This study examined how poverty and the lack of health insurance coverage were related to perceptions of racial and ethnic bias in health care in a national sample of blacks, Hispanics, and whites who had a regular physician. Our results indicated that uninsured blacks and Hispanics were more likely to report that they had experienced racial and ethnic bias in the health care they received than did their privately insured counterparts. In addition, poverty was associated with an increased likelihood of perceived racial and ethnic bias among white respondents but not among members of the other racial and ethnic groups.
We cannot determine to what degree the respondents' reports of racial and ethnic bias reflected actual instances of biased behavior by their health care providers or to what degree they resulted from other factors not examined in this study. The actual nature of the association of provider behavior with perceptions of racial and ethnic bias among patients is not well understood; yet, we know that in contemporary America, subtle, often unconscious, forms of bias against racial and ethnic minorities are prevalent (e.g., Bargh, Chen, and Burrows 1996
; Bobo 2001
; Dovidio 2001
; Dovidio and Gaertner 2002
). Even individuals who explicitly disavow racial and ethnic stereotypes can unwittingly exhibit biased perceptions and behaviors under certain conditions (Stepanikova 2006
). Arguably, stereotypes and biased perceptions may affect how some health care providers interpret information about minority patients, how they behave during patient visits, and how they make decisions about what types of treatment are appropriate (Schulman et al. 1999
; Bogart, Kelly, Catz, and Sosman 2000
; Rathore et al. 2000
; van Ryn and Burke 2000
; van Ryn and Fu 2003
For a variety of reasons, some minority patients may have concluded that racial and ethnic biases negatively influenced the quality of their health care, even if they received care that was appropriate. This is not surprising, given that minority individuals commonly experience discrimination in their daily lives (Kessler, Mickelson, and Williams 1999
). As a result, they may develop a kind of stigma consciousness that makes them more likely to interpret daily events through the lens of race and ethnicity (Bird and Bogart 2001
). Importantly, some patients experience barriers to high-quality health care that are unrelated
to their race and ethnicity; yet, because of their high-stigma consciousness, they may attribute these difficulties to racial and ethnic discrimination. Lack of insurance could be one such barrier that potentially contributes to an increased likelihood of reporting racial and ethnic bias among the uninsured blacks and Hispanics in our study.
Evidence from social psychology (e.g., Bargh, Chen, and Burrows 1996
; Blair and Banaji 1996
) suggests that if providers have racial and ethnic biases, they may play a stronger role in the delivery of care when providers face increased levels of stress (Stepanikova 2006
). Consequently, we might expect to find a larger racial and ethnic disparity in the quality of care in health care settings that serve large numbers of socioeconomically disadvantaged patients, because the providers working in these settings may experience increased levels of stress and fatigue. They often see large numbers of patients, have inadequate administrative support, and face other stressors. The poor and the uninsured receiving their care in such resource-poor settings may therefore be more likely to experience, and to report, racial and ethnic bias in health care, potentially contributing to the association of poverty and lack of insurance with perceived racial and ethnic bias revealed by our study. Also consistent with this argument is our finding that Hispanics interviewed in English who receive care in community clinics, which are typically resource-poor, are more likely to report bias compared with those who receive their care in private practices or outpatient hospital departments, which are typically more resource-rich.
Our data do not enable us to determine precisely which of these explanations, if any, reflect an accurate understanding of the processes leading to the associations between socioeconomic disadvantage and perceived racial and ethnic bias found in our study. Our data also do not specify why
lack of health insurance was associated with perceived racial and ethnic bias among some minority respondents but not among white respondents, and why
poverty was associated with perceived racial and ethnic bias among whites, but not among racial and ethnic minorities, although these findings are not particularly surprising to those who study poverty and inequality more broadly. The broader literature which is not limited to health care suggests that some whites believe they have been victims of reverse discrimination (Fraser and Kick 2000
). In addition, we know that poverty is often viewed as a stigma, perhaps even more so by whites (Amato and Zuo 1992
An important limitation in this study concerns the lack of information in the survey about the identities of the regular physician, the physician seen in the last visit, and the physician delivering care on the occasion that lead to the report of bias. Without such information, we cannot determine whether in the questions about racial concordance, communication, and bias a respondent referred to a single physician or to multiple physicians. It seems reasonable to expect that many respondents referred to a single physician but those who referred to multiple physicians potentially increased the measurement error in our data.
The subjective nature of the patients' reports of racial and ethnic bias in health care can be considered another limitation, because these reports do not necessarily measure whether the patient's racial and ethnic background actually had an independent impact on the quality of health care delivered to the patient. At the same time, the fact that these reports reflect patients' subjective experiences can be considered a strength of the study. In recent years, scholars and policy makers have called for increased attention to patients' experiences with health care as one part of their efforts to improve the quality of care. They have also stressed the importance of culturally sensitive care, arguing that such care could improve the overall quality of health care for minority patients. Yet, as LaVeist, Rolley, and Diala (2003)
point out, there are few studies of cultural competence from the perspective of patients. Our study sought to contribute to the understanding of one aspect of patients' experiences with cultural sensitivity (or the lack of it) as reflected in their subjective perceptions of racial and ethnic bias in the health care they receive.
Another strength of our study is the use of a national sample, which makes the results more generalizable to the U.S. population (and subsets of it) compared with some of the earlier studies that used samples consisting of special patient populations. At the same time, the scope of our study is limited to blacks, Hispanics, and whites. Our results are not generalizable to individuals of other racial and ethnic backgrounds. In addition, because we only studied people with a regular physician, our results do not generalize to people without a regular physician. More research is needed to determine whether an association between perceived racial and ethnic bias and socioeconomic disadvantage extends to those without a regular physician, especially because these individuals tend to be affected by poverty and lack of insurance more often than others.
What are the implications of the findings described in this study? In addition to the benefits of health insurance for access to health care services and for the overall health of the population, which have been amply documented, universal health insurance coverage may help reduce perceptions of racial and ethnic bias among some minority patients. These implications are preliminary and must be supported by future research on the direction of causality and on how various aspects of socioeconomic disadvantage are linked to racial and ethnic disparities in the quality of health care.
Our results reveal that several factors beyond the lack of insurance and poverty contribute independently to patients' perceptions of racial and ethnic bias in health care. Especially important is the quality of physician–patient communication. Previous research suggests that physician–patient communication characterized by clarity, attentiveness, and empathy is associated with patients' more positive experiences, including higher perceived respectfulness of the health care providers (Johnson, Roter, Powe, and Cooper 2004
), higher patient satisfaction, and reduced emotional distress following consultation (Zachariae et al. 2003
). Communication breakdowns may lead to patients' perceptions of racial and ethnic discrimination, regardless of whether providers' racial and ethnic biases actually influenced the quality of care delivered to the patient. If further research finds causal effects between physician–patient communication and patients' perceptions of racial and ethnic bias, we will have evidence suggesting the importance of training physicians in culturally sensitive communication skills to improve those aspects of the quality of health care that are reflected in patients' experiences, and, ultimately, to assist in designing a health care system that provides high-quality care to all patients regardless of their race, ethnicity, and socioeconomic status. Programs currently being developed to increase the extent to which physicians in training are culturally sensitive to their patients' needs and behaviors should be investigated as part of the broader effort to improve health care.