We’ve all heard, seen, and read about the racial tension between the white people within central Minnesota and the immigrants and people of color who also live here. I have been given the amazing opportunity to talk about how the issue of discrimination goes far beyond the central Minnesota group of white people writing editorials in the paper attempting to maintain the system that benefits the white majority within our community. This article will go deeper into how the health care system has perpetuated stereotypes and false information that has led to poorer health care for people of color. Providing you with data, policies, impact, and strategies for reducing these issues will give you some insight and tools to better offer support to the marginalized individuals you may interact with in the community. Possessing an understanding of their experiences and systems they function in is key to providing the best practices for your clients.
Institutional discrimination is the bigger, societal version of individual discrimination that refers to a pattern of unfair treatment based on being a member of a specific group that is woven into the daily workings of our society. (Healey, Stepnick, O’brien, 2018) Without further understanding of what institutional discrimination is and how it affects people within our communities, people like medical professionals cannot provide accurate, informed care for those who have experienced discrimination and subsequent misinformation.
Let’s start with the myths about black people within the medical profession.
- They have thicker skin
- They present the same as white people
- Their blood coagulates quickly
- They are less sensitive to pain
- They over-exaggerate symptoms
- They more often display med-seeking behavior
These five examples of myths within the health care system are not new, despite sounding like they should be from an ancient medical textbook from back when they still saw black people as slaves and perpetuated myths like these to further advance medical research. Unfortunately, these are still myths believed by many medical students as recently as 2016. (Sabin, 2020) A whopping 40% of students in their first and second year of medical school reported they believed black people had thicker skin than whites. (Sabin, 2020)
A study in 2016 found trainees who believed black people are not as sensitive to pain as white people were then less likely to treat the pain of black people appropriately. (Sabin, 2020)
Another study from 2012 simulated black and white teenagers following a surgery, finding that implicit (unconscious) bias led to a higher likelihood of decreased prescription of appropriate pain medications only in the black patients. (Sabin, 2020)
A study comprised of 802 non-Hispanic black people and 902 non-Hispanic white people was conducted in 2017. (Bleich, et al., 2019) This study found about one-third of the black people in the study reported they had experienced discrimination in a clinical setting and 22% avoided seeking health care due to anticipating discrimination.(Bleich, et al., 2019)
The study conducted by Bleich, et al. found broad patterns of discrimination against black Americans that spanned far beyond isolated, individual experiences. (Bleich, et al., 2019)
Racism, both implicit and explicit, has a profound impact on the physical and mental health of people of color, and make accessing health care even more difficult for those marginalized groups. (Rees, 2020)
The U.S. Department of Health and Human Services found:
- both male and female Black people have lower average life expectancy than their white counterparts (Rees, 2020)
- 42.2% of Black men had high blood pressure compared to only 30.2% in white men, and 44% of Black women compared to 28% of white women had high blood pressure. (Rees, 2020)
- Only 60% of Black and Latinx people over the age of 65 got a flu vaccine compared to 70% of white and Asian people of the same age group. (Rees, 2020)
- People of color have higher rates of mental health issues due to discrimination, and racism is strongly associated with higher rates of stress, anxiety, and depression in Black and indigenous people of color. (Rees, 2020)
- 1/3 of black people reported experiencing discrimination in a clinical setting
- 22% of black people avoid seeking health care
- Black people have lower life expectancy
- People of color have higher mental health issues due to discrimination
Looking back at the history of the United States and the role of slaves for the advancement of medical treatment is no secret, but despite abolishing slavery America continues to have issues with implicit bias within the medical community.
While Black people are twice as likely to have difficulty finding and securing adequate health insurance and there are less available up-to-date clinics available, Black Americans are not receiving the same quality of care as their white counterparts. (Bridges, ND)
Most recent studies conclude that it is not the recipients of the health care, but rather the providers that are the largest contributing factor to lower overall health outcomes for Black Americans than their socioeconomic status. (Bridges, ND) The conclusion is that racial disparities in health care are explained by looking into the practitioners who are making the choice not to provide people of color the most effective treatments. (Bridges, ND)
The stereotypes and bias can be implicit or explicit, but it is rare that a health care provider will admit to any sort of negative attitude toward any racial group, just as the general public would do. (Bridges, ND) The lack of open explicit racial bias indicates implicit bias is likely the more common harmful contributing factor in the inadequate care. It is very unlikely that a physician would knowingly, intentionally treat or prescribe differently to their patients who are Black. (Bridges, ND)
It is likely that practitioners have been exposed to negative narratives about Black people within their communities and in society which can have a dramatic impact on unconscious bias and attitudes toward that racial group. (Bridges, ND)
A study that administered the Implicit Association Test (IAT) to physicians found those who harbored pro-white bias were less likely to prescribe pain medication to Black people than white, despite the symptoms being the same. (Bridges, ND)
Public Policies Across America
The Affordable Care Act (ACA) has increased the number of Americans who have health coverage, but the Black population continues to be more likely to lack appropriate health coverage with 9.7% of Black Americans being uninsured compared to 5.4% of white Americans. (Taylor, 2019) While coverage is more accessible, the cost continues to be high for those with lower income with average cost for a family being $8200 per year. (Taylor, 2019)
While Medicaid programs have been an asset for low income, pregnant, elderly, and disabled Americans, it is funded by each state in cooperation with the federal government. (Taylor, 2019) The southern states with higher concentrations of Black Americans (58%) have also been the states that are less likely to expand Medicaid coverage under the ACA. (Taylor, 2019) The states of Texas, Florida, and Georgia have the largest number of uninsured African Americans, and also implemented draconian work requirements as one of the conditions for participation in the Medicaid programs. (Taylor, 2019)
President Biden is currently working on a public insurance option that builds upon the ACA by adding options to those seeking coverage. (Taylor, 2019) Biden’s plan ensures prescription costs are affordable, pre-existing conditions are covered, and offers a tax credit to families to help lower the cost. (Taylor, 2019)
In order for Black Americans to attain adequate insurance and access to quality care, the system must be modified to address the social factors that cause people of color to remain in coverage gaps and acknowledge how racism plays a part in health outcomes for those individuals. (Taylor, 2019)
Impact of Institutional Discrimination
Let’s use the example of John.
John has sickle cell anemia, often causing significant pain that requires medical treatment for him to carry out his daily tasks and work.
John has had some negative experiences with doctors in his local clinic assuming John was drug seeking to get high rather than attempts to lessen his pain. They refused to prescribe him pain medications and sent him home with ibuprofen. This has led to John avoiding going to the clinic and has been missing work due to increased pain. John does not have paid time off but does have basic health insurance. His insurance requires him to pay a copay every visit and the clinics that do prescribe him the medication he needs are “out of network” which costs him significant amounts of money to get his medical needs met.
John must travel about an hour to get adequate health care from a provider that does not display implicit bias, but it takes a toll on John. He has developed some depression and anxiety issues about attempting to prove to his doctors he is not a drug addict nor seeking medications to get high.
Has this scenario happened to anyone you know who is white?
Are you aware John is not alone in his struggles?
How would you propose resolutions to John’s problems, when the more he attempts to seek help, the more he is labeled as “drug seeking?”
Strategies For Reducing Institutional Discrimination
To help reduce the institutional discrimination that is prevalent in health care there are some steps outlined that can help individuals and the organizations they work for to improve outcomes for the people of color within their communities.
All health settings need to collect data on patient pain management and categorize it by race and ethnicity, gender, insurance status, and other characteristics. (Sabin, 2020) This data needs to be reviewed within the health care systems regularly and create policies and strategies to address any disparities that may arise from the data. (Sabin, 2020)
Maintain an environment where individual providers continually address their own bias using the IAT, for example. Educators must help their trainees understand that implicit bias is common, even among those who are against those biases. (Sabin, 2020) They should also note that internalizing messages from within our culture can influence some implicit bias and is not the same as discrimination or racism. (Sabin, 2020) Practicing mindfulness to focus on everyday life and work to recognize when we have made a mistaken assumption. (Sabin, 2020)
Educational programs targeted at dispelling misinformation about race and pain within the medical community is essential, just as much as implicit bias. (Sabin, 2020) Learning about these disparities can help practitioners improve practices and understand that the most well-meaning staff can harbor biases. (Sabin, 2020) It should also be noted that the education related to implicit bias must be grounded in science, inclusive, nonjudgmental, and appropriate to the audience, and include effective strategies for reducing the impact of bias on the patients. (Sabin, 2020)
Individual discretion can be attained by using standardized checklists, clinical guidelines, and system-wide protocols. (Sabin, 2020) The Centers for Disease Control and Prevention and the American Academy of Pain Medicine provide valuable resources for monitoring and prescribing pain medications. (Sabin, 2020)
Pain is an individual experience, but researchers are working to create measures of pain that are beyond the interpretation of the provider from the patient’s reports. (Sabin, 2020) Ongoing studies and gathering of information and new ways to treat pain is critical for resolving the inconsistencies within the American health care system.