Black Representation in the Primary Care Physician Workforce and Its Association With Population Life Expectancy and Mortality Rates in the US

Introduction

This study evaluates the links between Black representation among primary care physicians (PCPs) and health outcomes for Black individuals in the United States. It investigates whether having higher levels of Black PCP representation at the county level is linked to higher life spans and lower mortality rates of Black individuals; the study also explores whether Black PCP representation at the county level mitigates health disparities between Black and white individuals.

The study utilizes county-level data, including poverty rates, uninsured rates, and median home values, across three years – 2009, 2014, and 2019 – for evaluating the effects of Black PCP representation on Black life expectancy and mortality.

The study’s importance lies in its implications for health equity and public health policy. The authors mention past studies showing greater availability of primary care services in communities being linked to better population health outcomes, including longer lifespans and lower levels of mortality. However, differences in health outcomes still persist between Black and white individuals. Therefore, by focusing on the relationship between Black PCP access and Black health outcomes, this research increases the field’s understanding regarding the influence of a higher prevalence of Black PCPs on health outcomes for Black individuals within a respective geographic area.

The authors of this study include John E. Snyder, Director of the Office of Planning Analysis and Evaluation at the Health Resources and Services Administration within the U.S. Department of Health & Human Services (HHS); Rachel D. Upton, Senior Health Scientist at the Office of Planning, Analysis, and Evaluation at the Health Resources and Services Administration (HRSA); Thomas C. Hassett, Health Scientist at the Office of Planning, Analysis, and Evaluation at the Health Resources and Services Administration (HRSA); Hyunjung Lee, Health Equity Data Analyst at the Office of Health Equity at the Health Resources and Services Administration (HRSA) and Research Scientist at the Oak Ridge Institute for Science and Education; Zakia Nouri, Senior Research Analyst at Workforce Studies at the Association of American Medical Colleges; and Michael Dill, Director of Workforce Studies at the Association of American Medical Colleges.

Methods and Findings

Methods

This study uses a cohort design, meaning it observes a group of participants over a period of time. County-level data were collected for three years: 2009, 2014, and 2019. Data sources included: 

• The American Medical Association (AMA) Physician Masterfile which provides details about physician characteristics and where they practice;
• Databases from the Association of American Medical Colleges (AAMC) that contain self-reported race and ethnicity information about physicians; and
• County-level population data on race and ethnicity, which were derived from 5-year estimates from the Census Bureau’s American Community Survey.

Counties included in the study were required to have at least one Black PCP in one or more of the specified years. Out of the 3142 Census-defined U.S. counties, 1618 counties met this requirement and were included in the analysis while the rest were excluded due to the absence of Black PCPs. The main variable studied was the proportion of Black PCPs to Black population in each county, known as the community representativeness ratio. The study’s main measures were age-adjusted life expectancy, mortality rates for Black individuals, and disparities in mortality rates between Black and white individuals. 

To evaluate the association between Black PCP representation and the aforementioned outcome measures, the researchers utilized mixed-effects growth models. These models allowed the researchers to analyze data change over time and across different groups and include both fixed effects (consistent across all observations) and random effects (varying across different groups). The analysis controlled for factors such as poverty rates, uninsured rates, and rural or urban status among others.

Findings

The study found that having a greater representation of Black PCPs within a given county was associated with improved health outcomes for Black individuals. Specifically, a 10% increase in Black PCP representation was linked with an increase in life expectancy by approximately 31 days and a decrease in mortality rates by approximately 13 deaths per 100,000 Black individuals. In addition, higher levels of Black PCP representation were associated with a decreased disparity in mortality rates between Black and white individuals within a given county. Furthermore, the study’s analysis revealed that the association between Black PCP representation and life expectancy was even stronger in counties with higher poverty levels.

Ultimately, these findings show a positive association between Black PCP and improved health outcomes for Black people and suggest the need for strategies to increase the presence of Black primary care physicians to potentially reduce health inequities and improve overall public health.

Conclusions

The findings suggest that having higher ratios of Black PCPs within a given county is associated with better health outcomes for Black people. Specifically, the study demonstrates that a higher proportion of Black PCPs is associated with longer life expectancy and lower mortality rates among Black individuals. The Black-white mortality disparity reduces in counties with higher ratios of Black PCPs, as well. This beneficial effect is more pronounced in areas where poverty rates are higher, which suggests that the benefits of higher of Black PCPS are amplified more in socioeconomically disadvantaged areas.

Based on the study’s findings, the authors recommend targeted investments and policies aimed at increasing the number of Black PCPs, particularly in underserved and high-poverty areas. Strategies could include expanding support for medical education programs that recruit and train Black students, as well as implementing retention initiatives to ensure these physicians remain in practice within these geographic areas.