recent research covering a 20-year timespan demonstrated that African Americans and Latinos continue to experience more barriers to healthcare services compared with white individuals.

    “Moreover, despite the implementation of US policies to reduce healthcare disparities, recent research covering a 20-year timespan demonstrated that African Americans and Latinos continue to experience more barriers to healthcare services compared with white individuals [71].”

    From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [71]

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Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Psychological distress did not increase significantly for Asian individuals

    Minor

    The discussion says severe psychological distress increased significantly for all groups, whereas the results explicitly say its change among Asian individuals was not significant.

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Authors
Mahajan, S., Caraballo, C., Lu, Y., Valero-Elizondo, J., Massey, D., Annapureddy, A. R., Roy, B., Riley, C., Murugiah, K., Onuma, O., Nunez-Smith, M., Forman, H. P., Nasir, K., Herrin, J., & Krumholz, H. M.
Affiliations
  • Yale New Haven Hospital (US)
  • Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
  • Yale University (US)
  • Cincinnati Children's Hospital Medical Center (US)
  • Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • Houston Methodist (US)
Corresponding author
Krumholz, Harlan M.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2021-08-17
Volume
326
Issue
7
Pages
637
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2021.9907
PMC
PMC8371573
OpenAlex
W3195936663
Cited by
368
References
83
Citations by year
2026: 73 · 2025: 90 · 2024: 83 · 2023: 69 · 2022: 41 · 2021: 11 · 2020: 1
FWCI
28.31
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • medRxiv (acceptedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion, cc-by-nc-nd)
Funders
  • State of Connecticut Department of Public Health
  • Yale University
  • Shenzhen Center for Health Information
  • National Institutes of Health (UL1TR001863)
  • U.S. Food and Drug Administration
  • National Heart, Lung, and Blood Institute (K12HL138037)
  • National Center for Advancing Translational Sciences
Topics
  • Social Sciences › Health › Health disparities and outcomes
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
  • Social Sciences › Health › Public Health and Social Inequalities
Keywords
racial and ethnic disparities, health status, health care access, health care affordability, health care costs, low income, Black people, Asian adults, White adults, health trends

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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