Discrimination and Disparities in Healthcare

Although we all deserve the best possible healthcare, in reality, discrimination and 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.

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 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.

However, other 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.

How common is 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.

Among the respondents who reported discrimination, the following characteristics were identified as the cause:

• 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.

Implicit bias impacts providers’ thoughts and actions.

Implicit bias is the unconscious prejudice you can feel about another thing, group, or person. This type of bias is involuntary and lies deep in our subconscious, affecting our actions without us realizing it.

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 can discrimination impact 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, 75.9% 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.
• 30.7% did not get needed care.

Certainly, all of these behaviors can negatively impact patient health.

It’s important to note that patients may not always be aware of discriminatory behavior. For instance, when your doctor recommends a treatment, you may not realize there are other alternatives, such as a cutting-edge treatment that your doctor doesn’t suggest due to an implicit bias.

Ethnic and racial discrimination in disparities in healthcare.

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, Blacks, American Indians, Alaskan Natives, and Hispanics receive worse care than whites on 33-40% of quality healthcare measures.

Note that quality measures include death rates for specific diseases, hospital admission rates, and post-surgical complication rates.

Many non-white patients feel discriminated against.

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. Those people felt their clinicians treated them unfairly or did not take their symptoms seriously because of their race, with 27% saying they did not get the care that they needed because of racism.

And 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.
• 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.
• Between 2002-2018, Black patients had, on average, a 15% higher chance of dying after a liver transplant than white patients. Moreover, between just 2017-2018, Black patients had a 60% higher relative chance of dying after a liver transplant than white liver recipients. Importantly, these discrepancies in survival rates held steady even after statistically adjusting for differences factors, such as age, sex, geography, diabetes, kidney disease, and others. Alarmingly, the survival gap between Black and white patients increased with the number of years post-transplant.
• Research shows that Black COVID-19 patients are less likely to receive medical follow-ups after hospitalizations, and more likely to have longer delays until they can return to work.

Black children are also harmed by racial discrepancies.

• One study found that Black children had 3.43 times the odds of dying within 30 days after surgery, as compared to white children.
• A study published in 2021 found that Black children had higher rates of complications and perforations after appendectomies.

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 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 on the basis of 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.

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.

Learn more about disparities in healthcare.

For more information, read Can Ethnicity and Race Impact Cancer Survival?

Learn more about patient engagement.

Although it is impossible for one person to erase the implicit and explicit bias faced by patients, there are steps you can take to reduce the impact. 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?

NOTE: I updated this post on 1-9-23.