Racial Disparities in Functional Impairment at the Very End Stages of Life

Racial disparities in life expectancy and mortality in the United States are longstanding and well-documented. In fact, for as long as researchers have collected data on mortality in the United States, studies show that White Americans have consistently enjoyed longer and healthier lives than Black Americans, with the most recent estimates by the CDC continuing to show a gap of about 3.5 years.

Yet despite these persistent differences in longevity, and counter to expectations, researchers have also found that racial differences in health tend to narrow in mid- to later-life. For example, Black adults generally experience higher rates of functional impairment (such as difficulty walking, climbing stairs, or lifting heavy objects) than their White peers, except at much older ages. At these older ages, some researchers have instead found that rates of impairment become similar—or converge—among both groups[1], shown in Figure 1.

**Figure 1.** *Example of Converging Racial Disparities in Functional Impairment*

Other studies have found that Black-White rates in functional impairment stop widening at older ages, resulting in a constant or persistent—rather than growing—disparity in health[2], shown in Figure 2.

*Figure 2. Example of Constant Racial Disparities in Functional Impairment*

One likely explanation for these inconsistent findings is that higher mortality rates among young and middle-aged Black Americans may result in a selective process where only the lucky few and most advantaged survive to the oldest ages. This may inadvertently distort statistical analyses such that it only appears that Black-White disparities narrow at older ages. Alternatively, this phenomenon may truly reflect a closing gap in racial disparities in health because the process of aging may universally deteriorate health for all groups. Additionally, federal programs such as Social Security and Medicare become widely accessible to all older adults, especially over the age 65, which may further reduce Black-White inequalities in resources and subsequent health outcomes. Understanding the true mechanisms underlying this process of diverging or converging health outcomes among Blacks and Whites has important implications for how governments and institutions estimate healthcare costs and allocate health services, as well as determining when in a person’s life interventions are needed the most.

Therefore, to address these conflicting findings, our study examined differences in functional impairment rates among a large North Carolina sample of Black and White, older adults during the vulnerable years leading up to the moment of death. The advantage of this approach is that it enabled us to set up a more direct comparison of Black-White differences in health in individual lives, while overcoming some methodological biases that may occur from higher rates of mortality among younger Black adults. Using this alternate approach, our results indicated that functional impairment rates among older Black adults increase at a faster pace than their White peers within the 2 years immediately preceding death. This Black-White divergence would not have been clearly visible had we adopted the standard approach, which typically uses an arbitrary age to set health comparisons. Additionally, our models also showed that financial resources necessary to address arising health needs, such as income, are especially important in reducing racial differences in impairment rates.

Overall, our study demonstrates the importance of exploring new methodological approaches when examining racial disparities in health. By shifting our focus from chronological age, our results highlight the individualized process of aging and the ongoing impact of inequality at the last stage of life. It is important to emphasize that our findings suggest that this inequality is not inevitable, however. Our analyses also indicated that resources such as income and supplemental health insurance are important for maintaining greater functional independence at older ages and can help to reduce the Black-White disparity. Accordingly, policymakers must strive to make greater and more equitable investments in health-related resources for Black Americans and other disadvantaged groups, even at the very end of life.