Uninsured, Publicly Insured Patients Face Implicit Bias in Health

Adult patients with public insurance coverage, like Medicare or Medicaid, and uninsured individuals are more than twice as likely to report facing implicit bias in health and otherwise unfair treatment than their publicly insured peers, likely because of their insurance status, according to reporting from the Urban Institute funded in part by the Robert Wood Johnson Foundation.

Particularly, 17.4 percent of adults with public insurance and 13.9 percent of those who were uninsured said they experience implicit bias from their healthcare providers for more than one reason. That compares to 6.4 percent of adults with private insurance who said the same.

Implicit bias in medicine is a decades-old problem that’s only gained attention in the past few years. Following the nation’s racial reckoning in 2020, the medical industry has looked at areas in which it perpetuates institutional racism, in part by reflecting on its own implicit biases.

This latest report from the Urban Institute drew on survey data from the April 2021 Health Reform Monitoring Survey, revealing that implicit bias in medicine is not only linked to race. Insurance status can also result in unfair treatment from medical professionals.

Patients who were uninsured or on public insurance were five times as likely to say their insurance status determines implicit bias and unfair treatment from medical providers. A mere 1.3 percent of folks with private insurance said they are the target of unfair treatment due to their insurance status, compared to 9.6 percent with public insurance and 7.4 percent of those without insurance at all.

Medical providers may be treating these patients differently, whether on purpose or because of implicit bias because they harbor associated beliefs about income or social status.

“When the healthcare system bases care and treatment decisions on insurance status, race, or ethnicity, it reinforces systemic structures of inequities that cause health disparities,” Mona Shah, senior program officer at the Robert Wood Johnson Foundation, said in a statement emailed to journalists. “As healthcare decision-makers commit to goals of achieving optimal treatment and wellbeing for all patients, it’s clear that those efforts need to include reducing systemic bias in care.” 

Notably, the researchers found that folks who say they are treated unfairly because of their insurance status are also more likely to say they are treated unfairly for another reason, too. The most common reasons patients said they’re treated unfairly include their income, the presence of a disability or health condition, and race or ethnicity.

In addition to reporting poor patient-provider interactions, individuals with public insurance said navigating the medical industry is difficult. While 16.2 percent of publicly insured patients reported insurance-related hassles, only 11 percent of those with private insurance reported the same.

These findings will be critical as the healthcare industry pushes forward in its efforts to promote health equity. Equitable outcomes begin with equitable patient-provide relationships, and in order to get there, industry leaders need to address implicit bias in medicine.

“Understanding who is experiencing unfair treatment and patients’ perceptions of why they are being treated unfairly helps policymakers and payers implement effective policies to prevent such treatment,” Dulce Gonzalez, research associate at the Urban Institute, said in a public statement. “Because patients report unfair treatment due to their race and ethnicity from front office staff and providers at about equal rates, efforts to reduce these negative experiences will need to target both of these sources.”

Patients report experiences of implicit bias and unfair treatment based on other characteristics, separate reporting from the Urban Institute and RWJF has found. In August 2021, the organizations released data showing that 3.2 percent of patients of all races experienced some sort of unfair treatment in the medical setting.

That figure came out to 7.7 percent of Black respondents and 5.2 percent of Hispanic respondents, signaling a racial bias permeating the healthcare industry.

The Urban Institute and RWJF also said that around half of those reporting unfair treatment in medicine said it happened when interacting with a front desk worker; 55 percent said they experienced unfair treatment with a clinician, like a doctor or a nurse.

Those negative interactions could have downstream impacts on patient health, to say nothing of the moral issues at play. Nearly three-quarters of those who said they experienced discrimination in the healthcare setting took action to mediate it, with 39 saying they handled it by delaying their medical care.

Postponing patient access to care can have downstream effects, like deteriorating chronic illness or delayed detection of new diseases. Ultimately, limited care management and preventive care can result in more acute—and often life-threatening—episodes.