Disparities in Healthcare

Although we all deserve the best possible healthcare, in reality, disparities in healthcare harm patients throughout the US. For instance, patients can experience discrimination in healthcare based on their race, ethnicity, gender and more. Additionally, a patient’s characteristics can lead to disparities in healthcare due to factors such as biased treatment and access to care. Unfortunately, discrimination and disparities in healthcare impact health and outcomes for patients.

Discrimination in healthcare.

A study published in 2020 found that discrimination in healthcare is more common than previously recognized. Twenty-one percent of people who responded to their nationwide May 2019 survey reported experiencing discrimination in the healthcare system. Moreover, 72% of those reported experiencing discrimination more than once.

The respondents reported discrimination related to the following characteristics:

• 17.3% – racial/ethnic
• 12.9% – educational or income
• 11.6% – weight
• 11.4% – gender
• 9.6% – age

Their analysis found that the odds of experiencing discrimination were higher for respondents who identified as female. Conversely, the odds were lower for older respondents, those from households earning at least $50,000/year, and for those reporting good or excellent health. Importantly, these numbers may not reflect the actual number of patients who experience discrimination. because some who face discrimination may not even realize it.

Needless to say, some healthcare providers are aware of their biased feelings while others may not even realize they are discriminating against particular patients.

How can discrimination impact patient health? Patients who experience discrimination can have poorer care and/or outcomes. Additionally, those who experience discrimination may not trust their providers, may not communicate openly or may avoid medical care altogether.

Race matters, unfortunately.

The racial health gap in the US is well-documented. And it starts from day one. Blacks have a higher infant mortality rate (11.3 Blacks vs. 5.1 whites per 1,000); American Indian and Alaska Natives have an infant mortality rate of 8.1/1,000.

Latinx and Blacks experience 30-40% poorer health outcomes than white Americans, causing increased illness rates and shortened life spans. Although the life expectancy gap between Black and white Americans has narrowed, disparities still persist. Improvements in the healthcare system have increased life expectancy for most Americans, but white Americans have gained the most. This larger health gain for whites widens the racial gap in health. Importantly, other ethnic groups suffer from disparities in healthcare as well.

How wide is the gap?

According to a US government report, 33-42% of Blacks, American Indians, Alaskan Natives and Hispanics receive worse care than whites on 33-40% of quality healthcare measures.**

Many Black patients feel discriminated against.

A 2020 survey by Urban Institute found that 10.6% of Black adults felt discrimination or unfair judgement by a healthcare provider based on their race, ethnicity, disability, gender, sexual orientation, or health condition – a rate almost 3x higher than white adults and about 2x higher than Latino/Hispanic adults

A biased algorithm increases disparities in healthcare.

A report issued in October 2019 exposed a serious bias against Black patients. The researchers examined an algorithm commonly used by health systems (hospitals, etc.) to identify and help patients with complex health needs.

The researchers discovered the algorithm favors white patients over Black patients, even though the Black patients were sicker and had more chronic health conditions. Why? The algorithm used health care costs from insurance claims data to predict and rank which patients would benefit the most from additional care. But that’s faulty reasoning because, in general, Black patients access health care less often than white patients, even for the same chronic conditions. So, the algorithm incorrectly concluded that Black patients are healthier because they spend less money on health care.

When the study’s authors retrained a new algorithm using patient’s health data, rather than insurance claims data, they found an 84% reduction in bias.

(Note – this study evaluated one particular commercially available algorithm, but researchers indicate racial bias exists in other algorithms as well.)

Examples of how 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. For example, Black patients are significantly more likely to suffer dangerous bleeding, infections and other serious problems related to surgical procedures than white patients treated in the same hospital, according to a 2021 analysis from the nonprofit Urban Institute.
• 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. Although 25% of Black Americans have high blood pressure (compared to 10% of white Americans), Black patients are 10% less likely to be screened for high cholesterol than white patients.
• One study found that Black children had 3.43 times the odds of dying within 30 days after surgery, as compared to white children.
• As compared to white patients, Black patients were less likely to receive hospice care and more likely to visit the ER and undergo intensive treatment in the last 6 months of life.
• A 2020 study found that pulse oximeters – devices used to externally measure oxygen levels in blood – sometimes fail to accurately read the oxygen levels of Black patients. Researchers found that nearly 12% of the time, the pulse oximeters showed Black patients had safe oxygen levels, when in fact, blood showed unsafe oxygen levels. In comparison, this type of discrepancy occurred less than 4% of the time in white patients. Certainly, this discrepancy can put Black patients in serious, potentially life-threatening, danger from untreated low oxygen levels.

Gender disparities can 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.

Women’s health and healthcare is negatively impacted in many ways just because they are women. A few examples:

Doctors often overlook or minimize women’s pain.

Women are more likely to suffer from pain than men; and both male and female doctors are more likely to dismiss women’s pain. For instance, one survey found that 83% of women with chronic pain feel the healthcare system discriminates against female patients. Women report pain that is more frequent, more severe and longer lasting than men. But research shows doctors less aggressively treat women for pain as compared to men. One emergency room study found that women waited 16 minutes longer than men to receive pain medication, and were less likely to receive opioids.

Doctors often treat women with heart disease inappropriately.

Heart disease in women is underdiagnosed and undertreated:

• One study of women (30-55 years old) hospitalized for heart attacks found that the healthcare system was not consistently responsive to women, resulting in delays in workup and diagnosis.
• Women are nearly twice as likely as men to die within a year after a heart attack, partly because “cardiovascular care has been slow to acknowledge the gender differences in heart disease”.
• Results from the traditional treadmill tests to detect heart problems are more likely to be inaccurate for women because the scoring system is based on results from middle-aged men.

Things are worse for women with diabetes.

• Women with diabetes have significantly poorer outcomes than men.
• Diabetic women are more prone to heart disease and more likely to suffer a fatal heart attack, but research shows they often receive less aggressive treatment for cardiovascular risk factors.

Disparities in healthcare for disabled patients.

Although more than 61 million Americans have disabilities, disabled patients face healthcare disparities. In a recent survey of 714 US doctors, 82.4% stated they believe that people with significant disability have worse quality of life than nondisabled people. Additionally, only 40.7% felt very confident about their ability to provide the same quality of care to patients with disability. And only 56.5% strongly agreed that they welcomed patients with disability into their practices. Moreover, 18.1% strongly agreed that the healthcare system often treats disabled patients unfairly. It’s hard to imagine that these findings don’t indicate disparities in the care of disabled people.

Disparities in care based on financial well-being. 

Your financial well-being can directly impact your health. 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. 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.”

Additionally, according to a US government report:

• 56% of those from poor and low-income households have worse care for almost 60% of quality measures** as compared to high-income households.
• 42% of patients from middle-income households received worse care for >40% of quality measures** compared to high-income households.

As expected, having a good insurance plan makes a difference. Uninsured people had worse care than privately insured people for almost 2/3 of healthcare quality measures. Quality measures include death rates for specific diseases, hospital admission rates, and post-surgical complication rates. See the complete list of quality measures here.

Examples of how income levels can impact health:

• 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.

Disparities in healthcare based on patient’s sexuality.

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.

Research shows that LGBT patients can experience denial of care, inadequate care, verbal abuse, disrespectful behavior and other barriers to high quality care. Unfortunately, the education and training for healthcare professionals regarding the unique needs and treatment of LGBT patients is lacking.

What can you do about 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, sexuality and/or gender. Finally, speak up if something doesn’t seem right and get 2nd, or even 3rd, opinions.

For more information, read my blog post Why Isn’t Healthcare The Same for Everyone?

Learn more about disparities in healthcare.

For more information, read:

• Can Ethnicity and Race Impact Cancer Survival?
• Is There Gender Bias in Medicine?

Learn more about patient engagement.

All patients benefit from being engaged in their care. For tips that can help you get the best care possible, 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?

**Quality measures include death rates for specific diseases, hospital admission rates, and post-surgical complication rates. See the complete list of quality measures here.

NOTE: I updated this post on 7-20-21.