Although we all deserve the best possible healthcare, in reality, discrimination and disparities in healthcare harm patients throughout the US. Patients can experience discrimination in healthcare based on their race, ethnicity, gender, age, sexuality, and more. Biased treatment and limited access to care can lead to worse outcomes. Unfortunately, discrimination and disparities in healthcare are systemic issues that will be difficult to overcome.
What’s the difference between discrimination and disparities in healthcare?
Discrimination in healthcare occurs when a provider treats others differently based on personal factors, such as age, race, ethnicity, sexuality, wealth, education and more. Discriminatory treatment, which is a form of bias, can be conscious or unconscious. For example, providers may dismiss a patient’s symptoms or health concerns. Or providers may base treatment recommendation on the patient’s insurance, may not provide care in a patient’s preferred language, or may treat a patient unfairly.
On the other hand, disparities in healthcare refers to differences in health conditions, treatments, and outcomes. Some of the disparities are due to discrimination, such as when certain groups experience systemic worse health outcomes, have an increased rate and severity of certain diseases, and have greater difficulty accessing healthcare services.
Importantly, some disparities can be due to genetics. For instance, Black people are more likely to get sickle cell anemia. And Black smokers develop lung cancer at younger ages than white smokers, even when they smoke fewer cigarettes.
Implicit bias impacts providers’ thoughts and actions.
Importantly, some healthcare providers are aware of their biased feelings while others may not even realize they are discriminating against particular patients. How is that possible? Implicit bias, the unconscious prejudice you can feel about another thing, group, or person.
Implicit bias is involuntary and lies deep in our subconscious, affecting our actions without us realizing it. Note that people, including healthcare providers, can also have explicit bias – meaning they are aware of their negative opinions regarding a certain group.
Most clinicians want to provide excellent medical care to all their patients, regardless of race, gender, sexual orientation, or finances. However, since we are all subject to implicit bias, it is at play in many medical encounters, and can influence how providers interact with patients.
Unfortunately, implicit bias can impact patient health in many ways.
Firstly, implicit bias may impact the types of treatment options offered to particular groups of patients. For instance, implicit bias may lead providers to avoid recommending expensive, cutting-edge treatments, based on their assumptions that certain groups of patients cannot afford specialty care. Alarmingly, research shows that many non-white cancer patients are not offered the same high-quality care as white patients.
Additionally, implicit bias may cause providers to assume patients have limited health literacy, leading providers to limit their explanations of a diagnosis and treatment options. When this happens, patients cannot fully understand their condition and/or participate in shared decision making.
Simply put, patients who experience discrimination can have poorer care and/or outcomes.
How common is bias and discrimination in healthcare?
A 2022 survey of over 2,000 adults by MITRE-Harris indicates a large number of people feel their healthcare providers have biased views against them.
Alarmingly, more the 50% of Blacks and Hispanics feel the “healthcare provider is biased against me based on their attitude, words, or actions”. Overall, 40% of respondents felt providers were biased against them.
Interestingly, 52% reported they have felt their symptoms were “ignored, dismissed, or not believed” when seeking medical treatment. Moreover, 6 out of 10 members of the Hispanic community report those types of feelings.
Importantly, the results indicate that some people are much more likely to experience bias, doubt, or language barriers when seeking treatment, including:
- People identifying as a person with a disability.
- Those with chronic health conditions.
- Members of the LGBTQ+ community.
- People who manage access to healthcare for a family member or friend.
Findings from another survey.
A 2019 survey found lower rates of discrimination in healthcare. Of the 2,100+ respondents, 21% of respondents reported experiencing discrimination in the healthcare system. Moreover, 72% of those reported experiencing discrimination more than once.
Among the respondents who reported discrimination, the following characteristics were identified as the cause:
- 17% – racial/ethnic
- 13% – educational or income
- 12% – weight
- 11% – gender
- 10% – age
Their analysis found that the odds of experiencing discrimination were higher for respondents who identified as female. Conversely, the odds of experiencing discrimination were lower for older respondents, those from households earning at least $50,000/year, and for those reporting good or excellent health.
An important caveat.
The numbers from these surveys may not reflect the actual number of patients who experience discrimination. because some who face discrimination may not even realize it. For instance, when your doctor recommends a treatment, you may not realize there are other alternatives, such as a more expensive cutting-edge treatment, that your doctor doesn’t suggest due to bias.
Ongoing stress from discrimination harms patients.
Any chronic stress, including the stress caused by discrimination, wreaks havoc with our bodies and minds. The prolonged stress response and resultant exposure to our stress hormones increases our risk of many health problems, including:
- Digestive problems.
- Muscle tension and pain.
- Heart disease, heart attack, high blood pressure and stroke.
- Sleep problems.
- Weight gain.
- Memory and concentration impairment.
How can discrimination and disparities in healthcare influence patient behavior?
Patients who experience discrimination, often by sensing a provider’s implicit bias, can have a poor patient experience. When this happens, patients may:
- Fail to engage in their care.
- Become distrustful of their providers and the healthcare system.
- Not communicate openly with their providers.
- Avoid medical care.
For example, a 2020 Urban Institute’s survey asked people if they ever felt that doctors treated or judged them unfairly based on their race or ethnicity, and if so, how it impacted their care. Importantly, among those who reported feelings of discrimination, 76% reported that such treatment or judgment disrupted their receipt of healthcare. Within this group:
- 39% delayed care.
- 34.5% looked for a new healthcare provider.
- 31% did not get needed care.
Certainly, all of these behaviors can negatively impact patient health.
Discrimination and disparities in healthcare harm ethnic and racial minorities.
The racial health gap in the US is well-documented. Latinx and Blacks experience 30-40% poorer health outcomes than white Americans, causing increased illness rates and shortened life spans.
Sadly, a 2022 study by The Commonwealth Fund found that 25% of Black and Hispanic adults over age 60 said they’ve experienced racial discrimination in healthcare.
A few examples of how discrimination and disparities in healthcare impact minorities:
- Black patients are more likely to suffer injuries and acquire illnesses while hospitalized, as compared to white patients of the same age and gender while treated in the same hospital.
- The death rate from breast cancer for Black women is 50% higher than for white women. Racial and economic inequities in screening and treatment options contribute to this difference in survival rates.
- Blacks have higher rates of heart failure and strokes than whites.
For an in-depth look at the issue, read my blog Ethnic and Racial Discrimination in Healthcare.
Discrimination and disparities in healthcare harm women.
Doctors and nurses treat women differently from men, which can delay treatment and cause harm. Additionally, medical research has long been focused on men, leading to guidelines for diagnosis and treatments based on a man’s biology.
This male focus has caused misdiagnosis and harm for women, because tests, dosages, symptoms, and treatments for major diseases have long been based on the “typical” 154-pound white male patient.
Fortunately, times are changing, and research is starting to focus on men and women.
For a full article on how discrimination and disparities can impact women’s health, read my blog Is There Gender Bias in Medicine?
Discrimination and disparities in healthcare harm LGBT+ patients.
Sadly, discrimination in healthcare endangers LGBTQ people’s lives through delays or denials of medically necessary care.
Adult LGBT+ patients may receive poor quality of care due to stigma, lack of awareness by healthcare providers, discrimination, and insensitivity to the unique needs of this community. Similarly, LGBT+ youths face hurdles to quality care.
Many medical providers are implicitly biased against LGBT+ patients.
Unfortunately, many healthcare providers have explicit or implicit biases against LGBT+ patients.
One study examined the attitudes towards LGBT+ patients among almost 20,000 healthcare providers (doctors, nurses, mental health providers, and others). Sadly, among heterosexual providers, implicit preferences always favored heterosexual people over lesbian and gay people.
Research shows that LGBT+ patients can experience denials of care, inadequate care, verbal abuse, disrespectful behavior, and other barriers to high quality care.
LGBT+ patients experience widespread discrimination and harassment.
Importantly, results of a July 2021 survey of LGBT+ adults by the Kaiser Family Foundation found that LGBT+ people were more likely to report a range of negative provider experiences. For instance, LGBT+ people are more likely to report that medical providers blame them for their health conditions or dismiss their concerns.
Additionally, the findings of a 2010 survey by the National Gay and Lesbian Task Force and the National Center for Transgender Equality found rampant discrimination of transgender people. For instance, 28% of respondents reported experiencing harassment in medical settings.
A 2017 survey by Center for American Progress (CAP) of lesbian, gay, bisexual, and queer (LGBQ) found the following, based on their experiences during the previous year:
- 9% stated a doctor or other provider used harsh or abusive language when treating them.
- 7% reported they experienced unwanted physical contact from a doctor or other provider (such as fondling, sexual assault, or rape).
Additionally, the CAP 2017 survey of transgender people showed concerning levels of mistreatment in the previous year. Among the responses:
- 23% said a doctor or other provider intentionally misgendered them or used the wrong name.
- 21% said a doctor or other provider used harsh or abusive language when treating them.
- 29% reported they experienced unwanted physical contact from a doctor or other provider (such as fondling, sexual assault, or rape).
LGBT+ patients can struggle to receive health care services.
Unfortunately, it can be hard for LGBT+ patients to find care providers willing to treat them.
In a 2017 survey by Center for American Progress (CAP), 8% of lesbian, gay, bisexual, and queer (LGBQ) respondents reported that in the previous year, a doctor or other provider refused to see them because of their actual or perceived sexual orientation. Additionally, 6% reported a doctor or other provider refused to give them health care related to their actual or perceived sexual orientation.
Even more alarming, in the CAP survey of transgender people, 29% of respondents were refused care in the previous year. And 12% reported a doctor or other provider refused to give them health care related to gender transition.
And in the 2010 survey of transgender or non-conforming people, 19% reported being refused medical care. The numbers were even higher for non-white respondents.
LGBT+ patients avoid healthcare due to discrimination.
Discrimination – even the potential for discrimination – can deter LGBTQ people from seeking medical care.
In the 2017 CAP survey, 8% of all LGBTQ people avoided or postponed needed medical care the previous year due to disrespect or discrimination from healthcare staff. The number jumps to 14% for respondents who experienced discrimination based on their sexual orientation or gender identity in the past year. Among transgender people, 22% avoided or postponed care.
Similarly, in a survey of gay, lesbian, and bisexual veterans, 25% of respondents reported avoiding at least one Veterans Health Care Administration (VHA) service because of concerns about stigma.
Many providers don’t understand this populations’ needs.
Unfortunately, the education and training for healthcare professionals regarding the unique needs and treatment of LGBT+ patients is lacking. For instance, in the survey of transgender and non-conforming people, 50% reported having to teach their medical providers about transgender care.
Clearly, this lack of understanding of the needs of this population impacts the quality of care provided. Unsurprisingly, many LGBT+ patients receive unsatisfactory or unequal healthcare treatment.
LGBT+ people may have poorer health.
The results of the July 2021 report, Kaiser Family Foundation show that LGBT+ adults more commonly report being in fair or poor health than non-LGBT+ adults, despite the fact they are a younger population.
Additionally, LGBT+ people reported higher rates of ongoing health conditions, disability, or chronic illnesses.
Discrimination and disparities in healthcare harm disabled patients.
Although the Americans with Disabilities Act (ADA) prohibits healthcare discrimination based on disability status, patients with disabilities continue to experience unequal care access due to discrimination and implicit bias.
For instance, recent research found that doctors deny care to people with disabilities and have biased attitudes toward disabilities.
In addition to patients with disabilities facing implicit and explicit bias from providers, they may also have to contend with physical barriers, such as lack of wheelchair access.
Doctors report difficulties caring for patients with disabilities.
In a recent survey of 714 US doctors, only 41% felt very confident about their ability to provide the same quality of care to patients with disabilities. And only 56% strongly agreed that they welcomed patients with disability into their practices.
And 18% strongly agreed that the healthcare system often treats disabled patients unfairly.
Additionally, in a recent focus group comprised of a total of 22 doctors, the doctors identified multiple barriers to providing care for people with disabilities.
For starters, nearly all the doctors stated they received little or no training on the ADA and its implications for their practices. And the doctors expressed a lack of sufficient knowledge, experience, and skills among themselves and their clinic staff need to care for people with disabilities. Some doctors shared they have denied care to people with disabilities or tried to remove people with disabilities from their practices.
Furthermore, some expressed negative attitudes about the ADA.
All participants reported physical barriers to caring for people with disabilities, including accessible buildings and equipment to conduct basic health assessments. In fact, the doctors were particularly concerned about the ADA’s requirements for providing accommodations. Importantly, the doctors felt they did not receive adequate reimbursement for accommodations made. Because of this financial burden, some doctors tried to discharge disabled patients from their practices.
Additionally, none of the doctors were able to provide written materials in Braille. Unsurprisingly, many providers reported relying on caregivers during healthcare encounters.
Experts believe that doctors’ bias and general reluctance to care for people with disabilities play a role in perpetuating the health care disparities they experience.
People with disabilities may have poorer health.
There are many disparities in care and outcomes among people with disabilities.
For instance, adults with disabilities are 3 times more likely to have heart disease, stroke, diabetes, or cancer than adults without disabilities. And mortality rates are higher among adults with disabilities as compared to adults without disabilities.
Discrimination and disparities in healthcare based on socioeconomic status.
Your socioeconomic status – where education, income, and type of job – can directly impact your health. Unsurprisingly, there is a well-established connection between poverty and poor health. People with low income and low educational levels are more likely to be sick, and more likely to have worse outcomes, including death. Additionally, people living in impoverished communities have an increased risk for developing a mental illness.
According to the US Department of Health and Human Services, “low-income Americans have higher rates of physical limitation and of heart disease, diabetes, stroke, and other chronic conditions, compared to higher-income Americans.”
Unfortunately, poor health also contributes to reduced income, which creates a terrible loop sometimes referred to as the health-poverty trap.
Barriers to care for those with low socioeconomic status.
People with low socioeconomic status (SES) face barriers accessing health care that contribute to worse health outcomes. For example, people may have trouble getting health insurance, or paying for expensive procedures and medications. Importantly, low-income people are more likely to work in jobs that do not provide health insurance.
According to a 2021 Kaiser Family Foundation poll, almost 50% of respondents stated that money kept them from getting needed care. And 29% reported they did not take their medication as prescribed because of the cost.
As expected, having a good insurance plan makes a difference. In fact, uninsured adults in the US have less access to recommended care, receive poorer quality of care, and experience worse health outcomes than adults with insurance.
And on top of financial barriers to care, people of low socioeconomic status are more likely to live in neighborhoods without easy access to doctors, clinics, and hospitals.
Providers bias against patients with low socioeconomic status.
Compared with other patients, doctors are less likely to perceive low socioeconomic status (SES) patients as intelligent, independent, responsible, or rational. Additionally, doctors believe low SES patients are less likely to comply with medical advice and return for follow-up visits.
Importantly, studies show these perceptions impact doctors’ clinical decisions. For instance, studies show that doctors delay diagnostic testing, prescribe more generic medications, and avoid specialist referrals for low SES patients versus other patients.
It’s worth noting some doctors think choosing care options that align with a patient’s socioeconomic status can improve patient compliance and thereby improve health outcomes. But other doctors believe that limiting care options due to low SES leads to worse outcomes.
There are also doctors who won’t care for lower SES patients due to low reimbursement rates from public insurance programs.
Examples of the impact on low SES patients.
Clearly, receiving fewer diagnostic tests, less medication, and lower quality care, can impact outcomes, including mortality rates. Here are a few examples:
- One study found that low household income and education level were associated with higher risk of mortality and rehospitalization after an acute myocardial infarction (heart attack).
- Researchers found that low SES patients with coronary heart disease had to wait longer for invasive coronary procedures than high SES patients, which can lead to worse outcomes and worse quality of life.
- A study on cancer found that low SES was associated with a more advanced disease stage at the time of diagnosis, and with less aggressive treatment, for prostrate, breast, and colorectal cancers. These results indicate that low SES is a risk factor for all-causes of death after a cancer diagnosis.
- In the US, only 60% of low-income women are screened for breast cancer vs. 80% of high-income women.
- In low-income neighborhoods, diabetic patients are 10 times more likely to have a limb amputated than those from affluent areas.
Unsurprisingly, many studies show that people with lower SES tend to feel less satisfied with their care.
Discrimination and disparities in healthcare due to patients’ age.
Ageism, which refers to stereotypes, prejudice, and discriminatory behaviors against older adults, is fairly common among healthcare providers. Unsurprisingly, studies show that ageism can affect the quality of care provided for older adults.
For instance, doctors are less likely to involve older patients in conversations regarding treatment decisions, as compared to younger patients. And doctors tend to be less patient, respectful, involved, and optimistic when dealing with older patients.
Certainly, doctors must consider a patient’s age when making care decisions. However, when age becomes the main factor, or the only factor, considered, treatment is impaired and can be described as inadequate.
Are doctors reluctant to treat older patients? Do doctors, patients, and families agree when considering quality of life versus extending life at any cost?
Doctors treat older patients differently, which can impact outcomes.
In a study of lung cancer patients in the UK, researchers found large age-related differences in treatment and mortality rates in patients with lung cancer, largely independent of other non-age related factors. For example, patients 75+ years old were significantly less likely to have a surgical resection of non-small cell lung tumors, even though many reports show postoperative recovery is not age dependent.
Additionally, this study found a clear age bias in diagnostic procedures, which was attributed to the doctors’ reluctance to run intrusive diagnostic tests among older patients. Interestingly, the overall mortality rates at 6 months was 42% for patients younger than 65, compared to 58% for patients over 75.
Nurses may not treat older patients with respect.
Ageism can cause nurses to treat older patients disrespectfully, including using a patronizing tone, shouting, and not involving them in decision making.
One study highlights the difficulties providers face when caring for older patients.
A 2017 study analyzed data from focus groups of doctors, nurses, and social workers who work in either long-term care facilities, primary care clinics, and/or hospitals in Israel.
The participants identified difficulties related to working with older patients, as follows:
- Difficulties dealing with older patients who had their own opinions about needed treatments, often unwilling to follow professional advice.
- Challenges raised by many older patients’ need for constant attention, including ongoing demands and constant complaints.
- Problematic, but not very prevalent, offensive behavior, including yelling, cursing, and in extreme cases, even spitting on or hitting providers.
- Unpleasant experiences, including diaper changes, bathing patients with deformities, or dealing with patients who have neglected their appearance/hygiene.
- Dealing with family members who refuse to share the responsibility for the older patient with the healthcare provider. And dealing with family members who complain about the treatment provided to their loved one.
Discriminatory and biased behaviors towards older patients.
Given the challenges of caring for older patients, it’s not surprising the focus group revealed several types of discriminatory and biased behaviors, including communication issues and quality of care issues.
Discriminatory communication patterns.
Importantly, the participants indicated they often do not involve older patients in care discussions. Instead, they bypass the older patient and involve younger family members, or, disturbingly, simply make decisions without any meaningful conversation with the patient or family.
Interestingly, the participants admitted they may use ageist communication patterns simply for convenience. Asking questions and explaining things to older adults requires patience and speaking slower or louder, which providers believe is too time consuming.
Additionally, the participants reported using discriminatory and insulting communication with older patients, including using condescending and infantilizing language.
Providing inappropriate care.
The participants discussed several ways in which older adults receive inappropriate or lower quality care, reflecting age-biased discriminatory practices. For instance, older patients may receive inappropriate care that can potentially cost their lives, such as not trying as hard to revive an older patient.
Additionally, treatment of older patients may remove their dignity. For instance, staff may diaper older patients, even when not needed, to save themselves from taking them to the bathroom.
The question of what constitutes “inappropriate care” for older patients is complicated. In certain medical circumstances, providing less care is the right thing to do. Sometimes doctors justify the differential care offered to older patients as an attempt to avoid invasive treatments.
For example, for older cancer patients, a doctor may focus on reducing suffering instead of ordering further testing or curative treatments. Doctors may feel that this is a more “compassionate” choice, not an undertreatment due to ageist perceptions. But, missing out on these treatments can result in lower quality of life for older adults and possibly cause untimely death.
Two important notes.
Firstly, the medical providers in this group acknowledged the importance of working with and caring for older patients. Some even claimed that they prefer working with older adults and serving as their advocates. Perhaps the results would be different for providers who don’t find the work important or rewarding?
Secondly, the researchers note this was a relatively small study, based on participant’s overt and self-aware ageism. Importantly, the participants were not asked about contextual factors that could impact ageism. The study authors suggest the need for further research to determine the extent of ageism in healthcare.
Discrimination and disparities in healthcare due to patients’ weight.
Importantly, many healthcare providers have strong negative opinions and stereotypes about people with obesity. Unsurprisingly, there is considerable evidence that stigmatizing attitudes impact how providers perceive and treat obese patients. For example, bias can impact how providers make decisions regarding care options.
One study found that even doctors who specialize in treating patients with obesity have a high level of anti-fat bias. Additionally, these doctors significantly endorsed the implicit stereotypes of obese people being lazy, stupid, and worthless.
How can these biased opinions impact patient care?
There are several ways in which biased attitudes can impact the quality of care provided. for instance, numerous studies have found that primary care providers tend to treat their obese patients differently, with providers:
- Less likely to engage in patient-focused communication with their obese patients.
- Having less respect for obese patients.
- Spending less time with obese patients.
- Over-attributing symptoms and problems to obesity, thereby failing to recommend diagnostic testing or to consider treatment options beyond suggesting the patient should lose weight.
Discrimination can impact patient behavior.
When patients with obesity experience poor treatment, or even expect poor treatment, they may avoid medical care, and mistrust doctors.
And if obese patients feel stigmatized, or are worried about being stigmatized, they may withdraw from the encounter. This can make it harder to recall instructions or advice, which can reduce their adherence to care plans. Additionally, feelings of discrimination may cause patients to minimize the importance of any recommendations, which can also reduce adherence.
Furthermore, concerns about embarrassment may cause patients with obesity to avoid medical care. For instance, research shows obese women are less likely to go for gynecological cancer screenings. And obesity was associated with a decrease in breast cancer screening for white women, but not for Black women.
Certainly, when patients avoid or postpone diagnostic tests and/or treatments, they may develop more advanced conditions that are harder to treat.
What can you do about discrimination and disparities in healthcare?
To get the best care, no matter your characteristics, it is important to engage in your medical care. For example, know your family medical history, follow all recommended screening guidelines, and research your diagnosis and treatment options.
Importantly, ask your doctors about any unique health risks associated with your race, ethnicity, weight, age, disability, socioeconomic status, sexuality and/or gender. And don’t be afraid to speak up if something doesn’t seem right. Finally get 2nd, or even 3rd, opinions – you’re not insulting your doctor.
Learn more about patient engagement.
Although one person cannot erase implicit and explicit bias in healthcare, you can reduce the impact on your health. Importantly, all patients benefit from being engaged in their care, which can help you get the best care possible. For tips, read these blog posts:
- Understanding Medical Information Is Harder Than Most Realize.
- 10 Tips for a Better Medical Appointment.
- How Can You Get the Best Healthcare? Actively Participate!
- 10 Tips to Communicate Better with Doctors.
- What is the Best Time of Day for Medical Care?
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