This study is among the first to examine the association between perceived discrimination and perceived quality of care in a large, ethnically and racially diverse population-based sample and to evaluate the sociodemographic variables and other indicators of access and satisfaction associated with perceptions of health care quality within four primary racial/ethnic groups. In this representative cohort of California’s non-institutionalized adults, we found that Asians and African Americans were less likely than other racial/ethnic groups to rate the quality of their health care favorably. In addition, although discrimination in health care was reported by respondents from all racial/ethnic backgrounds, members of minority populations were significantly more likely to report being discriminated against compared to non-Hispanic whites. Across racial/ethnic groups, respondents who believed that they would have gotten better health care if they were of a different race were more likely to report lower quality of care.
Interestingly, we found that after adjusting for perceived discrimination, African-American race was no longer a significant predictor of ratings of quality care, suggesting that the difference between African Americans and non-Hispanic whites′ ratings of quality care can be explained primarily by African Americans perceptions of discrimination in the health care setting. This finding is consistent with other studies among African Americans where perceived racism had a significant effect on patients′ ratings of care.7,10
For example, La Viest and colleagues found that African American race was not an independent predictor of poor patient ratings of care after accounting for patients′ ratings of perceived discrimination in a sample of cardiac patients.28
Similar to findings from other studies, Asian Americans reported lower ratings of quality care compared to non-Hispanic whites.29,30
This difference persisted even after adjusting for ratings of perceived discrimination, suggesting that other factors may be more important in trying to understand Asian Americans′ low ratings of health care quality. The findings from this study highlight specific challenges associated with perceived health care quality that Asian Americans encounter, such as problems with access to specialists and problems finding a personal doctor with whom they are happy. While it may be the case that racial/ethnic differences in ratings of care reflect different response tendencies rather than actual differences in experiences with care,9,31,32
other conflicting evidence suggests that Asian Americans are truly more dissatisfied with their care than non-Hispanic whites.29,33,34
Some researchers have argued that one recommended strategy for trying to address response bias when comparing ratings across different cultural/ethnic populations is to collapse responses at the higher end of the scale.9
Nonetheless, understanding other factors associated with Asian Americans greater dissatisfaction with their health care quality is an important step for future research.
Hispanics in our study reported the highest quality of care ratings despite reporting high discrimination rates. In previous research based on the National Consumer Assessment of Health Plans Study (CAHPS) data,9
Hispanics reported negative experiences in every specific area assessed, including getting health care needed, provider communication, and timeliness of care, yet they rated the health care received more positively than any other racial or ethnic group.9
This was particularly true for Hispanics who spoke only or mostly Spanish, as we found in our study. For Hispanic respondents, ratings of discrimination, health care access, and satisfaction with the provider were significantly associated with ratings of perceived quality, suggesting that Hispanics are more satisfied with their health care when the entire system provides a setting that is culturally and linguistically compatible.35
Our study is subject to several limitations. The cross-sectional study design precludes causal inferences between racial/ethnic discrimination in health care and perceived quality of care. People who are more sensitive to discrimination or more apt to report it may also be more sensitive and willing to report other problems with their health care. Furthermore, the definition of quality of care may vary widely among patients, even within the same race or ethnicity. Due to the design of this study, we cannot determine if the differences in reported quality of care were due to patient expectations, differences in perception, or actual care received. Nevertheless, this study highlights the importance of understanding the relationship between perceived discrimination and ratings of quality care within each racial/ethnic group.
This research documents the existence of perceived racial and ethnic discrimination in health care and its association with respondents′ ratings of perceived quality of care. Although the overall prevalence of perceived discrimination in health care settings appears to be relatively low, the experience of such discrimination is strongly associated with respondents′ evaluations of their overall health care experience. The belief that the quality of care received is lower than that received by members of other racial/ethnic groups may be a contributing or mediating factor not only in health care satisfaction,14,16,17
but also in adherence to medical advice10
and medication regimens.10,12
Even when receiving medical care considered to be objectively adequate by other process or outcome measures, patients may rate it as poor if they felt discriminated against or mistreated in the process. Furthermore, perceived discrimination has profound health impacts.36,37
Previous studies have found that perceived racial/ethnic discrimination has been associated with worse mental and physical health among African Americans,38,39
Therefore, efforts to improve quality of care in the US must also address racial/ethnic discrimination and perceptions of inequality in the health care system.42
Such efforts may be most effective if they target populations that are at greatest risk for perceiving discrimination and the underlying factors associated with ratings of poor health care quality.