Healthcare as a Tenant of Systemic Racism in the United States
As we continue to explore the “Web of Racism” and its focus on systemic racism in the United States, healthcare stands out as an institution that historically reproduces race-based disparities (McClellan, 2020). Centuries of “slavery, segregation, and contemporary white oppression severely limit and restrict access of many Americans of color to…adequate health care and health outcomes” (Feagan & Bennefield, 2014). A closer look at what is meant by “healthcare disparities” includes the different ways that racism is manifest in the clinical and hospital experiences of Black, Indigenous and People of Color (BIPOC). Taking time to learn about the varied layers of racism at work within the healthcare system produces several different lenses with which to learn more about this topic. For instance, the experiences of individuals in hospital emergency rooms chronicle personal encounters with racism in health care (King & Redwood, 2016). Concurrently, there are accounts of caregiver biases and discrimination as factors that contribute to race-based healthcare disparities embedded in the structural framework of health systems and hospitals (2016, 1). A broader view of these same instances of inequity shows how public policies and laws further exacerbate and maintain race-based injustices in healthcare. This featured topic looks at several key focus areas that, in part, comprise the dynamics of systemic racism in health care.
Equally important as the ways the healthcare system marginalizes certain patient populations, this blog also looks at some ways that the United States healthcare system has progressed in its efforts to eliminate racial biases in these same areas of individual care experiences, structural inequities, and overall policies and laws. We conclude with some resources for learning about equity efforts in health care. As noted, the first section looks at the experiences of individuals in hospitals, one way that race-based inequities occur in hospital emergency rooms, and a method that caregivers are applying to address unconscious biases in healthcare.
Individual Bias: A Visit to the Emergency Room
Countless narratives show that “physicians’ perceptions of patients may systematically vary by patient race…[and] may explain some of the variance in physician behavior toward and treatment of [the] patient” (van Ryn & Burket, 2000). For example, emergency room physicians more readily order pain medication for White patients than for Black patients under the physician’s care (Chapman, Kaatz, & Carnes, 2013). At the same time, studies show that while physicians seemed to accurately assess pain levels among emergency room patients who were BIPOC, these doctors continued to provide less pain medication to these patients than to White patients with similar severe injuries. While accounts of these types of personal experiences are well documented, this emergency room dynamic is not unique to the healthcare experiences of some BIPOC patients in emergency room settings. Comparable clinic and hospital experiences for BIPOC women, men, youth and children can be found in the media and in medical research literature.
While experiences such as those mentioned in the previous paragraph chronicle deficiencies in how BIPOC individuals experience clinic and hospital treatment, there is evidence that equity-focused initiatives in healthcare are working to interrupt and diminish racism in how BIPOC experience health care in clinics and hospitals. For example, a professional coaching tool that is being implemented in clinical training and practice is called “The 5Rs of Cultural Humility” (Masters et al., 2019). This approach to learning about and recognizing one’s conscious and unconscious biases has helped medical providers pause and practice intentional self-monitoring practices. Findings show that the 5Rs can prevent healthcare workers from succumbing to race-based biases in the ways they deliver healthcare experiences to people who’ve historically been underserved and who are atrociously vulnerable to poor care due to race-based inequities in the United States healthcare system.
Increased awareness of these race-based injustices in healthcare can lead to a deeper understanding of how institutions such as healthcare, housing and education contribute to the maintenance of a social system that offers advantages to people who are deemed the “mainstream” or “dominant” social group – most often this constitutes White middle-class communities – and deny access to health-related resources to patients who are BIPOC. At the same time, recognizing how healthcare providers are striving to address conscious and unconscious biases in how healthcare professionals work with BIPOC patients is inspiring and hopeful. In the next section, race-based inequities, as well as efforts to diminish these injustices, are examined as part of the structure or system of healthcare in the United States.
Structural Bias
Structural or systemic racism as a concept first shows up in healthcare literature in the 1960s. Ture and Hamilton (1967, 3 – 4) are two medical professionals who sought to learn more about systemic racism in United States healthcare practices. They noted that “racism involves [making] decisions and policies [drawing] on considerations of race for the purpose of subordinating a racial group.” Their work showed that society promoted racism through “less overt… identifiable [racist practices that were] no less destructive of human life” (Feagin & Bennefield, 2014, 1). One way that structural racism in healthcare shows up is by looking at accounts of hospitals or long-term care facilities that serve predominantly BIPOC communities. For example, there is evidence that these facilities tend to be “for-profit, urban facilities” (Yearby, Clark, & Figueroa, 2022, 191). Alongside this observation, BIPOC communities tend to experience shortages of available internal medicine doctors, surgeons and access to qualified mental health professionals (192). These two areas of inequity are further amplified for BIPOC living in rural communities. Intersecting factors such as these realities contribute to findings that show that overall, BIPOC communities frequently have few, if any, options for healthcare beyond the poorly staffed, understaffed, and thus, underperforming and underfunded clinics and hospitals. These substandard factors also contribute to a greater risk for “safety events and complications” during a patient’s clinic or hospital visit for BIPOC (192). Although this is by no means an exhaustive account of the structural race-based inequities in health care, these realities demonstrate how institutional systems in the United States reproduce an unjust, racially biased healthcare system that marginalizes and inadequately meets the care and recovery needs of the country’s BIPOC communities.
While these structural injustices significantly influence how BIPOC experience access to health care, there are organizations and individuals whose work seeks to eliminate or, at the very least, decrease race-based healthcare access disparities that plague city and rural communities that are home to a majority of BIPOC and their families. For instance, Patient Navigation (Budde, et al., 2022) is a recent concept that establishes “...care for vulnerable and disadvantaged populations such as migrants, ethnic minorities, homeless or uninsured persons [and]...facilitates early detection of diseases and access to care” (p.5). People who serve as patient navigators generally have experience as social workers, physician’s assistants, nurses, or people outside of the human services professions fields who have gained an understanding of the importance of this vital role through sustained personal experiences within the medical system. This trend toward Patient Navigation programs shows positive outcomes in the areas of increased access to care, reduced wait time for diagnosis and treatment, improved care plan coordination, and care continuity for patients who are BIPOC. Patient navigation experiences have also been linked to reduced emergency room visits and lowered readmission rates. Intervention programs such as patient navigation resources are one way that the healthcare equity gap is being effectively addressed in the United States healthcare system. Next, let’s examine how biases in law and policies reproduce systemic racism through the structure of healthcare.
Political Bias in Law and Policy
Historically, public resources that fund healthcare initiatives and access are determined through state and federal policy and laws. “Racism has implicitly and explicitly been an integral part of the US government’s structuring and financing of the healthcare system” (Riqaiijah, Clark, & Figueroa, 2022, 188). A lack of data that shows the degree to which BIPOC in cities experience ineffective or, at worse, injurious effects through healthcare decreases the likelihood that these metrics are considered when policymakers support or propose healthcare policies and laws. Some argue that the purported absence of data as evidence of race-based healthcare inequity is partly responsible for the reproduction of race-based systemic inequities in state and federal laws and local practices. Another visible and persistent example of how healthcare inequities support a two-tiered system that results in substandard care for BIPOC is the way that health insurance is structured in the United States. The federal government recognizes that “inadequate health insurance is one of the largest barriers to healthcare access, and the unequal distribution of coverage contributes to [race-based] disparities in health (2022, 187). These health insurance inequities are further underscored as insurance policies and practices become more decentralized through federal, state, and local interpretations of what constitutes an insurance-covered health event or experience.
While policymakers promote the laws that determine how insurance companies design health insurance policies – and this results in race-based inequities found in health care coverage – it is also the case that some policymakers champion health insurance reform efforts aimed at eliminating race-based inequities in health care access as such is related to state and federal policies that limit or deny health care to BIPOC patients. To illustrate, an article from Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity (Geller, et al., 2023) notes that efforts are being made to increase the amount of metric information and other types of data that are specific to chronicling the needs of patients who are BIPOC in the United States healthcare systems. As noted in the previous paragraph, a lack of data related to the healthcare experiences of BIPOC is part of the reason that race-based healthcare inequities are inadequately addressed in policy and law. These efforts to accurately represent the healthcare disparities faced by BIPOC through state and federal data sources can provide policy and lawmakers with the metric information needed to underscore the need to more effectively address this race-based inequity through reformed policies and laws.
Conclusion
This blog sought to foreground some of the ways that systemic racism is represented in the United States healthcare system. Though the write-up itself is by no means comprehensive, the available information on this topic makes it clear that BIPOC experience race-based inequities in all facets of their healthcare experience: personally, institutionally and through healthcare policies and laws. The broader view of this problem unfolds as we consider that poor healthcare results in overall lower life expectancies for BIPOC.
At the same time, it is useful to examine elements of progress in repairing racial inequities in the United States healthcare system in order to acknowledge and celebrate the work of healthcare activists, medical professionals, and policymakers who recognize the importance of this issue in efforts to diminish systemic racism. While there has been inspiring progress in these equity efforts, it’s clear that poor health care contributes to the factors that maintain the racial divide in the areas of employment, socioeconomic status, and overall wellness for BIPOC. An awareness of this kind of social injustice and the cascading impact that this has on individuals, families, and communities cannot be dismissed or ignored in efforts to enact anti-racist practices and policies in local communities, states, and nationwide. The inroads toward healthcare equity demonstrate that though there remains much learning to be done, there is progress at the individual, structural and policy levels of how BIPOC experiences healthcare in the United States.
Resources to learn more about healthcare and race-based disparities in the United States:
Health Equity Animated: Race – Youtube video
What is Health Equity? – Youtube video
What is Health Equity and Why Does It Matter? – Youtube video
Resources to learn more about healthcare advocacy and services for BIPOC in the United States:
Reclaiming Wellness Recap – Youtube video
Illustrate Change: Medical Illustration Featuring People of Color – Youtube video
Oakland Clinic Brings Holistic Health Care to BIPOC Communities – Youtube video