Implementing a Black Women Best framework

Public policy can stack the deck against groups of people based on their race, gender, or other aspects of their identities. When those identities intersect, policy failures can overlap, compounding their effects. For example, systems that especially harm women and especially harm Black people are especially harmful to Black women.

This report traces how low pay, limited or ineffective health care, and a deeply flawed criminal legal system combine to reinforce poor health and economic outcomes for Black women. When policymakers ignore these intersections, they neglect one of their basic responsibilities: to create public policy that helps everyone, regardless of race, gender, ability, or status.

In Ohio, Black people are more likely than white people to experience poverty[1] and women[2] are more likely than men (Figure 1). Where those identities overlap — with Black women — the harm is greatest: Ohio’s Black women are more likely to experience poverty than Black men or white people regardless of gender (Figure 2).

Figure 1

Figure 2

This disparity is in part due to unequal pay. Black workers of all genders are paid less than their white counterparts and have been for at least a quarter century. Before 1993, the median wage for Black women in Ohio was greater than that of white women, for reasons that illustrate the complexity of intersecting identities: Policy Matters economist Michael Shields suggests that Black women’s higher median pay through the 1980s and early ‘90s is linked to their more consistent participation in the workforce compared to white women. White women worked less outside the home because white men were making higher wages at the median than other groups, which both enforced and permited gender-based limitations on white women outside the home.[3]

In fact, the gap between the median wage for Black workers and the median for white workers has grown since 1979, in part because over that period Black Ohioans’ pay actually fell by $0.59 an hour, adjusting for inflation — even as white Ohioans’ pay rose by nearly a dollar.[4]

Across races, women are paid less than their male counterparts, both because occupations that are primarily held by women are undervalued and low-paid[5] and because they are regularly paid less for the same type of work.[6] In fact, the gender pay gap nationally[7] increases as women age: The older women get, the greater the pay disparity between them and their male counterparts.[8]

Gender- and race-based factors compound disparities for Black women. In Ohio, employers pay Black women less at the median than any other race or gender group.[9] Since 1979, wages for Black women grew just $1.81[10] (11.6%), going from $15.59 in 1979 to $17.40 in 2022. By comparison, white women’s wages grew by $4.90 (32.4%), going from $15.11 in 1979 to $20.00 in 2022. That means Black women were paid 87 cents for each dollar paid to a white woman — and 67 cents for every dollar paid to a white man.[11] In 2022 Ohio’s median earnings follow a familiar pattern when considering the intersection of race and gender: Black women’s median earnings were significantly lower than their male and female counterparts.[12]

The pay disparity drives the poverty disparity, and directly drives child poverty, as Black women are more likely than their counterparts to be the sole or primary breadwinner for their families. Nationally, 68.3%[13] of Black mothers bear that responsibility — due in part to a criminal legal system that disproportionately harms Black men.[14] Equal pay for Black women and increased opportunities for economic stability, education, training, and childcare will have dramatic impacts on family security and child poverty.

Figure 3

In Ohio, where low-paying jobs are among the most common,[15] it is likely that a disproportionate share of those jobs are held by Black women. (We cannot say this for certain because the state does not report this data by race—see footnote 7.) The likelihood is based on two things we do know: (a) Black women are overrepresented nationally[16] in the types of low-paying jobs that are common in Ohio, and (b) Black women in Ohio are more likely than white women (or any other demographic group of women) to be either employed or actively looking for a job.

Nationally, Black women are overrepresented in one sector of the economy that does offer some higher-paying jobs: health care. (Health care is also part of one of the largest and fastest-growing sectors in Ohio’s economy.)[17] However, recent research finds that Black women are concentrated in the most dangerous and lowest-paid jobs in that industry.[18]

Black women have been underserved by policies that supported white women’s increased participation in post-secondary education,[19] eased the burden of childcare,[20] reduced food costs,[21] and created some measure economic stability in times of crisis. Heightened precarity and barriers to advancement shuttle Black women into low-paying work — or out of the workforce altogether.[22]

Economic insecurity drives poor health outcomes,[23] creating a vicious cycle: Being sick (or having to care for loved ones who are sick) makes it more difficult to maintain a steady job, which makes it more difficult to build a secure financial foundation, which makes a person more likely to experience negative health outcomes.[24] For example, Black Ohioans are more likely to die from chronic diseases than their counterparts in other racial groups,[25] in part because they are less likely to have access to adequate care.[26] The Health Policy Institute of Ohio (HPIO) ties that lack of access directly to economic conditions.[27] In their 2023 Health Value Dashboard, they report that seeing a doctor is cost-prohibitive for 1.6 times as many Black Ohioans as white Ohioans, a disparity that, if eliminated, would mean almost 45,000 more Black Ohioans could afford care.

Ohio’s legislature recently missed an opportunity to help more Ohio women (especially Black women) afford health care. Governor DeWine proposed a state budget that would have increased pregnant women’s eligibility for Medicaid to 300% of federal poverty level (a family of three with income just over $74,580 annually).[28] The legislature eliminated that provision, doing disproportionate harm to Black women, who are more likely than others to work jobs that don’t offer health care.[29] Expanding Medicaid access as the governor proposed would have increased Black women’s access to and quality of care, which could reduce their obscenely high maternal mortality rates. The legislature was presented with this option. They rejected it.

A lack of access to health care and other necessities — for example, nutritious food — are among the factors linked to high incidence of hypertension and other stress-related illnesses that drive poor health outcomes for too many Black women, especially Black mothers. The Journal of the American Heart Association identifies hypertension as “a major risk factor for eclampsia, preeclampsia, stroke, heart failure, and myocardial infarction” — some of the leading contributors to maternal mortality,[30] which plagues Black women in Ohio. They are more likely than women in other racial groups to die while or shortly after giving birth, suffering 29.5 deaths per 100,000 births in 2022. That is more than twice as likely as white women, whose maternal mortality rate that year was 11.5 deaths per 100,000.[31]

Figure 4

Black mothers who survive the birth process are more likely than women of other races to experience postpartum depression but are less likely to receive treatment[32] — which one study suggests may be attributed to a lack of outreach, low-quality services, or inadequate processes for postpartum mental health care.[33] Conversely, Black women nationally are less likely than white women to develop breast cancer — but they are more likely to die from it, suggesting a disparity in the quality and effectiveness of the care they receive.[34]

Boston University’s pioneering Black Women’s Health Study[35] has found — over the course of nearly 30 years and among 59,000 study participants — that “Black women are more likely … to die from cardiovascular disease, hypertension, stroke, lupus, and several cancers…twice as likely [as] white women to develop diabetes over age 55…[and] face greater [barriers to] health care, including a lack of health insurance, higher medical debt, and longer travel times to hospitals.” The study has helped establish links between experiences of racism and a variety of illnesses, including heart disease.[36] Researchers suggest this could have to do with the fact that experiences of racism increase the production of cortisol, a driver of chronic stress, which has itself been linked to heart disease.[37]

HPIO has found that Black Ohioans’ experiences with racism in the health care system itself may be driving poor health outcomes.[38] In their 2023 Health Value Dashboard, HPIO found that Black Ohioans are ten times more likely than white Ohioans to be “treated worse in health care due to [their] race,” and that, if personal experiences of racism were eliminated, “238,122 fewer Black Ohioans would experience physical or emotional symptoms” resulting from those experiences.[39]

No single policy is responsible for these ugly truths. That is the nature of intersectional oppression: Multiple failings converge on Black women. Black women face racial discrimination, and a disproportionate share of Black women experience violence, trauma, and financial burdens that uniquely place them at a higher risk for depression and psychological distress that negatively impact their mental health outcomes.[40] Sometimes the problem comes from medical professionals themselves: Studies have found persistent “fantastical” beliefs among white medical students and residents that Black patients have a higher tolerance for pain[41] and other “superhuman” medical characteristics.[42] These beliefs are rooted in the racist and cruel treatment of enslaved African Americans. The influence such beliefs could have on the treatment of Black women giving birth — and the related trauma they experience[43] — are unthinkable.

These racist assumptions occur in a health care system that too often neglects cultural competency, a critical element of efforts to reduce health disparities. The phrase refers to the ability of providers, practitioners, and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of their patients.[44]

For example, a culturally competent mental health provider must understand and be responsive to psychological characteristics that are common among Black women, including those identified by the “superwoman schema,”[45] a framework derived from Black feminist theory.[46] This framework helps health care providers, researchers, educators, and others understand the “perceived obligations” and pressures for Black women to be “superwomen” through incredible hardships by projecting strength, prioritizing caring for others over themselves, and resisting dependence and vulnerability. The framework is used now to understand the uniquely intersecting traumas[47] experienced by Black women, and the resiliency they may demonstrate.

The superwoman schema (and a lack of the cultural competency necessary to understand it) also partly explains why Black women are often reluctant[48] to seek professional mental health services.[49] Another reason may be that too few doctors look like them: Just 2.8% of practicing physicians in the U.S. are Black women.[50] If the gender breakdown is similar among Black mental health providers, then roughly 1% of practicing psychiatrists and 2% of psychologists providing care are Black women.[51]

Barriers to good health for Black women are especially clear in Ohio’s jails and prisons. The Prison Policy Initiative finds that people with low incomes are more likely to be sent to jail or prison.[52] Black women in Ohio are more likely to work in low-paid jobs and have limited access to health care, including mental and behavioral health support. That intersection of race-, gender-, and income-based discrimination overlaps with a legal system that too often criminalizes addiction, mental health crisis, and behaviors driven by destitution. Because of the intersections of race, class, and the legal system, Black women specifically are at risk for incarceration.[53] While only 0.12% of Black women in Ohio are incarcerated,[54] they are incarcerated at higher rates than women of other races.[55]

Incarceration further stacks the deck against Black women creating higher risks of a range of health problems,[56] including mental illness.[57] As one study put it, “research has consistently revealed the health issues of incarcerated women are treated inadequately or largely ignored” in jails and prisons.[58]

Further, an analysis of county-level data shows that incarceration harms whole communities: Every 1-per-1,000-person increase in the local jail incarceration rate was associated with a 6.5% increase in death rates from infectious diseases, and a 2.5% increase in suicide and drug related death in the county population.[59]

Ohio has taken positive steps to mitigate some of the damage of incarceration by creating the Medicaid Pre-Release Enrollment Plan in 2014. The program, long advocated by the American Bar Association, enrolls people in Medicaid before they leave incarceration, jumpstarting a connection to health services. A 2018 evaluation showed that the program was accomplishing its goals of improving physical and mental health (93.8% and 84.6% of the respondents reported such improvements).[60]

Medicaid’s inmate exclusion provision restricts or cuts off access to life-saving health services for people who are incarcerated, increasing the likelihood of chronic illness and new or worsening behavioral health issues. Many, including the American Bar Association have called for the federal repeal of the inmate exclusion.[61] This repeal would allow people in jails and prisons to be enrolled or continue their enrollment while incarcerated, drawing down federal funding for health care, allowing the savings to offset other costs while providing people with evidence-based care and care coordination. This could help disrupt a cycle that traps far too many women who, with effective care, could be living healthy lives with their families and communities.

The public policy choices that drive these inequitable outcomes are especially and uniquely harmful to Black women — who are at the intersection of gender-, race- and income-based disparities — and they make life more difficult for working people of all races and genders. But that fact has a surprising flipside, summed up by Janelle Jones with the phrase “Black Women Best”:

If Black women—who, since our nation’s founding, have been among the most excluded and exploited by the rules that structure our society—can one day thrive in the economy, then it must finally be working for everyone.[62]

We believe that by designing public policy to directly benefit Black women, policymakers can uphold principles of justice and measurably improve the lives of all of Ohioans, regardless of their race, gender, or background. Policies that increase the well-being of Black women will reach others who are also struggling against the odds to live, study, work, raise families, and build communities.

There is recent precedent for using policy to target help to people who face unique, intersecting barriers to wellbeing. In the early days of the pandemic, Governor DeWine recognized the urgent need to remove public health obstacles that were creating disproportionately high rates of COVID among Black and Latine communities by improving the social, economic, and physical environments of those same communities. The governor initiated a “strike force” to examine the disparities. That group issued 34 recommendations.[63] The report is no longer available on the governor’s website, but Policy Matters documented many of the most important recommendations, including increasing state budget funding for the Ohio Housing Trust Fund in the state budget, to provide for more safe and affordable housing in Ohio.[64] Had these recommendations been taken up, Black women — and others who faced similar needs — would have had better health and security outcomes.

These policy recommendations, which incorporate many of those made by the governor’s strike force, would be a good start:

Make sure every job pays enough to cover the cost of living by raising the state minimum wage. An initiative petition now collecting signatures for inclusion on the ballot this year would raise Ohio’s minimum wage to $15 per hour by 2026. The Raise the Wage Act of 2023 would raise the federal minimum wage to $17 per hour by 2028. Raising the minimum wage in Ohio would help 1.56 million working Ohioans, of whom 44.2% are Black.[65]

Put more money directly in the pockets of low-paid workers and families by creating an Ohio Child Tax Credit and adding a 10% refundable option to Ohio’s Earned Income Tax Credit (EITC).[66] For reasons described in this report, Black families are disproportionately represented in the 40% of Ohio families with the lowest incomes, who were completely left out of recent state income tax cuts. This recommendation would benefit many of them directly.[67]

Raise pay for childcare providers and workers — who are disproportionately Black women. Legislators can do this by increasing reimbursement rates for providers of publicly funded childcare and requiring a large share of that money go to raising employee pay and improving working conditions.[68]

Help families put food on the table by expanding access to the Supplemental Nutrition Assistance Program (SNAP);[69] modernizing the program for Women, Infants and Children (WIC);[70] and maintaining supportive funding for Ohio’s food banks.[71] Food insecurity is prevalent among Black women — in large part because of the many economic disparities described in this paper, but also because of the continuing legacies of redlining.[72] Women are more likely to experience prenatal and postpartum depression when they have inadequate access to nutritious food during pregnancy — and their babies face greater risk of some birth defects.[73]

Increase financial support for Black women throughout the medical professional pipeline, from recruitment to advancement and employment,[74] so patients who are Black women can access doctors who are too.[75] Expanding access to the Ohio College Opportunity Grant — the state’s only need-based student financial aid;[76] and developing a high-quality Ohio Promise program that improves on college promise programs in other states are two ways to increase higher education access for Black women, and all Ohioans who have to choose between education and debt.[77] The Department of Health’s loan forgiveness programs should be expanded and promoted to encourage and support Black and brown medical students in primary care, nursing, psychology, psychiatry, and other specialty areas. Cultural competency among health care providers could quickly be improved by requiring medical professionals to participate in effective ongoing training to identify and address unconscious bias and to expand understanding of different community’s needs and barriers when interacting with the health care system.[78]

Interrupt cycles of reincarceration — and respect basic human dignity — by ensuring people in Ohio’s jails and prisons can access medical treatment, behavioral health resources, and mental health supports. With approval from the legislature, Ohio can apply for a waiver of Medicaid’s “inmate exclusion”[79] which, if granted by the federal government, would allow many more imprisoned people (including many Black women) to access the care they need.

Build relationships with Black women and the organizations they lead, from the grassroots to the statehouse. Hire more Black women —and pay them equitably for their work — in positions from which they can influence policy design and implementation, including government agencies and advisory boards. Policies to reduce the cost of education, alleviate education debt, greater unionization and equal opportunity hiring policies can support these goals.

Apply a health equity lens to policy and improve data collection. Prioritize equitable outcomes in policy agendas for communities of color; conduct impact assessments of proposed policy to ensure equitable outcomes for communities of color, tailoring policies to meet the needs of communities of color, and strategically allocating resources and funds to advance equity.[80] Black families in Ohio disproportionately live below the poverty line, the state and federal government pushing them into neighborhoods with substandard living conditions and environmental issues that further impact their health.[81] Ohio legislators should fund and support evidence-based policy focused on improving the economic, physical, and mental well-being by requiring demographic data collection and disaggregated reporting across state programing to eliminate disparities and improve outcomes.

Stop treating Ohioans who experience a mental health crisis as criminals. Expand crisis services that explicitly include statewide non-police alternatives to crisis response. Increase state funding for local care response programs and give funding priority to health-first crisis response.[82]

These policies would build on some others that are already helping Black women and many others — most notably legislators’ decision to expand Medicaid in 2014, under the Affordable Care Act (ACA). Because Black women are more likely than others to work jobs that don’t offer health care,[83] they benefit when Medicaid coverage improves or access expands.[84] Ohio legislators recently used the state budget to expand Medicaid’s postpartum coverage to 12 months, allowing more mothers more time access health care in the critical first year after birth.[85]

The last state budget expanded Medicaid coverage of doula services and extends funding for doula certifications through the Board of Nursing.[86] Doula services are a vital maternal health care service for Black pregnant people because in many cases, women of these demographics have reported experiencing racial discrimination in traditional birthing environments. Research indicates that having a doula present during pregnancy, childbirth, and postpartum can improve health outcomes for Black mothers and their babies.[87]

State legislators also appropriated $1.2 billion for FY 2024 and $1.1 billion for FY 2025 for the Department of Mental Health and Addiction Services,[88] with funding for local crisis services and infrastructure, evidence-based research through the State of Ohio Action for Resiliency Network (SOAR) and growing a robust behavioral health workforce. Funding for these services could likely expand access to mental health care for Black women.

In Ohio and beyond, racially inequitable and so-called colorblind policies have not worked for — and have actively harmed — marginalized communities, largely linked by race and gender. When harmful policies intersect, as they do too often for Black women, the consequences can be devastating across generations.

Despite their immense capabilities, potential, and resilience, Black women in Ohio will remain at a structural disadvantage until we make their well-being a policy priority. For Ohio to become a state where everyone — of every race and gender — can lead happy, healthy lives, we need our legislators to listen to Black women, and make policy decisions that benefit them directly.

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