Fighting Bias in Healthcare: Classism & Care Access

Classism in healthcare is a pervasive issue that significantly impedes access to quality treatment and care. The socioeconomic status of individuals often dictates the standard and frequency of healthcare they receive. This systemic bias typically involves prejudices, attitudes, and actions favoring the higher socioeconomic classes while marginalizing those in the lower strata of society.

This disparity is further exacerbated by a lack of affordable healthcare options for those in lower income brackets. Higher-income individuals typically have better access to medical resources, including advanced treatments and experienced professionals, leading to a pronounced difference in health outcomes across different socioeconomic classes.

Not only does classism perpetuate inequality, but it also slows societal progress as a whole: “It is essential to address classism because it hampers the potential to make meaningful gains in health outcomes. We need to address it if we want to really improve overall spending in healthcare as well as healthcare access and if we really want to address health inequities,” says Dr. Omolola Adepoju, health services researcher and clinical associate professor at the Tilman J. Fertitta Family College of Medicine.

While classism can occur anywhere, it tends to happen at a higher rate in Medically Underserved Areas (MUAs), as these areas are typically low-income and have a significant minority population: “MUAs include areas with a low proportion of primary care providers. These areas also have an elevated infant mortality rate, a high poverty rate, and a high elderly population. It’s a combination of all the things you don’t want to have,” shares Dr. Adepoju. “These can include inner cities and a lot of rural areas. Here in Texas, there are 35 counties that have five or fewer primary care providers.”

Dr. Omolola E. Adepoju is an accomplished academic and public health professional specializing in epidemiology and global health. Currently, she is a health services researcher and clinical associate professor at the Tilman J. Fertitta Family College of Medicine.

Dr. Adepoju’s expertise lies in infectious diseases, focusing on prevention, control, and surveillance. She actively contributes to international collaborations and initiatives, conducting fieldwork and implementing evidence-based interventions. Alongside her research, Dr. Adepoju is passionate about mentoring future public health professionals and has received recognition for her outstanding contributions to the field. She holds a master’s degree in public health from Emory University and a doctorate in health services research from Texas A&M University.

Classism manifests in healthcare in several concerning ways. Persons of lower socioeconomic status often receive a lower standard of care compared to their wealthier counterparts. This could be due to several reasons, including but not limited to limited access to health insurance, difficulty in affording out-of-pocket costs, and a lack of transportation to reach healthcare facilities.

However, classism exists at all levels of healthcare, not just towards patients: “In healthcare, the power structures and class system have physicians at the top and members of the community and staff like community health workers typically at the bottom. When I think of classism in healthcare, I think of how you have people who earn more and who are more educated at the very top of the pyramid. You then have people who actually interact with the community, who are often women and ethnic minorities with linguistic capabilities and cultural dexterity, at the bottom,” shares Dr. Adepoju.

“It’s a compounding scenario where you have gender and race intertwined with classism so that women and minorities are often in less complex jobs that create a huge wage differential, which in turn fuels classism in healthcare.”

Unfortunately, classism and racism are so inextricably intertwined it can be difficult to differentiate: “There are instances where they’re separate, but so many African Americans have reported experiencing discrimination no matter their socioeconomic status,” shares Dr. Adepoju. “It is exacerbated by living in medically underserved areas. Individuals who really need care cannot access care, often because they don’t trust the system. This affects life expectancy, mortality, morbidity, everything.”

Classism fundamentally shapes the access to and quality of healthcare that individuals receive. In Dr. Adepoju’s experience, the classism that affects who provides care and interacts with the patients has a profound impact on access: “Community health workers (CHWs) frequently belong to racial and ethnic minority groups they are serving and can provide some level of trust, which in turn results in better health care outcomes,” she says. However, many CHWs are not paid a living wage, so there is a lot of turnover in their roles, or they are experiencing insecurity issues like their clients, and they can’t be present like they would want to.

Without quality CHWs to help low-income people navigate the healthcare system, access to care continues to be a challenge: “If people can’t access care because they don’t understand the system, not only will they keep racking up costs because they don’t have a primary care provider and rely on emergency rooms, but they will also have poorer health outcomes. Things will keep getting worse until we address classism at its roots,” urges Dr. Adepoju.

The medical hierarchy, as well as the cultural differences, can even keep a patient who has a primary care provider from accessing care: “One of our faculty members said a patient told their CHW working with them, ‘I don’t have to put on my lipstick for you.’ They don’t feel they have to pretend to be someone they are not. But when they see the physician and nurses, they dress up and tell them what they want to hear,” shares Dr. Adepoju.

When lower-income people do manage to access care, it is often not aligned with their capabilities and needs: “A CHW in a doctor’s visit can email to explain that a patient can’t take the walk they recommend for their health because there’s no sidewalk around her house. So even though they are saying, ‘You need to walk 30 minutes a day,’ there’s no way for her to get to the park, and she can’t drive, or she doesn’t even have transportation,” explains Dr. Adepoju.

“Or they are told to buy fresh fruits and vegetables. If the doctors went into the community, they would know whether or not their patients live somewhere where they can even reach a grocery store. You have to know the community to know if the patient can even do what they are telling them to do. Patients are not just ignoring recommendations; they can’t follow them because of where they live.”

Addressing classism in healthcare requires a multi-faceted strategy aimed at dismantling systemic barriers and promoting equitable access to quality care. One place where Dr. Adepoju believes significant change can happen swiftly is with equitable pay for those healthcare professionals who directly interact with the community at their level: “If CHWs earn a livable wage, it would impact their position in the healthcare labor market. I would argue that it would increase their level in terms of the internal classism pyramid. This would help empower them to better care for the patients in the community. With enough income, they don’t have to worry about homelessness or food insecurity, but rather care for those they serve,” she says.

Despite conjecture and observation, to understand the root causes of classism and how it affects quality and access to care, more research is needed: “The first step is conducting a programmatic study without randomizing patients. You’re just doing a natural experiment, testing new models to see if they work. We need to start by understanding and testing how different models can give CHWs structural power. Because that, even by itself, can dismantle some systemic racism and classism in the healthcare system,” says Dr. Adepoju. “Compare the model we have right now, which is not working well, to new, innovative models of community health worker workforce and measure how it reduces institutionalized bias.”

Part of the research and surveying that needs to be done must include the community. “We have to engage in listening sessions with these communities to understand what the needs and perspectives are. We have to ask, ‘If you had a magic wand, what are the first three things you would do?’ Then, we have to work in tandem with those community groups to address those needs. This way, we are breaking the past structures in the class system a little bit by putting them in charge,” says Dr. Adepoju.

Lastly, Dr. Adepoju believes that rewarding CHWs for their work performance, much like physicians, can help improve outcomes and reduce classism: “Pay for performance is where healthcare team members receive financial rewards for meeting predetermined healthcare quality goals and maybe even lowering overall healthcare spend. Oftentimes, healthcare stakeholders share this reward. What if we include community health workers so they also receive financial rewards for meeting predetermined community health goals? That way, everyone has skin in the game, and we were incentivizing the right people, not just incentivizing the provider,” she says.