Racism permeates every aspect of society — healthcare included. Numerous studies have documented disproportionately negative health outcomes for people of color, and worse, medical care can exacerbate existing social factors that lead to poor health for disadvantaged groups.
Combating systemic racism in healthcare systems starts with understanding the many forms of racial discrimination and prejudice embedded in them. A crucial first step entails identifying and understanding how multiple forms of racial injustice affect patients, healthcare professionals, and healthcare providers — and what changes can make healthcare inclusive and equitable.
Discrimination and Racial Bias in Healthcare
Discrimination against patients of color limits their access to healthcare and the quality of their treatment.
To root out structural inequalities in healthcare, we should look to the ways that implicit bias affects both interpersonal dynamics (such as those between a patient and a clinician) and organizational dynamics (such as dynamics within healthcare institutions).
Implicit Bias and Interpersonal Dynamics
Medical practitioners take an oath to “do no harm,” but evidence shows that doctors and the greater population exhibit the same levels of implicit bias.
Implicit bias is the tendency to unconsciously associate groups (for example, people of color) or category markers (for example, Blackness) and a negative evaluation (implicit prejudice). In a seminal report by the Institute of Medicine in 2003, “Unequal Treatment,” a team of physicians, behavioral scientists, public health experts, and other health professionals concluded that even when access-to-care barriers (such as income and insurance) were controlled for, racial and ethnic minorities received worse healthcare than white people received.
Racial and ethnic minority populations experience health disparities — differences in health outcomes that reflect social inequalities. Asian Americans, Black or African Americans, Hispanics or Latinos, Native Hawaiians and other Pacific Islanders, American Indians, and Alaska Natives all suffer from the effects of implicit bias in healthcare, according to the Centers for Disease Control (CDC).
Nearly 20 years since the publication of “Unequal Treatment,” the study’s results have been replicated again and again, confirming that implicit bias by medical practitioners and within the healthcare system plays a role in negative health outcomes for people of color. Implicit bias tests show, for instance, that physicians are more likely to provide requested pain treatment for white patients compared with Black patients. Repeated studies show that American healthcare workers, even those who are avowedly anti-racist, demonstrate a significant implicit bias against patients of color and a preference for white patients, as reported by Scientific American.
How can this be? On the one hand, healthcare providers may consciously condemn racism in healthcare and negative stereotypes associated with disadvantaged groups (including those to which such medical professionals may themselves belong). On the other hand, our culture consistently depicts people of color in stereotyped and pejorative ways.
While researchers continue to theorize how cultural depictions perpetuate stereotypes and prejudice, the effects of implicit racial bias in medicine are clear.
Case Study in Implicit Bias: Pain Treatment
Well-documented studies show patients with darker skin tones of all ages receive lower doses of pain medication compared with white patients in the United States. One cause for this inequality is unconscious racial bias that originated in the era of chattel slavery.
In a 2016 study, many white medical students surveyed wrongly assumed that Black patients had a higher pain tolerance compared with white patients, according to studies by the Proceedings of the National Academy of Sciences of the United States of America cited by Medical News Today. When asked to provide justification for their decision to offer less pain medication, these medical students repeated unsubstantiated misconceptions that Black people had thicker skin or less sensitive nerve endings. These biased beliefs can be traced back to racist doctors in the 19th century who used these “facts” about people of color to justify violence and unethical medical testing on slaves.
Medical myths such as these persist to this day in healthcare as unconscious, implicit biases. The effects? Patients of color receive worse care than their white counterparts receive. For example, today, Black children with appendicitis are less likely to receive appropriate pain medication compared with white children. This is true also for people of color with recurring cancer compared with white people with the same disease.
Even when doctors disavow racism, medical professionals may still carry unconscious bias that they must actively resist. One way that hospitals have begun to combat implicit bias is through standardizing care procedures and practices. The hope with standardized procedures and practices is that no patient, regardless of race or ethnicity, will receive worse care than any other patient receives.
Racial Underrepresentation in Healthcare
Discrimination and bias leads fewer people of color to enter the healthcare profession and affects the lives of those who do. For example, a 2019 study by the Journal of the American Medical Association looked at 15 years’ worth of U.S. medical school students. It found that the proportions of Black, Hispanic, and American Indian or Alaska Native medical students increased at a much slower rate compared with students of other races and ethnicities, including white students. The result? The physician workforce still fails to represent the U.S. population demographics.
Racial Inequities in Healthcare
People of color die sooner and suffer more preventable illnesses in our healthcare systems compared with white Americans — even in controlled studies that allow for variables such as age, location, education level, socioeconomic status, and total income.
The statistics reflect racial inequities in healthcare:
- A recent Cigna study found higher rates of cancer, diabetes, childhood obesity, and heart disease among Black Americans linked to the lack of economic resources, limited access to healthcare, and delay in treatment.
- Compared with white Americans, Black Americans die prematurely from all types of diseases, including diabetes, hypertension, strokes, and, more recently, COVID-19.
- Metrics such as the infant mortality gap and the maternal mortality gap reveal legacies and current practices of racial exclusion and discrimination in our health systems. Black newborns die 250% more often than white newborns in the United States. Black mothers are at least three times more likely than white mothers to die due to complications in childbirth.
- Black Americans between the ages of 18 and 49 are twice as likely as whites to die from heart disease.
- Predominantly Black ZIP codes are 67% more likely than other ZIP codes to lack adequate numbers of primary care physicians (PCPs), according to a 2012 study.
- Black Americans ultimately wait longer than white patients for life-saving treatments, such as initial EKGs.
These gaps reflect who has access to adequate medical care, employment, adequate pay, and safe environments — and who does not.
Racism in the Insurance Marketplace
Business models in healthcare drive broad inequities. For example, the U.S. healthcare system offers services to patients based on their insurance access. The multilevel structure of access to insurance tiers the quality of care that patients receive, and data shows that it racially segregates the care that patients receive.
The Affordable Care Act (ACA) made more people eligible for Medicaid federally, but many U.S. citizens continue to go uninsured in states that opted out of the Medicaid eligibility expansion. By estimate, 46% of Black working-age adults live in the 15 states that refused to implement the ACA’s expanded Medicaid benefits.
Moreover, around 20% of Black adults and 35% of Latinx adults can not access health insurance compared with 10% of white and Asian adults, according to a study cited in Medical News Today. This leaves working-class people to pay for their own medical care out of pocket.
When unemployment rises, so does the racial disparity in medical insurance. In states that expanded eligibility for Medicaid, the ACA covers 36% of unemployed adults, whereas in states that did not, only 16% of unemployed adults are covered.