Racial Health Disparities, COVID-19, and a Way Forward for US Health Systems

Addressing Provider Bias

At the patient care level, healthcare providers have a role in ensuring patients have positive experiences with the healthcare system; this is an opportunity to address medical distrust. Providers should recognize the burden of psychosocial stress and place-based risk that contributes to patients’ presentations and clinical courses. In patient encounters, this awareness should translate to action, acknowledging patients’ experiences and individuality and upholding their dignity. Under conditions of burnout, physicians’ biases are more likely to manifest in patient encounters,¹⁶ and although stress and burnout among providers are likely at an all-time high during the COVID-19 pandemic, patients of color must not suffer disproportionately.

Addressing Structural Bias in Care Provision

Health systems should establish checklist-based protocols in order to mitigate the impact of bias on patient care, such as on referrals for advanced therapies. Algorithms used to automate certain aspects of care should not be biased against Black, Hispanic, and Indigenous patients, as has been the case with algorithms that lead to Black patients receiving lower levels of care compared with White patients with similar clinical presentations.⁸ Health systems should therefore systematically collect racial and sociodemographic data and implement rapid-cycle evaluation of processes and outcomes to root out biases. In tracking their own performance in providing equitable care, health systems should create feedback systems that inform individual providers of their practices for improvement, and individual departments should hold frequent “morbidity and mortality” style reviews of practices and outcomes to continuously improve. Additionally, collaborations with and financial support of community-based organizations to ensure safe transitions of care and to contribute to addressing patients’ unmet social needs should become the norm. This is particularly relevant for COVID-19 survivors who may face long-term chronic physical and mental sequelae such as post–intensive care syndrome and require multidisciplinary care.¹⁷

Workforce Equity, Diversity, and Inclusion

Health systems should also examine and address the ways in which they contribute to racial health inequities beyond healthcare provision. Among healthcare organizations, hospitals employ the majority of low-wage healthcare workers, most of them Black or Hispanic women. Nearly half of Black and Hispanic female healthcare workers earn less than $15 hourly (cited as a living wage, which could help prevent a significant number of premature deaths),¹⁸ and a quarter are uninsured or on Medicaid. Raising the hourly minimum wage to at least $15 would reduce poverty among female healthcare workers by 27.1%.¹⁹ Mortality decreases as income increases, and the lowest-income healthcare workers have a nearly six-fold higher risk of death relative to their highest-earning counterparts, a gradient steeper compared with other fields.²⁰ Health systems should guarantee occupational safety and adequate wages and benefits and provide employees with career-advancing opportunities that would facilitate upward mobility.

In addition to the aforementioned structural inequities embedded within the healthcare infrastructure, low-wage Black healthcare workers report experiencing interpersonal discrimination at work, such as being assigned more tasks compared with their White peers and having others higher up the hierarchy, such as supervisors, nurses, and physicians, assume they are incompetent. Workplace discrimination spans the organizational hierarchy. Black nurses and physicians report both interpersonal and organizational discrimination from patients and other healthcare workers and in terms of barriers to opportunities through hiring and credentialing processes.²¹ Black physicians are at greater risk of burnout and attrition, which is partly attributable to experiencing discrimination.^22,23

To address these experiences, health systems should invest in creating a work climate that is inclusive and explicitly stands against racism and other forms of discrimination. The rise of the Black Lives Matter movement has contributed to improving people’s attitudes toward Black people over the past years,²⁴ whereas implicit bias trainings, commonly employed to improve diversity and inclusion, may unwittingly further entrench the denial of the impact of racism (by attributing it to implicit rather than explicit attitudes)²⁵ or heighten intergroup racial anxiety and reduce individuals’ intentions to engage in intergroup contact.²⁶ Moreover, evidence shows interracial contact in medical school yields more positive explicit and implicit attitudes toward Black people among non–Black medical trainees, whereas bias trainings do not,²⁷ and a positive racial climate in medical school yields a greater interest in serving underserved and minority populations among non–Black medical trainees.²⁸ In other words, fostering a culture and structure that champions racial justice and diversifying the healthcare workforce would synergistically improve non–Black healthcare workers’ attitudes toward Black people while also improving the working conditions of Black healthcare workers and the experiences of Black patients. Healthcare is the fastest growing industry in the United States, and such initiatives would likely have a tremendous impact on moving the needle toward health equity.