Race and U.S. Healthcare in Early and Modern Systems

Racism is defined as a form of discrimination (altered treatment of members of different ethnic, religious, national, or racial groups) that categorizes groups/communities by certain characteristics and differences which others consider inferior. (“Racism, bias, and discrimination”, n.d.). An example of racism in the United States' (U.S.) healthcare system is healthcare professionals denying appropriate care to minority people (Yearby et al., 2022). People of color have been negatively impacted by the embedded racism in the country, restricting them from higher level care and better health outcomes. Studies have shown that racial minority groups in the United States suffer from higher rates of illness and death, with a life expectancy to be 4 years lower in Black Americans than White Americans (“Racial Discrimination in Healthcare: How Structural Racism Affects Healthcare“, 2021; Racism and Health”, n.d.). Research has also revealed that racial identity is independently related to lack of health insurance as low income, minority people with poor health had 68% less odds of being insured compared to high-income, White people with good health (Yearby et al., 2022). In this article, we will discuss racism in modern health care in the U.S. and current initiatives being performed to improve health care in racial and ethnic minority groups, markedly in Black and Hispanic communities.

Early health policy and law were created in such a way to deprive people of color of increased wages and employee benefits such as paid sick leave and health insurance, markedly in Black communities. The Hill-Burton Act in 1946 was established to provide public hospitals and care facilities, no matter the race and served as one the nation’s initial health initiative to increase funding for healthcare facility construction to increase access to health services in exchange for facilities to provide care to all persons regardless of income or race (“Hill Burton Free and Reduced-Cost Health Care, 2022; Largent, 2018). Northern representatives of the country advocated for non-discriminatory use of federal funds whereas southern representatives argued for state and local authority allocation of funds without interference from the federal government. Ultimately, the act catered to the South’s requests and included a “separate-but-equal” provision, which allowed racial discrimination as long as there was an equity in health services and care for Black American communities (Largent, 2018). Despite improved healthcare outcomes in the Black community from the stated provision, issues and debate arose as some members of the Black community. Some viewed the Hill-Burton assistance necessary for the Black community to receive funds for improvement in healthcare and health resources to Black patients while others opposed these funds as they were seen as an acceptance of segregation.

Figure 1. How systemic racism impacts health (“Systemic Racism Is a Public Health Crisis”, 2022)

In 1962, Hill-Burton’s segregated provision was later deemed as unconstitutional following the federal court case, Simkins vs. Moses H. Cone Memorial Hospital (Largent, 2018). Dr. George Simkins, an African American dentist and president of the National Association for the Advancement of Colored People (Greensboro, North Carolina chapter), sued Moses H. Cone Memorial Hospital and Wesley Long Community Hospital which were accused of denying admission to one of Simkin’s patients due to his race as well as refusing hospital staff privileges to providers based on race (Thomas, 2006). Simkins and other involved plaintiffs argued that these facilities had received funding under the Hill-Burton Act and had violated their rights under the Fourteenth Amendment which states “No State shall make or enforce any law which [compromise] the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws” (“Fourteenth Amendment”, n.d.). Simkins also stated the “separate-but-equal” provision within the act is deemed as unconstitutional and in violation of the Fourteenth and Fifteenth amendment (U.S. citizens' right to vote will not be denied or compromised by the U.S. or any state on the basis of race or color) (“Fifteenth Amendment”, n.d.; Thomas, 2006; Fourteenth Amendment”, n.d.) Initial court rulings stated that Simkin’s claims were not applicable to violating the stated amendments. However, in 1963, an appeal was created for the case and the U.S. Court of Appeals overturned the initial ruling and ruled in favor of Simkins and deemed the act’s provision to be unconstitutional (Largent, 2018; Thomas, 2006). This court case served as a stepping stone for further reform such as the 1964 Civil Rights Act which prohibited segregation in public areas and racial discrimination in employers.

Furthermore, the country created two medical assistance programs: Medicare and Medicaid. Medicare is a federal health program for people aged over 65 years whereas Medicaid is a federal and state program to assist low income individuals with medical costs (“What’s the difference between Medicare and Medicaid?”, n.d.). These programs served as an initial federal address to the limited healthcare services in minority populations, providing funding to recruit medical providers to serve underserved areas, where racial and ethnic minority populations disproportionately reside. However, these positive initiatives were only a face value initiative, continuing to embed racism from early health policy decision making. For example, Yearby et al. (2022), describe an example of the inequity of Medicare and Medicaid programs in the U.S. by early health policy making:

For instance, as long as nursing homes made a good-faith effort to use non-discriminatory language in marketing materials, the government certified the homes to participate in Medicare and Medicaid even if they continued to use discriminatory practices to deny admission to members of racial and ethnic minority groups…. the federal government gives tremendous flexibility that allowed them to underfund Medicaid or limit Medicaid eligibility in a manner that disproportionately kept racial and ethnic minority populations from qualifying for Medicaid coverage.

Figure 2. Barriers to improving health equity (Hostetter & Klein, 2021).

Implicit bias refers to unconsciously associating groups (i.e. People of color) or categories markers (i.e. Degree of someone’s skin color) in a negative connotation (“Implicit Bias”, n.d.). Implicit bias assessments conducted by researchers reveal that medical providers are more likely to provide pain treatment to White patients compared to Black patients (“Racial Discrimination in Healthcare: How Structural Racism Affects Healthcare”, 2021; Racism and Health”, n.d.). Qualitative studies conducted with Black and Hispanic patients report experiencing racism with healthcare staff with behaviours such as as avoidance of touch, being excluded from health care decisions, and being rudely treated or belittled (Hamed et al., 2022). However, patients of color are not the only ones affected, but also minority healthcare staff, as nurses of color have reported feelings of distrust with other healthcare staff due to racist experiences, dealing with excessive emotional toll. A review conducted by Sim et al. (2021) investigating the perspective of healthcare staff and patients on racism in healthcare, reported that minority patients state they often are stereotyped as being less intelligent, of low economic status, and experience providers questioning their understanding of health information.

A published autobiographical case report by Dr. Tyler Smith, a medical provider and woman of color, (2021) describes her treatment of a diabetes mellitus (DM) diagnosis. Smith states while her attending physician during medical school was sincere and thorough with questions and concerns about DM, Smith’s primary care staff eluded that if she did not obtain her lab results soon that Smith was “going to die” as well as her clinician stating her lab results indicated pre-diabetes without explanation. Further into Smith’s treatment of DM, her first specialist provider stated that Smith did not fit the mold of someone with diabetes, judged by her age and body shape. Smith postulates how other patients with diabetes are perceived based on race, ethnicity, weight, and community, stating “some health professionals assume patients of color tell a falsehood about their medical history and therefore are non-compliant with taking medication”.

Figure 3. Perceived Discrimination in Medical Setting (Benjamins & Middleton, 2019)

To mitigate racism in healthcare, research has also focused on specialized training given to healthcare providers on how to address issues of racism to eliminate stereotypes and prejudices against minority groups. Nelson et al. (2015) reported effects of healthcare providers participating in a training module centered on racism and healthcare consisting of three 2-hour training sessions over a 3-month period. The authors concluded that the awareness level of racism increased significantly among participants as 100% of the providers state they agree or strongly agree that racism affects healthcare after completing the training module. The authors also note that White participants demonstrated a significant decrease in feelings of effectiveness in providing care to patients of color versus white patients. Cénat (2020) states the explanation for lack of care access is not financial, but mainly due to poor experiences in healthcare and discriminatory attitudes towards patients of color. The author proposes that healthcare professionals need to provide ‘anti-racist care’, which recognizes issues related to racial discrimination to effectively address unequal care in minority groups. Cénat describes the four pillars or main guidelines to anti-racist care, “Awareness of racial issues, an assessment adapted to the real needs of Black individuals, a humanistic approach to medication, and a treatment approach that addresses the real needs and issues related to the racism experienced by Black individuals”. These study reports identify the gap of equal care in racial and ethnic groups and white healthcare providers and also highlights the need for further education addressing racism in healthcare to better serve patients of color.

Figure 4. Statistics of racial disparities in healthcare (Shah, 2021).

Part of the differences in health outcomes in U.S. healthcare are due to racism towards people of color. Racism in healthcare is the product of deeply rooted racial discrimination that has occurred over decades in U.S. healthcare policy and health care practice (Yearby et al., 2022). It is necessary that healthcare providers acknowledge that racism in medical settings continues to exist as a pertinent issue in the U.S. If providers are able to identify this issue, then they are more likely to effectively reflect on how their actions can impact care of patients of color and promote change in their behavior. Training on racism in healthcare can improve healthcare providers knowledge, attitude, and address implicit provider bias (Peek, 2010) which in turn allow for equity in healthcare among people of color and improve health outcomes in these communities. Despite research efforts of implementing necessary racial training to healthcare providers, studies lack explanation on how racism is formed in healthcare and hidden behind healthcare practice that is branded as “non-racial” (Hamed, 2022). Racism in healthcare is no easy fix, but rather a collective effort from healthcare professionals to identify and acknowledge racial issues in order to correct biased behavior and provide equal care to racial and ethnic communities.

Bibliographical References

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Visual Sources

Cover Image: Dua, A. (2020). The way we collect covid-19 data perpetuates racism in healthcare. NewScientist. [Image]. Retrieved February 15, 2023 from https://www.newscientist.com/article/mg24732993-300-the-way-we-collect-covid-19-data-perpetuates-racism-in-healthcare/ Figure 1: Systemic Racism Is a Public Health Crisis. (2022). National Institute for Health Care Management. [Image]. Retrieved February 19, 2023 from https://nihcm.org/publications/systemic-racism-is-a-public-health-crisis Figure 2: Hostetter M., & Klein, S. (2021). Confronting Racism in Health Care: Moving from Proclamations to New Practices. Commonwealth Fund. [Image] https://doi.org/10.26099/kn6g-aa68 Figure 3: Benjamins, M. R., & Middleton, M. (2019). Perceived discrimination in medical settings and perceived quality of care: A population-based study in Chicago. PloS one. [Figure]. 14(4), e0215976. https://doi.org/10.1371/journal.pone.0215976 Figure 4: Shah T. (2021) Racial disparities in healthcare: A call to action. HealthScape. [Image]. Retrieved February 15, 2023 from https://www.healthscape.com/insights/racial-disparities-in-healthcare-a-call-to-action/