Beyond Cost: Racialized Barriers to Healthcare Access Among Black Refugees in the United States

Background and Purpose: Racial health disparities remain among the most persistent forms of inequality in the United States. For Black refugee newcomers, these disparities are magnified by their abrupt introduction to the U.S. racial hierarchy, often accompanied by discriminatory treatment, cultural exclusion and institutional neglect. Unlike U.S.-born Black Americans, many Black refugees arrive with limited exposure to anti-Black racism but quickly become entangled in a landscape shaped by historical racial conflict, weakened infrastructure, and fragmented healthcare systems. These experiences are compounded by eroded social capital, disrupted networks and economic precarity rooted in prolonged displacement. Collectively, these forces shape both objective access to care and subjective perceptions of when and how to seek it. This study examines how structural and psychosocial factors influence healthcare access and cost-related delays among Black refugee populations in the U.S., situating their experiences within broader racial and ethnic disparities.

Methods: Data were drawn from the Annual Survey of Refugees (2020–2022), yielding a nationally representative sample of 4,532 refugees resettled in the U.S. between 2015 and 2021, including 1,351 Black participants (807 men, 538 women). Two multilevel logistic regression models were estimated to examine (1) delay in medical care due to cost and (2) self-reported healthcare access. Predictors included race (Black vs. non-Black), sex, age, time in the U.S., insurance, employment, physical and mental health, literacy, discrimination, and civic trust. Resettlement location was modeled as a random intercept to account for unobserved differences due to geographic variability. Model fit was assessed using AIC and convergence diagnostics. Adjusted predicted probabilities were calculated using marginal effects, and subgroup analyses were conducted for Black participants.

Results: Both models converged (delay model gradient = 0.001; access model = 0.010) with acceptable fit (AIC = 2358.1 for delay; 3166.8 for access). In the delay model, Black participants had lower odds of delaying care due to cost (OR = 0.62, p = .003), while no racial difference emerged in healthcare access (OR = 1.11, p = .32), revealing a mismatch between reported delay and actual access. Post-hoc models focusing on Black participants showed that structural integration factors were strong predictors across both outcomes. Full-time employment (OR = 0.85 for delay; 1.35 for access) and longer insurance coverage (OR = 0.90; 1.09) were associated with improved outcomes. Civic trust, measured by confidence in local police, was linked to reduced delay (OR = 0.73) and increased access (OR = 1.30). Resettlement location accounted for less than 5% of the variance in outcomes. Poor physical and mental health, discrimination, and literacy challenges also significantly shaped healthcare engagement.

Conclusions and Implications: Findings reveal a paradox in Black refugee healthcare: despite reporting fewer cost-related delays, they experience lower overall access, suggesting that barriers extend beyond affordability to include structural exclusion, institutional distrust, and racialized disconnection. This challenges the adequacy of traditional cost-based models of access and calls for more comprehensive frameworks in refugee health policy. Enhancing culturally responsive navigation through community-based partnerships and equity-focused resettlement may further improve healthcare access and reduce delay in help seeking.