Discrimination in the Health Care System
August 1, 2018
Racial and ethnic minorities continue to be subjected to a sustained pattern of disparate treatment in health care with no panacea for the confluence of contributing factors. In the 2003 provocative landmark report, Unequal Treatment; Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (IOM) exposed a painful truth about the health care system. When racial and ethnic minorities enter the clinical arena, they are less likely to receive routine medical procedures, appropriate cardiac medications, or essential clinical services. The differences in how minorities are treated in health care contribute to their higher rate of disability and mortality.
Since the 2003 IOM report, the tendency for racial and ethnic minorities to receive an inferior level of care has not abated. A 2007 systematic review conducted by the Department of Veterans Affairs (VA) found that African American male veterans received less aggressive pain management for osteoarthritis, providers gave them less information about cancer, and clinical decision making varied based on the veteran’s race. More recently, the Agency for Healthcare Research and Quality revealed in the 2016 National Healthcare Quality and Disparities Report that “most disparities have not changed significantly for any racial and ethnic groups…especially among people in poor and low-income households, uninsured people, Hispanics, and Blacks.” Although the gap in health insurance coverage between minorities and whites has narrowed, differences have actually widened for quality indicators such as annual foot exams and prevention of lower extremity amputations among diabetics. Indeed, the persistence of health care disparities, which the Institute of Medicine defined as “differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness or intervention,” is alarming and depicts a dismal reality for ethnic and racial groups.
Although health care professionals pledge to deliver equitable and high-quality care to all individuals, the literature illustrates a different portrayal of what occurs during some clinical encounters; a narrative that has been difficult to reconcile. A recent poll conducted by the Robert Wood Johnson Foundation (RWJF), NPR, and the Harvard T.H. Chan School of Public Health revealed that some minorities have opted against seeking medical care rather than risk being treated poorly or subjected to discrimination. One can readily appreciate how perceived inequalities contribute to delays in treatment; which tend to worsen health outcomes, fuel the frustration of providers who earnestly desire to promote the health of the communities they serve, and trigger provider thoughts such as “if only they came in sooner.”
The inequalities in treatment described above are not meant to suggest that health care providers are racists. Conversely, the literature suggests a multitude of complex factors that influence treatment decisions and drive inequality. For example, Dr. Bowen-Matthews asserts, in Just Medicine; A Cure for Racial Inequality in American Health Care, that the Civil Rights Act of 1964 diminished overt racism and amplified covert acts of discrimination. Cognitive and social scientists suggest that the human brain is designed to categorize and label information to make sense of the constant deluge of stimuli. The brain’s propensity to group, judge and discriminate sets the stage for stereotypes, unfounded beliefs, and unconscious biases that could influence treatment decisions.
The historical roots of injustice, coupled with unconscious bias and the human tendency to discriminate raises two critical questions. First, could providers, who espouse to be egalitarian, navigate around the invisible forces that threaten to interrupt the delivery of equitable care and align their actions with their intentions? Indeed, this question has eluded humans for centuries. Secondly, is the United States doing enough to address discriminatory practices that infiltrate the health care arena? The RWJF has begun to illuminate the effects of discrimination and unmute conversations. However, unless more is done to counter negative thoughts and images that influence provider behaviors during clinical encounters with minorities, historical stereotypes and discriminatory practices are likely to continue.
The deconstruction of mental models that facilitate disparities coupled with educational policies that ensure students graduate with the knowledge, attitude, and skills to address discrimination, could be what’s missing from the equation that seeks to disrupt the historical patterns of injustice. Classroom conversations that help future providers counter negative stereotypes, explore how discrimination influences health outcomes, and identify practices that align professional values to behaviors, could fuel efforts to extinguish health care disparities.
Educational settings that provide opportunities for students to explore race-related topics that consider discrimination, racism, and privilege are critical. For example, the misguided beliefs regarding intellectual inferiority persist and could influence how providers deliver information to minorities. Addressing this issue allows the construction of language that seeks to eliminate this false stereotype. However, some educators prefer not to discuss race. Indeed, disrupting the climate of disparities requires race-related discourse.
Students in the health professions should argue against a curriculum that does not adequately address or contextualize race; students at Brown, Harvard, Yale, UCLA and others have shown that student advocacy can successfully facilitate curricular change. Educational settings should foster conversations regarding how society perpetuates health care disparities and embolden students to speak to the ways that they will extinguish discrimination. No health professional should graduate ill-prepared to mitigate their biases and safely discuss ways to dismantle discriminatory practices. Instead, future providers should consider the effects of discrimination and how human tendencies lead them to behave in ways that diverge from their intentions. One simple step to begin the development of this curricular dialogue would be to have educators discuss Discrimination in America: Solutions for Health and ask students to complete the following prompt “To reduce the risk to discriminate against my patients, I…?”
The social injustices that plague society have found their way into the clinical arena. The IOM and other organizations have legitimized and illuminated what is still difficult for many to accept; health care providers are not immune to the broad reach of discrimination because housed in every one of us is the ability to discriminate. Even still, it is difficult to accept that providers could discriminate since they are trained to be social justice advocates. However, the reality remains that race and ethnicity are still significant predictors of the quality of health care that is received. The quest to eliminate disparities has morphed into a national health equity movement. The extent to which this new language, grounded in optimism, makes a difference, may hinge on conversations that disrupt negative attitudes or assumptions regarding minorities. While educating patients is critical to extinguishing health care disparities, the greater burden of education continues to sit with providers. Hopefully, educators will not shy away from difficult conversations that address discrimination and will speak to the power of race inside the health care system.