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March 5, 2021

Addressing Racial Discrimination in US Health Care Today

Author Affiliations
  • 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2The Commonwealth Fund, New York, New York
JAMA Health Forum. 2021;2(3):e210192. doi:10.1001/jamahealthforum.2021.0192

From the public statements and initial actions of the Biden administration, it is clear that addressing racial discrimination will be a high policy priority. This comes alongside a growing national awareness of the seriousness of this problem by leadership groups in health care and medicine. This article addresses 2 central issues related to racial discrimination in health care: the extent of reported discrimination in various health care settings among Black and Latinx households and recommended policies to hold health care institutions accountable for addressing racial discrimination.

Discrimination in Health Care

It is important to examine patients’ recent experiences with health care from their own perspectives. We report experiences of discrimination based on a national survey conducted in November 2020 by the Harvard T.H. Chan School of Public Health and the Commonwealth Fund using a representative sample of Black and Latinx households. We focused on experiences of discrimination in health care within the past 12 months during a period that encompasses the COVID-19 outbreak, in contrast to prior surveys documenting lifetime discriminatory experiences.1,2

The survey results show that in the past year, more than one-third of Black (36%) and Latinx (35%) adults report that they or household members, who had seen a health care professional or been hospitalized overnight, experienced 1 or more forms of discrimination. The most commonly reported types of discrimination included not being offered the best available treatment (Black respondents: 19%; Latinx respondents: 21%), being denied or delayed access to needed health care services (Black respondents: 12%; Latinx respondents: 12%), and not being referred to see specialists (Black respondents: 12%; Latinx respondents: 9%) because of their race, ethnicity, or language spoken.

The Need for Accountability

Addressing racism in health care has been on the national agenda for decades, with limited progress. Our survey results show a need for increased accountability among individual health care institutions in addressing racial discrimination and also demonstrate the feasibility of including racial/ethnic discrimination measures in surveys of patients’ experiences with health care. What does not currently exist is a link between these types of discrimination measures and federal quality metrics gathered by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services.

As suggested by these survey results, a key step to improve accountability is to develop a mechanism for patients to routinely provide feedback about their personal experiences with discrimination. Already, health care organizations regularly conduct standardized patient satisfaction surveys, which are viewed as important indicators of health care quality and guide quality improvement efforts. Discrimination questions could be easily added to existing surveys and should be prioritized with the ever-growing trend toward patient-centered care and value-based incentive payments. Collecting routine information about discrimination in patient experiences would allow individual health care organizations to track their own progress and benchmark themselves against peers.

Notably, federal regulations already require hospitals participating in Medicare and Medicaid (which includes the vast majority in the country) to establish a patient grievance process that allows patients to address concerns. However, this process can be long and complex. Information about patient experiences with discrimination needs to be collected more systematically and among a larger swath of patient populations to fully understand the problem.

A second key step to enhance accountability is transparency. Results from surveys about discrimination should be publicly reported. This would strongly incentivize individual health care institutions and medical practices to identify the reduction of discrimination as a strategic priority. Transparency may also help enhance structures, processes, and outcomes of care and pinpoint critical areas for improvement. Medicare and Medicaid could use this information to hold providers accountable and require action steps to address discrimination, as appropriate. Additionally, this information can inform the development of national strategies to address discrimination in health care at a time when improving racial equity is a core federal priority.

A third key step is using information about patient experiences to implement specific policy and education practices. This needs to go beyond brief diversity trainings, which have become common in medical schools and among health care professionals and appear to have limited effectiveness. The goal should be to confront health care professionals with evidence of their own discriminatory behavior and provide concrete actions for addressing it. For example, interventions specifically designed to reduce prejudice appear to be effective and have lasting effects.3

A significant number of people are restricted about where they can seek care based on their insurance. Therefore, a fourth key step is expanding provider networks so that patients have more choices to obtain care elsewhere if they face discrimination. This will be especially important for patients with publicly funded health insurance (ie, Medicaid or Medicare), who are more likely to perceive discrimination in health care than patients with employer-sponsored coverage.4 This may also help to break the vicious cycle fueling health inequities, in which those who have experienced discrimination are less likely to obtain care.

A fifth key step is to create a more diverse pipeline for the future health care workforce because only about 5% of physicians are Black or Latinx, whereas these groups represent 13% and 19% of the US population, respectively. This is increasingly important, as the US is expected to be majority-minority by about 2025. Among other benefits, greater health care workforce diversity may foster a more racially sensitive institutional culture for patients.

Conclusions

By their own account, more than one-third of Black and Latinx households have experienced discrimination in the health care setting during the past year, largely amid the COVID-19 pandemic. Effectively addressing racial discrimination in health care can be at least partially accomplished by holding health care institutions and medical practices accountable for the actual experiences of minority patients. An important step in this direction is to routinely measure and publicly report patients’ personal experiences with discrimination.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bleich SN et al. JAMA Health Forum.

Corresponding Author: Sara N. Bleich, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 405, Boston, MA 02115 (sbleich@hsph.harvard.edu).

Conflict of Interest Disclosures: Dr Bleich reported receiving grants from the Commonwealth Foundation. No other disclosures were reported.

Disclaimer: The views expressed in the article are solely the personal views of the authors.

References
1.
Bleich  SN, Findling  MG, Casey  LS,  et al.  Discrimination in the United States: experiences of Black Americans.   Health Serv Res. 2019;54(suppl 2):1399-1408. doi:10.1111/1475-6773.13220PubMedGoogle ScholarCrossref
2.
Nong  P, Raj  M, Creary  M, Kardia  SLR, Platt  JE.  Patient-reported experiences of discrimination in the US health care system.   JAMA Netw Open. 2020;3(12):e2029650. doi:10.1001/jamanetworkopen.2020.29650PubMedGoogle Scholar
3.
Forscher  PS, Mitamura  C, Dix  EL, Cox  WTL, Devine  PG.  Breaking the prejudice habit: mechanisms, timecourse, and longevity.   J Exp Soc Psychol. 2017;72:133-146. doi:10.1016/j.jesp.2017.04.009PubMedGoogle ScholarCrossref
4.
Alcalá  HE, Cook  DM.  Racial discrimination in health care and utilization of health care: a cross-sectional study of California adults.   J Gen Intern Med. 2018;33(10):1760-1767. doi:10.1007/s11606-018-4614-4PubMedGoogle ScholarCrossref
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