Effects of poverty and lack of insurance on perceptions of racial and ethnic bias in health care.

Patients' perceptions of racial and ethnic bias and discrimination in health care are not uncommon among minority health care users. Based on national studies, as many as 15 percent of Latinos/Latinas and 12 percent of blacks report that they had been judged unfairly or treated with disrespect by a health care provider because of their race or ethnicity (Lillie-Blanton et al. 2000). Twenty-three percent of blacks and 15 percent of Hispanics believe they would have received better medical care if they were of a different race or ethnicity (LaVeist, Rolley, and Diala 2003). In some special patient populations, perceived discrimination is even more prevalent. A study by Bird, Bogart, and Delahanty (2004), for instance, reveals that more than 70 percent of HIV-positive patients report having experienced discrimination based on their race or color while receiving treatment. Because this study did not control for race, the overrepresentation of blacks among the HIV-positive patients may have contributed to the finding of a high prevalence of perceived racial discrimination. As one might expect, perceptions of racial and ethnic discrimination are much less common among white Americans. In one national study, only 1 percent of the whites reported having been judged unfairly or treated with disrespect because of their race or ethnicity (Lillie-Blanton et al. 2000). Yet, 16 percent of whites, 30 percent of Hispanics, and 35 percent of blacks believed racism was a “major problem” in health care, suggesting that many Americans are concerned about equity in the health care system. Perceptions of racial and ethnic bias and discrimination in health care are linked to a number of undesirable outcomes, including lower overall satisfaction with care (Bird et al. 2004), a higher likelihood of putting off medical tests and treatment (Van Houtven et al. 2005), lower likelihood of receiving preventive health care services (such as cholesterol testing, diabetic foot exams, flu vaccinations, and hemoglobin a1c testing [Trivedi et al. 2005]), poorer self-rated health, increased depression, and increased AIDS-related symptoms among HIV patients (Bird et al. 2004), as well as poorer glycemic control, poorer physical functioning, and higher symptom burden among diabetic patients (Piette, Bibbins-Domingo, and Schillinger 2006). This evidence is consistent with the broader literature indicating that the physical and mental health of Americans who experience discrimination in their daily lives tends to suffer (Kessler, Mickelson, and Williams 1999; Krieger 2000; Williams and Neighbors 2001; Williams, Neighbors, and Jackson 2003). Only a handful of studies have addressed factors beyond race and ethnicity that may contribute to perceptions of racial and ethnic bias in health care. One study found that the odds of reporting racial discrimination in health care decreased with increasing income and self-rated health, even after controlling for race and ethnicity (LaVeist, Rolley, and Diala 2003). Another study revealed that black patients who reported perceptions of race-based discrimination in interactions with their health care providers were more educated and more aware of the problem of racial stigmatization compared with other black patients (Bird and Bogart 2001). Little is known about how other factors relate to perceived discrimination in health care. Two factors that are especially important in the context of health care delivery are poverty and the lack of health insurance. We know that they represent formidable barriers to obtaining high-quality health care (IOM 2002; AHRQ 2003). These structural obstacles affect minorities more commonly than whites (Hargraves 2004). As the numbers of the poor and the uninsured, who are disproportionately nonwhite, continue to rise in America (Strunk and Reschovsky 2004; The Kaiser Commission of Medicaid and the Uninsured 2005; DeNavas-Walt, Proctor, and Lee 2006), it is important to better understand the implications of poverty and lack of insurance for patients' experiences, especially among nonwhites and people with limited English skills, who also face language barriers to high-quality care (David and Rhee 1998; Carrasquillo et al. 1999; Weech-Maldonado et al. 2001). The purpose of this paper is to investigate whether poverty and lack of insurance are related to perceived racial and ethnic bias in health care. While this problem is not well understood in the context of health care, the sociological literature suggests that socioeconomic disadvantage is linked to perceived racial and ethnic discrimination in other areas of daily living (Kessler, Mickelson, and Williams 1999; Watson, Scarinci, Klesges, Slawson and Beech 2002). This literature leads us to expect that the poor and the uninsured will be more likely than others to report that they have experienced racial and ethnic bias in health care. We test the relationships between poverty and lack of insurance using a recent national sample of health care users who have a regular physician. We also examine whether the effects of poverty and lack of insurance vary among people of different racial, ethnic, and language backgrounds.