In 2010, at the end of the great recession that disproportionately harmed racial minorities and women, the federal government recognized that health disparities are caused by the social determinants of health (SDOH) (Figure 1), which are outside an individual's control. In fact, research shows that SDOH account for 80 to 90 percent of health factors that contribute to health outcomes. One of the five SDOH is economic stability (employment and wages), which accounts for 40 percent of the health factors that contribute to health outcomes.
To address the SDOH and health disparities, state and local governments adopted the health-in-all-policies (HiAP) approach to integrate policy responses across sectors and used health impact assessments (HIAs) to ensure decisions regarding laws and policies consider the health impacts. Unfortunately, recent research has shown that the application of HiAP and use of HIAs has not resulted in broad changes or actual reductions in the SDOH or health disparities. This is because neither the HiAP nor the HIAs require government officials or policymakers to understand or address historical and contemporary structural racism in laws and policies affecting the SDOH that cause poverty and lead to racial health disparities.
Structural racism operates at the societal level and is the power used by the dominant group to provide members of the group with advantages, while disadvantaging the nondominant group. The dominant group uses structural racism not only to obtain resources, such as employment and wages, but also to limit the nondominant group's access to these resources. During the Jim Crow era, structural racism sponsored by the federal and state governments explicitly created advantages for Caucasians and disadvantages for African Americans. Structural racism still exists after the Jim Crow era, which significantly disadvantages minority women and limits their access to health care.
In 2016, women had higher poverty rates than men in the United States. In fact, women have higher poverty rates than men in every state except Colorado and Idaho, where the rate is equal. The poverty rate for African American women is 21.4 percent, 18.7 percent for Latinas, and 22 percent for Native women, which was higher than the U.S. poverty rate of 12.7 percent. The poverty rate of African American women is almost twice the rate of Caucasian women in every state except Montana. The rates are highest for working-age women. According to a U.S. Census Bureau report on poverty, "the poverty rate for women aged 18 to 64 was 13.4 percent, while the poverty rate for men aged 18 to 64 was 9.7 percent, 3.7 percentage points lower." The difference in poverty rates is in part due to structural racism that prevents minority women from obtaining the same employment opportunities as Caucasians, limiting their ability to earn living wages.
The unemployment rate for African Americans has been at least twice as high as Caucasian unemployment for all but seven years during the 53-year period between 1962 and 2015. Research shows that more than one-third of jobs are filled through referrals, which has not changed for the last 26 years. For example, Ezorsky reported that in the 1980s and 1990s, over 80 percent of executives found their jobs through networking and 86 percent of available jobs did not appear in classified advertisements. Moreover, regardless of job title, industry, or location, minority women applicants were much less likely to report receiving an employee referral than their Caucasian male counterparts.
More specifically, minority women were 35 percent less likely to receive a job referral than Caucasian men. As a result of racially segregated neighborhoods, Caucasians do not interact with minorities at work, home, or other places and thus do not refer them for jobs. Consequently, Caucasian men use their power at work to refer more Caucasian men for jobs, which disadvantages minority women. Furthermore, U.S. organizations pay out employee referral bonuses. In fact, 42 percent of U.S. organizations pay out referral bonuses, and it is even higher for the technology industry, where 58 percent provided employee bonuses for referrals. Hence, these referral policies are an example of structural racism, because the policies advantage Caucasian men (the dominant group) by increasing their access to employment and referral bonuses, while limiting minority women's (the non-dominant group) access to employment and bonuses.
Even if minority women are hired, they are disproportionately employed in low-paying occupations, such as childcare, nursing, cleaning, waitressing, and teaching. Based on a Center for American Progress report, "nearly half--43 percent--of the 29.6 million employed women in the United States were clustered in just 20 occupational categories, of which the average annual median earnings were $27,383." Notwithstanding this segregation of women to low-paying jobs, when women work in similar professions and jobs as men, there are gender and racial inequalities in pay. The standard for most jobs is for employers to use past wages instead of qualifications as the basis for current pay, which advantages Caucasians, while disadvantaging minority women. This is because past wages for minority women are often less even though minority women have similar or higher qualifications than Caucasian men. Thus, wage disparities are an example of structural racism because the standard used for current pay advantages Caucasian men (the dominant group), while disadvantaging minority women (the non-dominant group).
Since 1967, the earliest year collecting wage information, minority women have made less than Caucasian males. In 1967, African American women made on average $0.43 for every $1 paid to a Caucasian man. By 2012, African American women made on average $0.64 for every $1 paid to a Caucasian man. The pay gap between African American women and Caucasian men is wider among older women, with the two biggest pay gaps being in women aged 25 to 44 (67 percent of male Caucasian pay) and 45 to 64 (59 percent). Because the widest gap is among older women, it should not be surprising that even when African American women have some postsecondary education, they are still paid less than Caucasian men. (Id.)
African American women with some college get paid $15.58 an hour compared to $22.51 an hour for Caucasian men with some college. In fact, African American women with some college get paid only $0.42 more an hour than Caucasian men without a high school degree. African American women with an advanced degree, such as a master's degree, make $7 less per hour than Caucasian men with a bachelor's degree and $17 less per hour than Caucasian men with an advanced degree.
Latina women are paid $0.54 for every $1 paid to a Caucasian man, the largest gap between all men and women. Specifically, women of Central American origin make 46.8 percent of what Caucasian men make, while women from Mexico make 50 percent; women from the Dominican Republic make 52 percent; and women from Cuba, Puerto Rico, and South America make less than 67 percent. Latina women with an advanced degree get paid $7.53 less an hour than Caucasian men with only a college degree. As Latina women and Native women increase their educational attainment, their pay gap with Caucasian men increases. In fact, Latina women and Native women need a master's degree before they surpass the wages of a Caucasian man with only a high school degree. The largest pay gap for Latina women is $17 an hour for workers with more than a college degree.
In terms of annual pay, African American women with a bachelor's degree or more make $50,200, about the same as a Caucasian man with some college. A Caucasian man with a bachelor's degree or more makes $76,708 annually, almost $27,000 more than an African American woman with a bachelor's degree or more. African American women with a bachelor's degree make $46,000 annually, only $3,500 more than a Caucasian man with only a high school diploma. African American women with a master's degree make $55,843, compared to $86,330 for Caucasian men with a master's degree.
Overall, African American women would have had to work seven months into 2017 to be paid the same as Caucasian men in 2016, while Latina women would have had to work 10 months into 2017 to be paid the same as Caucasian men in 2016. (Id.) Over their lifetime, African American women will have a lifetime wage gap of $867,920 and have to work until age 84 to earn what a Caucasian man will earn by the age of 60. Over their lifetime, Native American women will have a lifetime wage gap of $960,280 and must work until age 90 to earn what a Caucasian man will earn by the age of 60. Over their lifetime, Latina women will have a lifetime wage gap of $1,056,120 and must work until age 94 to earn what a Caucasian man will earn by the age of 60.
