Inequality in quality: Toward a better understanding of micro-mechanisms underlying racial/ethnic disparities in American health care

Racial/ethnic minority patients receive poorer quality medical care when compared to White patients who have similar levels of access to health care and are comparable on a number of sociodemographic characteristics. This dissertation asks why these racial/ethnic disparities in health care exist. Using scholarship in cognitive social psychology, I develop a model of micro-level mechanisms underlying racial/ethnic interaction in health care contexts. I argue that racial/ethnic cognitions, which correspond to widely held cultural beliefs about racial/ethnic groups, are among factors contributing to poorer quality care for minority patients. These cognitions are mostly automatic, but they nevertheless shape medical decisions in ways that disadvantage minority patients, especially in health care contexts characterized by high stress, such as in managed care settings.; I evaluate the proposed model using survey and experimental methods. The survey study uses data from a probability sample of privately insured Americans. I find that controlling for insurance policies, characteristics of health care, and sociodemographic factors, Blacks, Hispanics, and members of other minority groups evaluate the quality of the care they received during their last visit to their primary care physician less favorably than do Whites. The adjusted differences between Whites and Hispanics interviewed in English are larger when managed care policies are used than when these policies are not used. Disparities between Whites and Hispanics interviewed in Spanish and between Whites and non-Black, non-Hispanic minority individuals are more common in managed care contexts than in other contexts.; The experimental study focuses on the role of physicians' racial/ethnic cognitions in medical decisions under varying levels of stress. I find that under high stress, physicians whose implicit cognitions about Blacks or Hispanics were activated by subliminal exposure to Black or Hispanic stimuli evaluated a hypothetical patient's condition as less serious compared to physicians subliminally exposed to White or neutral stimuli. Similar effects were not obtained under low stress or for explicit cognitions. Taken together, the two studies suggest that implicit (but not explicit) cognitions may contribute to racial/ethnic disparities in health care, especially in stressful contexts, and that stress-inducing managed care cost-containment policies may exacerbate racial/ethnic disparities.