Everyone deserves access to the best possible healthcare. But, sadly, ethnic and racial discrimination in healthcare, along with disparities, harm patients throughout the US. Many factors impact the quality of care received and outcomes for Blacks, Hispanics, American Indians, and Alaska Natives.
What’s the difference between ethnic and racial discrimination and disparities?
Ethnic and racial discrimination in healthcare occurs when a provider treats others differently based on their race or ethnicity. 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.
Importantly, ethnic and racial discrimination significantly impacts the health of people of color, negatively affecting mental health. Additionally, discrimination can contribute to high blood pressure, negative health behaviors, and early aging.
On the other hand, ethnic or racial disparities in healthcare refers to differences in health conditions, treatments, and outcomes. Some of the disparities are due to discrimination, such as when ethnic or racial 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 widespread is ethnic and racial discrimination in healthcare?
A 2022 study by The Commonwealth Fund found that 25% of Black and 23% of Hispanic adults over age 60 said they’ve experienced racial discrimination in healthcare. Specifically, they felt their clinicians treated them unfairly or did not take their symptoms seriously because of their race. And 27% said they did not get the care they needed because of racism.
Interestingly, across all races, women were more likely than men to report racial discrimination in healthcare, likely due to gender bias in healthcare.
Unsurprisingly, compared to respondents who didn’t experience discrimination, those who reported discrimination were more likely to:
- Have worse health status
- Face economic hardships
- Feel more dissatisfied with their care.
Additionally, 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 Hispanic adults.
Importantly, the findings from these studies may not reflect the actual number of patients who experience racial discrimination in healthcare because some who face discrimination may not even realize it.
Implicit bias leads to discrimination.
Implicit bias is the unconscious prejudice you can feel about another thing, group, or person. This type of bias is involuntary, and can involve both positive or negative attitudes and stereotypes. Furthermore, this type of bias lies deep in our subconscious and affects our actions without us realizing it.
Medical providers experience implicit bias just like the rest of us, which can influence how providers interact with patients and may contribute to health disparities for minorities. Interestingly, a 2015 literature review determined that most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color.
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.
Unfortunately, implicit bias can impact patient health in many ways.
Firstly, implicit bias may impact the types of treatment options offered to non-white patients. For instance, implicit bias may lead providers to avoid recommending expensive, cutting-edge treatments, based on their assumptions that non-white patients cannot afford specialty care. In fact, research shows that many non-white cancer patients, including those with brain tumors, 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 the doctors 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.
Furthermore, patients often sense a provider’s implicit bias, leading to a poor patient experience. Patients who notice implicit bias may not engage in their care, and/or may become distrustful of the healthcare system. Both of these actions can negatively impact their health.
Social determinants of health contribute to disparities.
Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
Certainly, it’s easy to understand how cost, affordability, and access to care can contribute to disparities in care and outcomes. For starters, Black, Hispanic, and American Indian/Alaska Native (AIAN) populations are less likely to have health insurance, making it more likely they will face cost-related barriers to getting care.
Additionally, people in these populations are less likely to have a usual source of care, such as a primary care doctor. And they are less likely to regularly receive preventive services like vaccinations.
And, many people of color face racism and discrimination when dealing with healthcare providers and therefore may receive lower-value or suboptimal care.
For more information on this topic, read The Commonwealth Fund’s report Achieving Racial and Ethnic Equity in U.S. Health Care.
You can also learn more about 7 top SDOH in the PatientEngagementHIT article How Do Social Determinants of Health Affect Patient Wellness?
Racial discrimination discourages patients from seeking healthcare.
In addition to the social determinants of health that can make it hard to access healthcare, those who have experienced racial discrimination in healthcare may not trust their providers, may not communicate openly, or may avoid medical care altogether.
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 sensing discrimination, 75.9% reported that such treatment or judgment disrupted their ability to receive healthcare services. Within this group:
- 39% delayed care.
- 34.5% looked for a new healthcare provider.
- 30.7% did not get needed care.
A biased algorithm increases racial disparities in healthcare.
A 2019 report exposed a serious bias against Black patients. 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 insurance claims data to predict and rank which patients would benefit the most from additional care.
But that’s faulty reasoning. 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.)
Stigmatizing language in medical records fosters racial discrimination in healthcare.
A study analyzed electronic health records (EHRs) from an urban academic medical center to determine if patient race or ethnicity is correlated with the use of negative patient descriptors, such as “resistant” or “noncompliant”.
The records of Black patients were 2.54 times more likely to have at least one negative descriptor, as compared to white patients. Certainly, these findings raise concerns about stigmatizing language in EHRs and its potential to worsen racial and ethnic healthcare disparities.
Medical research lacks minority participation.
Clinical trials use human volunteers to evaluate medical products like medications, vaccines, or devices for safety and effectiveness. Having participants from diverse backgrounds is critical for advancing health equity.
However, people from racial and ethnic minority groups are often underrepresented in clinical trials. This is a concern because people of different ages, races, and ethnicities may react differently to certain medications, vaccines, or devices.
Black patients have historically been underrepresented in clinical trials. So in 2015, the Food and Drug Administration (FDA) launched a five-year plan to improve diversity in clinical trials for newly approved drugs.
Unfortunately, a 2021 review of the FDA’s Drug Trials Snapshots website showed no evidence of an increase in the number of Black trial participants. Instead, Black patients remained inadequately represented in clinical trials for drugs. And less than 20% of drugs had data regarding treatment benefits or side effects reported for Black patients.
Why does this matter? If there is no data on the safety and effectiveness of treatments for patients of color, it’s harder for doctors to determine which medications and dosages to recommend.
Concerns related to studies on screening for disease.
In addition to a lack of diverse patients in clinical trials evaluating medications, there is also a lack of diverse representation in research regarding screening recommendations. For instance, although about 13% of the US population is Black, Black people made up just 4.4% of participants in the National Lung Screening Trial. This trial, a large, multiyear study, evaluated if screening with low-dose CT scans could reduce mortality from lung cancer. A lack of diverse representation in these types of trials can lead to delayed diagnoses and higher mortality rates.
US minorities have worse outcomes and shorter life expectancies.
Expectedly, discrimination and disparities can lead to poorer care and/or outcomes. In fact, racial disparities in US healthcare are well-documented. And it starts from day one. In the US, Blacks, Hispanics, American Indian and Alaska Natives each have a higher infant mortality rate than whites.
Hispanics and Blacks experience 30-40% poorer health outcomes than white Americans, causing increased illness rates and shortened life spans.
And American Indian/Alaska Native (AIAN) people live fewer years, on average, than white people.
According to The Commonwealth Fund, Black and American Indian/Alaska Native (AIAN) are more likely to:
- Die from treatable conditions.
- Die during or after pregnancy.
- Suffer serious pregnancy-related complications.
- Lose children in infancy.
- Have chronic health conditions, including diabetes to hypertension.
It’s discouraging to learn that although improvements in the healthcare system have increased life expectancy for most Americans, white Americans have gained the most, further widening the gap.
Minorities receive worse care.
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 the quality measures used include death rates for specific diseases, hospital admission rates, and post-surgical complication rates.
Read below for specific examples of disparities in care.
The impact of ethnic and racial discrimination and disparities in healthcare.
Ethnic and racial discrimination and disparities cause patients to receive worse care and/or have worse outcomes. Here are some examples:
Cancer treatment and outcome disparities.
Unfortunately, cancer patients of color may not receive the same quality of treatments that white patients receive. For instance:
- The death rate from breast cancer for Black women is 50% higher than for white women. Experts believe racial and economic inequities in screening and treatment options contribute to this difference in survival rates.
- And another study found that newly diagnosed Black cancer patients were less likely than white patients to receive proton beam therapy (PBT), especially for cancers for which PBT is recommended over photon-based radiation therapy.
For more information on this topic, read Can Ethnicity and Race Impact Cancer Survival?
All surgical procedures carry a degree of risk, but Black patients may have more risk than white patients. For instance, a 2021 analysis by the nonprofit Urban Institute found that Black patients are more likely to suffer dangerous bleeding, infections, and other serious problems related to surgical procedures, as compared to white patients of the same age and gender treated in the same hospital.
For instance, Black patients had a 27% higher rate of postoperative sepsis infections, as compared to white patients of the same gender and age group treated in the same hospital. Additionally, Black patients had a 30% higher rate of pulmonary embolism or deep vein thrombosis during the surgical process.
Access to surgical consultations in emergencies.
A surgical consultation is a critical first step for patients with emergency general surgery conditions. In a retrospective study of over 1.6 million patients, Black Medicare patients were significantly less likely to receive a surgical consultation, as compared to similar white patients.
Heart disease is the number one killer in the US. And cardiovascular diseases accounted for 874,613 deaths in the US in 2019. Unfortunately, racial disparities in cardiovascular disease make Black patients less likely to undergo coronary intervention or invasive angiography.
Importantly, Blacks have higher rates of heart failure and strokes than whites. 25% of Black Americans have high blood pressure, compared to 10% of white Americans. However, Black patients are 10% less likely to be screened for high cholesterol than white patients.
Alarmingly, a study at the University of Michigan found that Black patients who undergo minimally invasive procedures for clogged arteries are more likely to die or be readmitted to the hospital within 90 days of the procedure, as compared to white patients. Moreover, 75% of white patients were referred for cardiac rehabilitation, compared with 58.5% of Black patients.
The researchers believe social determinants of health played a significant role in the disparity of outcomes between Black and white patients.
Patient safety issues.
Unfortunately, all hospital patients face safety hazards. However, research shows that Black patients have a higher risk. In fact, one study found that Blacks had a higher risk of developing a hospital-acquired infection or experiencing an adverse drug event. Moreover, after adjusting for patient and hospital factors, the study showed that patients in hospitals with the highest percentage of Black patients had an increased risk of a hospital-acquired infection or adverse drug event.
Access to hospice care.
Hospice care can be extremely helpful to patients at the end of their lives and helpful to their families. However, 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.
Increased risk of death from transplants.
Certainly, organ transplants are risky. But they may be even riskier for Black patients. One study found that between 2002-2018, Black patients had a 15% higher chance of dying after a liver transplant than white patients. Interestingly, Hispanics did not have the same increased risk of death.
Moreover, between 2017-2018, Black patients had a 60% higher chance than white patients of dying after a liver transplant.
Importantly, these discrepancies in survival rates held steady even after statistically adjusting for 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.
Inadequate treatment for pain.
If you’ve ever experienced chronic pain, you know how miserable you feel and how life-altering it can be. However, assessing and treating pain is complicated for doctors because everyone experiences pain differently.
Therefore, providers must use their judgement to determine the cause and severity of the pain, and possible treatment options. Since providers must rely on their own judgment, it’s easy for them to be influenced by their own personal perceptions and biases.
Sadly, Black patients are consistently undertreated for pain. In fact, a meta-analysis of 20 years of studies covering many types of pain in numerous settings found that Black patients were 22% less likely than white patients to receive any pain medication.
Importantly, doctors do not intentionally avoid helping Black patients manage pain. Instead, the inequities in pain treatment are due to complex influences, including implicit biases that healthcare providers don’t even realize they have.
A large part of the implicit bias may be long-held misconceptions about Black people. It seems impossible, but many people believe that Black people have thicker skin and less sensitive nerve endings.
Alarmingly, a 2016 survey found that 50% of white 1st and 2nd year medical students believe that Black people have thicker skin than whites. And the trainees who thought Black people were less sensitive to pain were less likely to treat their pain appropriately.
Providers who believe these ridiculous falsehoods about biological differences, even subconsciously, may offer inadequate treatments to Black patients experiencing pain.
Racial and ethnic minorities fare worse with COVID-19.
COVID-19 has taken its toll on people around the World, but racial and ethnic minorities in the US have experienced higher rates of infection, hospital stays and death, compared to white, non-Hispanic people.
Additionally, 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.
Why? The Mayo Clinic outlines possible factors that increase the risk of COVID-19 harm for people of color in the US, including:
- Racism. As already discussed, racism leads to unfair and unjust treatment for people of color.
- Other medical conditions. Stress from facing racial discrimination is linked to heart disease, obesity, diabetes, high blood pressure, and kidney or liver disease. And these diseases can each increase the risk of getting severely ill with COVID-19.
- Type of work. Many people of color have jobs that involve public interaction, which can increase the risk of getting COVID-19.
- Location. Minorities may live in homes with many other people, often in crowded conditions in heavily populated areas. These factors increase their exposure to COVID-19 and can make it harder to get treatment.
- Access to health care. Racial and ethnic minorities are more likely to face barriers to getting care. Research also shows that people of color are often more greatly affected by public health emergencies.
Higher maternal death rates.
Pregnancy and childbirth are dangerous times for all women. But, Black women are at higher risk of complications. For instance, Black women are more likely to have gestational diabetes, preeclampsia, hypertension, and a slew of other problems.
Moreover, Black women are also more at risk of dying. In 2020, the maternal death rate for non-Hispanic Black women was roughly three times that of both non-Hispanic white women and Hispanic women. Additionally, American Indian and Alaskan Native women also have an elevated risk of maternal death compared to white women.
Experts believe a lack of access to care and poor quality of care play a role in the higher risk of maternal death, particularly for women at lower socioeconomic levels. But, even Black women who are relatively well-off have an increased risk of complications due to systemic racism in the healthcare system.
For more information, read 10 Pregnancy-Related Complications Black Women Should Know About on WhatToExpect.com.
Children are also harmed by racial disparities.
A retrospective study of over 483,000 New York City low-risk newborns found the risk of unexpected deaths of newborns was higher among Black and Hispanic infants, as compared to white infants. Importantly, 1/3 of Black and Hispanic women gave birth in hospitals with high maternal complication rates, compared to 10% of white and Asian women. The study indicates that hospital quality contributes to preventable newborn deaths among low-risk, full-term births.
Here are a few more study results about the impact on children:
- Black children had 3.43 times the odds of dying within 30 days after surgery, as compared to white children.
- Black children had higher rates of complications and perforations after appendectomies.
- Hispanic babies have a death rate 3.4% higher than white babies and Black babies have death rates 4.1% higher than non-Hispanic white babies.
Can racial discrimination and disparities be fixed?
Of course, no single person can erase years and years of racial discrimination and disparities in healthcare. It is going to take time, motivation, and money for the stakeholders – including local and Federal governments, hospitals, doctors, and the public – to fix this problem.
Diversifying the healthcare workforce could reduce disparities and increase patients’ trust in the healthcare system. Interestingly, one study found that Black men were more likely to choose preventive services, including invasive services, when they met with a Black doctor, as compared to meeting with a non-Black doctor. The researchers surmise that Black doctors caring for Black patients could significantly reduce the rate of cardiovascular death for Black men.
Additionally, improving access to medical translation services, and providing training on implicit bias and culturally competent care could help patients of color receive quality care.
An exciting program in Boston.
In late 2021, Boston Medical Center launched the Health Equity Accelerator to transform healthcare with a goal of eliminating gaps in life expectancy and quality of life among different races and ethnicities. They started with five clinical areas where they see major disparities:
- Infectious diseases
- Chronic conditions
- Behavioral health
Hopefully, other hospitals will follow suit and create similar programs!
What can you do if you are part of an ethnic or racial minority group?
Certainly, you can’t fix racism by yourself. Combatting racism isn’t easy. But there are a few things you can do to lessen the impact of discrimination and disparities.
Consider these suggestions:
- Advocate for yourself – don’t let doctors intimidate you.
- If something seems wrong, speak up! Don’t be afraid to be the polite, squeaky wheel.
- Prepare for appointments. Write down all your questions ahead of time, and make sure you mention your top 2-3 concerns at the beginning of every appointment.
- Get a 2nd, or even a 3rd, opinion. If you are diagnosed with a serious illness, or suspect you might have a serious illness, try to get an opinion at a teaching hospital. For more information, read Why are Second Opinions Important?
- If needed, ask for a language interpreter.
- If you think your doctor is discriminating against you, try to find another doctor. For more information, read How Do You Find a New Doctor You Can Trust?
- Use a notebook at home to keep track of questions and symptoms. And use it to take detailed notes at every appointment. Read Why Take Detailed Notes at Doctor Appointments?
- Keep all your medical documents organized and together. Bring them to every medical appointment.
- Follow guidelines for screenings and preventive care. Read Do You Know What Types of Health Screenings You Need?
For more tips, read these blog posts:
- 10 Tips to Communicate Better with Doctors.
- 10 Tips for a Better Medical Appointment.
- Communication Gap Among Doctors.
- Should You Record Medical Appointments?
- How Can You Get the Best Healthcare? Actively Participate!
- 6 Tips to Better Manage Your Care.
- Understanding Medical Information Is Harder Than Most Realize.
- What is the Best Time of Day for Medical Care?