Black-white life expectancy gap shrinking
by Tim Lockette
Oct 06, 2013 | 4811 views |  0 comments | 58 58 recommendations | email to a friend | print
MONTGOMERY — A black child born in America in 2013 can expect a life around four years shorter than a white child born on the same day.

Grim as that number is, Sam Harper sees it as good news.

"The gap has been shrinking," said Harper, an epidemiologist at Canada's McGill University. "The good news is that life expectancy for everyone is rising, but black life expectancy is rising faster."

Harper works in Montreal, hundreds of miles from the Deep South — but he doesn't have to live here to see one of the most telling signs of America's black-white divide. For at least a century, and likely much longer, black Americans have lived measurably shorter lives than their white counterparts.

Even today, the differences are stark. According to the most recent figures from the Centers for Disease Control and Prevention, black men in America can expect to live 72 years on average, compared to 77 years for white men. For women, lives are longer and the gap is shorter — 78 years for black women, 81 years for white women.

As part of an ongoing series on the different ways black and white people experience life in Alabama, The Star asked Harper and others to explain why there's still a gap in lifespan between the two groups. Those experts told a story of slow but steady progress, with medical advances and public policy efforts seemingly paying off in the long term.

That progress may be at a crossroads. The Affordable Care Act, also known as Obamacare, is expected to narrow the gap black-white gap in health care coverage — something that could eventually affect life expectancy. Still, some warn that large numbers of black Alabamians could miss out the program’s advantages if the state continues to resist health care reform.

Multiple factors

Julia Sosa is reluctant to cite just one reason for the racial gap in life expectancy.

"It depends on the angle you're taking with the question," said Sosa, assistant director of the state's Office of Minority Health.

If it's hard to sort out just one cause, it may be because African-Americans in Alabama, as a group, have poorer outcomes on almost every measure of health than their white counterparts.

The gap starts at birth. The infant mortality rate for black children in Alabama is roughly twice that for white children. The numbers of black children who die by accident or homicide before age 19, state numbers show, are nearly as high as the numbers of white deaths, even though the black population is much smaller. Later in life, blacks are more likely to be obese, and to have diabetes or heart disease.

Figures from the Centers for Disease Control and Prevention show that nationwide, heart disease is responsible for about one year in the life-expectancy gap between black and white Americans. Cancer accounts for a little more than half a year.

Sosa can cite several causes for each of those disparities, but poverty looms large among those reasons. Many Alabamians, she notes, live far from medical facilities and stores that sell healthy food, or don't know where to get care.

"It can be about education, it can be about socioeconomic level," she said. "I can't give you a single, clear-cut answer."

One thing that is clear is that African-Americans are much more likely to lack health insurance. One out of every six non-elderly Alabamians lacks health insurance, according to the Kaiser Family Foundation, a nonprofit that studies health issues. Most of the uninsured are white, but black people are disproportionately represented among them. About one-fourth of Alabamians are black, but one-third of the uninsured are African-American.

Simple and not-so-simple

Sometimes the link between poverty and early death is simple and clear. When state officials began to study the causes of infant mortality in Alabama, they found that a number of infant deaths were caused by co-sleeping – the practice of parents sharing their beds with infants, which can lead to fatal accidents. On further examination, state officials found that a number of young mothers simply couldn't afford a crib. So the state set up a program, funded by businesses and nonprofits, to buy cribs for moms living in poverty.

It was a good program, said Richard Burleson, head of the state's Child Death Review Team.

"It didn't catch on across the state the way we'd hoped, maybe because of the recession," he said.

Other links between poverty and early death aren't quite so clear. Sosa cites Department of Public Health statistics that show white residents getting certain cancers at higher rates — though African-Americans are slightly more likely to die of those same cancers.

Those numbers would seem to indicate that black patients with cancer simply weren't getting screened or treated. That could be due to lack of insurance, Sosa said, or it could be something else — such as a lack of awareness about their disease.

"A lot depends on when you go for your first screening," she said.

Sosa's office works on the knowledge gap. Funded largely by federal grants, the Office of Minority Health holds screenings and health fairs to boost awareness of health problems, and to get people in touch with agencies designed to help them. The office also works with doctors to help them communicate better with patients from diverse backgrounds.

It's hard to measure the success of any one of those projects, Sosa said.

"If we have a large crowd, we consider it a success," she said.

Slow success

Measured in the long term, however, the shrinking black-white gap is more clearly a success story.

Twenty years ago, the life expectancy gap was much larger, said Harper, the epidemiologist.

Harper cites three main reasons for the shrinking gap. Medical advances significantly reduced mortality from HIV infection, which disproportionately affects the black community. The homicide rate has declined steadily since its height in the early 1990s. And improved treatments for heart disease have prolonged the lives of people who have it.

Harper, Sosa and others told The Star that an increase in the number of insured people would likely raise life expectancies in every racial category.

On the narrower question of whether the Affordable Care Act would close the black-white gap, Harper said the answers aren't so clear.

At least one cross-national study suggests that under Canada's publicly-funded system of health care, racial disparities are lessened, even if they don't disappear. But Harper is quick to note that race doesn't have quite the same meaning in Canada.

"Canada doesn't have the same legacy," he said.

What about Massachusetts, which already has a health insurance program similar to Obamacare? Harper has been comparing the shrinking gap on a state-by-state basis, for an as-yet-unpublished paper. He said his preliminary results show the gap actually shrank more in Alabama than in Massachusetts over a 20-year period — but he's not sure that means anything, because the Massachusetts system is relatively new.

"I'm not sure it's the right time frame we'd need to answer that question," he said.

To expand or not?

If nothing changes, Alabama will still have a significant number of uninsured adults after the Affordable Care Act goes fully into effect at year's end.

In a ruling last year, the U.S. Supreme Court concluded that the federal government can implement the ACA, but can't order states to expand Medicaid, the joint state-and-federal health care program for people in poverty.

In Alabama, adults with children can be covered by Medicaid if they live below the poverty line. The original plan, under Obamacare, was to extend that coverage to people with incomes as high as 138 percent of the poverty level — covering a gap between people on Medicaid and people who can afford their own insurance.

Alabama Gov. Robert Bentley, like most governors in the South, declined to expand the program — despite federal subsidies that would cover most of the cost of the expansion.

Bentley said Alabama's Medicaid program needed to be fixed before it could be expanded. He launched an effort to make cost-cutting reforms in the program, which will cost the state more than $600 million this year.

That could have a significant impact on health care outcomes for black Alabamians, said Jessica Stephens, who studies minority health disparities for the Kaiser Family Foundation.

Kaiser's numbers show approximately 428,000 uninsured Alabamians who would get insurance if Medicaid expanded. (That’s near the high end of the estimates produced by researchers at the University of Alabama Birmingham last year. Most state officials quote UAB’s middle-range estimate of 300,000 people.)

According to Kaiser’s numbers, minorities make up more than half of those who’d get coverage under Medicaid expansion — including 152,000 African- Americans and 55,000 Latinos.

Stephens said she didn't know whether long-term resistance to the Medicaid expansion would affect the longevity gap. But it would likely keep states from closing the gap on many of the race-based disparities in health outcomes, she said.

"These disparities could actually increase," she said.

The Star's attempts to reach Bentley's staff for comment were unsuccessful.

Stephens, however, said she didn't think resistance to the Medicaid expansion will last forever.

"We saw this with adoption of Medicaid and with CHIP (children's health insurance programs)," she said. "It took some states some time to accept them."

Capitol & statewide reporter Tim Lockette: 256-294-4193. On Twitter @TLockette_Star.

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