Healthcare Disparities

Healthcare Disparities: Minority Populations
Introduction
The United States is a major world power and a major industrialized nation. Despite this fact, its healthcare system does not provide universal access to care, in stark contrast to most other affluent world powers. Some citizens have access to highly comprehensive insurance through their employers while others do not. Certain low-income individuals qualify for either subsidized insurance through the Affordable Care Act (ACA) or for Medicaid, the state-administered healthcare insurance program for the poor that is partially federally funded. The disparate ways in which healthcare insurance is provided in the United States often results in highly disparate allocations of care to individuals. But even when patients have insurance, cultural, linguistic, and psychological barriers can further exacerbate equal access to care for minority populations.
Definition
The existence of healthcare disparities in the United States has been well-documented. Not only are certain illnesses such as diabetes and heart disease more prevalent in economically and historically discriminated-against populations, but as noted by Gollust (et al., 2018), they can take the form of personal psychological indignities inflicted by the healthcare system. In a mixed methods research study of 53 health providers at a Veteran’s Health Administration facility, one African-American providers described experiencing personal discrimination when seeking treatment for back pain, noting that his concerns was not regarded as valid; another provider stated he perceived that due to unconscious bias “white patients may be given the benefit of the doubt” when complaining about symptoms members of other population groups were not (Gollust, et al., 2018, p.7). Even if providers are not consciously aware of biases, unconscious biases were seen as significantly contributing to healthcare disparities in the form of invisible barriers to care.
Factors Impacting the Issue
Data suggests that socioeconomic status and race are two of the biggest factors which can impede equal access to health services, even in a post-ACA world. This is particularly the case in regards to mental healthcare which is often not perceived as a necessity in the same manner as primary, physical care. Yet inadequate treatment for mental health has been linked to poorer physical health, given that people who struggle with mental illnesses often struggle to find employment or to maintain a functional state of personal care. The descriptive research study by Jones (et al., 2018) found that even after the ACA became law, significant disparities based upon race and income were manifested in access to mental healthcare services, despite the fact that the ACA mandated psychiatric coverage for all healthcare plans offered to consumers.
Researchers obtained data from the Medical Expenditures Panel Survey (MEPS). Of the 2747 subjects with severe mental health issues, all members of the historically discriminated-against racial groups were found to be less likely to see a primary care provider for physical health issues (Jones, et al., 2018). Even members of historically discriminated-against groups who did use primary physical care providers were found to be less likely to have a primary care mental health visit. Culture may also have contributed to these disparities, given within certain groups, visits to mental health professionals may be less normalized; primary care providers seen by these populations, based upon their personal levels of expertise or knowledge of the patient’s health history may also have been less willing to diagnose and refer individuals with mental health conditions.
Researchers noted as the ACA stands as law in the United States, over time, some of these disparities may become less acute. Regardless the study underlines the importance of regular contact with providers to monitor patients with mental health issues, to ensure their conditions are monitored and they receive adequate treatment. This is particularly true if they largely see providers in public, clinical settings who may not have the confidence to treat both mental and physical health issues. Patients with severe mental health issues may benefit from specialized care but need access to such providers, both through financial support via insurance and also more aggressive prompting from primary care providers.
Another significant and concerning area of disparities in health that are often overlooked concern children in the United States and their healthcare coverage. Although children have additional support by which to obtain healthcare coverage, this does not eliminate inequities. In a qualitative research study by Tan-McGrory (et al., 2018) which involved a focus group of 16 research and clinical professional experts working in 10 pediatric care delivery systems in the US and Canada, limited English proficiency of children and their families was found to be a significant barrier in obtaining adequate care, since parents would often struggle in understanding communications from pediatricians. Parents may also be reluctant to see providers because of concerns regarding authority figures or simply be concerned about looking foolish because of a lack of understanding.
Providers noted the importance of obtaining the parents’ preferred language of communication, and if all possible, transmitting doctors’ written instructions in the parents’ language of choice. For parents who did not speak English, this should be noted in the patient’s file, and speaking and writing English should never be presumed of a patient. Although these guidelines were specific to pediatric care, many of the suggestions by providers to enhance multicultural competence could be transferred to adults, such as making sure the patient was literate as well as health literate, and ensuring that the patient left the office with adequate understanding to provide care at home, given the vast majority of treatment is conveyed in that setting (and hospital stays are getting shorter and shorter).
Another area of disparity in pediatric settings that may also be relevant to more general health settings is that of sexual identification and sexual orientation. More and more children in primary care practice are identifying outside of the gender binary, are identifying as transgender, or as on the LGBTQ spectrum (Tan-McGrory, et al., 2018). Providers should be aware of how to speak with sensitivity on these issues, the medical concerns that are raised regarding transgender children, and also sexual health issues for gay adolescents. Providers that cannot speak with sensitivity may create barriers between individuals and the healthcare system which are difficult to overcome, despite the fact that members of these groups are often the most in need of support and outreach.
A final barrier to care identified by Tan-McGrory (et al., 2018) by the interviewed providers was ensuring which parents had the authority to make healthcare decisions, given the increasingly bifurcated nature of the modern family. Many parents may remarry, or children may be cared for by grandparents in addition to parents. As families age, older patients may likewise have caregivers with different ideas about how to manage care, and this can create disparities of care when there are conflicts and miscommunications. Patients with multiple complex conditions seeing different providers may receive conflicting and incomplete advice due to a lack of communication channels (Tan-McGrory, et al., 2018). But simply because the patient is not a member of a standard nuclear family or has an unusual or complex medical condition does not mean he or she is not entitled to the same type of care and the same quality of care as other patients.
The Impact on Nursing
Although on an individual basis, nurses cannot always provide a comprehensive solution, multicultural competence can be significant in overcoming psychological barriers to accessing care. Offering linguistically competent care, taking patients’ concerns seriously, and being aware of how disparities of income and past prejudices have generated negative experiences with the healthcare profession are all necessary for the nurse to offer care in a truly compassionate and culturally fluent manner.
References
Gollust, S. E., Cunningham, B. A., Bokhour, B. G., Gordon, H. S., Pope, C., Saha, S. S., Jones,
D. M., Do, T., … Burgess, D. J. (2018). What causes racial health care disparities? Inquiry, 55. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862368/pdf/10.1177_00469580187628 40.pdf
Jones, A. L., Cochran, S. D., Leibowitz, A., Wells, K. B., Kominski, G., & Mays, V. M. (2018).
racial, ethnic, and nativity differences in mental health visits to primary care and specialty mental health providers: Analysis of the Medical Expenditures Panel Survey, 2010-2015. Healthcare (Basel, Switzerland), 6(2), 29. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6023347/pdf/healthcare-06-00029.pdf
Tan-McGrory, A., Bennett-AbuAyyash, C., Gee, S., Dabney, K., Cowden, J. D., Williams, L.,
Rafton, S., Nettles, A., Pagura, S., Holmes, L., Goleman, J., Caldwell, L., Page, J., Oceanic, P., McMullen, E. J., Lopera, A., Beiter, S., … López, L. (2018). A patient and family data domain collection framework for identifying disparities in pediatrics: results from the pediatric health equity collaborative. BMC pediatrics, 18(1), 18. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793421/pdf/12887_2018_Article_993.p df