Health Hazard

About one in seven Coloradans — 15.1%, or 620,000 people — reported “sometimes” or “often” experiencing unfair treatment when getting medical care at some point in their life, according to data from the 2019 Colorado Health Access Survey (CHAS).

The impacts of being unfairly treated are far-reaching. Unfair treatment is associated with increased stress and poor health outcomes. Similarly, past experiences of unfair treatment can influence future decisions on whether to seek needed care.

Some Coloradans are more likely to report experiencing unfair treatment than others. Women are more likely to report unfair treatment than men — 17.9% vs. 11.8% (see Figure 2). People with no insurance or public coverage as well as younger adults also disproportionately report unfair treatment in care. 

Understanding these disparities is critical to ensuring that all Coloradans have access to equitable and fair treatment and can pursue needed care without fear of discrimination. 

This brief focuses on the following guiding questions:

• Who reports experiencing unfair treatment when getting medical care in Colorado? 
• For what reasons do Coloradans believe they are treated unfairly?
• How do reports of unfair treatment affect health status and willingness to pursue future health care treatment? 

Unfair Treatment and Health 

Discrimination in health care settings is associated with poor health outcomes. Coloradans in fair or poor health were three times as likely to say they had been treated unfairly sometimes or often as those in good, very good, or excellent health (32.6% to 11.4%). Similarly, 34.2% of Coloradans who reported poor mental health also said they were treated unfairly sometimes or often, compared with 10.6% in good mental health.

This is consistent with other research that has found associations between perceived discrimination when getting care, quality of care, and adverse health outcomes. In one study, individuals reporting discrimination were more than twice as likely to also report fair or poor quality of care.

Perceived unfair treatment can also lead to avoidance of necessary medical care. A study examining the associations between perceived discrimination and cancer screening among American Indian women found that past experiences of unfair treatment negatively influence use of cancer screening services and health care-seeking behaviors. Generally, previous studies show that perceived discrimination in a health care environment is associated with delayed treatment, underutilization of behavioral health services, and increased emergency department and hospital visits.

Insurance Status and Ability to Pay 

When insurance status is considered, reports of unfair treatment by men and women highlight another key indicator of perceived provider bias. Coloradans without commercial insurance were more likely to report discrimination. Notably, 34.4% of uninsured men reported unfair treatment, compared with 8.1% of men with commercial coverage. And 26.2% of women with public insurance coverage reported unfair treatment, compared with 13.1% with commercial coverage (see Figure 4). The disparity between uninsured men and women is also notable, particularly because more uninsured men report unfair treatment than women. The reason for this difference is not currently clear and deserves further exploration. 

Insurance status can serve as a proxy for overall socioeconomic status. In other words, these data could reflect unfair treatment and perceived ability to pay. A person is more likely to go without insurance, for example, if they work in an occupation or an employment sector that is less likely to provide full benefits and/or if they have an income that’s too low to purchase health insurance.

Reported Reasons for Unfair Treatment

Coloradans cited a range of reasons for the unfair treatment they reported experiencing in the past. More than 17% of Coloradans cited race or skin color, 20.9% cited gender or sex, and 21.5% cited having a disability. However, the top reported reason for unfair treatment was age — of those who reported “sometimes” or “often” being treated unfairly, 32.6% shared that age was the reason why (see Figure 5). 

The proportion of women who cited age as a reason was even higher. Colorado women were more likely to report “sometimes” or “often” experiencing unfair treatment because of their age compared with men (39.6% and 22.6% respectively) (see Figure 6).

Even more striking, women were over five times more likely than men to report that past experiences of unfair treatment were due to gender —28.6% of women compared with 5.3% of men (see Figure 5). These data are significant and in line with literature suggesting that women are less likely to receive adequate time with physicians and/or are ignored despite frequent requests for care. A repeated theme found in these studies is the consistent dismissal of women’s health care needs.

Consequences of Unfair Treatment 

The effects of past experiences of unfair treatment are longer-lasting than just the moment of discrimination as they can lead to Coloradans forgoing care that they may desperately need. More than 5% of Coloradans- — about 283,000 people -—
reported that they had passed up care due to concern about unfair treatment. The difference between the number of women and men who avoided seeking care because of fear of unfair treatment is also significant. Some 6.0% of women compared with 4.3% of men did not seek needed care due to concern about unfair treatment, a statistically significant variation (see Figure 7). 

One of the most likely reasons for forgoing care due to unfair treatment is to avoid the stress associated with discriminatory experiences. Of those who reported “sometimes” or “often” being treated unfairly, 94% reported experiencing some level of stress, with over 40% describing the experiences as “extremely stressful” (see Figure 8).

Higher proportions of men reported experiencing low stress associated with unfair treatment. More than 35% of men reported that experiences of unfair treatment were either “not stressful at all” or “a little stressful” compared with 19.7% of women. The opposite trend occurs when examining experiences of great stress. Over 47% of women described these experiences as “extremely stressful” compared with 28.3% of men (see Figure 9).

This is significant given the impact of stress on other health outcomes. Stress can contribute to increased heart rate, high blood pressure, and other problems and is linked to mental health issues such as anxiety and depression. 

Policy Challenges and Opportunities 

Addressing unfair treatment in the health care system will require engagement at multiple levels of policy and community. From upstream solutions such as educational reform to incentive programs that center on cultural responsiveness, there are many opportunities to begin to chip away at discrimination within society’s health care structures.

Reenvision Medical Training 

While experts often recommend training as the main proposed solution for bias and discrimination in health care, it is important to consider the full career progression of physicians. Instead of waiting until an incident brings about a need for bias training, emphasizing cultural responsiveness in the medical school application process and throughout the training of medical students would facilitate earlier adoption of critical skills. Studies have found significant and positive changes in attitudes toward lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) patients following intentional training to promote more positive medical student or provider attitudes toward patients, particularly when training materials incorporate patients’ input.

Create Space for Honest Feedback

Too often the only opportunity for those who have experienced unfair treatment to share that experience is retroactive reflection through surveys like the CHAS. By creating additional secure forums for honest feedback, patients will be able to more frequently flag areas needing improvement and identify better access channels for resolution. Real-time data allow for real time changes. Implementing ombudsman programs in health care settings that focus specifically on unfair treatment could provide a needed safe forum for this kind of feedback. Studies show that ombudsman services are particularly necessary when individuals have unique needs, a natural power differential exists, and/or the system of care is complex. Given the relationships patients have with providers, the complexity of the health care system, and the social weight of certain identities, the impact of such a program could be significant. 

Redefine Value in Value-Based Care

As the health care landscape shifts increasingly to value-based payment systems — a form of reimbursement that ties payments for care to the quality of care — redefining the meaning of value can emphasize and incentivize cultural responsiveness. The recent focus on innovation and value-based care has centered on delivery system reform which, though important, does not directly pinpoint the root cause of unfair treatment and how it presents itself and affects patients. Tying value and quality to indicators of cultural responsiveness would reward health care professionals for taking intentional steps toward providing equitable care for all patients. The Colorado Department of Health Care Policy and Financing (HCPF) is currently investigating new ways to emphasize cultural responsiveness and health equity. HCPF hired a diversity, equity, and inclusion manager who will lead the charge in implementing cultural competency trainings for providers participating in value-based payment primary care programs. The department is also exploring new Alternative Payment Model measures that address racial disparities, such as ensuring better race/ethnicity data collection and measures aimed at mitigating potential language barriers.

Who’s Missing From This Analysis?

The CHAS asks respondents for demographic information, including race, ethnicity, and gender identity. This brief does not include an analysis of unfair treatment among LGBTQIA+ Coloradans because of this sample size issue. But there is no question that communities of color and members of the LGBTQIA+ community have long had to navigate systems that are inextricably rooted in racist, heteronormative, and sexist structures.

Patients who seek care and belong to one or more marginalized communities regularly confront physicians or others in the health care system who may or may not be explicitly biased, but who operate in an inherently discriminatory system. Although the present data cannot contribute to quantitative analysis of these specific categories, it is indisputable that throughout the history of this country nondominant racial, ethnic, disability, and sexual identities have experienced unfair and discriminatory treatment when seeking medical care. Readers are urged not to review this brief separate from this history and context.

Conclusion 

The CHAS data on unfair treatment in the health care system are sobering. With nearly one in seven Coloradans reporting experiences of unfair treatment at some point in their life, addressing conscious and unconscious bias in health care is critical. 

All Coloradans should be able to access needed health care without the fear of discrimination or bias. And the fact that 94.1% of those who reported unfair treatment experienced some level of stress from the encounter shows that these experiences have direct negative impacts on the health of Coloradans. 

The road toward a more equitable health care landscape is by no means easy or clear, but raising the issue is a first and necessary step. By dedicating resources to and encouraging engagement with this issue, Colorado can continue to strive to improve the health of all communities.