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Barriers in care access for the marginalized individual: a provider’s role

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Barriers in care access for the marginalized individual: a provider’s role

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Barriers in Care Access
For the Marginalized Individual:
A Provider’s Role
by
Kacee R. Roberson

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2022

© Copyright by Kacee R. Roberson 2022
All Rights Reserved

The Committee for Kacee R. Roberson certifies the approval of this Dissertation

Committee Member Name Dr. Anthony Maddox
Committee Member Name Dr. Brandon Martinez
Dr. Monique Datta, Committee Chair

Rossier School of Education
University of Southern California
2022

iv

Abstract
The need to address health disparities that exist in the United States has not gone unnoticed.
Physicians remain at the heart of patient care and their role in addressing gaps that affect their
patients has evolved over the years. Access to quality healthcare services has been generally
difficult for those of frequently marginalized backgrounds. History lends itself as evidence the
systems and structures that exist not only create a barrier to access health care but also the impact
it makes on health outcomes. Recognizing these barriers as social determinants of health, this
dissertation pieces apart the impact of those determinants and how physicians and the
organizations they work for can affect positive change. This study sought to create a
conversation around how marginalized individuals experience health care from a physician's
perspective. By exploring the association of physicians to identification and mitigation of
determinants, the foundation for systematic and organizational change can begin.
Keywords: health equity, care access, health disparities, social determinants in healthcare

v
Dedication
To the ones who matter. You know who you are. My kiddo, my Bear, my reason. I wanted to
give you everything I never had but always needed. We grew up together and you have taught
me so much about life and humility. I would not be here today without the nurturing of my big
sister. Thank you for watching out for us growing up. To my very best friends, you both believed
in me even when I doubted my own worth. Your love and encouragement has many times been
what kept me pushing through this life.

Acknowledgements
Thank you to Dr. Monique Datta for guiding me through this journey from beginning to
end. I appreciate your continued support and will always remain grateful. I not only felt I had a
mentor in you but also a friend. To Dr. Anthony Maddox, I will forever envy your brilliant mind
and appreciate the push to think beyond the horizon and into the stars. Dr. Brandon Martinez, not
only did you guide me through learning while it seemed society was crumbling before us when
the voices of BIPOC were fighting to be heard but you also helped shape my work to align with
the passion that lays in me. I send my appreciation and thanks to each professor at USC during
my journey, in one way or another you left a mark. A huge thank you to the physicians who took
the time to chat with me. As we battle through a global pandemic, I acknowledge your time is
limited and valuable. Your contribution of experience and passion will lead healthcare in the
direction we all need.

Table of Contents
Abstract .................................................................................................................................... iv
Dedication .................................................................................................................................. v
Acknowledgements ................................................................................................................... vi
List of Tables ............................................................................................................................. x
List of Figures ........................................................................................................................... xi
Chapter One: Introduction to the Study ...................................................................................... 1
Context and Background of the Problem ......................................................................... 2
Field Context and Mission .............................................................................................. 4
Purpose of the Project and Research Questions ............................................................... 4
Importance of the Study .................................................................................................. 5
Overview of Theoretical Framework and Methodology .................................................. 6
Definition of Terms ........................................................................................................ 8
Organization of the Study ..............................................................................................10
Chapter Two: Review of the Literature......................................................................................12
Theoretical Framework: Critical Race Theory ...............................................................12
The History of Law, Race, and Healthcare .....................................................................13
The Link Between Race and Health Outcomes ..............................................................16
Social Determinants and Race Leading to Health Inequality ..........................................24
Structural Racism and Discrimination as a Cause...........................................................24
Role of the Healthcare Organizations, Community, and Physicians in Determinants ......27
Data and Resource Limitation ........................................................................................28
Need for Data: Resource Improvement ..........................................................................29

Physician and Organizational Resources ........................................................................29
Existing Solutions to Address Health Inequality ............................................................31
Notable Organizations and Institutions Working for Health Equality .............................32
Micro-Level State Health Policy to Address Inequality in Care ......................................33
Affordability and Medicaid Expansion with the Affordable Care Act ............................34
Conceptual Framework ..................................................................................................36
Conclusion ....................................................................................................................39
Chapter Three: Methodology .....................................................................................................40
Research Questions .......................................................................................................40
Overview of Design .......................................................................................................40
The Researcher ..............................................................................................................42
Data Sources..................................................................................................................43
Interviews ......................................................................................................................43
Document Analysis .......................................................................................................44
Participants ....................................................................................................................44
Instrumentation..............................................................................................................45
Data Collection Procedures ............................................................................................45
Credibility and Trustworthiness .....................................................................................48
Ethics… ........................................................................................................................48
Chapter Four: Findings ..................................................................................................49
Participants ....................................................................................................................50
Findings Research Question One ...................................................................................51
Lack of Resources Available to Patients ........................................................................52

Language Barriers .........................................................................................................61
Discussion Research Question One ................................................................................65
Findings Research Question Two...................................................................................66
Addressing Bias .............................................................................................................66
Responsibility to the Community ...................................................................................70
Physician Limitations ....................................................................................................73
Perceptions of Duty of Care ...........................................................................................75
Discussion Research Question Two ...............................................................................76
Summary .......................................................................................................................76
Chapter Five: Recommendations ...............................................................................................78
Transportation Shuttles to and from Community Stops ..................................................78
Mobile Clinics with a Nurse Practitioner, Physician Assistant, or Physician ..................79
Culture and Bias Training with Specific Focus on the Community Served .....................80
Non-Traditional and New-Age Considerations ..............................................................81
Future Research .............................................................................................................83
Implications for Racial Equity in Healthcare to the Rossier Mission ..............................84
Conclusion ....................................................................................................................85
References ................................................................................................................................87
Appendix A: Interview Protocol .............................................................................................. 108
Appendix B: Document Analysis Protocol .............................................................................. 112

List of Tables
Table 1: Data Sources 40
Table 2: Assigned Pseudonym, Age, Self-identified Gender, Ethnicity, and Practice 49
Table 3: Lack of Reliable Transportation and Impact 52
Table 4: No Childcare Help 54
Table 5: The Impact of Culture on Care Treatment and Outcomes 58
Table 6: The Role Language Barriers Play in Care 60
Table 7: Bias Exists 64
Table 8: Participant, Percentage, Community, Barriers 68
Table 9: Limits to What Can We Do 70

List of Figures
Figure 1: Physician Bias on Care Decisions 19
Figure 2: Effects of Social Determinants on Health 25
Figure 3: Conceptual Framework 37
Figure 4: Thematic Analysis 46

1

Chapter One: Introduction to the Study
Barriers to access and the quality of healthcare, rendered to members of ethnic and racial
minority groups have been prevalent over the decades (Edwards, 2011). According to the
American Medical Student Association (n.d), disparities in health affecting members of minority
groups result from multiple factors. The Kaiser Family Foundation (KFF, 2020) found that 79%
of Black Americans attributed a lack of equitable health outcomes to systematic racism than did
peers of other ethnic and racial groups. In the survey, 66% of respondents indicated the
government’s lack of response in 2020 to the current COVID-19 pandemic was related to the
higher fraction of deaths among people belonging to minoritized ethnic and racial groups versus
White Americans. Overall, individuals of minoritized ethnicities frequently experience poor
health outcomes because their access to healthcare is inadequate (Centers for Disease Control
[CDC], 2017; Penner et al., 2013).
The CDC (2017) determined that lack of access specific to ongoing quality preventative
healthcare for marginalized individuals underlies the adverse health outcomes they suffer. A
historical trend of lacking access to healthcare for these groups has continued for decades, and
thus, people marginalized from access to care are in the most precarious position in the current
national health crises related to COVID-19. Additionally, in 2017 the CDC acknowledged the
long history of discrimination and racism as crucial factors related to low-quality health. The aim
of this field study is to address the lack of access and barriers to healthcare service for those of
minoritized groups using the specific experiences of medical professionals from the United
States. For ease of reading, these individuals will be referred to throughout this dissertation as
marginalized individuals.
2

Context and Background of the Problem
To grasp the disparities experienced by marginalized groups regarding access and quality
healthcare, understanding the structural system’s contribution is valuable. In 1933, an example of
the structure of racism that began to exist in the United States was a system referred to as
redlining (Hillier, 2013). The practice was used to draw real estate lines so that neighborhoods
favored White Americans only and that people of color were required in specific herded areas.
Redlining was not banned until 1968. Housing marginalized people in these designated areas
gave way to these populations, and primarily African Americans, not having access to the same
resources as White Americans. Disparate access is indicative of the systemic structural failure
marginalized people experience in the United States. An overall lack of access to societal and
economic resources suppressed socioeconomic advances for Black Americans (Assari, 2018).
Title IV of the 1964 Civil Rights Act mandated that hospitals cannot discriminate based
on race, color, or origin (Department of Labor [DOL], 1984). Significantly, this law only
impacted those organizations receiving federal funds such as Medicare dollars. After Title IV,
there have been instances that demonstrated inequitable practices in healthcare service continue
to exist. Upon implementing the Affordable Care Act (ACA), it included provisions to tighten
the intention of Title IV specific to healthcare to better integrate services (Chandra et al., 2017).
Although the Affordable Care Act, federal law, closed some of the more apparent gaps in
affordability and healthcare insurance coverage, it does not mitigate the structural racism in
many other areas, such as structures at national and organizational levels.
Gee and Ford (2011) illustrated another example producing the same inequities over
generations as system policies that historically favored White Americans. There have been
attempts to resolve uneven policies like more contemporary topics such as notable organizations
3

dedicated to reducing disparities according to the National Research Council and Institute of
Medicine (2013), healthcare policies that impact individuals cost of care, resources, quality, and
access to services. These examples reflect the long-term consequences of structural racism and
how it has carried forward into modern-day America.
As historically marginalized individuals navigate healthcare systems, several
determinants impact their access and outcomes of care, such as insurance coverage, availability,
conscious and unconscious bias, and systematic barriers (Mkandawire-Valhmu, 2018). These
factors can have long-term consequences. For example, Riley (2012) found that a lack of quality
of care has led to adverse health outcomes that are more evident for marginalized groups. Grogan
and Gusmano (2007), using interviews and evaluation of data from Medicare, private insurers,
and their participants, concluded that frequently marginalized individuals are less likely to
receive prompt preventive care, leading to late diagnoses of chronic and terminal illnesses.
Without broader access to care, these individuals experience less favorable outcomes than the
population majority (The Agency for Healthcare Research and Quality [AHRQ], 2010).
The AHRQ has reported core measures concerning healthcare quality and disparities
relating to access, affordability, care coordination, effective treatment, healthy living, and patient
safety. Consistent with prior years, the AHRQ (2010) found compared to White Americans, 40%
of African Americans received inferior care in core measures, 20% inferior care for Asian
Americans, and Hispanic Americans received about 60% inferior care in core measures. The
same report included that people of low-socioeconomic status received substandard care
compared to those of high income in approximately 80% of measures. Other reported evidence
showed data concerning the negative impacts from a lack of access to care, especially for people
of frequently marginalized groups (Mkandawire-Valhmu, 2018).
4

Field Context and Mission
The focus of the study was on the field of medical practice and includes physicians
located in the Western part of the United States providing emergency, surgical, or preventative
care services in a variety of healthcare system settings. The Western United States was essential
to the study as five of the six majority-minority states are within the Western region as of the
2019 census. A focus on integrated health system capacities, systems that provide multiple points
of service for patients, allowed for a broad examination of possible barriers. This approach
supported the site-specific review, in context, the use of the study results. The physicians had
various experiences and perspectives on the care available and given to individuals within the
definition of frequently marginalized individuals. The research questions were aimed to gather
data regarding the marginalized patient.
Purpose of the Project and Research Questions
The purpose of the study was to solicit physician narratives regarding their experiences
and perspectives in their professional interactions. In addition to narratives the study additionally
entailed an analysis of documents to identify factors influencing inequities in care and how they
are addressed at the organizational and physician level. The study also served the purpose of
providing individual organizations, not directly identified, information and support with the
direction of offering more equitable care by changing organizational practices and physicians
preserving their duty of care through actionable recommendations. The research questions
intended to identify macro-level barriers in healthcare systems, while probing questions
narrowed in on micro-level individuals’ experiences of the study participants and professional
practices. These questions were developed to gather feedback from past and current experiences
5

and understand organizational practices they have worked within throughout their professional
careers.
Research Question 1: What is the impact physician and patient resources have on advancing the
access, treatment, and outcomes for marginalized patients?
Research Question 2: To what degree of accountability do physicians display a professional duty
of care in addressing disparate outcomes for marginalized patients?
Importance of the Study
The problem is critical to address because marginalized individual’s livelihood and basic
health needs are being underserved (Satcher & Higginbotham, 2008). Over many decades,
consistently marginalized individuals have received lesser quality health care than White
Americans (Mkandawire-Valhmu, 2018). Additionally, a lack of extensive high-quality results
had led to ineffectiveness in identifying racial, ethnic, and socioeconomic inequities in healthcare
due to failures in accounting for such variables, differing from federal standards (Moy et al.,
2005). The experiences gathered from the field study with the participants could fill in the gaps
regarding the lack of information and provide new insight. If the barriers to equal access and
quality care are then identified, organizations and physicians can take preventative and
mitigating measures to address the barriers and level a more equitable health care experience for
marginalized individuals.
The CDC (2019) described health equity as all individuals receiving equal access and
distribution of health care resources. The conclusion met by the CDC (2019) was that equity in
healthcare is limited by negative social determinants that disproportionately affect the health of
frequently marginalized individuals. As the AHRQ (2010) reported, this problem is significant
because the quality of care is improving, but access and disparities among marginalized groups
6

are not. Stone (2012) pointed to unfavorable health outcomes, including death, as one of the
consequences of not addressing the lack of access to quality care. Increasing the quality of life
and presenting untimely death are outcomes needed for individuals who are members of minority
groups (Stone, 2012). Addressing this problem could impact healthcare practice by providing
equitable resources to marginalized individuals and closing the gap in access to quality care
(Riley, 2012).
Overview of Theoretical Framework and Methodology
The critical race theory (CRT) framework critically examined the influences in the
healthcare system related to racial discriminations at the structural, systematic, and institutional
levels of organizations. The United States has a documented history of lacing of equitable
service in social and governmental systems due to race. Mkandawire-Valhmu (2018) suggested
that health care should be offered with an acknowledgment of race and not the expectation of
color-blindness. When healthcare systems and physicians fail to acknowledge the many factors
that impact care access, solving inequities becomes more difficult to resolve (Burgess et al.,
2004).
The study methodology was qualitative; data collection included using in-depth
interviews with physicians from the Western part of the United States, who are active in
emergency, preventative, and surgical care. Additionally, an analysis of public documents for
corresponding organizations was conducted to enhance the information collected through the
interviews. Physicians were selected to gain insight due to the professional Hippocratic oath
taken, with particular attention to lines 1, 3, and 7, which reads from the only national network of
medical professionals, the American Medical Association (AMA, n.d.). This oath reflects the
7

duty and commitment these medical professionals take to serve all people equally and to the best
of their ability. The oath states,
1. A physician shall be dedicated to providing competent medical care, with
compassion and respect for human dignity and rights.
2. A physician shall uphold the standards of professionalism, be honest in all
professional interactions, and strive to report physicians deficient in character or
competence, or engaging in fraud or deception, to appropriate entities.
3. A physician shall respect the law and also recognize a responsibility to seek
changes in those requirements which are contrary to the best interests of the
patient.
4. A physician shall respect the rights of patients, colleagues, and other health
professionals, and shall safeguard patient confidences and privacy within the
constraints of the law.
5. A physician shall continue to study, apply, and advance scientific knowledge,
maintain a commitment to medical education, make relevant information
available to patients, colleagues, and the public, obtain consultation, and use the
talents of other health professionals when indicated.
6. A physician shall, in the provision of appropriate patient care, except in
emergencies, be free to choose whom to serve, with whom to associate, and the
environment in which to provide medical care.
7. A physician shall recognize a responsibility to participate in activities contributing
to the improvement of the community and the betterment of public health.
8

8. A physician shall, while caring for a patient, regard responsibility to the patient as
paramount.
9. A physician shall support access to medical care for all people. (p. 1)
Using a qualitative methodology allowed the research to engage the healthcare
professionals with a reflective story-telling setting and gather data using questions to limit
biasing and alter the participants’ lived experiences. Upon completion of data collection, there
was an analysis of the participants’ responses. The researcher explored the perceived barriers and
outcomes for marginalized individuals then provided recommendations on potential forward
resolutions.
Definition of Terms
Affordable Care Act (ACA) refers to a federal statute enacted by Congress in 2010
overhauling the healthcare system and insurances (Healthcare.gov, n.d.).
Agency for Healthcare Research and Quality (AHRQ) refers to an agency within the
federal government’s Health and Human Services department collects and produces
information to make health care safer, higher quality, more accessible, equitable, and
affordable (Health and Human Services, 2017).
American College of Physicians (ACP) is a professional organization of physician
specialists promotes quality and professionalism in medicine to improve health outcomes
(ACP, n.d.)
California Office of Multicultural Health (COMH) refers to a collective policy office
with the Department of Public Health and Health Care Services focused on improving
programs for racial and ethnic populations specific to California (HHS.gov, n.d.)
9

Civil Rights Act is a federal level act that affirmed the prohibition of discrimination based
on race, color, religion, sex, or national origin (DOL, n.d.).
Critical Race Theory is a theory that concerns how race as a social construct and
longstanding racism creates a system that categorically places individuals of color at a
disadvantage (American Bar Association [ABA], 2021).
Equitable refers to the state of consideration in being impartial and unbiased objectives
(IHI, 2021).
Field Study refers to a collection of raw data outside of an office setting (Durdella, 2019).
Health and Human Services (HHS) is a branch of the federal government that provides
oversight and services to improve the health of Americans (HHS.gov, n.d.).
Marginalized Individuals is a proper noun that refers to individuals of ethnic minority
races such as African Americans, Hispanic Americans, or Asian Americans/Pacific
Islanders (Minnesota Psychological Association, 2017).
Henry J. Kaiser Family Foundation is a non-profit organization that focuses on the
healthcare needs Nationally and globally with particular attention to policy,
communication, and partnerships (Kaiser Family Foundation n.d.).
Hippocratic Oath is an oath that serves as a binding document that lays out the principles
- ethical and moral standards that conduct themselves under (PBS, 2001).
Integrated Healthcare System refers to medical offices and facilities set measures to
provide patients the care they need, for the value, and when needed. These organizations
use multiple delivery points and policies to set the expectation of offering services
described by the World Health Organization (WHO, 2008).
10

Institutional Review Board refers to a board consisting of an administrative body
established to protect the rights of human research subjects (FDA, 1998).
National Institute on Minority Health and Health Disparities (NIMHD) is a branch of the
federal government’s Health and Human Services division leads research to improve
health and reduce racial disparities (NIMHD, n.d.).
Office of Minority Health & Health Disparities (OMHD) is an office within the National
Health and Human Services Division was created to improve the health of minoritized
populations by enhancing health policies and programs (HHS, n.d.).
Structural Racism refers to the systems that exist in local, state, and federal practices,
policies, and norms promote ways that continue inequity based on race (Aspen Institute,
2004).
Organization of the Study
This study is organized into five chapters. In the introductory chapter, macro-level
information is provided for understanding the problem under study. It also provides an overview
of the purpose, importance, theoretical framework, and definitions. Chapter Two includes an
extensive literature review to provide current and historical context solidifying the problem and
the importance of the role physicians play in providing care and the perception of patient
experiences. Chapter Three contains the description of the qualitative methodology that was
used. These methods allow the researcher to gather narratives from interviews with physicians to
help shape the micro-level problem to form actionable conclusions. Chapter Four includes the
presentation of findings and summaries from the field research. Finally, Chapter Five
encompasses the final summation of all the information gathered and links the findings to the
background of the problem and why the problem should be addressed. The conclusions drawn
11

could assist healthcare organizations and physicians in the United States review the information
collected in their system context with recommendations to move forward.

12

Chapter Two: Review of the Literature
Access to quality healthcare for all remains a fundamental tool for achieving positive
health outcome experiences and a healthy, sustainable life (American Sociological Association
[ASA], 2005). Therefore, health begins with a collaborative effort between physician and patient.
However, marginalized ethnic groups have experienced inequities created through systems, laws,
and structures, leading to inadequate health care and access to health resources. These
circumstances hinder healthy outcomes for marginalized people. Understanding this history is
key to recognizing current inequities and determining how to move forward. In this literature
review, a synthesis of results is presented, reflecting the evidence of relationships between
race/ethnicity and health outcomes, resource limitations, and lack of access to care. These
characteristics and circumstances affect marginalized peoples in the United States.
Theoretical Framework: Critical Race Theory
Delgado and Stefancic (2013) introduced the critical race theory (CRT) as a movement
driven by intellect and a framework based on the premise that race is not naturally occurring but
is, instead, socially constructed to use for oppression. Furthermore, CRT asserts that laws and
legal institutions are inherently racist, and therefore, the legal system perpetuates inequities
between Whites and non-Whites. The CRT theoretical framework was developed in the mid-
1970s. Over the years, the theory evolved and includes additions and revisions while crediting
critical legal studies and radical feminism as prior movements that greatly influenced the
development (Delgado & Stefancic, 2017). Through an integration of theories, awareness, and
experience CRT motivates improvement in race equity using research, scholarship, and practice
(Ford & Airhihenbuwa, 2010).
13

In Critical Race Theory: an introduction, Delgado and Stefancic’s (2017) 3
rd
edition,
they described the framework as the study and transformation of the relationships among race,
discrimination, and power. These authors used the theoretical framework to question the
foundations of the systems rather than focusing on how civil rights and ethnic factors impact the
systems. One of the cornerstones of CRT is that racism has become challenging to address
because it is not broadly acknowledged. For example, Rocco et al. (2014), when addressing CRT
and organizational policies and procedures, recommended that these guiding documents be
specific in acknowledging race and not being developed from a neutral lens. CRT challenges the
contemporary attitudes that color-blindness is synonymous with an erasure of racism (Ford &
Airhihenbuwa, 2010). Other core concepts of CRT, such as micro-aggressions, institutional
racism, and White privilege, have been used to analyze its relevance in present-day issues such
as health (Bridges, 2019). Therefore, this theory provides a paradigm for understanding
healthcare history for marginalized groups and how current laws, institutions, systems, and
structures continue to promote disparities in healthcare.
The History of Law, Race, and Healthcare
Several historical events in the United States have contributed to the culmination of
structural and discriminatory practices still felt by marginalized individuals today, and such
practices include societal racism and discrimination (Evans & Gusmano, 2021). Evans and
Gusmano (2021) conducted a review concerning Black Americans and vaccinations and
determined that to bridge the disparities, the country must make fundamental changes to laws
and policies. Furthermore, the effects of structural and discriminatory practices have directly
contributed to the level of quality and access to healthcare for marginalized individuals
14

(Genevieve et al., 2020). Reviewing laws and practices related to disenfranchisement can be
linked to race and current-day healthcare disparities.
Beginning in 1890, Black Americans were subjected to the Poll Tax law. This law
disenfranchised Black Americans from voting and effectively minimized or eliminated their
representation by elected officials (Smithsonian, n.d.). The lack of political representation
supported by local, state, and federal anti-voting laws reinforced the systematic oppression of
Black Americans Other federal laws were ratified, and the Poll Tax exacerbated the effects of
segregation and voting.
From 1933-1968, the federal government initiated and administered the Home Owners’
Loan Corporation (HOLC), which effectively served as a means for banks and cities to control
where individuals could live, thus, serving as a de facto tool for maintaining segregation.
Utilizing federally legal practices, banks began drawing “redlines” around neighborhoods where
Black Americans could not receive loans for houses. Using these redlines, they created maps of
areas intended to exclude Black people from purchasing homes by refusing to lend for those
homes in some desirable areas and isolating them in areas with undesirable attributes (Krieger et
al., 2020). Additionally, the loans available to Black people frequently included abusive loan
terms that negatively impacted borrowers in the terms and penalties. Individuals forced to live in
segregated areas are harmed by a lack of access to resources otherwise available to those living
in more desirable areas. When the practice of redlining was effectively banned, the continuation
of barriers created to resources continued with the Jim Crow Era and government-mandated
segregation of cities and schools. Systematic practices, such as redlining, although more recently
it is formally out of practice, legacy continues to impact communities with residential
segregation. As a result, the health of these segregated communities has become compromised,
15

and when combined with high poverty, resources are essentially out of reach. Impacts such as
lacking local hospitals becomes a possibility. Ko et al. (2014) evaluated urban hospital closures
over 20 years and found that circumstances including segregated communities and poverty
increased the probability of hospital closures. Additionally, Clark (2005) reviewed the negative
impact of hospitals closures on marginalized communities by reviewing quantitative data. The
data showed reduced access by closures created strain for the remaining local hospitals trying to
fill in. Through additional data review the evidence showed resources being a primary strain in
remaining facilities, reduction in physicians due their role linked to the hospitals in question
being close, and thus marginalized individuals forced to seek basic care in emergency
departments (Clark, 2005). Discrimination and racism have continued in other forms that support
health care inequities, and these are felt similarly by other minoritized racial and ethnic groups in
the United States.
Current immigration laws continue to create discriminatory structures for frequently
marginalized individuals. These more recently created laws and regulations take precedence
from past laws designed to create inequity for marginalized persons. The Undesirable Alien Act
of 1929 serves as an example of a law enacted to reduce or stop the passage of Mexican
immigrants to American by criminalizing border crossing (Immigration History, 2019). In a 2017
study, Budiman et al. (2020) reported 4.9 million Hispanic Americans were identified as living
in the United States without resident documentation. Artiga et al. (2016) performed a systematic
review of policies that impact immigrants and individuals in the country deemed undocumented
by the 1929 Act. They determined that undocumented immigrants are less likely to seek health
care out of fear of deportation or other legal ramifications. Although individuals in the United
States without resident status can obtain “emergency care” paid from some state sources, such as
16

Medicaid, this access does not cover preventative or follow-up care. The emergency must be
evaluated for qualification for payment (Artiga & Martinez, 2019).
Notably, Asian Pacific Islanders or Japanese Americans experienced confinement in
internment camps after WWII, underpinning current discrimination and racism (Mio et al.,
2007). This history of discrimination encountered by Asian Americans has led to long-term
adverse health effects. Jensen (1997) completed an extensive review of the literature, conducted
a qualitative study, and determined that Asian Americans’ experiences since internment included
crippling health effects, such as lingering post-traumatic stress and increased cardiovascular
disease.
The American Academy of Physicians (n.d.) recognized that disparities in healthcare
continue to impact people based on the history of racism, systematic segregation, and
discrimination. Additionally, the Department of Health and Human Services (2016)
acknowledged the need to eliminate said disparities due to race with the creation of multiple
initiatives to combat the issue. This brief evaluation of history is a foundation for understanding
the links between individuals’ race and ethnicity and their disparate health access and outcomes.
The Link Between Race and Health Outcomes
Racism in society has created gaps in health care that can ultimately cost individuals’
lives (Patel & Rushefsky, 2008). Where gaps in care exist, they are not typically specific to one
ailment or circumstance, and the impacts can be related to distinct factors and a culmination of
factors that lead to poor outcomes. For example, using logistic regression, Hines et al. (2017)
found in a comparison of multiple racial ethnic groups, that approximately 90% of receive care
inconsistent with minimum recommendations for success in care than White Americans. When
individuals receive substandard care, patient dissatisfaction becomes more likely. Marginalized
17

individuals have reported disapproval and even discrimination in their care. In a survey of over
17,000 participants, White Americans perceived substantially less discrimination in their
healthcare than those of other races and ethnicities (Lyles et al., 2011). These barriers in health
services for specific groups of people directly impact their quality of care, including the type of
services offered and avoidable procedures (Fiscella et al., 2000). In a longitudinal, multilevel
study, Fiscella et al. (2000) used participants’ self-rated health perceptions, experiences, and
recorded mortality rates. In comparison to White Americans, marginalized individuals continue
to lag in access to care, quality and timeliness of care, and health outcomes (Koh et al., 2011).
The disproportionate adverse outcomes that affect marginalized individuals are partly
attributed to factors such as physician bias and insufficient knowledge of health issues for those
minoritized groups. According to the ACP (2010), inequities in healthcare experienced by
individuals of marginalized ethnic and racial identities can be attributed, in part, to geography,
health coverage, access, culture, and stereotyping. Organizations providing care should have the
resources, availability, and experience needed to meet quality measures and care offerings
equally for all patients of any ethnicity or race. Physicians are equally essential in their role when
seeking resources for patients and providing equitable care experiences.
Role of Physicians
Physicians are at the heart of patient care and experience. As written in the Hippocratic
oath taken by all physicians, doctors commit to becoming one of the singular conduits between
patients and their health (AMA, n.d.). Cochran and Kenny (2014) described the role of a primary
care physician and their essential link to preventing disease, managing the continuity of care
beyond primary, identifying risk, and enhancing the health of their patient. Thus, implying the
need for physicians to take a holistic look at a patient’s environment when in their care. An
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individual is one part of the larger public served by physicians, and therefore, individuals’ health
advances public health. According to Lockwood (2004), there remains professional
accountability for physicians to utilize their training, knowledge, and expertise to advance the
public’s health.
Physicians and Bias
Bias is not always glaringly obvious; it can be unconsciously but is evidenced in a
physician’s actions (Figure 1). Patients’ and physicians’ attitudes, expectations, and behaviors
can all contribute to bias. Bias can have roots in prejudice and stereotypes, or both (Smedley et
al., 2002). Hoberman (2012) detailed the relationship physicians to have with their patients and
the documented history of physicians labeling patients as obnoxious, problematic, or undesirable.
These attitudes can bias clinical decision-making when evaluating a patient’s concerns or
verbalized symptoms. However, not all bias results in unequal treatment of care plans. As found
in a University of Colorado (2014) study, patients who are people of color experience
discrimination and tend to high blood pressure received the same level of medication as their
White peers. The report also included that bias could impact care outcomes in other settings,
especially those without an established relationship with a physician or where medical guidelines
result in time-burdened decisions.
Ryn and Burke (2000) conducted a study utilizing surveys completed by 193 physicians,
of which 84% self-identified as White, representing 618 patient encounters, found that
physicians were more likely to dismiss Black American patients as less educated, less intelligent,
and susceptible to abuse drugs and alcohol, and therefore, less likely to follow treatment
recommendations. The physicians completed the survey after a patient encounter and were asked
to rate subjects such as a patient’s intelligence, pleasantness, independence, irrationality,
19

responsibility, and education (van Ryn & Burke, 2000). Minoritized individuals have reported
bias when receiving preventative care, medication maintenance, specialty service, and physician
interaction (Peek et al., 2010). Further, Peek et al. (2010) acknowledged institutional racism as
evidence for creating differences linked to race and access to goods and services, such as
healthcare.

Figure 1
Physician Bias on Care Decisions

Patient
Social, economic,
and cultural
influence
Patient input and
ability to
communicate
Physician
communication and
input
Serotyping and
prejudice (concious
and unconcious)
Disparate Clinical
Decisions
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Availability of Diverse Physicians for Marginalized Individuals
The diversity of physicians available to provide care directly impacts the relationship
between physician and patient. The AAMC reports that as of July 2019, only 5% of active
physicians in the United States identified as Black or African American and only 5.8% as
Hispanic Americans. The majority of physicians (56.2%) identified as White. The disparity
becomes significant when patients need access to physicians that share cultural and ethnic
similarities (Hagiwara et al., 2017). Hagiwara et al. (2017) found that racially discordant care
frequently resulted in racial bias and poor communication. Patients expect communication and
trust from their physicians. Similarities between patients and physicians can lead to improved
communication and time spent at appointments (Cooper et al., 2003), better decision-making
(Saha, 2020), and reduced bias (Hagiwara, 2017). Based on the information from the studies
cited, organizations and physicians might find benefit in focusing on relationships with patients
and their ability to relate to diverse groups. Maldonado et al. (2014) suggested that organizations
should hire physicians with diverse backgrounds to mitigate some of the reported healthcare
disparities associated with discordant care.
Professional Accountability
Physicians, bound by their medical ethics as stated in the Hippocratic Oath, have a direct
responsibility to protect human rights (Physicians for Human Rights, n.d.). This duty of care in
ending racial disparities in social structures begin with individuals utilizing their platform to
create change. Reviewing the roles of physicians in addressing racial inequalities, Attilus (2020)
urged fellow physicians to address their biases and acknowledge the privilege that allows them
an advantage in the social structure to fight for equity actively. Advocating for a patient is not
optional; instead, it is the duty of physicians to actively dismantle systematic structures that
21

create inequity and provide the patient quality healthcare (Ayotomiw et al., 2020). Physicians
can use the power embedded in the privilege of the profession to advocate for change. For
example, medical education courses can include an essential focus on equity, including
continuing education, building partnerships with the community, remaining active in public
health policy, and providing whistle-blower protections for physicians who speak out against
inequities and challenging its creation (Ayotomiw et al., 2020). This advocacy can jump start
individual change within the physician, but organizations should share responsibility as well. The
reality remains that racism kills (Boyd et al., 2020), and this situation creates a responsibility for
a physician that goes beyond treating a patient without considering the social determinants that
contributed to sickness (Attilus, 2020).
Comparison of Data by Race and Ethnicity
The KFF has conducted numerous studies regarding patient feedback and has compiled
statistical data on racial health equity and outcomes. From January 2020 to January 2021, Black,
Hispanic, and Native American adults aged above 18 died at a rate 1.5 times higher than White
Americans in the same age category (KFF, 2021). Among adults reporting on their perceptions
of discrimination in healthcare, 70% of Black and 43% of Hispanic Americans perceived bias in
health care, and only 41% of White Americans reported encountering bias (KFF, 2021). In 2020,
approximately 20% of Black and Hispanic Americans were affected by discrimination in care,
but only 5% of White Americans were affected (KFF, 2021). Additionally, Black Americans
have experienced physicians failing to believe they were truthful regarding their symptoms; these
incidences were reported 30% more often for Black than White Americans. Thus, the lack of
belief from physicians resulted in the physician refusing tests, treatment, or pain medication that
22

Black patients felt were necessary (KFF, 2021). Disproportions in numbers continue when
addressing specific health indicators such as pregnancy.
The CDC (2019) reported pregnancy-related causes of death were two to three times
more likely for Black and Native (Alaskan) American women than White women. Moreover, the
CDC included that most pregnancy-related complications are preventable. In 2020, Al-Agba
reported that morbidity statistics had worsened for Black women, indicating they were 243%
more likely than a White woman to die of pregnancy-related causes. Furthermore, in 2019 the
Commonwealth Fund determined Black Americans were more likely to die than White or
Hispanic Americans from preventable, including pregnancy-related, conditions in every state
where data were collected.
Researchers have reported wide disparities in illnesses and diseases between members of
minority groups and White Americans. As evidenced in results from a 2018 CDC study, 14.3%
of Black children under 18 years old were diagnosed with asthma compared to 5.6% of White
children. As shown by the National Center for Health (2019) statistics, 11.5% of White
American, 9.5% of Black American, 7.4% of Hispanic American, and 6% of Asian American
adults over 18 years old suffered from heart disease in 2017. However, Black Americans were
more than twice as likely to die of heart disease. Additionally, the results demonstrated that in
adults over 20 years old, Black Americans were nearly one and a half times more likely to have
hypertension, and Black and Hispanic Americans were more likely to be affected by obesity and
diabetes than White people. These results indicate that due to access discrepancies, members of
minority groups suffer the impact of poor health more often than those among the dominant
demographics.

23

The Impact of Lacking Access to Care
The lack of access to quality care can result in the preventable progression of diseases.
The outcomes include treatable conditions becoming unmanaged and leading to or increasing
secondary conditions for individuals with little access to healthcare. Flores and Tomany-Korman
(2008) found an increased likelihood for youths in marginalized groups to have suboptimal
health status, including obesity, asthma, and behavioral and emotional difficulties. Notably, that
90% of White youths were receiving primary care, but only 77% of Black and 68% of Hispanic
young people reported having ongoing primary care management. Radley (2019) determined that
Black Americans are more likely than any other ethnic group to die before 75 years old of
preventable diseases. Preventable and manageable diseases include health diagnoses such as
diabetes and heart conditions.
Canedo et al. (2018) identified that individuals in certain marginalized groups receive
significantly less than the necessary treatment for their manageable diabetes. In a quantitative
study, the researchers compared outcomes in five key areas concerning diabetes management
and how to control three specific determinants (Canedo et al., 2018). Furthermore, they found
that on all five measures, Hispanic Americans faired lower than White Americans while Black
and Asian Americans fell short in three of the five categories. Ferdinand et al. (2017) focused on
the impact of disparities for marginalized individuals in cardiovascular care. In their report,
Ferdinand et al. investigated the relationship between healthcare access and adherence for Black
Americans, and the results showed that Black Americans were two to three times more likely to
die from preventable heart conditions.
For the Missouri Foundation of Health, Hadley (2006) performed an analysis of decades
worth of statistics surrounding patient illnesses and outcomes. The researcher uncovered that the
24

impact of care access could be linked to morbidity and mortality. Overall, evidence supports
negative impacts for marginalized groups with identifiable disparities in the care they receive
relative to most White Americans. The history and link between race and health are attributable
to marginalized individuals’ social determinants.
Social Determinants and Race Leading to Health Inequality
The World Health Organization (2010) identified social determinants of health as
socioeconomic, structural, and environmental. The organization further reduced those
overarching determinants down to income, education, occupation, social class, gender, race, and
ethnicity. These characteristics follow an individual throughout their life experiences, and they
influence health and access to healthcare. The Alliance for Strong Families and Communities
(n.d.) determined that social determinants make up 80% of factors impacting an individual’s
health while the remaining 20% are attributed to their access to quality healthcare. These factors,
which make up a significant fraction of health outcomes, become concerning because researchers
have shown that marginalized individuals are disproportionally affected by these factors (CDC,
2020).
Structural Racism and Discrimination as a Cause
Multiple systems, such as economic, healthcare, education, nutrition, and social
environment, create the infrastructure that supports an individuals’ access to healthcare and
impacts health outcomes (KFF, 2021). The systems are designed, knowingly or unknowingly,
with structural racism such that outcomes result in racial inequities (Yearby, 2018). Unequal
access produced by those systems contributes to the social determinants experienced by
marginalized individuals. For example, Yearby (2018) reviewed census data in determining
poverty occurred at a higher rate for Black than White Americans with a root cause being a lack
25

of equitable employment opportunities due to discrimination. Further, this distinguished the
ability to pay for health versus lack of accessible health services. These outcomes result from
systems that have created wealth gaps for marginalized individuals, who historically have less
wealth and little to no access to health coverage.
The KFF (2020) surveyed Black and White Americans about their perception of systemic
barriers for Black people preventing health outcomes equivalent to those of White Americans.
The results showed that 79% of Black Americans saw structural and systematic racism as an
obstacle, while only 43% of White Americans saw it as a barrier for Black Americans (KFF,
2020). In this study, 65% of Black Americans polled reported being personally impacted by
systematic and structural racism. Acknowledging the formal structures underlying the system of
racism currently existing in the healthcare culture promotes improvements in health outcomes for
marginalized individuals (Bridges, 2018).
Racism and discrimination have been identified as social determinants of health,
impacting access and outcomes to care (Davis, 2020; Paradies et al., 2015). In addition, prejudice
can permeate through stereotypes, views, biases, and discrimination. Since the impact of racism
shapes the determinants experienced by marginalized individuals, Williams and Mohammed
(2013) used an extensive review of empirical research to conclude that social and institutional
racism, embedded in policies and law, have contributed to those determinants negatively
impacting health (Figure 2). The researchers compartmentalized racism into two categories,
institutional and cultural. During the review of institutional racism, Williams and Mohammad
(2013) evaluated historical and modern-day practices that continue to purpurate discrimination
such as segregation, governmental laws, forced relocations of native peoples, and incarceration
rates. Further, cultural racism embedded in society was supported during a review of surveys
26

surrounding stereotypes Whites carry regarding Blacks. Ultimately, the findings linked disparate
health effects to individuals of marginalized races based on the determinants caused by racism.
Figure 2
Effects of Social Determinants on Health

Structural Racism
and
Discrimintation
Economic Stability
Community
Environment
Education
Food/Nutrition
Social and Community
Context
Healthcare System
Mortality
Morbidity
Life Expectancy
Health
expenses/status
Functional limitations
27

Role of the Healthcare Organizations, Community, and Physicians in Determinants
In healthcare, organizational policies and procedures can lead to disparities when social
determinants are not considered. Administrative systems such as patient reminder systems,
patient education, physician training, and consciously mandated influences on the culture of
responsibility are ways a healthcare organization can actively mitigate social determinants of
health (Jack et al., 2012). Frequent patient reminders from an automated system can assist in
effectively increasing patient appointment attendance. In a 2008 study, da Costa et al. reviewed
data consisting of 29,000 patient appointments of those 7,890 were sent automated reminders, in
comparing the rate of attendance, those sent reminders had a reduction of non-attendance of
upwards to 14.49%. Patient education can be valuable for adhering to medications (Shea, 2018),
understanding health conditions, creating a healthy lifestyle, and advancing knowledge of an
individual’s health status. Additionally, physician training becomes essential to an organization
because physicians are the front line in mitigating determinants that a patient may experience.
Acknowledging and incorporating social determinants into a patient’s health plan is
critical to improving outcomes. The American Academy of Family Physicians (AAFP, 2019)
identified behaviors that physicians can use proactively to address determinants when planning a
patient’s care. These behaviors include knowing a patient’s determinants and correlating them to
their health effects; developing cultures in the practice that directly address implicit bias and
promote cultural proficiency; understanding the community the practice serves and the inequities
that exist; as well as advocate for change to public policy to impact change (AAFP, 2019). A
physician could satisfy these recommended behaviors by surveying patients with questions, for
example, by providing yes/no options regarding their social environment, such as:
• I do not exercise enough.
28

• My job or employment does not meet my needs.
• I do not have enough access to food.
• My housing situation is unstable or unsafe (Leavitt, 2018).
A physician should try to understand all factors underlying a patient’s illness and
familiarize themselves with the evidence to assess adequate treatment plans adequately
(Thomasson, 2014). Adversely, inconsistency in physician’s willingness to be accountable and
actionable with paving the way for change in social determinants lends to the continuance of
disparities in health outcomes and care. Leavitt Partners (2018) conducted a survey in 2017
consisting of 621 physicians across various health systems and practices. They revealed that not
all physicians deemed determinants of health as necessary information or felt they had a
responsibility to address these issues. The study found that although over 50% of the physicians
surveyed felt resolving the determinants could increase the likelihood of positive outcomes, 90%
surveyed did not feel a responsibility to assist in a patient finding affordable or stable housing;
specifically, 84% of the respondents did not see responsibility regarding food security and 69%
transportation. Determinants play an initial role in patients’ access and outcomes; however,
physicians need the resources to provide the care specific to patients’ demographics.
Data and Resource Limitation
Health systems with limited data on patients’ racial and ethnic backgrounds hinder the
providers’ ability to properly assess quality outcomes. Data impacts a patients’ utilization of
services, and the providers’ ability to target communities with specific needs (Fremont et al.,
2016). Addressing disparities in healthcare by focusing on enhancing policies and allocation of
resources should begin with collecting socioeconomic class, race, and ethnicity (Nernez et al.,
2009). As physicians assess a patient’s total health profile, resources for individuals provide an
29

avenue to mitigate adverse outcomes. The resources needed to provide a continuity of care for
patients include various data, organizational and operational investments, referrals, and
specialties.
Need for Data: Resource Improvement
A lack of multiple data sources collecting patient demographic, ethnic, and geographic
information creates barriers to addressing racial, ethnic, and socioeconomic disparities in
healthcare (Moy et al., 2005). Patient data remains an essential factor in gathering pertinent
information for evaluation. Sharma et al. (2015), reviewed cancer outcomes for African
American women and found that more research was needed to understand the disparities in care
related to socio-cultural and economic contributing factors. Data specific to race and ethnicity is
needed to improve treatment, plans, and preventative recommendations. Moreover, Ulmer et al.
(2009) detailed the need for additional data collection to pinpoint healthcare disparities supported
by health organizations. Access to quality care includes the physician being equipped with the
resources and data to provide such care. Without the information for physicians, a discontinuity
will likely continue health outcomes for marginalized individuals (Ulmer et al., 2009). Data
resources are one part of a larger picture that includes resources available to physicians and
organizations providing care.
Physician and Organizational Resources
Healthcare physicians often lack the resources necessary to provide adequate care to
marginalized individuals. Doctors face the challenge of scarcity of resources based on
organizational allocations, at times influenced by geographic area and impacting minoritized
ethnic populations disproportionately. Hurst et al. (2007), in a survey of 656 physician
respondents regarding their resource availability, they concluded a willingness by the physicians
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to entertain cost-restraint decisions for patients. Organizational factors can sometimes create
unintended consequences of lack of availability and equity in care. The respondents averaged 25
years of practice and attributed negative impacts to a lack of resources; these adverse outcomes
included death.
There are unique situations specific to racial and ethnic groups for which many
healthcare physicians do not have the resources or tools necessary to identify the needs and
treatments for these patients (Yancy et al., 2011). The availability of physicians without relatable
race backgrounds creates a problematic foundation for marginalized individuals in receiving
adequate healthcare and having positive outcomes (Jacobs et al., 2006). Jacobs et al. (2006) used
a focus-group study of Black adult men and women regarding race and their physicians; the
participants indicated that physicians’ interpersonal and technical competencies were the
foundation for building trust. Results suggested that the participants linked trust to interpersonal
competence, showing empathy and listening, and technical competence to the physician’s ability
to make a correct diagnosis or follow-up care. In this study, participants expressed distrust in
physicians who lacked these skills, and particularly those of foreign nationality, and who focused
on profit, bias, and appeared to promote experimentation in the patient’s treatment. Thus,
magnifying the need for trust in a physician to provide for successful outcomes.
Bach et al. (2004) used mixed methods to consider over 4,355 physicians’ perceptions
and revealed that of the participating physicians, 22.6% who treated Black patients, were not
board-certified, compared to only 12.9% treating primarily White patients. A lack of board
certification presented barriers for these physicians working with marginalized communities
because they could not obtain access to additional resources, specialist referrals, and surgeon
chart review, which are needed for a patient’s treatment plan. Thus, these circumstances can
31

create a potentially reduced quality of care as a physician’s qualifications can impact their ability
to access resources for their patients and reduce the quality of service provided (Dumke, 2004).
Disparities experienced by marginalized individuals can be sourced back to the disproportionate
number of lower quality physicians providing less than optimal care (Chandra et al., 2017). As
further evidenced in the Bach et al. (2004) study, 27.8% of the 4355 physicians providing care to
primarily Black patients reported an inability to provide high-quality care. An inability to
provide high-quality care impacts the need for solutions to addresses these inequalities.
Existing Solutions to Address Health Inequality
Solutions created over the years to bridge the inequalities have helped but continue to fall
short of eliminating health inequalities for marginalized individuals. In 1964 Title IV of the Civil
Rights Act created a requirement that health systems receiving federal funds not discriminate
based on race, color, or national origin. However, the Act did not apply to physicians rendering
service (Chandra et al., 2016). This unintended loophole allowed independent physician practices
to operate in ways that might not have otherwise fallen in compliance with Title IV. Since the
passing of Title IV, efforts have been made to close the gap in care that creates the remaining
disparities experienced by marginalized people (Chandra et al., 2017). An example of these
efforts is creating organizations focused on promoting health equity and equal services to all,
state-specific legislation, and a federal focus on health coverage affordability with the expansion
of the ACA (Purnell et al., 2016). While these solutions have played vital roles in advancing
access and health for marginalized individuals, more work is needed (Syrop, 2016). Necessary
continued efforts include linking interventions to community and care, research to address the
entirety of health needs, addressing cultural differences, and holistic approaches to care as the
patient preference. Decades of disparate practices in American society have led to creating
32

private, local, state, and federal organizations joining with action plans to provide resources and
advocate for change.
Notable Organizations and Institutions Working for Health Equality
At the forefront of providing support and promotion of healthcare equality are
organizations that devote their work to closing the divide experienced by marginalized
individuals (American Medical Student Association, n.d.). Organizations such as these play a
critical role in influencing change in the systems and structures that marginalize specific groups
of people. Transformation of local, state, and national policies requires an abundance of
resources (Kanus, 2009); notable organizations, such as The Office of Multicultural Health,
National Institute on Minority Health and Health Disparities, and the KFF, provide contributions
for change.
Created in 1986, the Office of Minority Health & Health Disparities (OMHD) provides
resources aimed toward improving the health of marginalized individuals through influencing
policy and programs. The office has three separate divisions. The policy division concentrates on
health policies and other initiatives that close the gaps experienced by the underserved in
healthcare and promotes health equity for marginalized individuals. The division of program
operations leads federal grant initiatives. They assist in operationalizing and monitoring health
policies with oversight in education, awareness, and service delivery. Finally, the division of
information and education collaborates with community partners and programs internally and
externally to promote resources to bring health equality (MinorityHealth.HHS.gov, 2019).
In partnership with the federal Health and Human Service governmental agency and
additional state policy offices, the California Office of Multicultural Health (COMH) - State
Partnership Program provides access to grants, resources, and programs for marginalized groups.
33

This partnership is a collaborative effort to close the disparities experienced in health by racial
and ethnic populations living in California. The mission of this agency is to raise continuing
awareness of the health disparities and increase marginalized individuals’ use of available health
services (HHS.gov, n.d.).
The National Institute on Minority Health and Health Disparities (NIMHD) began as a
program in 1990, but under the ACA, the program became a full-fledged institute under the
National Institutes of Health rather than a program. The institution focuses on research and
training to close health disparities experienced by marginalized individuals. The NIMHD
participates in partnerships with both federal and non-federal organizations to enhance their
reach (NIMHD, n.d.)
The KFF is one of the largest non-profit organizations focused on research, policy
influence, and journalism to highlight national healthcare. Currently, the organization has
dedicated resources on various topics, with one aimed at racial equity and health policy. This
branch of the organization conducts research and reports data to frequently address racial and
ethnic inequalities and health policy that it impacts (KFF, n.d.). These organizations provide
high-level visibility to data, statistics, programs, and recommendations for improvement, but
they can sometimes take the role to help move legal actions forward. The organizations named
assist in moving forward the goal to closing the gaps in care in addition to health policy.
Micro-Level State Health Policy to Address Inequality in Care
One way to address known disparities in care is to enact health policy. The WHO (n.d.)
described the necessity for health policy to achieve specific goals through plans and actions.
Health policy can exist at any level of the federal government: the judiciary, legislative, and
executive branches. Legislative action can increase public health, access, prevention and reduce
34

disparities (Anderson, 2012). When laws are created, they tend to be specific to health needs, as
evidenced in recent legislation. While the examples of bills are not all-inclusive to the proposed
bills sitting with the state legislatures, they reflect efforts to use the law to mandate change.
Assembly Bill 241 Implicit Bias and Continuing Education established a requirement that
by 2022, continuing education credits for physicians should encompass curriculum to address the
implicit bias in medical care. The bill includes the requirements that organizations offer courses
in continuing education to meet the specific accrediting standards in the bill (CA.gov, 2019).
Senate Bill 464 Dignity in Pregnancy and Childbirth Act is a newly enacted law designed
to reduce the effects of implicit bias in patients’ pregnancies, childbirth, and postnatal care. This
law sets requirements for healthcare organizations to ensure equitable health outcomes regardless
of race and ethnicity and to do so with dignity and respect. Organizations need to implement an
evidence-based implicit bias program for all health care physicians involved in the perinatal care
of hospital patients that meet specific requirements as outlined in the bill (CA.gov, 2019).
Senate Bill 48 Dementia and Alzheimer’s disease proposes a requirement for renewal of
professional medical licenses that entails a minimum of four hours of continuing education
focused on strategies to address bias in decision-making that can increase disparities or examples
of bias and its unintended impacts (CA.gov, 2021). State laws provide a bridge by narrowing
identified gaps by creating requirements for physicians and organizations, but a first step is
tightening the divide in the availability of healthcare insurance coverage.
Affordability and Medicaid Expansion with the Affordable Care Act
Healthcare coverage has been identified as one of the leading factors for marginalized
individuals gaining access to quality health care (KFF, 2000). The ACA was implemented in
2010 to address healthcare coverage, affordability, and standard requirements for care delivery.
35

According to Medicaid and CHIP Payment and Access Commission (n.d.), this legislation
addressed affordability by implementing a government-run healthcare marketplace that allowed
current private health insurers, such as AETNA, Blue Cross Blue Shield, Kaiser Permanente, and
UnitedHealth to provide coverage to individuals utilizing federally funded plan options. These
options were intended to significantly reduce premiums or eliminate them. Individuals with
difficulty affording healthcare coverage can take advantage of multiple plan options in the state
where they live, with the premium offset for those with reduced income. However, since the
implementation of the ACA, multiple insurers have opted to decline offering coverage or the
reduced-cost plans in the marketplace (Kodjak, 2016).
Along with offering assistance with premiums in the marketplace, the ACA offered a
provision for states allowing the ability to accept federally matched funds to expand Medicaid
coverage to previously ineligible individuals (Blahous, 2013). Medicaid is state-run with federal
and state financial partnerships. The program is at no cost to recipients. Medicaid is a health
insurance program providing coverage to over 74 million low-income adults, children, disabled
persons, and seniors (National Conference of State Legislatures, 2021). The provisions supported
a streamlined application and review process and raised the maximum federal poverty limit to
qualify (MACPAC, n.d.). The expansion of Medicaid was not mandated for states to adopt. As of
March 2021, the KFF (2021) found that only 39 states and the District of Columbia had
approved and implemented the expanded coverage. Between 2013 and 2020, those states
participating in the Medicaid expansion had enrollment increases by 41.7% or 15.9 million
individuals, according to the Medicaid and CHIP Payment and Access Commission (n.d.). In
2013, the KFF found that among Medicaid recipients, 21% identified as Black, 25% as Hispanic,
and 14% as being of more than one race or ethnic group. These statistics offered insight into the
36

demographics among those using the program. The expanded qualification requirements have
since been linked with increased coverage, utilization of healthcare services, and quality
outcomes (Mazurenko et al., 2018).
Criticism of the ACA and Civil Rights
Article 1557 of the ACA was provisionally designed to address civil rights within
healthcare coverage. The Article reflected a formal approach to equity that Blake (2016)
questioned as appropriately applied healthcare distribution. An objective of the ACA was to
provide access to health insurance for those who otherwise would not be offered or able to afford
it. People of marginalized groups were at substantial risk of being uninsured due to disparities in
access to education, leading to lower-paying jobs and careers in which employers did not offer
coverage or offer substandard coverage (Dark & Payne, 2013). The ACA explicitly calls for
healthcare disparities to be reduced. However, Yearby (2018) argued that the law failed to
recognize the root causes of racial biases, such as social determinants, therefore, is inadequate in
balancing access to care for marginalized individuals. Additionally, the ACA expressly excludes
undocumented immigrants from accessing coverage in the healthcare marketplace (KFF, 2019).
These existing solutions discussed aim to increase access and laws intended to decrease
discrimination felt based on race, but they fall short of providing specific recommendations that
organizations and physicians can use to enact change.
Conceptual Framework
When race underlies the basis of a social privilege system, individuals marginalized by
society frequently land at the bottom of the hierarchy (Aspen Institute, 2004). As race is woven
into the fabric of American society, its historical and systematic use remains prevalent in today’s
edifices, from housing to healthcare. The conceptual framework utilizes the social science
37

theoretical framework of critical race theory (CRT) as a blueprint in examining the relationship
of how race in conjunction with the law and other systematic structures have continued to
promote inequities for marginalized individuals (ABA, 2021). As healthcare organizations create
internal practices and promote cultures, physicians absorb this information and reinforce their
conscious or unconscious bias.
The current study aims to explore the relation to the origins of disparities with the
different variables addressed in studies. The purpose of this study is to review narratives given
by physicians regarding professional interactions and experiences to create an overview of
factors influencing inequities in care. The conceptual framework supports understanding the
following issues, physician practices, organizational policies, documented social determinants of
marginalized patients, treatment, and healthcare outcomes (Figure 3). The history of racism and
discriminatory laws are links race and health outcomes (Bailey et al., 2021); social determinants
have emerged due to historical and current practices, creating the need to study the role of
healthcare organizations and physicians and how that role can impact change. Institutional
racism embedded in healthcare organizational practices has reduced access for marginalized
individuals to needed resources. Smedley et al. (2002) researched literature and practices for the
Institute of Medicine and found that systemic interventions are necessary to improve healthcare
equity for marginalized individuals through policies and procedures. As the systems create a
culture of promoting equity, physicians have the direct ability during patient encounters to
account for their total environment to encourage enhanced health outcomes.
38

Figure 3
Conceptual Framework

39

Conclusion
A synthesis of the literature supports the assertion that historical racism and inequities
have supported structural discrimination and unequal health access among demographic groups,
particularly for the outcomes of marginalized individuals. While research has supported the
historical connection between racism and health, the lapse in analysis falls between
understanding the impacts and macro-level solutions. Health disparities were not created in a
short time or by limited numbers of influences; instead, a culmination of factors, as addressed in
this review, led to current disparities that appear to be increasing for marginalized groups. A
physician’s observations of a patient’s social environment and determinants can be pivotal for
proper treatment and prevention. Additional research should be pursued to gain supplementary
information beyond past studies and the current study should be conducted to analyze routine
encounters between physicians and patients.

40

Chapter Three: Methodology
The purpose of the study was to solicit physician experiences and perspectives of their
professional interactions and complete a document analysis to identify factors influencing
inequities in care and how they are addressed at the organizational and physician level. Chapter
Three is organized with an overview of research questions, a description of the methodology
chosen, the background of the researcher, data sources to be used, and the approach to ethics.
This chapter serves as the foundation for recruiting potential participants and how the interviews
were documented, analyzed, and supported through a supplemental analysis of documents.
Research Questions
RQ1: What is the impact physician and patient resources have on advancing the access,
treatment, and outcomes for marginalized patients?
RQ 2: To what degree of accountability do physicians display a professional duty of care in
addressing disparate outcomes for marginalized patients?
Overview of Design
The research is a qualitative field study with interviews and document analysis as data
sources. The participants and organizations represented in the study will remain confidential
through pseudonyms, such that their identities are withheld. Information gathered regarding the
participants’ demographics included self-identification of race/ethnicity, gender, and age. The
professional experiences of physicians from differing health organization backgrounds are
included to capture a broader range of experiences with diverse marginalized individuals and
identify barriers to care. Further, an analysis of public documents to understand better the
information obtained from the participants and corroborate or discern conclusions made from the
interviews was included in the study. Institutional Review Board (IRB) approval was obtained.
41

This approach allowed the study to advance knowledge regarding inequities in health
care created by bias in healthcare organizations and social constructs of physicians. The use of
interviews and the narrative support raw information to be solicited from the participants. While
these physicians speak from professional experiences with patients, they may also be asked to
bring experiences of peers and professional organizations they personally encountered.
Transcripts created from the interviews were reviewed three times to appropriately code
keywords and analyze their words for repetition and confirmation.
Table 1
Data Sources
Research Questions Interviews Document Analysis
What is the impact physician
and patient resources have on
advancing the access, treatment,
and outcomes for marginalized
patients?

X X
To what degree of
accountability do physicians
display a professional duty of
care in addressing disparate
outcomes for marginalized
patients?
X

42

The Researcher
Salient identities give an individual a sense of uniqueness and positionality. My journey
with positionality begins with identifying as a woman, member of the LGBTQ community, of
mixed ethnicity, working in the health field for the past 15 years, and a lifelong healthcare
patient. Positionality and identity become easy to identify by when the world sees you outwardly
as such. I am a woman first. I have experienced discrimination because of my gender in the
professional environment over the years. While being a woman has come with benefits and
challenges over my lifetime it is just one piece of who I am.
The next highly identifiable part of my identity is my ethnicity. Over the years I have
frequently felt forced to place myself into one bucket of racial identity. The ethnicity I have more
aligned as has been Mexican American as my father is a second generation American with his
maternal lineage deriving from Guanajuato region of Central Mexico. This is my relatable
ethnicity because I was raised primarily with the cultural aspects our Mexican heritage in food
and family traditions. Although I primarily identify with the culture I was raised, I am of
multiple ethnicities. I am of multiple European, Indigenous Americas (Mexican), and African
roots of varying degrees.
As a professional having worked in the healthcare field at both the patient service level
and administration this positionality is directly tied to this study work. I have worked with
patients in a direct contact capacity for many years before moving into an administrative position
behind the scenes roughly 10 years ago. All the salient identities that create my positionality also
create my passion for this study and commitment to its substance and credibility.
Protocols were set to appropriately represent the voice of the physicians selected to
participate in the study. I had no direct ties to the participants solicited for an interview and will
43

have no direct relationships with the organizations used for document analysis. Protocols set
were purposeful to pay particular attention in allowing the participants to guide the interview to
reduce potential assumptions stemming from my positionality.
Data Sources
Data sources used included semi-structured interviews and document analysis. In-depth
interviews were performed before reviewing documents. Data collected supported the purpose of
the study and conceptual framework (Bowen, 2009). Essential information was gathered from
the participant interviews and public domains used to gather documents for analysis. The
document analysis consisted of searching specific websites for the organizations identified and
linking that information to the participants’ answers to the interview questions when they derive
from the same organization.
Interviews
Interviews should include building relationships with participants to encourage trust and
entice rich and detailed dialogue (Steinar, 2006). Magnusson and Marecek (2015) described
interpretive research, using in-depth interviews, as a meaningful way for the participant to reflect
on professional and personal experiences. The interviewer sought to maintain a conversational
tone with free flow of information. To promote this flow, information prior to the interview was
reviewed to become familiar with the category of physician practice being interviewed to adjust
language and speaking style. Furthermore, the study was intended to gain knowledge, and the
focus was on the participant to encourage open dialogue and lead the narrative. The interview
questions allowed the narrative to emerge rather than seeking bounded answers.
44

Document Analysis
Document analysis data collection consisted of a systematic review and evaluation of
information. The analysis performed used publicly available information obtained from
organizations electronically. Examples of documents collected included advertisements,
brochures/pamphlets, news articles, public records, organizational websites, and publications.
The data sources were reviewed separately and then compared to find commonalities and
additional ties addressing the research questions. Information within the sources reviewed
included resources linked for patients, funding for projects, research organizations have
completed, and community presence. Document analysis is noted as a common method utilized
in combination with literature reviews to incorporate the information and make
recommendations (Bowen, 2009). Moreover, the secondary method complimented the
trustworthiness of the data.
Participants
Convenience sampling was the primary method used to recruit participants for the study.
The approach entailed identifying individuals as practicing physicians and, with the best effort,
represent professional experience in the Western United States. Physicians were solicited to
participant via an email providing an introduction, the purpose of the study, and how their
contribution could be of value. In addition to the convenience sampling, claim referral, or
snowball sampling, was used to recruit potential participants when additional participants were
needed. Additionally, to increase the participant invitation pool, participants were solicited
utilizing connections from the years’ experience in the field and peers with physician associates
interested in participating. In determining the number of individuals invited to participate, the
goal was that the sample size be large enough to continue the development of information
45

collected but small enough to allow for rich in-depth analysis (Vasileiou et al., 2015). The total
number of participants invited to join an interview was 15 to reach adequate data saturation
(Francis et al., 2010). Saturation has become a standard in the health sciences field when
identifying sample size Additionally, best effort was made for participants to represent a variety
of backgrounds to allow diversity. No compensation was offered to participants.
Instrumentation
Research instruments should be valid, reliable, free of bias, and intended to provide
information in context (Chenil, 2011). The first instrument intended to collect data was a
researcher-developed interview protocol with questions intended to emphasize the participants’
experiences and perspectives and stimulate in-depth narratives (Brinkmann, 2014). The
researcher also created an interview protocol including electronic informed consent and
demographic questions. The nature of questions and context directly linked to the identified
research questions and conceptual framework. Semi-structured interviews were used for the
purpose of knowledge gathering and the flexibility of continued dialogue (Brinkmann, 2014).
Secondly, data analysis was conducted to extract meaning from the data collected in the
interviews.
Data Collection Procedures
Data collection for both semi-structured interviews and document analysis was performed
using formal protocols. Roller and Lavrakas (2015) described in-depth interviewing as a
qualitative method to capture what participants are doing, thinking, and why. To accomplish this,
participating physicians were asked for interviews, taking place at times and locations to
accommodate their schedules, geographic location, and be conducted by phone or video chat
unless otherwise allowed. Each interview was scheduled for 60 minutes. Data from the
46

interviews was captured utilizing a built-in transcription service available in the video
application or via recording device and uploaded to a transcription service, with the express
permission of the interviewees. The participants were given the option to participate in the video
session without indicating their name on the recording session, to further protect their identity. If
the participant expresses concern with a video recording, the interview was offered in an audio
only format and the participants name withheld. If a participant did not offer approval for the
interview to be recorded in any form, detailed notes were taken by hand. Document analysis data
collection consisted of viewing public domains of organizations represented by the interviewees.
Pseudonyms were used to protect the identities of the physicians and their organizations.
Documents were used to target patients identified as marginalized, demographic areas covered
by services, and any additional information relevant to the problem of practice.
Interviews
Thematic analysis (TA) was used for data analysis in this qualitative study. There are
three parts to thematic analysis when analyzing qualitative data. Willig and Stainton (2017)
described TA as containing three general steps, sorting data collected, codes, theme (Figure 4).
In this study, the researcher used the interview transcripts, created codes based on responses, and
determined common themes or patterns. The study gathered and became familiar with the
information collected, assigned appropriate codes to keywords and phrases in the data.
Furthermore, the researcher searched for patterns across the participant responses, in-depth
analysis, identify patterns or themes, and give relevant wording to the themes (Morensten, 2020).
Document Analysis
A thematic analysis was additionally used for data analysis in the document review to
support consistency in the interpretation of data. TA in the context of document analysis involves
47

the researcher taking a complete re-review of the information, then organizing to create codes,
categories, and themes (Bowen, 2009). Codes can be divided further into sub-sections, as needed
to properly sort and code the information collected (Guest et al., 2006). This approach was
particularly beneficial to compliment the narratives and resulting themes from the interviews.
Further, the links found between the interview and document themes were used to answer the
research questions.
Figure 4
Thematic Analysis

Interview
Transcripts and
Document Analysis
Notes
Group Information
Collected and
Generate Codes
and Levels
Catagorize and
Organize Themes
48

Credibility and Trustworthiness
To ensure the integrity of the study, the focus was on the credibility technique identified
as Interviewee Transcript Review (ITR). To promote continued credibility, this study will utilize
two data collection methods in the form of semi-structured interviews and document analysis
(Shenton, 2004). Further, the information obtained from both methods were compared to find
commonalities. These methods were utilized to ensure findings are comprehensive and
thoroughly developed. Additionally, ITR was offered so that participants can check their
responses for accuracy before analysis and comment on the overall findings. This procedure
allowed for the participants an option to review the information collected and the researcher’s
interpretations (Hagens et al., 2009).
Ethics
Consent, confidentiality, consequences, and the researcher’s role present ethical
uncertainty, which were supported by the protocols and guidance of IRB (Willig & Stainton,
2017). The study protocol ensured direct responsibility for respecting the physicians’ interests in
participating in interviews. Participants were informed of their right to decline answering any
question at any time. Before the interview began, the participants were asked for their explicit
consent, and the researcher explained how the information collected from the interview will be
used. The participants were assured that all organizational or professional information obtained
will be masked so that their identity remain anonymous. To achieve the level of confidentiality
promised to the participants, participants were provided the information regarding the specific
recording device used during the interview. Furthermore, after transcription, evaluation of the
data, and completion of degree all information collected will be disposed of after approval of this
dissertation.
49

Chapter Four: Findings
The purpose of the study was to solicit physician narratives about their understandings
and perceptions in their interactions with patients, specifically those of minoritized ethnicities.
The study included an analysis of documents to distinguish factors prompting inequities
experienced in healthcare from an organizational and physician perspective. Referring to the
duty of care discussed in Chapter Two, it reiterates the role physicians play in addressing
patients’ entire environment impacting their access to care and their care outcomes. The selected
research questions that were explored are as follows:
RQ1: What is the impact physician and patient resources have on advancing the access,
treatment, and outcomes for marginalized patients?
RQ2: To what degree of accountability do physicians display a professional duty of care
in addressing disparate outcomes for marginalized patients?
The study sought to solicit experiences and recommendations from physicians
surrounding barriers identified impacting patient access to care and their outcomes. The research
questions were intended to elicit a discussion surrounding the environment experienced and how
it is addressed. The theoretical framework centers around the basis for the critical race theory and
how race impacts individual’s environment. Further, the conceptual framework then ties in the
role of physicians in providing care and addressing those environmental impacts.
These environmental impacts are addressed as social determinants of care and the barriers
they present for a patient. Additionally, a data analysis was conducted using five public websites
for medical centers to compliment the information gathered from the interviews. These websites
were examined for links, references, and other material referencing the identified themes.
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Participants
In the requests for participants to interview there was initial skepticism on why
physicians were selected as the focus. This led one potential participant who engaged in early
conversations with me via email to ultimately decline to participate. The prospective participant
stated that they were concerned the study would have a too narrow focus on physicians and
patients and thus ending up with findings criticizing physicians. Although this study focuses on
physicians and patients, there is an acknowledgment that administrators need to be included
when considering recommendations. There were six additional participants that initially engaged
and expressed interest, but contact ceased once the formal invitation went out to establish a day
and time for an interview.
Selected participants of the study were current practitioners in the medical field providing
care in the following medical areas: obstetrics and gynecology, primary care, family medicine,
general surgery, emergency medicine, and administrative hospitalist. The participants varied in
both age and professional experience. Additionally, the physicians’ care setting experience
spanned from public health care provider settings to private medical organizations. Data
saturation was reached by the eighth interview. Table 2 reflects the participants’ assigned
pseudonym, self-identified age, gender, ethnicity, and years in practice.

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Table 2
Assigned Pseudonym, Age, Self-identified Gender, Ethnicity, and Practice
Participant Age Range Gender Race Years in
Practice
Alan 46 Male Vietnamese 9
Walter 44 Male Japanese 16
Nelson 40 Male Asian-American 7
Nicole 35 Female White 6
Ashley 34 Female Asian-
American/Filipino
5
Kim 33 Female Biracial/African
American/Mexican
American
7
Ben 71 Male White 43
Nick 55 Male White 18

Findings Research Question One
The purpose of the research question was to elicit responses from participants and draw
conclusions on the impact physicians view resources to have on their ability to treat marginalized
patients. Themes that emerged from participant interviews focused on the limited resources
available to the patient. The themes include a lack of sufficient transportation, no childcare help,
the insufficient hours of physician availability, language barriers, and cultural differences.
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Lack of Resources Available to Patients
Resources, both available to the physician and patient, limits the ability to reduce barriers
in care access. Lacking resources can negatively impact access to care and treatment outcomes.
The inability to access resources for these known barriers specific to social determinants of
health signify a breakdown in the system and structures the patients depend on.
Lack Sufficient Transportation
The first theme that emerged from research question one was a lack of sufficient
transportation available for the patient. Of the eight participants, five indicated that transportation
was a barrier for their marginalized patient population. The ability to get to a doctor’s
appointment relies on having transportation. “Transportation has been a barrier for my patients as
far as I can remember”, expressed Nick. Alan candidly shared the inability to timely navigate the
city with public transportation and that even the best of circumstances can take 20 or 30 minutes
to travel a short distance. He added that it would be nice if “[organizations] were like Disneyland
and had a shuttle that picked up patients up free of charge. I feel like that's a big issue [they] can't
even come to an appointment or drive home safely from surgery”. Each participant conveyed in
some manner how impactful it is for patients to maintain appointments and to be on time to
create quality medical care.
Conversely, Ben indicated that the medical center where he works is in an area with
ample access to public transportation. He added that the center is also very walk able; it is in a
neighborhood highly accessible to people by foot and bus lines. The only complaint they [the
medical center] encountered in recent years was an $8 parking fee implemented but, ultimately,
the fee was reversed by the medical center after receiving negative feedback.
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Transportation was a recurring theme as a barrier for those patients identified as
marginalized. When asked how the barrier of transportation impacts patients, participants gave
the following examples of problems associated to lack of transportation: not making the
appointment entirely, having a day surgery that they were not allowed to drive themselves home
from or that they should not be using public transportation to get home from, unreliable public
transportation timing, and an inability to maintain regular preventative care. Table 3 reflects the
responses received when asked what they considered to be the most encountered barriers for a
patient and what it means for their care.

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Table 3
Lack of Reliable Transportation and Impact
Participant Responses
Alan [They] might take two or three buses and if [they] encounter traffic now
suddenly those individuals show up to the clinic an hour or two hours late.
Walter People are taking bus rides and that is their only option.
Nelson Depending on the transportation modes and [even] people that have
transportation, some people live three hours away.
Ashley From practical standpoint it is important to us that our patients have good
transportation because many don't.
Kim Many patients rely on public transportation which cannot be reliable in many
cases, thus patients can be late to appointments. These patients will either end up
getting cancelled or rescheduled which further perpetrates delay of care and
disparities.
Nick [I’ve worked] at three different organizations over the last 15 years, all were
[predominately] marginalized, and none were convenient as far as public
transportation or drop off location compared to the facility.

The influence transportation has on care can be traced back to the social determinants
identified in the literature review section of this study (see Chapter Two). While Nelson did not
identify transportation as a barrier, he did state that follow-up care was often impacted due to
transportation as “depending on the transportation modes and people that have transportation,
55

some people live, you know, three hours away.” Nicole emphasized these determinants when she
shared,
There could be many issues that people, even despite their insurance status can face,
family support, job issues, access to healthy food, and childcare. I think all of those
things disproportionately affect those who are frequently marginalized.
A data analysis of four independent websites from high profile medical facilities on the
West Coast of the United States provided little evidence of how to get to a medical facility using
public transportation or transparent cost of parking, if applicable. While the websites all provided
directions on how to get to the facility, none offered links or resources on how to utilize public
transportation and only one that shared parking costs. The solo website that gave transparent
parking cost indicated only the first hour was free with a daily maximum of $15. As patients
struggle with having adequate and reliable transportation, they also must consider who can watch
their other children while at an appointment.
No Childcare Help
Availability of childcare created a barrier for patients and disproportionately impacted
those frequently marginalized. Alan alluded that there is a repeated theme of patients expressing
lack of childcare as to why they are unable to make appointments or schedule surgeries. It was
commonly noted in the responses that patients wanted to adhere to treatment but felt they had to
put it off due to lack of convenience with their childcare.
Walter shared that his organization does try to be proactive in mitigating this frequent
barrier by offering childcare for patients while attending appointments or office visits. He stated
that this does help the patients keep appointments and adhere to follow-up treatment plans more
easily. A review of three independent medical facility sites revealed only one facility offered
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childcare services while a patient was receiving care. The site indicated the service was free of
charge but had limited availability and hours. When childcare was addressed at Walter’s facility
there was a decrease in no-show appointments. Table 4 reflects the responses received from
participants when asked to detail barriers they see a patient face and how it impacts care.

Table 4
No Childcare Help
Participant Responses
Alan I hear from patients “I don't have anyone to take care of my kid so I can't come
into the hospital and be out and stay overnight for three nights.
Ashley [Patients] really want to be engaged and care but are limited from doing so
because of difficulties with …. childcare.
Kim Many issues [patients] face… like childcare.
Nick I have had patients show up with young children, but many simply cancel
because they can’t afford to bring the kids.

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Patients are put in a position to choose between their health and being able to care for
their existing children. The barrier of lacking childcare help to attend appointments not only
prevents timely appointments but also the ability to adhere to treatment. Alan straightforwardly
revealed how some conversations he has with marginalized patients emphasize the severity of
patient care impact due to childcare needs. Alan shared,
Sometimes I’ll have to have to talk to them, like, I understand that you have childcare
issues. But if you don't treat this, you're going to come back in an ambulance [and] they
may not be able to save you.
As patients struggle with barriers, physicians express frustration with the ability to spend
adequate time with their patient during appointments. Further, participants began to breakdown
what they saw as barriers from internal controls in the organizations they work for.
Insufficient Availability and Overscheduling of the Physician
The second theme to emerge from research question one was that of insufficient
availability and overscheduling of physicians. Asked to name three specific barriers exacerbated
by insufficient physician resources, four out of the eight participants identified poor availability
and overscheduling. Often being scheduled with only 15-minute intervals between patients,
participants reported a lack of accommodating clinic hours to meet the needs of patients with
irregular schedules.
Participants indicated they want to offer more by way of asking questions, interacting,
and finding referrals but feel limited in what time they did have with the patient. Walter
described insufficient availability as the need to link care secondary to having to work. He
specifically went on to say, the “vast majority of our outpatient clinic hours are your standard
work hours, which is when people [the marginalized population] generally have to work”.
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A 2008 study by the Population Reference Bureau [PRB] determined that Blacks and
Latinos are more likely to work outside of standard business hours. Moreover, Blacks and
Latinos are more likely to work evening, late night, in overnight hours. Nick added, “my patients
need their paycheck and so they cannot be calling into work trying to make an appointment let
alone frequent follow-ups”. A data analysis of five independent websites from healthcare
organizations showed the average clinic hours of operations are 7:00 AM to 5:30 PM.
Limited staff also resulted in insufficient availability and patients having to wait months
for an appointment in some cases. The connected theme of frequent overscheduling of
physicians, due to limited staffing, results in less time allotted with the patient. Excessive wait
times can impede care maintenance and reduce quality treatment outcomes. However, staffing
and availability it largely out of the physician’s control. Nelson said,
We can't increase availability until they hire more doctors. [But] they can't afford to hire
more doctors. So, where are they going to get the money, especially since so much of the
money is based off procedures and those procedures are getting cancelled especially with
COVID [happening].
The physicians who expressed overscheduling strain all reported their population of
marginalized patients as >80%. Overscheduling can not only impact the patient's ability to access
appointment availability, but it can also affect the physician’s ability to complete administrative
task. Ashley indicated that because of COVID and dense scheduling, they had significant patient
backlogs. Nelson expanded on his experience of having only 10 to 15 minutes of interaction with
a patient and how that can negatively impact those with significantly complex medical
diagnoses. Further Nelson added, “the occasional additional barrier of language or social
economic background can quickly take away from the fifteen minutes allotted per patient”. This
59

finding concluded that the brief time allotted for physician-patient interaction can quickly be
absorbed by navigating additional hurdles such as cultural differences and language barriers.
Cultural Differences
Cultural differences can affect a patient’s outlook on healthcare; likewise, it can play a
role in how a physician relates to and understands a patient. As the values and beliefs of cultures
can vary, they can create an unconscious lack of understanding thus the inability to resolve the
barrier in care. Galanti (2011) stressed that if the ambition of the American healthcare system is
to provide the most equitable care, then providers must understand cultural differences that can
lead to conflicts resulting in substandard care.
When the participants were invited to share specific barriers their marginalized patients
experienced, cultural and language barriers topped the list for seven of the eight participants. The
solo participant who did not indicate a barrier in language or culture was not due to the barrier
not existing, but the participant’s organization used appropriate mitigation tactics that were
working for their community served. Ben stated that his organization makes purposeful attempts
to create medical centers in areas with high visibility to public transportation and walking
distance of highly populated minoritized communities.
Several of the participants were of immigrant backgrounds and identified with
marginalized groups in the United States. Their experiences within their own families
contributed to their approach in providing care for individuals they related to culturally.
Moreover, it also allowed them to see how cultural differences could negatively impact a
patient’s care if a physician did not understand their background.
Nelson shared that growing up in a Third World country health care was never a priority;
instead, food on the table was a high priority. He further added, “[so] unless you're dying in
60

severe pain you would not seek care and that was the mentality they continued to use today.” The
resulting conversations with participants who themselves came from marginalized backgrounds
gave personal affirmation to the impact cultural differences make and the physician’s ability to
provide care. When considering what impact an understanding of culture has on both the
physician’s ability to provide care and a patient’s trust in seeking care, the participants shared
what it meant for their practice.
Nicole contributed the following example that addresses how culture can additionally
play a role in health literacy based on different beliefs and behaviors. These differences can
significantly affect how patients respond to treatment plans and care outcomes. “Something as
simple as understanding certain foods related to one's cultural background and how they are
harder for the patient to avoid may exacerbate illness” stated Nicole. Knowing this information
puts the physician in a place of empathy towards the patient and additionally allows the
physician to offer alternative foods to help ease or prevent illness. Table 5 shows the responses
when asked to elaborate on the extent culture plays for those considered marginalized and their
care.

61

Table 5
The Impact of Culture on Care Treatment and Outcomes
Participant Responses
Alan Distrust is evident with people [patients] and they are the most vulnerable
people.
Walter There is a general hesitancy to engage in social services and whatnot. I think
there's an assumption that it doesn't exist… [there are also] a number of patients
undocumented.
Nelson Cultural values often impact the understanding of what good health means and
what it means to take good care of yourself.
Nicole Certain cultures or ethnic groups may not adhere to treatment because they may
not understand.
Nick I can tell when a patient doesn’t trust me. I’m a White man they see as not
understanding them.
Patient perceptions of healthcare bias and cultural understanding are often not favorable.
Blacks, Hispanics, and Asians are more likely to sense unfair judgement, being treated
disrespectfully based on their English fluency, or that their overall healthcare would be improved
if they were White (Johnson et al., 2004). As each participant ruminated on cultural barriers, a
clear related roadblock and theme identified was language barriers.
Language Barriers
The barrier of English as a second language was prevalent in every interview conducted.
Participants communicated the difficulty in building trust with patients who have limited English
understanding. Nick expressed the importance language can play in navigating patients to the
62

correct resources or social worker. Additionally, when patients are given resources such as
referrals, Ashley voiced concern that given the language hurdle the quality of content or
assistance is diminished. When physicians are reliant on social work services to connect patients
to community resources, language barriers can impede the ability to articulate needs. Moreover,
there are times when language obstacles lead to stereotypes and that can impact the ability to
provide equitable care.
Language barriers often work hand in hand with cultural barriers, as evidenced by the
responses given from participants when identifying specific barriers to care. Ashley spoke to the
experience of using translators, “even when working with a translator or having an in-person
translator, I think that it can contribute to a lack of quality experience and their [the patient’s]
understanding of the care received.” Nick shared that the robotic translation experience can
appear boxed to the patient although using a family member runs the risk of information not
being fully translated or the family member themselves not understanding and translating
incorrect information. Participants who disclosed their own background with parents or family
members with a first language other than English, described how as a child they were the sole
conduit for communication of complicated medical information between patient and provider.
Nelson shared his personal experience with growing up and both parents not speaking English
well.
Whenever they wanted to seek any type of health services, they would need us kids to tag
along to provide translation. [They] will seek health services only from doctors who
spoke the same language. It made them feel more comfortable and at home and they felt
like they will listen to and be better understood from a cultural perspective.
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Having a clear understanding as to the role language barriers play and not only accessing
care but also attaining quality care outcomes remained a priority for several participants. The
acknowledgement that language can impede the care process but also how as a physician to
navigate the system in the best way for the patient to understand. Nick shared that a vital piece to
positive care outcomes is a patient understanding what is required of them and needed to
maintain care. Table 6 represents the responses received when participants were asked what role
and impact language has on the patient’s trust in provider and approach to care.

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Table 6
The Role Language Barriers Play in Care
Participant Response
Walter Even within sort of like you know if you're going to take you know one ethnic
group… that's a very diverse group right there are people who are marginalized
because of their inability to speak English clearly
Nelson The biggest thing, especially coming from an immigrant background is language.
Nicole Folks that just have less health literacy or less you know understanding of the
system don't necessarily know like… I should ask for a social worker…
marginalized [due to] language barrier[s].
Ashley I do myself often worry that the quality of counseling and the content of the
counseling is not the same as our English or native English-speaking patients.
Kim Patients can be stereotyped and judged based… language.
Ben The nurses who are working on [a] shift with the competence [to translate] the
medical Center has a list of who's fluent [and what language].
Nick Language has been a hard one over the years, it makes it difficult to build a
trusting patient-doctor relationship.
Not every participant found language as a significant barrier for their patients. Ben, the
solo participant that overall faced fewer barriers to care than his counterparts for marginalized
patients, acknowledged their experience is not the norm. Furthermore, he addressed how their
organization met the needs of the patient by mitigating known obstacles at the door. Ben offered
a recommendation based on the success he found within his organization concerning the ability
to provide care for those marginalized and encountering language barriers.
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On the floors, for example, there's an iPad on a stand [that] is moveable and if I'm going
to see a person who speaks only Croatian when I walk in the room the nurse already has
the iPad open and the Croatian translator there so I can just start my conversation.
Without saying, who speaks Croatian? You know that kind of stuff we are doing is
amazing and builds an immediate relationship as well.
Discussion Research Question One
Based on responses from each of the participants, the themes intersect with one another
giving evidence to support that there is a systematic breakdown in mitigating barriers.
Individuals experience social determinants that were often influenced by historical events, as
presented in Chapter Two, created environments restricting their access to care. The geographic
location of many facilities compared to where many marginalized individuals live due to factors
such as redlining, have influenced access to medical centers and availability of public
transportation. Additionally, the facilities that are available often suffer from reduced resources,
including availability and scheduling. These same social determinants can impact the trust
patients have in their provider.
Experiences of social racism and discrimination exacerbated by cultural differences by
marginalized individuals influences the trust they have in providers (Oakley et al., 2019). For a
physician understanding and addressing cultural differences and language barriers impacts the
ability to communicate efficiently with patients. Nelson pointed out that, “c\Cultural values
differ and cultural priorities and cultural background difference, so if you're able to understand
the patient better from that perspective, even if you don't speak the language it helps.”
Given the responses shared during the interviews from all but one participant, the
researcher determined that marginalized patients are not receiving the care needed. The
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participants were then asked to rate on a scale of one to 10 their ability to effectively care for
their marginalized patients. The average scores ranged from six to seven, and only one
participant selected 10. The outlier giving the only rating of 10 on the scale was Ben. Throughout
the interview, Ben frequently complimented the measures his organization takes to address
barriers. Proactively addressing barriers is particularly key given his patient population was
identified as greater than 80% marginalized. One participant gave a rating of three and expressed
frustration specifically around resources available to patients and patients’ ability to mitigate
barriers. As resources disproportionately impact marginalized patients the duty of care held by
the physician can also create barriers to care.
Findings Research Question Two
Research question two detailed the outlook physicians have on their duty of care with
mitigating barriers experienced by their marginalized patients. The question was not intended to
place blame on or to hold the physician solely accountable for the responsibility to ensure that
marginalized patients are receiving equitable care as their non-marginalized counterparts.
Addressing bias, responsibility to the community, physician limitations, and perceptions of duty
of care emerged as the leading themes for the research question.
Addressing Bias
Nearly every participant saw the responsibility to address bias in healthcare as a duty.
Nick disclosed that bias, whether intentional or unintentional, is more widespread than openly
discussed in the field. The strong relationship between medical distrust and perceived racism
amongst patients has been documented in previous studies like Hammond’s (2010) study of 126
Black men. Alan discussed bias in the profession, specifically for those marginalized. He
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described how a lack of sensitivity is displayed particularly for Black patients and believing in
the level of pain they express.
You often don't take what they say at face value. [And] that can lead to a potential
misdiagnosis because it was the same pain they complained about the last time.
Physicians do their evaluations but there are times they're going to be missed because
now your lens is narrow.
Participants who were open about their own biases were equally passionate about seeking
education and skills to lessen the prejudices they may bring into their practice. In many states,
license bias training is required but as several participants pointed out, even with this training
both conscious and unconscious bias remains. Some experience it firsthand. Nelson shared his
thoughts on bias from a firsthand perspective:
Implicit bias, [is] a huge problem and we all know that, and I think we started to address
that by training on recognition of implicit bias and how to minimize implicit bias among
healthcare providers, and I think that's a good first step, but, again, we are you know,
naturally, as human beings, we tend to be biased anyway and depending on our
background where we came from as an immigrant, I’m aware of the bias and obviously
trying to overcome that because I’ve grown up in that kind of environment, but let's just
say someone who's not an immigrant.
Participants were asked what factors related to bias did they see lead to differing patient
outcomes for frequently marginalized individuals. Bias becomes a barrier when it impacts the
approach or outcomes of care for a patient. Table 7 reflects participant responses shared when
asked about the existence and impact of bias from the profession.
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Table 7
Bias Exists
Participant Responses
Alan I obviously can't speak with a broad brush to every doctor at this facility, but I
will tell you that that bias exists.
Walter [I think] there are more fundamental bias.
Nelson It's unintentional so this subconscious bias that you, you bring into an
interaction and it's very important that you as a healthcare provider really know
[and] remind yourself… greater awareness of your own biases.
Ashley [I] definitely do think bias happens [especially] with our Spanish speaking
patients.
Nicole I think we [physicians] make assumptions all the time. Hopefully many of us are
trying to be aware of our biases and how they affect us and our patients.
Kim Patients can be stereotyped and judged based on… social situations present,
race, [or] background.
Ben [If a marginalized patient] needed a prescription and we thought they would get
follow-up care we would prescribe them the minimum amount of medication.
Nick I’d like to think it is more unconscious, but it is for sure there. The biases come
out in many forms for marginalized folks [patients].

Alan shared the following professional experiences where bias led to outright
discrimination for patients:
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We have Black physicians on our faculty that were treated like criminals during their
pregnancy, having security called on them because they're Black and their partners are
Black and when they advocate for themselves, they're looked at like they are being the
aggressor; and that is the hospital they work at. Did you know that if you're a Black
woman in America you are four to five times more likely to die in your pregnancy than a
White woman?
The current continuing education requirements for bias training have not proven to be
sufficient. “The whole system is biased” stated Nicole. Each participant contributed individual
stories about how they have encountered bias both personally and professionally in the field.
More than one participant shared the statement that Black patients are treated less aggressively
for pain. All described how they saw marginalized patients being treated differently; however,
the majority stated that they felt it was subconscious bias.
Kim added that through her personal life experiences, she tries her best to demonstrate
cultural competency and understanding of the experiences many marginalized patients go
through. Using specific instances of prejudice surfacing in care experience, Alan added that
“[Black] patients, it's been known people [physicians] make assumptions that [Blacks]
exaggerate their pain more or that their pain tolerance is higher, so they don't need as much
medication.” While addressing bias that can be displayed in care settings is part of the solution,
the limitations physicians feel can create additional burdens.
Understanding how a physician views their duty of care and how they might go about
addressing barriers that patients experience was integral in developing the recommendations
addressed later in this study. The findings from the interviews were that while physicians feel an
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innate sense of duty to provide equitable care, they feel limited in organizational support or with
resources.
Responsibility to the Community
Line 7 of the Hippocratic oath (PBS, 2001), states that a physician should engage in the
contribution to the advancement of public health and the community. How a physician interacts
and acknowledges the challenges faced by their patients can impact their ability to identify and
mitigate barriers. The ability to immerse themselves personally in the community can allow for
an increased sense of understanding in barriers experienced and how to help. Although Nick
stated that he does not live in the community he serves, he does frequently visit the area during
off hours for outings. The thought process behind this, Nick shared, was that seeing what the
community was like culturally and socially was important for him to feel connected.
While many physicians might not find the time to spend off hours in their community,
Ben recommended the possibility of in-service hours at facilities to gain better understanding.
Further, he indicated that the organization is staffed by individuals who live in the community
the hospital serves. Therefore, by setting aside time to interact with those individuals it would
also be an increased sense of connection to the community. Ways to connect with the community
set the tone for the broader responsibility and duty of care. However, the participants often felt
that even if barriers are known, they do not always see support in the resources they are allotted
to address them.
Alan addressed his desire to dig deep into making systematic change is broader than his
organization. He discussed roles such as volunteerism along with state and local community
advocacy, as ways for physicians to get involved and impact change. Alan further mentioned that
while this would be ideal, many in the profession do not have the leisure time to get that
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involved. One way to be connected is to live in the community you serve, said Nick. Although he
noted that he does not currently live in the area he works. Table 8 reflects responses when
participants were asked what percentage of their patient population is considered marginalized
and if they [the physician] live in the community that they also serve.
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Table 8
Participant, Percentage, Community, Barriers
Participant Percentage of your patients considered marginalized? Do you live in the community you work?
Alan Greater than 75% “Yes, I guess it depends”. “I live in X city and work in
X community”.
Walter >90%*Participant rejected the definition of marginalized as used
in this dissertation.
No.
Nelson 80% No. “I prefer to live in the suburbs”
Ashley 50% “It is a big area so it would be a partial yes”
Nicole >70% “The Community like working class community but also
quite proximal to a bunch of rich white people”
Kim 90% Public practice
Less than 10% Private practice
Yes. “I live 10 minutes away from my private practice”
Equally “5-8 minutes from public practice”
Ben >70% Yes. “I made it a priority to live in Los Angeles”
Nick At least 80% No. “It is fairly low-income in the area I practice and
did not seem safe to live”

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Physician Limitations
Another theme that emerged from research question two was that of limited resources.
When considering the percentage of the participants' patients identified as marginalized the
higher the population the greater impact of barriers. The ability to give patients the attention
needed to address barriers and still service their health concerns is limited from both a time and
resource perspective. When asked what participants saw as their duty of care in the context of
mitigating barriers for marginalized patients, each answered that the responsibility is there but
the reality of being able to carry it out was dim.
The ways participants felt they upheld their duty of care varied. A few shared examples
of how they do their best such as reviewing intake sheets prior to the onset of visits, placing a
referral if barriers appear, automatic social work recommendation, and asking questions during
the visit for demographic and social information gathering. These are all initial steps to the
recognition of barriers and existing internal organizational resources. However, when patients
experience one or more social determinants of care, the ability to provide resources lessens.
Additionally, Walter pointed out that marginalization is not always strictly based on ethnicity.
Understanding this, outside social and environmental factors of a patient need to be explored
when considering how to best mitigate barriers they experience. However, the current study
focuses on the social structures and environments that systematic racism created over the years.
These social structures then enable environments that disproportionally affect marginalized
individuals leading to negative consequences, such homelessness, income disparities, insurance
coverages, and care availability.
The understanding of social determinants of care in combination with other means in
intersectionality can assist in the mitigation of additional barriers. Some participants added that
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there is no real follow-up after information is gathered and it does not always link to valuable
services. Intake sheets and social work referrals were deemed as surface level attempts to assist
patients, said Nick. Moreover, social workers can also be limited to what resources they have and
at times no one is asking the right questions. Table 9 displays the participants’ responses to the
question that if barriers were identified, how did they address them.

Table 9
Limits to What Can We Do
Participant Responses
Alan There are intake sheets [collected] before they even see me in the office [triage of
sorts].
Walter [Limited knowledge plays a role] I think that there are many more resources than
what we've realized are available.
Ashley Work at encouraging more people to practice in rural area [because these areas
suffer from physician shortages and marginalized individuals have limited care
options].
Kim [I] only consult social work really. I ask who they live with and their occupation.
Ben [I feel it is my duty] to ask questions [so I] don’t always call a social worker first.
Most people I work with stick with the clinical stuff and something social comes
up they'll call the social worker.
Nick They ask questions when the patient checks in [but] they are canned. I try to ask
more questions but what do I do with that information after [you know]?
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Perceptions of Duty of Care
When social determinants of care were identified for their patients, participant were
asked what action, if any, did they take to assist in mitigating them. The answers to this question
sparked additional dialog for several participants, and the subsequent questions they had were
centered around how they viewed their responsibility towards duty of care.
Some participants saw a duty of care beyond the treatment room, such as advocating in
both the voting booths and community involvement for change and volunteerism. Ashley
asserted that if you enter the medical profession, you should feel responsible for advocating
change and equal care experiences. Kim shared her viewpoint on the profession’s duty of care:
Honestly there is quite a bit [of responsibility]. And maybe it depends on your specialty;
but philosophically as being in the medical field [physicians should] come into medicine
from the standpoint of social and [her medical specialty] justice. From that standpoint and
with that perspective, an intent to alleviate in personal encounters and structurally
disparities; and, from a policy standpoint, breakdown structural barriers that create and
cultivate health disparities. [Though] I don't know that every physician feels that way.
Many of the participants expressed a desire to do more both directly within the profession
and even in the social context of their personal life to better the access and care for marginalized
individuals. Some of those actions included considering political agendas and how they voted or
giving back in community service ways. Nearly all participants shared personal stories of how
marginalized individuals not receiving adequate and equitable care impacted them and how they
upheld their duty of care.
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Discussion Research Question Two
Research question two focused on flushing out the responsibility felt by physicians in
their moral and ethical duty of care within the profession. There were four predominant themes
that resulted from the conversations. In the first theme it was addressing bias as well as the
impact both personally and professionally for the participants. The second theme of
responsibility to the community focuses on the specific duty of the physician profession in
immersing in their community. In the third theme it elaborated on what limitation are felt by the
physicians in resources and what impact that has on their ability to address barrier. Additionally,
within that theme it identified holes in organizational resources to addresses barriers they
identified for patients. The final theme discussed the perceptions of duty of care and what that
meant to the participants.
While only Ben expressed deep satisfaction and how his organization supported the
efforts to reduce inequities experienced by marginalized patients, the remaining seven
participants expressed some level of dissatisfaction. For my personal, professional,
organizational standpoint each participant addressed a factor within those categories that
influenced their ability to fulfill their duty of care. However, participants were hopeful for the
future of physicians and where the new class of residents can make positive changes in the field.
It was not a matter of not wanting to do more to decrease barriers but more the feeling of
inability given their time and resources allotted.
Summary
Findings in this study surfaced from analysis through the critical race theory (CRT)
framework. The CRT framework created a foundation to conceptualize the link barriers
marginalized individuals experience to their healthcare access and outcomes. Both research
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questions addressed the moving parts within the conceptual framework. Research question one
focused on barriers experienced by the patient and how physicians and organizations are
currently addressing them. The second research question focused on a physician’s duty of care
and what that means in their moral and ethical obligation to advance health access and outcomes
for patients, especially those disproportionally affected.
Utilizing the perspective and experiences of physicians is essential in that journey given
their role as part of the nucleus of healthcare. Physicians and organizations need to address
biological, psychological, and social influences on a community and national level to effectively
increase positive health outcomes (Kwok & Sands, 2017). The experiences of physicians play an
important role in identifying the gaps in impediments to healthcare equity. The impact of
resources, culture, and bias have on advancing the access, treatment, and outcomes for
marginalized patients requires understanding to properly create recommendations.

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Chapter Five: Recommendations
The purpose of the study was to solicit physician narratives surrounding their interactions
with patients, specifically those of minoritized ethnicities experiencing barriers to care. Barriers
experienced present a determinant of imbalanced healthcare equality. Information gathered from
the study may assist physicians and their organizations of practice to find reasonable
accommodations to reduce barriers to care encountered by patients. From the findings there are
three recommendations that surfaced to address them. Recommendations include transportation
shuttles, mobile clinics, and internal cultural bias training.
The recommendations developed following the study center around cost effectiveness,
impact, and feasibility. The goal was to develop recommendations that would take limited time
to develop and could be implemented more expeditiously. Conclusions from the study were that
major barriers that disproportionately impacted marginalized patients were access to
transportation, cultural differences, and bias. Evidence supports that mitigating the barriers
identified can increase patients' access and produce increased positive health outcomes (Michael,
2018). One of the dominant themes that came from the study was the impact that lacking
reliable transportation had on the ability to attend appointments for patients.
Transportation Shuttles to and from Community Stops
Lack of access to transportation was found to play an instrumental part in patients
keeping appointments and adhering to treatment recommendations based on participant
interviews. Alleviating the barrier of reliable transportation by offering shuttle service for
patients with appointments directly lessens any negative impact to care tied to it. Additionally,
this can also address corresponding barriers identified when the shuttle can be used not only for
the patient but also for their children. By placing the pickup and drop off points conveniently at
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common intersections and community points, the organization can create reliable access to the
facility and patient adherence to treatment.
Access and affordability can play significant roles in a patient's ability to maintain
appointments. Providing reasonable accommodations to address this barrier can result in positive
returns on investment for providers. In a study reviewing the cost benefits for a Missouri hospital
system after they offered patients free appointment transportation, the study found the return on
investment at $7.68 for every $1 invested (Transpark, n.d.). Moreover, offering transportation
resulted in the organization collecting significant revenue increases from less missed
appointments. As organizations see a cost benefit, patients will be afforded the opportunity to
maintain their primary health and adhere to treatments.
Mobile Clinics with a Nurse Practitioner, Physician Assistant, or Physician
A lesson learned during the global COVID-19 pandemic was that frequently
marginalized individuals are less likely to have access to reliable internet or smartphones, which
greatly limit the use of telemedicine for video visits (Benjenk et al., 2021; Graves et al., 2021).
Video visits were used widely during the pandemic to make up for the inability to attend an
office visit. Mobile clinics can assist in reducing the barrier of transportation and childcare
concerns by bringing the clinic to the patient’s community.
Mobilizing the units with professionals who have capability to diagnose and write
prescriptions will open the option of staffing nurse practitioners, physician’s assistants, or
physicians. Staffing the mobile units with individuals capable of treating patients but not limited
to physicians, will allow organizations to allocate reasonable funding without the barrier of
physician recruitment and salary. Nelson shared the barrier of funding deficiencies for hiring
physicians as a reason for limited hours and availability. Mobile clinics have the flexibility to
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relocate on a rotating schedule to various locations and time availability. This type of flexibility
will create options for the patients, specifically ones with irregular work schedules. This
recommendation also addresses three of the themes from research question one. Mobilized units
visiting the community can eliminate the barrier of transportation, childcare, and limited
physician time availability.
Becks et al. (2020) conducted a review of the implementation of mobile clinics and
marginalized areas of Australia, New Zealand, Canada, and the United States. The review
concluded that the use of mobile clinics to reduce barriers experienced with availability of health
care contributed to overall improvement in patient wellbeing. Additionally, Yu et al. (2017),
analysis of 51 studies regarding the use of mobile health clinics found that the use resulted in a
cost effective and cost saving care delivery model.
Culture and Bias Training with Specific Focus on the Community Served
Chapter Two’s literature reviewed discussed the requirement of training for medical
professionals that include bias training. However, bias can be individualistic depending on the
population served. Developing specialized bias and cultural sensitivity training within an
organization and not relying on statewide or federal trainings creates the ability to customize.
The training would create a connected partnership between the community and the physicians
who serve them. To best serve the purpose of the workshop, the curriculum should be created
directly from the organization so that specific needs and culture of the community are addressed.
This approach allows the physician to be presented with direct community knowledge and with
nuances that make the most impact. In this instance, physicians would attend workshops
containing information specific to marginalized demographics served as well as existing
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resources in the community for referrals. In addition, the physician can learn about current events
in the community and how the community is affected.
In 2017 BMC Health offered a workshop that joined patient volunteers with physicians
with the purpose of sharing specific community needs and concerns. BMC Health then
conducted a mixed-methods study after the event and within two days and as far as two months
later, surveys indicated there was significant increase in patient confidence in service (Durey et
al., 2017). Furthermore, the study concluded that the workshop increased physician confidence in
the ability to treat the specific patient population. Additionally, the study reported increased
scores across three factors: communication, relationship, and awareness (Durey et al., 2017).
These internal trainings would be required of practicing physicians at the organization.
As with many organizations and required annual trainings, the internal culture and bias training
would need to be refreshed. The intent of an annual requirement would be to ensure that there is
a continued relationship and connection with the community in its current state. The training
should be offered multiple times a year but required no less than once a year for professionals
practicing at the organization.
Non-Traditional and New-Age Considerations
The three recommendations above take into consideration the lack of monetary resources.
It is additionally important to address what futuristic opportunities can be explored if they were
not. In times where the world is fast-changing, organizations might need to think outside the box.
Non-Board-Certified Physician Recruitment
An outside the box recommendation would be for organizations to seek individuals who
lack board certification and may be limited in their ability to employ elsewhere. This could be
controversial to stakeholders, but the impact could be beneficial. Organizations could approach
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this by seeking to reimburse or pay certification fees in exchange for a commitment to practice.
According to recent research (California Health Care Almanac, 2021), in California .2% of
physicians did not report or have their board-certification and approximately 10% of physicians
nationwide are without (Wheat Medical, 2020). Board certification indicates the practicing
physicians are up to date on the latest in their respective field, this is not to be confused with
licensure. There can be several reasons physicians don't seek or have been denied board
certification, the cost to maintain being one. While lacking board certification could present
some barriers, the additional staff may open availability for organizations that suffer shortages
and provide an increase in patient preventative care and maintenance.
Artificial Intelligence
In an age where technology has been used in many new ways this may not be such a
radical recommendation. Some organizations have begun utilizing robotic video visits for patient
visits in hospital settings. The recommendation would be to take this technology and expand it to
the artificial intelligence of complete robotic patient visits. While the use of robotic video visits
in current settings requires a physician to be behind the camera, organizations can move beyond
that. Building in the robotic technology answers to FAQs, the ability to prescribe basic
medications, order tests, or read lab results can reduce patient wait times and increase positive
treatment outcomes. While some patients might be initially apprehensive to such technology,
studies have found many patients open and welcoming to the notion (Vallès‐peris et al., 2021).
Limitations and Delimitations
Limitations are issues that are not within the control of the researcher or otherwise
reflected as weaknesses within the study (Leedy, 2013). With the use of in-depth interviews
comes the limitation that participants may not be forthright and honest in their responses.
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Additionally, there could be limitations based on participants who initially agree to the interview
but then decline to participate, choose to end the interview early, or skip questions thus limiting
the amount of information collected. Limitations could also be experienced with video and or
phone interviews, as Roller and Lavrakas (2015) pointed out, as this method lacks the
opportunity to build rapport with the participants and could provide ease or encouragement in
ending the interview, potentially abruptly. Positionality and bias may also present as a limitation.
With the conceptual framework of this dissertation, the intention was to gather insight from the
professional experiences of physicians. Their contribution with interviews and willingness to
share were essential in gathering accurate data for recommendations.
Delimitations experienced might exist in the data collected and what the researcher will
not be able to do (Leedy, 2013). Two delimitations were identified in this study. First, though the
literature review was extensive, it was impossible to thoroughly represent every ethnicity and
law that has existed over the decades that played a part in creating the systems that promote
disparities. Furthermore, the stakeholders, although carefully selected, might pose as a
delimitation. There was an attempt to gather a variety of experiences both personally and
professionally from recruited participants, but the scope was limited to the West Coast of the
United States. Physicians were selected as the target population for this study due to their
relationship with patients and their oath taken to protect human rights.
Future Research
Future research needs to include gathering patient experiences in accessing health care
and their perspective on treatment. Additionally, future research can target professionals and
patients from specific communities to create very individualized recommendations. By soliciting
and targeting a narrower scope, organizations or physician practice can develop unique
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recommendations and mitigation techniques to service their community equitably. Moreover,
advanced systematic research on a community, state, national, and international scale may assist
in better resolutions to reach equitable care.
Secondly, advancement of research can continue after implementing the
recommendations and determining their impact. Building on the findings in this study will allow
for steps to begin in closing gaps. That research can be intended to further mitigate additional
barriers experienced and whether the existing measures are creating a significant impact.
A third future study would be to broaden the geographical area of recruitment. By doing
so, the experiences shared may contribute a more inclusive look at barriers from rural to urban
areas. This study utilized participants practicing on the West Coast.
The last recommendation for future studies would be to incorporate hospital
administrators and board members. Incorporating these key stakeholders may bring additional
insights to the operational and financial implications. By having this understanding, it would
open the ability to creating recommendations based on what is realistic for organizations.
Implications for Racial Equity in Healthcare to the Rossier Mission
Health care has been plagued by implications of social determinants, racial bias, and poor
access disproportionately tied to marginalized individuals. Visibility into this disparity met the
national podium when the Affordable Care Act was implemented. That itself was not enough and
it did not address the system in its entirety.
Disparities impacting those of our black and brown skinned peers continue with limited
access to quality healthcare. This study was created with purposeful intention to begin driving
systematic change at the nucleus of health care, with physicians. Aligning with the Rossier
School of Education’s mission to achieve equity through the health care practice and policy, one
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must drive systematic change. Additionally, in that mission, the desire to question the systems of
power that have historically shaped the policies and practices perpetrating the inequalities this
study addresses.
Conclusion
People are dying and society should care. Statistics say, people of color are
disproportionately impacted by barriers created in a society that has historically never been fair.
Understanding that addressing the purpose of this dissertation goes far beyond the interaction
between a physician and the patient, it needs to come with a demand for change systematically.
The structural and systematic racism and discrimination that exists not only in this country but
worldwide impacts humanity. There are marginalized individuals out here fearing a walk down
the street, watching TV in their own living room, sleeping in their own bed, or going for a jog.
To live in peace without the fear of being targeted simply for existing. Accessing healthcare
should not be another barrier society brings upon them.
Looking at the systems and structures that were built over hundreds of years and the lack
of significant change, even after the acknowledgement of racism and discrimination as a public
health crisis, there is shame to be had. As an individual who myself comes from a marginalized
background, I can attest to how the barriers presented in this dissertation can negatively impact
care. Coming from that marginalized background I encountered what it was like to seek the
hospital on the white side of town rather than where I lived. It is no longer a secret for those who
know what marginalization feels like but there is a dependency on those privileged enough to dig
into the systems and impact change to act.
Silence is complicity. The failure to acknowledge the inequity that exist in healthcare for
those frequently marginalized would be naive. To move forward, society must acknowledge the
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disgrace created and perpetrated over the years by dismantling the things that are morally and
ethically not right. Investing in small changes to the system can greatly impact an individual's
ability to simply live and that itself should be reason enough to act.
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Appendix A: Interview Protocol
Introduction
Thank you for accepting my invite to participate in this study. As we discussed prior to
scheduling this meeting you received information pertaining to your right to exclude any
information you wish, skip any questions, or decline to continue at any time - do you have any
questions about that?
I would like to request your permission to record the interview so that I can accurately
capture your responses and ensure that I am representing your contribution as well as I can. Do
you have any questions before we get started?
Research Questions:
RQ1: What is the impact physician and patient resources have on advancing the access,
treatment, and outcomes for marginalized patients?
RQ 2: To what degree of accountability do physicians display a professional duty of care
in addressing disparate outcomes for marginalized patients?
1. Can you tell me a little about your background in healthcare? (RQ2)
a) How long have you worked at your current organization?
b) Have you practiced in any other fields?
c) Do you live in the community you work?
i. If yes, what do you observe in the environment on a personal basis that
might create barriers for a patient?
ii. If no, do you find things offered a better or less level than the community
you serve?
iii. Can you tell me more?
2. How do you see environmental factors contributing to the health-related outcomes for
patients? (RQ1, RQ2)
a) Are you aware of any factors that currently impact your community served?
b) Can you name a few or give some specifics on how you see it impacting?
109

3. If social determinants have been identified by your organization are there currently any
mechanisms have been implemented to close those gaps? (RQ1, RQ2)
a) Does your individual practice inquire about a patient’s social environment?
b) What information do you collect from a patient regarding determinate factors?
4. In what way do you experience the care differing for frequently marginalized
individuals? (RQ1, RQ2)
a) How would you describe the differences?
b) Are resources a factor?
i. Organizationally?
ii. Professionally – resources that you, the physician has at your disposal?
iii. Patient experienced?
5. From your professional experience in what way do treatment outcomes differ from
marginalized individuals? (RQ1, RQ2)
a) For preventative or preventable care?
b) Do you see the outcomes differing linked to disparities in care received?
6. How would you describe your ability to effectively serve marginalized patients in your
care on a scale of 1-10 with 10 signifying extremely able? (RQ1)
a) Tell me about your rating.
b) Can you elaborate on any direct factors, internally or externally?
7. Of the population you provide care for about what percent/average would you say are of
marginalized groups? (RQ1)
a) Do you know the size of your organization?
8. What are three specific barriers that contribute to marginalized patients potentially
receiving substandard care? (RQ1, RQ2)
a) Can you tell me a little more about these barriers?
b) Do barriers impact how you approach a patient in creating a treatment plan?
110

10. Is there any specific incident that has occurred that led you to recognize marginalized
patients may receive a different quality of care? (RQ2)
a) Did the experience change the way you approached care?
10. What factors related to bias do you see lead to differing patients’ outcomes for frequently
marginalized, if any? (RQ2)
a) Can you tell me more?
b) Are these personal experiences or experiences of other professionals you have
encountered?
c) Have any experiences, of yours or other peer professionals, concerned you with
how bias may impact a patient?
11. Tell me about a time in your experience, or that of a peer, patient needed an adjust to a
recommended course of treatment based on barriers that have identified such as access,
coverage, education? (RQ1, RQ2)
a) Are these factors frequently considered when treating a patient?
12. How do you address barriers you have identified for a patient? (RQ1, RQ2)
a) What mechanisms do you use?
b) How do you follow up?
c) Are there any other resources you or your organization provides for the patient to
mitigate?
13. What would you say is your role in creating addressing environmental factors you spoke
about? (RQ2)
a) Can you tell me more about why you feel that way?
14. Tell me about the culture of your organization. (RQ1, RQ2)
a) What do you see as positives?
b) Where do you see improvements needed?
c) How do you see the patient represented in the organization’s practices?
111

15. Does your organization take any steps to mitigate disparities that exist in the community
they serve? (RQ1)
a) What are they?
16. What impact does healthcare coverage have on the types of care for marginalized
patients? (RQ1)
a) Do you find a noticeable disparity in coverages for patients of marginalized
ethnicities?
b) And what about on the types of outcomes for marginalized patients?
c) Is there consideration for things coverage may not cover? e.g. physical therapy,
psychological therapy, prescriptions
d) Does your organization link individuals to programs offerings free or reduced cost
coverage options? (e.g. Medicaid, ACA marketplace)
17. Is there any other information you’d like to share?

112

Appendix B: Document Analysis Protocol
1. Healthcare organization websites along with connected resources and available links.
2. An organization’s published research, White Paper publishing, or similar.
3. A review of public findings, newspaper articles, public communication releases, and
financial records.
RQ1: What is the impact physician and patient resources have on advancing the
access, treatment, and outcomes for marginalized patients?
RQ 2: To what degree of accountability do physicians display a professional duty
of care in addressing disparate outcomes for marginalized patients?
Healthcare Organization Websites Analysis Prompts:
1. Does the organization outwardly address barriers in care? (RQ1)
2. Does the organization provide access to resources electronically or guide the individual to
where the resources are located? e.g. healthcare marketplace signup (RQ1, RQ2)
3. Are there any references specific to the communities the organization serves? (RQ1)
4. Are there links connecting the site visitor to community resources not directly healthcare
related? e.g. SNAP, food banks, housing assistance (RQ1, RQ2)
Published Research Analysis Prompts:
1. Indication of accountability in reducing disparities based on race/ethnicity? (RQ2)
2. Investment of resources to identifying care disparities and have they increased positive
outcomes? (RQ1, RQ2)
3. Position the organization has on factors impacting care? (RQ1)
4. Have organizations or their physicians gathered data specific to racial and ethnic
determinants? (RQ1, RQ2)
Public Findings, Articles, Communications Analysis Prompts:
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1. Involvement in factors that impact patients outside of direct care? e.g. social justice,
current events? (RQ1, RQ2)
2. Have organizations made a clear connection with the community they serve in closing
inequalities in their care? (RQ1, RQ2)
3. Do public findings such as lawsuits or judgements conflict with the assertions made by
the physicians or organizations regarding work being done or accomplished? (RQ1)
4. Does the organization publicly connect patients to resources? (RQ1)
5. What is the community saying about the organization? (RQ1)

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Asset Metadata

Creator Roberson, Kacee Renee (author)

Core Title Barriers in care access for the marginalized individual: a provider’s role

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-05

Publication Date 04/25/2022

Defense Date 03/03/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag bias healthcare,health disparities,health equity,healthcare access,marginalized care access,OAI-PMH Harvest,social determinants healthcare

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Datta, Monique (committee chair), Maddox, Anthony (committee member), Martinez, Brandon (committee member)

Creator Email airey2004@gmail.com,krrobers@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111117821

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