As physicians at urban safety net clinics, we read the study by Cuffee et al.1 with great interest. In New York City, where we practice, perceived racial/ethnic discrimination is likely tied to insurance status. Among academic medical centers, a two-tier clinic system is often implemented with a faculty practice for privately insured patients and a trainee-focused practice for publicly insured and uninsured patients. Because racial/ethnic minorities are more likely to be uninsured or publicly insured, clinics are largely racially segregated, de facto.2 To examine this, and foster a dialogue with patients around this issue, we conducted a brief survey of primary care patients at three Federally Qualified Health Centers (Bronx, NY). The survey contained an oral informed consent, demographic questions, and two “yes/no” questions: (1) “Have you ever felt that the doctor or medical staff you saw judged you unfairly or treated you with disrespect because of your race or ethnic background?,” and (2) “Do you think there was ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?”3 Responses to questions on discrimination were compared by insurance status (abstracted from the medical record) by using the χ2 test; a P ≤ .05 was considered significant. Inclusion and exclusion criteria, and survey administration, are detailed in previous reports.4,5 The Albert Einstein College of Medicine Committee on Clinical Investigation approved this survey. Among the 248 respondents (Table 1), 8.1% felt that a doctor or medical staff member judged them unfairly or treated them with disrespect because of their race or ethnic background. Those with public insurance were more likely to report this compared with those with private insurance (15.0% vs 5.2%; P = .05). Of respondents, 13.3% thought there was a time when they would have gotten better medical care if they had belonged to a different race or ethnic group, with no significant difference between publicly and privately insured patients (10% vs 5.2%; P = .4). Analysis of uninsured patients was limited by small sample size. TABLE 1— Sociodemographic Characteristics of Survey Respondents (n = 248): Bronx, NY, 2011 In summary, patients with public insurance more often reported discrimination than did those with private insurance. This is potentially attributable to experiences in the clinic system for the publicly insured. Further research is needed to examine the role of insurance status, and the effect that dismantling the two-tier clinic system could have on perceived racial/ethnic discrimination and outcomes.
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Aug 14, 2014
Kim Doubal + 2
Open Access