Doing Away with Death by Implicit Bias in Healthcare

Written By: Mia Keys

There are many similarities between the U.S. justice and healthcare systems. For instance, when deciding how to de-escalate a tense or time-sensitive situation, both the justice and healthcare systems use protocols that are profile-reliant. We can recognize such protocols at work in recent media narratives of police fatally shooting or otherwise killing unarmed Black men. Undoubtedly, almost anyone can name at least one innocent Black man who died because an officer argued they “looked threatening”, or used similarly problematic racial stereotyping such as “big”, “aggressive”, or “he seemed to be carrying a gun” to justify prematurely resorting to excessive force.

But how does one’s appearance impact how they will be treated in medical settings? Can such profiling be just as deadly? Well, health insurers rely on risk assessment formulas, which consider one’s health history and likely health trajectory profile, to determine if a potential health plan enrollee will be a costly liability. For example, being a male and being younger is associated with riskier behavior, and therefore, more healthcare costs over a lifetime. An insurer would be less inclined to offer such a person a robust health insurance plan, which may determine whether one has access to life-or-death determining health services. Healthcare providers also rely on health profiling when making critical care decisions. While such a skill may be crucial, combining medical discernment with egregious health stereotyping can have dire healthcare consequences.

Imagine this, an emergency room physician impatiently questions a slightly overweight brown woman who has a limited English proficiency. She is clutching her chest, may be trying to explain that the pain she feels is excruciating. The doctor just thinks she’s being a bit dramatic, like Latinas he’s seen on telenovelas. The physician appears disinterested and responds bluntly as the patient answers his questions with a thick accent and distinct rolling r’s. The doctor hopes that he does not have to use LanguageLine. He steals a swift glance at his wristwatch, nods instinctively while rolling up his sleeves—and then hers—to check her pressure. Then, rather than waiting to get a language interpreter, the physician finds a reason to turn the patient’s case over to another provider in the vicinity, as he rushes off to a less complicated, and more English proficient patient. Consequently, the woman spends more time in the Emergency room, is subjected to more tests, which costs her and the health system more money.

Bias within the healthcare system befalls not just racial and linguistic minorities, but also sexual minorities and differently able-bodied persons, at disproportionate rates.

Many healthcare providers are doing the best they can to deliver culturally competent care. Yet all, unconsciously, project their implicit personal biases into the healthcare they provide, oftentimes to their patients’ detriment. So, what is the cure for implicit bias? There is none.

However, Section 1557, also known as “the Final Rule” of the Affordable Care Act (ACA), prohibits health insurers, providers, and health entities receiving federal funds from discriminating against people on the basis of their sexual orientation, ability status, age, race, color, national origin, gender, or an intersection of these class identities. This includes all entities accepting Medicaid, most Medicare, CHIP, and advance premium tax credits under the ACA. Most significantly, the Final Rule is the first federal civil rights law to prohibit sex discrimination in the healthcare context. The overall objective of the Final Rule is to help advance health equity and reduce health disparities by protecting populations that are most vulnerable to discrimination in the healthcare context.

Here’s the bottom line: bias takes lives. Implicit bias arises almost anytime anyone encounters “other” people, and even for the insurers facilitating or providers delivering healthcare.  It is triggered by highly stressful situations, which is why understanding one’s own bias is crucial. Health policies cannot legislate self-awareness. While the Final Rule is not a panacea for systems-wide implicit bias, it is a potentially transformative regulation designed to institute compassionate care ethics across the numerous sectors of our healthcare system.