A relatively undiscussed and unconsidered form of discrimination continues to plague our health care institutions. It’s about time we talk about it.
Insurance-based discrimination is the prejudicial treatment of a patient based on his/her insurance status. This type of discrimination mostly affects the 28.9 million Americans who have no health insurance coverage, although there is evidence of discrimination against people with public insurance, too.
Uninsured individuals are at greater risk of postponed and foregone medical care, prioritizing other essential needs like housing, food, and transportation. Further, there are more uninsured individuals coming from groups who receive fewer health services, including people with less education and lower incomes. These influences partially explain why the uninsured have poorer health outcomes and are more likely to die sooner.
Sadly, another possible reason for health inequities between the insured and uninsured is insurance-based discrimination. Several studies have documented its persistence in the US:
- In a 2015 study by Han et. al., data from the Minnesota Health Access Survey was used to find any association between discrimination and insurance type. The study found that insurance-based discrimination was higher among the uninsured compared to publicly or privately insured adults.
- A study in Durham County, North Carolina, analyzed responses from a national survey that was compared to a telephone survey and found that black respondents were more likely than the national sample to feel that they were treated with disrespect on the basis of their health insurance status (28% vs 14%; P<.001).
- In Oregon, women who felt they were treated differently by health care providers during their pregnancy up to their delivery based on their insurance status were largely those from lower income groups. The study found that insurance-based discrimination was significantly associated with lower annual incomes and inability to pay medical bills.
The problem with insurance-based discrimination is more than just a problem of perception. Though negative experiences attributed to insurance-based discrimination may discourage individuals from seeking treatment, a more direct problem with insurance-based discrimination occurs when patients seeking care are not given what they need because of their lack of insurance. In other words, health care practitioners — intentionally or unintentionally — may be providing inadequate health services on the basis of the insurance presented at triage.
Recently, a study published ahead-of-print in Medical Care presented findings of insufficient health care delivery that may have stemmed from insurance-based discrimination. The authors conducted a retrospective cohort using data on 59,540 adult patients with severe traumatic brain injury (TBI) in the national TBI registry between 2010-2015. The main exposure studied was insurance status (almost 19% were uninsured), and the primary outcomes were receiving a head computed tomography (CT) and the number of CT scans received. The authors found 4.47 per 100 fewer uninsured patients had any head CT than the insured. The uninsured also got fewer head CTs in total. These results were adjusted to be independent of clinical, demographic, and facility features.
The findings of this study are very important. TBI may present similarly between two individuals, despite both having very different underlying pathology requiring completely different treatments. CT scans are used to definitively distinguish patients’ neurologic pathologies and treat patients appropriately in a timely manner. Receiving treatment within 4 hours of arrival results in a significantly shorter length of stay and half the likelihood of mortality compared to later treatment. CT scans also play an important role in monitoring and managing patients with brain injury, as well as identifying higher-risk cases. Delaying, or choosing not to order, a CT scan for patients with severe TBI could therefore be extremely detrimental to a patient’s chances of survival.
Why would doctors not order CT scans for severe TBI patients who really needed them? The authors of the study offer a few interesting insights:
- Physicians could be trying to “spare” uninsured patients from scans because of their cost. If so, this is contrary to what current evidence and guidelines tell us on how we should be managing patients with severe TBI.
- It’s also possible that patients are asking not to have a CT scan done to avoid the cost. If so, appropriate guidance from a physician could help.
- Health care teams may be requesting fewer CTs for the uninsured because of pressure from hospital management to lower the cost of managing trauma patients. It’s possible that trauma center closures, combined with an increase in the number of insured patients, could reduce this pressure.
The study discussed above shows evidence of the impact of discrimination in people with TBI. Two other recent studies provide further evidence of uninsured people receiving fewer services. In a 2013 study of 21,000 patients with pelvic fractures in the National Trauma Data Bank, uninsured patients got fewer diagnostic procedures compared with their insured counterparts. And in a 2016 study of 91,000 patients with spinal fractures in the same database, uninsured patients were less likely to receive surgical care.
Regardless of whether the decisions made by the treating physicians were conscious or unconscious, the fact remains that insurance-based discrimination appears to influence treatment decisions that consequently could be harming patients. Awareness of insurance-based discrimination is the first, crucial step toward lowering the risk for patients.
In the words of Martin Luther King, Jr., “Darkness cannot drive out darkness; only light can do that.” This holds true for insurance-based discrimination. Ignoring the issue only fuels its perpetuation.
Red Thaddeus Miguel
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