Journal of General Internal Medicine

, Volume 33, Issue 10, pp 1760–1767 | Cite as

Racial Discrimination in Health Care and Utilization of Health Care: a Cross-sectional Study of California Adults

  • Héctor E. AlcaláEmail author
  • Daniel M. Cook
Original Research



Racial and ethnic discrimination in health care have been associated with suboptimal use of health care. However, limited research has examined how facets of health care utilization influence, and are influenced by, discrimination.


This study aimed to determine if type of insurance coverage and location of usual source of care used were associated with perceptions of racial or ethnic discrimination in health care. Additionally, this study examined if perceived racial or ethnic discrimination influenced delaying or forgoing prescriptions or medical care.


Data from the 2015–2016 California Health Interview Survey were used. Logistic regression models estimated odds of perceiving racial or ethnic discrimination from insurance type and location of usual source of care. Logistic regression models estimated odds of delaying or forgoing medical care or prescriptions.


Responses for 39,171 adults aged 18 and over were used.

Main measures

Key health care utilization variables were as follows: current insurance coverage, location of usual source of care, delaying or forgoing medical care, and delaying or forgoing prescriptions. We examined if these effects differed by race. Ever experiencing racial or ethnic discrimination in the health care setting functioned as a dependent and independent variable in analyses.

Key results

When insurance type and location of care were included in the same model, only the former was associated with perceived discrimination. Specifically, those with Medicaid had 66% higher odds of perceiving discrimination, relative to those with employer-sponsored coverage (AOR = 1.66; 95% CI 1.11, 2.47). Race did not moderate the impact of discrimination. Perceived discrimination was associated with higher odds of delaying or forgoing both prescriptions (AOR = 1.97; 95% CI 1.26, 3.09) and medical care (AOR = 1.84; 95% CI 1.31, 2.59).


Health care providers have an opportunity to improve the experiences of their patients, particularly those with publicly sponsored coverage.


health insurance race discrimination health care utilization 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest..


  1. 1.
    Shavers VL, Fagan P, Jones D, et al. The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care. Am J Public Health 2012;102(5):953–966.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Soc Sci Med 2006;63(6):1428–1441.CrossRefPubMedGoogle Scholar
  3. 3.
    Stepanikova I, Baker EH, Simoni ZR, et al. The Role of Perceived Discrimination in Obesity Among African Americans. Am J Prev Med 2017;52(1):S77-S85.CrossRefPubMedGoogle Scholar
  4. 4.
    Ayotte BJ, Hausmann LR, Whittle J, Kressin NR. The relationship between perceived discrimination and coronary artery obstruction. Am Heart J 2012;163(4):677–683.CrossRefPubMedGoogle Scholar
  5. 5.
    Krieger N, Jahn JL, Waterman PD. Jim Crow and estrogen-receptor-negative breast cancer: US-born black and white non-Hispanic women, 1992-2012. Cancer Causes Control 2017;28(1):49–59.CrossRefPubMedGoogle Scholar
  6. 6.
    Chae DH, Lincoln KD, Adler NE, Syme SL. Do experiences of racial discrimination predict cardiovascular disease among African American men? The moderating role of internalized negative racial group attitudes. Soc Sci Med (1982). 2010;71(6):1182–1188.CrossRefGoogle Scholar
  7. 7.
    Myers HF. Ethnicity- and socio-economic status-related stresses in context: an integrative review and conceptual model. J Behav Med 2009;32(1):9–19.CrossRefPubMedGoogle Scholar
  8. 8.
    Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med 2009;32(1):20–47.CrossRefPubMedGoogle Scholar
  9. 9.
    Lee C, Ayers SL, Kronenfeld JJ. The Association between Perceived Provider Discrimination, Health Care Utilization, and Health Status in Racial and Ethnic Minorities. Ethn Dis 2009;19(3):330–337.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Hausmann LRM, Jeong K, Bost JE, Ibrahim SA. Perceived Discrimination in Health Care and Use of Preventive Health Services. J Gen Intern Med 2008;23(10):1679–1684.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Van Houtven CH, Voils CI, Oddone EZ, et al. Perceived Discrimination and Reported Delay of Pharmacy Prescriptions and Medical Tests. J Gen Intern Med 2005;20(7):578–583.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Burgess DJ, Ding Y, Hargreaves M, van Ryn M, Phelan S. The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample. J Health Care Poor Underserved 2008;19(3):894–911.CrossRefPubMedGoogle Scholar
  13. 13.
    Mouton CP, Carter-Nolan PL, Makambi KH, et al. Impact of Perceived Racial Discrimination on Health Screening in Black Women. J Health Care Poor Underserved 2010;21(1):287–300.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Hausmann LR, Kressin NR, Hanusa BH, Ibrahim SA. Perceived racial discrimination in health care and its association with patients' healthcare experiences: does the measure matter? Ethn Dis 2010;20(1):40.PubMedGoogle Scholar
  15. 15.
    Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and Trust in the Health Care System. Public Health Rep 2003;118(4):358–365.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Stepanikova I, Oates GR. Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race. Am J Prev Med 2017;52(1):S86-S94.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Abramson CM, Hashemi M, Sánchez-Jankowski M. Perceived discrimination in U.S. healthcare: Charting the effects of key social characteristics within and across racial groups. Prev Med Rep 2015;2:615–621.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Vina ER, Hausmann LRM, Utset TO, Masi CM, Liang KP, Kwoh CK. Perceptions of racism in healthcare among patients with systemic lupus erythematosus: a cross-sectional study. Lupus Sci Med 2015;2(1):e000110.CrossRefGoogle Scholar
  19. 19.
    Hausmann LRM, Jeong K, Bost JE, Kressin NR, Ibrahim SA. Perceived Racial Discrimination in Health Care: A Comparison of Veterans Affairs and Other Patients. Am J Public Health 2009;99(Suppl 3):S718-S724.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Sorkin DH, Ngo-Metzger Q, De Alba I. Racial/Ethnic Discrimination in Health Care: Impact on Perceived Quality of Care. J Gen Intern Med 2010;25(5):390–396.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Hausmann LRM, Kwoh CK, Hannon MJ, Ibrahim SA. Perceived Racial Discrimination in Health Care and Race Differences in Physician Trust. Race Soc Probl 2013;5(2):113–120.CrossRefGoogle Scholar
  22. 22.
    Kandula NR, Hasnain-Wynia R, Thompson JA, Brown ER, Baker DW. Association Between Prior Experiences of Discrimination and Patients’ Attitudes Towards Health Care Providers Collecting Information About Race and Ethnicity. J Gen Intern Med 2009;24(7):789–794.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    D'Anna LH, Stevens GD, Malotte CK, Tsai K-Y. Does Health Care Setting Matter in Reports of Discrimination? J Ambul Care Manage 2010;33(4):314–327.Google Scholar
  24. 24.
    Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D. Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States. J Policy Anal Manage 2017;36(1):178–210.Google Scholar
  25. 25.
    Blumenthal D, Collins SR. Health Care Coverage under the Affordable Care Act — A Progress Report. New Engl J Med 2014;371(3):275–281.CrossRefPubMedGoogle Scholar
  26. 26.
    Carman KG, Eibner C, Paddock SM. Trends In Health Insurance Enrollment, 2013-15. Health Aff (Millwood) 2015;34(6):1044–1048.CrossRefPubMedGoogle Scholar
  27. 27.
    Sommers BD, Musco T, Finegold K, Gunja MZ, Burke A, McDowell AM. Health Reform and Changes in Health Insurance Coverage in 2014. N Engl J Med 2014;371(9):867–874.CrossRefPubMedGoogle Scholar
  28. 28.
    Alcalá HE, Roby DH, Grande DT, McKenna RM, Ortega AN. Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act. Med Care. 2017.Google Scholar
  29. 29.
    Sen AP, Chen LM, Cox DF, Epstein AM. Most Marketplace Plans Included At Least 25 Percent Of Local-Area Physicians, But Enrollment Disparities Remained. Health Aff (Millwood) 2017;36(9):1615–1623.CrossRefPubMedGoogle Scholar
  30. 30.
    Sommers BD, Kenney GM, Epstein AM. New evidence on the Affordable Care Act: coverage impacts of early medicaid expansions. Health Aff (Millwood) 2014;33(1):78–87.CrossRefPubMedGoogle Scholar
  31. 31.
    Wehby GL, Lyu W. The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender. Health Serv Res. n/a-n/a.Google Scholar
  32. 32.
    Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Med Care 2016;54(2):140.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    California Health Interview Survey. Report 1: Sample Design. Los Angeles: UCLA Center for Health Policy Research; 2016.Google Scholar
  34. 34.
    Barakat MT, Mithal A, Huang RJ, et al. Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments. PLoS One 2017;12(8):e0182346.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Cuffee YL, Hargraves JL, Rosal M, et al. Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. Am J Public Health 2013;103(11):e55-e62.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Armstrong K, Putt M, Halbert CH, et al. Prior Experiences of Racial Discrimination and Racial Differences in Health Care System Distrust. Med Care 2013;51(2):144–150.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Gee GC, Ponce N. Associations Between Racial Discrimination, Limited English Proficiency, and Health-Related Quality of Life Among 6 Asian Ethnic Groups in California. Am J Public Health 2010;100(5):888–895.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Haeder SF, Weimer DL, Mukamel DB. California hospital networks are narrower in Marketplace than in commercial plans, but access and quality are similar. Health Aff (Millwood) 2015;34(5):741–748.CrossRefPubMedGoogle Scholar
  39. 39.
    Haeder SF, Weimer DL, Mukamel DB. Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans. Health Aff (Millwood) 2016;35(7):1160–1166.CrossRefPubMedGoogle Scholar
  40. 40.
    Terhune C. Covered California aims to kick out poor-performing hospitals. 2016. Accessed 22 June 2017.
  41. 41.
    Ibarra AB, Gorn D. Covered California Imposes New Quality, Cost Conditions On Health Plans. 2016. Accessed 27 Dec 2017.
  42. 42.
    Pascoe EA, Smart RL. Perceived discrimination and health: a meta-analytic review. Psychol Bull 2009;135(4):531.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  1. 1.Department of Family, Population and Preventive Medicine, Program in Public HealthStony Brook UniversityStony BrookUSA
  2. 2.School of Community Health Sciences, University of Nevada, RenoRenoUSA

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