Almost one in five older patients with a chronic disease reported experiencing health care discrimination in a large national survey that asked about their daily experiences of discrimination between 2008 and 2014. Black patients were most likely to report discrimination by race, while White and Hispanic patients reported age, weight, or income discrimination more frequently.
The analysis by researchers at UC San Francisco, UC Berkeley, and Stanford University found that reported discrimination among Black patients declined significantly over the six-year study period, reducing the Black-White disparity from 8.2 percent to 2.5 percent until it was near that of White patients. But racial discrimination remained the most common reason by far that Black patients said they received poor service or treatment from doctors and hospitals. In addition to race or ancestry, the survey asked about discrimination by gender, age, religion, weight or physical appearance, physical disability, sexual orientation and financial status.
Researchers said all the groups in the study—Black, White and Hispanic—reported high rates of discrimination, and they urged continued monitoring of patients’ experiences, since reported discrimination is associated with worse health, lower satisfaction with health care and lower utilization of health services.
“Providers should be aware that a large fraction of patients will have experienced some form of discrimination in a health care setting,” said Amani Nuru-Jeter, associate professor of epidemiology and community health sciences at the UC Berkeley School of Public Health and senior author of the study. “Just by recognizing how common these experiences are for patients, clinicians may be able to offer better care.”
The study, published December 15 in the Journal of General Internal Medicine, analyzed biannual responses from 13,897 participants in the Health and Retirement Study who were 54 or older and had at least one of the following chronic conditions: hypertension, diabetes, cancer, lung disease, a heart disease, or stroke.
In 2008, 27 percent of Blacks with a major chronic health condition reported experiencing discrimination. The top three reasons reported that year were discrimination on the basis of race or ancestry (48 percent), age (29 percent) and financial status (20 percent). By 2014, the percentage of Blacks who reported discrimination had declined to 20 percent, while the percentage for Whites held steady at about 17 percent, and the difference between the two groups was no longer statistically significant. Among Whites, the top reasons for reported discrimination in 2008 were age (29 percent), weight/physical appearance (16 percent), gender (10 percent), and financial status (10 percent).
“If people believe they have received unfair treatment in the health care setting, that experience could negatively affect their experience with their providers, their willingness to go to their providers, and their adherence with their treatment, and thereby affect their health,” said Thu Nguyen, a UCSF researcher and the paper’s first author. “It’s still very common, and there’s a long way to go.”
Researchers said it was unclear why Blacks reported less discrimination in later years, although the change has come as medical schools are putting increased emphasis on implicit bias training. Another possible explanation is that a new cohort of study participants added in 2010 changed the composition of respondents so that they reported less discrimination. Reports by Blacks fell sharply from 2008 to 2010, but less so between 2010 and 2014, although no changes were observed for the White and Hispanic study participants who were also added in that new cohort.
“Whereas reports of discrimination decline among wealthier Whites, wealth does not provide the same protection for Blacks. Blacks’ reports of discrimination actually increase as wealth increases,” Nuru-Jeter said. “This finding is useful for continued efforts to improve health care experiences and suggests that a one-size-fits-all approach will not suffice.”
There was no clear trend for Hispanics over the six-year study period, whose overall rate of reported discrimination started just below that of Whites, edged up slightly, and then fell to where it was at the beginning of the study period. The types of discrimination that Hispanics reported most often in 2008 were age (27 percent), race or ancestry (23 percent), weight/physical appearance (14 percent), and financial status (14 percent).
The researchers said that patients with chronic conditions require more routine follow-up care than those with acute medical problems, and were therefore more vulnerable to the negative effects of perceived discrimination, which could dissuade them from seeking needed care.
Other authors are Anusha Vable, Stanford, and Maria Glymour, UCSF.