Beyond Equal Access

Black populations experience “diminished gain” in health outcomes even when they have access to protective socioeconomic and psychological factors, so policy initiatives must do more than removing barriers by using evidence-based strategies to achieve equal outcomes

Reviewed by Penny Sun


There is a large, consistent, and persistent gap in many different indicators of health status, across the lifespan, between Black and white populations. The author attempts to break this problem down to its root cause: first, the author notes that while it may be possible that there could be biological or genetic differences between Black and white populations, it is highly unlikely that this is the only reason for the gap in health outcomes. Next, the author notes that while Black patients receive lower-quality healthcare than white patients, this also does not explain the gap in health outcomes, since it ignores the fact that health status is also impacted by individuals’ socioeconomic and psychological factors. Finally, the author argues there are two ways that structural racism impacts the effect of socioeconomic and psychological factors on Black people’s health: “differential exposures” (lower access to protective socioeconomic and psychological advantages and higher amounts of health risks) and “differential effects”, or “diminished gain” (less “bang for the buck” out of the resources that they do have: the same economic, social, and/or psychological resources are less protective for Black people than for white people). The author points to evidence from large national surveys with multiple years worth of data from thousands of individuals over a wide range of participant age to show that typically protective social factors (employment, education, social networks) and psychological factors (self-efficacy, sense of control over life) have less impact on extending life expectancy or preventing premature mortality among Black patients than white ones. 

Thus, the key finding of this work is that differential exposure to risk and protection doesn’t fully explain the health gap between Black and white people: you can’t “solve” the gap just by removing socioeconomic differences, segregation, or discrimination because the evidence shows that improving socioeconomic status has less impact on health for Black patients than white ones. Social class and economic status modify the impact of race on health; but their intersection also amplifies the Black-white health gap by creating additional barriers to protective psychosocial resources. Secondly, you can’t “solve” the Black-white health gap by only focusing on the healthcare system because health is impacted by social and economic structure. Thus a broader, sociological approach to health disparities is needed. Using these insights, the author poses several social and economic policies that follow from their research. First, they note that income is not as vulnerable to diminished gain, so income redistribution is a crucially important policy strategy. Similarly, diminished gain shows that policies that aim for equality in access will not go far enough to achieve equality in outcomes, so there is a need for policies that directly target barriers at multiple levels and leverage protective factors, like religion and social support. At the same time, policies that expand the Black-white health gap must be avoided and policies that police discrimination must be enforced. 

This article brings together evidence to prove that the Black-white health gap results from social processes that prevent Black populations from fully realizing the protective potential of their resources, rather than individual behavior choices. This means that the health gap can be changed if there is a concerted push to address structural racism in US institutions. Dr. Assari is well-published in the effects of race, ethnicity, gender, and place on health consequences and is a leader in health equity research. He continues to push the research agenda on the impact of social and economic policies on attaining health equity, and also illuminates the complex interplay of race, gender, and class on health.

Methods and Findings

The research team observed data from large national surveys and cohorts: study duration ranged from 2 years to 25 years; study size ranged from 1,500 adults to more than 37,000 adults; and study populations ranged from adolescents to older adults.

The author’s hypothesis is: if Black people are less protected by socioeconomic class, then white people who lose socioeconomic resources should go through a bigger health loss than comparable Black people. The author used historical analyses to show that the Black-white health gap increases as a direct consequence of widening economic (income and wealth) disparities. The author considered five interconnected mechanisms to explain different determinants of “diminished gain” impacts on health, including structural racism in the labor market, purchasing power, chronic exposure to discrimination, cumulative disparities starting with an initial advantage, and cost of upward social mobility.


The author recommends using the evidence of diminished gain to drive development of social and economic policies and to guide future research. The research evidence shows that income demonstrates less effect of diminished gain compared to other socioeconomic and psychological factors, so income redistribution should be a central policy strategy to address diminished gain. Similarly, policies should leverage religion and social support because the evidence shows that they are particularly protective for Black populations. Diminished gain also separates access from outcomes: equal access does not go far enough to close the Black-white gap in health outcomes, so policies must go further to also remove barriers. This includes eliminating policies that widen the Black-white health gap and enforcing policies that aim to police discrimination. Finally, it is crucial that policies target individual, organizational, and institutional racism.

Strategies for income redistribution include raising the minimum wage for jobs typically occupied by BIPOC; closing the racial wage gap; and instituting tax policies that allow low income families to build wealth. Cash assistance and temporary financial incentives may help with deep poverty. Strategies for going beyond equal access include tailoring interventions and programs to address the specific needs of BIPOC communities. This means specifically removing structural and societal barriers to improving health outcomes, which supports the need for affirmative action. The author also points to the impact of the education, employment, housing, criminal justice, and economic (banking and lending practices) sectors on health outcomes.

The author concludes that because Black populations face more social and economic adversity, they have developed increased resilience to additional economic and psychological risk factors, unlike white populations. Thus, Black populations’ poor health outcomes result from their consistent exposure to many contemporaneous risk factors and systematic exclusion from protective factors. The author emphasizes the need to identify, measure, and mitigate health inequities across population groups and to conduct further research to separate the effect of culture and societal structure on creating and reinforcing health inequities. In addition, the author argues for the need for an intersectional framework to guide future research in examining and explaining differences in health status and health risks within Black populations. Finally, the author notes that although the totality of the body of research he draws on is sufficient to substantiate his argument, he points out that the individual studies are correlational not causal (due to ethical concerns). The author suggests that further studies that use more sophisticated analytical methods may further strengthen the argument.


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