LETTERS RACIAL DISCRIMINATION IN HEALTH CARE SETTINGS: DOES INSURANCE MATTER? 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

Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].

e10 | Letters

group?”3 Responses to questions on discrimination were compared by insurance status (abstracted from the medical record) by using the v2 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. 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. j

This letter was accepted October 27, 2013. doi:10.2105/AJPH.2013.301777

Contributors All authors contributed equally to this letter.

Acknowledgments This work was completed without external funding support.

References 1. 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. 2. Golub M, Calman N, Ruddock C, et al. A community mobilizes to end medical apartheid. Prog Community Health Partnersh. 2011;5(3):317---325. 3. Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. New York, NY: The Commonwealth Fund; 2002. 4. Karnik A, Foster BA, Mayer V, et al. Food insecurity and obesity in New York City primary care clinics. Med Care. 2011;49(7):658---661. 5. Shah MP, Edmonds-Myles S, Anderson M, Shapiro ME, Chu C. The impact of mass incarceration on outpatients in the Bronx: a card study. J Health Care Poor Underserved. 2009;20(4):1049---1059.

Marcus A. Bachhuber, MD Asiya Tschannerl, MD, MPH Claudia Lechuga, MS Matthew Anderson, MD, MS

About the Authors All authors are with the Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Marcus A. Bachhuber is also with the Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine. Correspondence should be sent to Marcus A. Bachhuber, 305 E 161st St, Bronx, NY 10451 (e-mail: marcus. [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

American Journal of Public Health | March 2014, Vol 104, No. 3

LETTERS

TABLE 1—Sociodemographic Characteristics of Survey Respondents (n = 248): Bronx, NY, 2011 Characteristic

Median (IQR) or % (No./Total No.)a

Age, y

37.5 (26.5)

Female gender

72.5 (174/240)

Race/ethnicity Black Hispanic, any race

46.4 (108/233) 47.6 (111/233)

White

0.9 (2/233)

Asian or Pacific Islander

1.7 (4/233)

Native American/Alaska Native

0.4 (1/233)

Other

3.0 (7/233)

Insurance Public (Medicare, Medicaid, or dual-eligible) Private None

65.1 (140/215) 27.0 (58/215) 7.9 (17/215)

Note. IQR = interquartile range. a The number of surveys with responses to the question of interest is given in the denominator.

March 2014, Vol 104, No. 3 | American Journal of Public Health

Letters | e11