By Héctor E. Alcalá, Amanda E. Ng, Sujoy Gayen, and Alexander N. Ortega
The Journal of the American Board of Family Medicine, July 2020
Introduction: Discrimination can compromise access to and utilization of health care and lead to poorer health. As such, it is important to understand the factors associated with experiences of discrimination in health care.
Methods: Using data from the 2015 to 2017 California Health Interview Survey (n = 63,100), this study examined whether insurance types and sites of usual sources of care were associated with reasons for perceived discrimination in health care and whether the reasons were associated with delaying health care. Odds of study outcomes were calculated among insured adults using logistic regressions. Insurance coverage types and sites of usual sources of care were the main independent variables. Six reasons for lifetime discrimination in health care were examined: 1) dissatisfaction with the health care system, 2) race or skin color, 3) age, 4) way the participant speaks English or other barrier to communication, 5) insurance status or type, and 6) income or education.
Results: Adults with Medicaid perceived more discrimination due to race or skin color relative to those with employer-sponsored coverage. This association does not vary by race/ethnicity. Perceived discrimination due to 1) dissatisfaction with the health care system, 2) insurance status or type, and 3) barriers to communication were each associated with increased delays in getting needed medical care.
Conclusions: Findings highlight potential insurance types and sources of care that could contribute to perceptions of being discriminated.
From the Discussion
This study observed that insurance type and sources of care are associated with lifetime perceptions of discrimination in health care. Perceived discrimination in health care was higher for those whose regular source of care is the ED relative to those whose regular source of care is a doctor’s office or HMO, but it did not vary substantially once specific reasons for discrimination were considered. In addition, participants receiving Medicaid were more likely to perceive discrimination in health care, with race or skin color being the only specific reason, when compared with their counterparts with employer-sponsored coverage. This supports prior work that observed that Medicaid patients reported lower satisfaction when compared with individuals with other types of insurance. The present study built on prior research that focused solely on racial and ethnic discrimination and showed that individuals with Medicaid were more likely to report perceiving racial or ethnic discrimination in health care.
This study observed that, even considering substantial health care reform, the experiences patients have in the health care setting vary systematically. Because this seems to be conditioned, at least in part, on the type of insurance a person has and where he or she receives health care, future reforms to the health care system are needed that provide a stronger overhaul of health care quality and must be better at addressing the effects of patients’ prior experiences with health care. In particular, because patients with several different public insurance coverage options experienced a higher burden of discrimination, not addressing these problems will disproportionally affect populations that are poorer and experience worse social determinants of health (eg, Medicaid enrollees). Furthermore, while perceived discrimination has a negative effect on health care utilization, our study suggests that the health care system needs to improve its ability to address certain types of discrimination to promote better population health.
By Don McCanne, M.D.
The Medicaid program works well from the standpoint that the benefits are comprehensive and the out-of-pocket exposure is minimal, providing relatively good financial protection in the event of medical need.
However, Medicaid is a welfare program and, as such, faces certain stigmas. People on the program are certainly aware of that and thus may be on guard for fear that they may be considered by others to somehow be less worthy, which could show up in the quality of care they receive or the enthusiasm with which it is rendered. In fact, the majority are now enrolled in Medicaid managed care programs which have reputations for stinting on care because of the low reimbursement rates they receive. For those receiving care outside of managed care organizations, it is generally known that reimbursement rates are very low and it may be difficult to know if providers are truly altruistic or if they are accepting Medicaid patients by default. At any rate, there is little political support for funding Medicaid at rates comparable to the private sector.
This uncertainty may cause patients to be on the watch for discrimination in their care. This may be particularly true for individuals who are already accustomed to discrimination because of their racial or ethnic backgrounds.
Unfortunately, this study adds to previous studies that confirm that racial and ethnic minorities indeed do perceive discrimination in the care they receive under the Medicaid program.
If we were to replace all current sources of health care funding with a single payer model of an improved Medicare for All, we would automatically eliminate discrimination that is based on the financing source, such as we see with Medicaid. Certainly other sources of discrimination would continue to require further remedies, but Medicare for All would provide a giant step forward toward social solidarity by virtue of an egalitarian health care financing system.
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