Listening to Black Californians:
How the Health Care System Undermines
Their Pursuit of Good Health

OCTOBER 2022

 

AUTHOR
Linda Cummings, PhD
Acknowledgments

CHCF thanks the Listening to Black Californians Advisory Group members for their time, guidance, and
support of the study.

Noha Aboelata, MD
Founder and Chief Executive Officer, Roots Community Health Center

Danté Allen, MA
Executive Director, CalABLE Act Board, California State Treasurer's Office

Abner J. Boles, Ill, PhD

Chief Executive Officer, Business Solutions Design
Project Director, Health and Wellness Alliance
Clinical Supervisor, The Refuge Inc

Oliver T. Brooks, MD
Chief Medical Officer, Watts Healthcare

David M. Carlisle, MD, PhD
President and Chief Executive Officer, Charles R. Drew University of Medicine and Science

Crystal D. Crawford, JD
Commissioner, Los Angeles County Public Health Commission

Venise C. Curry, MD
Consultant, Western Director, Climate Health and Equity Fellowship
(Medical Consortium on Climate and Health)

Vincent Harris
Former Executive Director, African American Voter Registration, Education, and Participation Project
Former Deputy Chief of Staff, Governor Gray Davis

Connie Stewart
Executive Director of Initiatives, Humboldt State University

David E. Thigpen, MS
Director of Undergraduate Programs, UC Berkeley School of Journalism

Wilma J. Wooten, MD, MPH
Public Health Officer, San Diego County Health & Human Services Agency

CHCF also thanks Jen Joynt for her role as project manager.
About the Author

This report was written by
Linda Cummings, PhD, health
services research consultant.
The research was designed,
conducted, and analyzed by
EVITARUS, a Black-owned pub-
lic opinion research firm in Los
Angeles. The interviews were
conducted by a cohort of inter-
viewers led by Managing Partner
Shakari Byerly.

About the Foundation

The California Health Care
Foundation (CHCF) is dedicated
to advancing meaningful, mea-
surable improvements in the way
the health care delivery system
provides care to the people of
California, particularly those with
low incomes and those whose
needs are not well served by the
status quo. We work to ensure
that people have access to the
care they need, when they need
it, at a price they can afford.

CHCF informs policymakers and
industry leaders, invests in ideas
and innovations, and connects
with changemakers to create a
more responsive, patient-cen-
tered health care system.

DESIGN BY DANA KAY DESIGN

Contents

15

28

35

37
39

Executive Summary
About the Research

SECTION 1: Black Californians' Health Behaviors
and Utilization

SECTION 2: Black Californians' Experiences with
the Health Care System

SECTION 3: Black Californians' Recommendations
for Addressing Racism and Discrimination in
Health Care

Conclusion
Appendix: Methodology

Endnotes

About Listening to Black Californians

PHASE I. Individual, hour-long interviews with 100 Black
Californians to understand their views on health and
well-being, their perceptions of discrimination and bias in
the health care system, and their views on what a quality
health care system looks like.

PHASE Il. A series of 18 focus groups segmented by
gender identity, sexual orientation, age, region, and
health insurance status. Discussions focused on structural
issues in the health care system.

PHASE Ill. A statewide survey of 3,325 Black Californians
to assess the extent to which the findings of Phases | and
|| are represented among the general Black Californian
population.

www.chcf.org/program/listening-to-black-californians

 
Executive Summary

( alifornia, home to the most culturally diverse

population in the country and the fifth-
largest Black population of any state, has a major
opportunity to be a leader in health equity. But,
again and again, research has shown that racism
and structural barriers in the health care system pre-

vent Black Californians from achieving the health
they actively seek."

Long-standing racial and ethnic health disparities
laid bare by the COVID-19 pandemic, coupled
with the powerful demonstrations against police
violence catalyzed by the murder of George Floyd,
prompted CHCF to investigate the relationship
between racism and health care that leads to unac-
ceptable health outcomes for Black Californians."
To identify solutions for dismantling persistent
health inequities, CHCF engaged EVITARUS, a
Black-owned public opinion research firm in Los
Angeles, to conduct qualitative and quantitative
research that listens deeply to Black Californians
talking about their experiences with racism and
health care.

Listening to Black Californians is one of the largest
studies focused on the health care experiences of
Black Californians to date. The qualitative phases,
conducted from June to December 2021, included
in-depth interviews with 100 Black Californians and
18 focus groups consisting of Black Californians
and key health care stakeholders. The interviews
and focus groups informed the content of a state-
wide survey, conducted from March to May 2022,
and completed by 3,325 adult Black Californians
recruited to reflect the population based on the
2020 US Census and 2019 American Community
Survey.

Key Findings

The Listening to Black Californians study found
that many Black Californians share similar atti-
tudes about health and similar experiences in the
health care system. However, there are also impor-
tant differences, as Black Californians are a diverse
group. This report focuses primarily on the findings
from the statewide survey, illuminating what Black
Californians have in common about health and
health care and where their attitudes and experi-
ences diverge.

Black Californians are highly intentional in their
pursuit of physical and mental health. Most Black
Californians report putting a great deal or quite
a bit of effort into getting appropriate screenings
or preventive care (77%); tracking health indica-
tors, such as blood pressure and cholesterol (71%);
and working to reach or maintain a healthy weight
(71%). A strong majority (79%) focus a great deal or
quite a bit on their mental health.

Most Black Californians are insured, have a regu-
lar provider, and have had at least one visit with
a health care provider in the last year. Nine in
ten Black Californians (90%) say they currently have
health insurance coverage, and 83% have a regu-
lar provider. Over 9 in 10 Black Californians (92%)
have seen a doctor or health care provider in the
last year.

Nearly one in three Black Californians has been
treated unfairly by a health care provider because
of their race or ethnicity. This experience is most
common among Black Californians with men-
tal health conditions (47%); those who identify as
LGBTQIA+, which includes lesbian, gay, bisexual,
transgender, queer or questioning, intersex, asex-
ual, and more (43%); those with disabilities (40%);
and women (40%). A significant number of Black
Californians overall (38%) and of Black women in

 

California Health Care Foundation

www.chcf.org 4
particular (47%), say there has been a time when
a health care provider did not treat their pain
adequately.

"Based on the Listening to Black Californians
survey results, Black people are actively
engaged in their own health care advocacy,
but this has not eliminated the systemic
issues that result in poor health outcomes."

- Venise C. Curry, MD, Listening to Black Californians
Advisory Group Member, Consultant, and

Western Director, Climate Health and Equity Fellowship
(Medical Consortium on Climate and Health)

More than one in four Black Californians avoids
care due to concerns that they will be treated
unfairly or with disrespect. Even higher numbers
of Black Californians who identify as LGBTOIA+
(41%) and those enrolled in Medi-Cal (35%) report
having avoided care.

Many Black Californians adopt measures to
mitigate potential negative experiences in prep-
aration for a health care visit. Two-thirds (66%) of
Black Californians report researching a health con-
dition or concern before meeting with a health care
provider, and over one-third (35%) say they have
tailored their speech and/or behavior to make a
provider feel at ease.

Black Californians agree on the importance of
strengthening the patient-provider relationship.
Virtually all Black Californians consider it extremely
important or very important to have a provider who
listens to them (98%), who spends the time needed
to answer questions (97%), and who discusses spe-
cific health goals (93%).

Black Californians have clear opinions on how
to make the health care system work better for
them. A strong majority of respondents believe it is
extremely important or very important to:

> Increase Black representation among health care
leadership (85%) and in the health care workforce
{80%}, as well as establish more Black-led, com-
munity-based clinics (80%).

>» Expand community-based education on how to
navigate the health care system and advocate
for quality care (84%) and increase the number
of Black community health care advocates (77%).

> Establish accountability for equitable care by
implementing financial (82%) and accreditation
(80%) incentives in the health care system, as well
as through provider training (80%).

> Develop more holistic approaches to health care
(73%) and expand access to non-Western and
alternative medicine (69%).

"I think by having more Black people
represented in the health care profession
and in those positions of power and able to
make the changes that we need for us...
will allow us to have our voices heard and
our concerns addressed better in the health
care system."

- Black man, focus group participant,
Central Valley stakeholders

The diverse voices of participants speak loudly
through Listening to Black Californians. They tell
us that eliminating the detrimental effects of rac-
ism and discrimination on their health is within our
grasp if we are willing to listen to Black Californians,
build trust and partner with them, and hold the
health care system accountable for equitable care.

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 5
About the Research

In 2021, CHCF engaged EVITARUS, a Black-owned
public opinion research firm in Los Angeles, to
conduct Listening to Black Californians, a study
to understand Black Californians' views on health
and their experiences with racism and health care.
The three-phase study listened deeply to Black
Californians to identify solutions to dismantle per-
sistent and unacceptable health inequities.

Qualitative: Interviews and
Focus Groups

In Phase | of Listening to Black Californians, 100
Black Californians were interviewed about their
views on health, their experiences with racism and
health care, and their perspectives on quality health
care. Interviewees, who ranged in age from 18 to
86 and resided in locations across the state, were
selected to reflect the diversity of Black Californians.
Interviews were conducted from June to August
2021. The interview findings are summarized in In
Their Own Words: Black Californians on Racism
and Health Care.

Phase Il of the study comprised 18 focus groups
with Black Californians and key health care stake-
holders. The focus groups were organized by
participants' type of health insurance coverage,
urban/rural classification, gender and age, sexual
orientation, and geographical region. The focus
groups expanded the findings of Phase | through
two hour-long discussions with each group. The
focus group discussions explored, in depth, partici-
pants' experiences with racism and health care as
well as participants' thoughts about specific recom-
mendations for improving the health care system.
The focus groups were held in November and
December 2021.

Quantitative: Statewide Survey

Phase Ill, the Listening to Black Californians
statewide survey, quantified the views of Black
Californians on their health and their experiences
with the health care system. EVITARUS used multi-
ple-frame sampling to achieve a population sample
of 3,325 adults in California who self-identify as
Black or African American. The sample included
an oversample of 330 Black Californians who
identify as LGBTOIA+. Participants were recruited
through voter registration rolls, a cell phone sample
drawn from census tracts with 25% or more African
American density, and a convenience sample par-
tially screened against the voter file. The survey was
conducted from March 5 to May 8 of 2022.

The state-level survey is one of the largest-scale sur-
veys to date focused on the health care experiences
of Black Californians. The survey sample is reflec-
tive of the population of Black adults in California
and was benchmarked against 2020 US Census and
2019 American Community Survey data. Phase |
and Phase II participants were screened out or oth-
erwise did not participate in the Phase III survey.

This report focuses primarily on the findings from
the statewide survey, with illustrative quotations
from the qualitative phases. More details about the
survey are available in the appendix.

 

California Health Care Foundation

www.chcf.org 6
Demographics of the
Survey Sample

The Listening to Black Californians statewide sur-
vey attempts to capture the diversity of Black
Californians, who hold many views in common but
also display distinct differences among subgroups
(Table 1).

The majority of the survey respondents identify as
Black/African American (76%), with the next largest
segments identifying as Black-multiracial (8%), or as
represented in the survey, "Black and mixed race/
biracial," and African (7%). Respondents age 18 to
35 were more likely to describe their ethnicity as
Black-multiracial (13%) than other age groups.

Survey participants reflect California's Black popu-
lation in gender, age, geography, and whether
they were raised in California. The survey sample
includes 1,829 women, 1,235 men, and 20 people
who identify as gender nonconforming/nonbinary.
About 10% of participants identify as LGBTOIA+.
Participants range in age from 18 to 100 and live in
every region of the state in urban, suburban, and
rural areas. More than three-quarters of the peo-
ple surveyed were raised in California. Participants
reflect the range of socioeconomic status of Black
Californians. The largest segment of respondents
has some college or community college education
(29%), followed by those with a four-year college/
Bachelor's degree (18%), an Associate's degree
(16%), or a Master's degree (6%). Income levels are
distributed across the Federal Poverty Level (FPL)
scale, with 28% of respondents at <200% FPL, 25%
at <200% to 399% FPL, and 30% at >400% FPL.
Most participants are registered to vote (89%).

Slightly more women (40%) than men (38%) report
having a serious health condition, such as high
blood pressure, high cholesterol, diabetes, or other
conditions. Almost one-fourth (23%) of participants
have a mental health condition, with a greater por-
tion of women (30%) indicating so than men (19%).

Table 1. Participant Demographics (N = 3,325, age 18+)

RACE/ETHNICITY

n

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black / African American 2,533 76%
Black-Multiracial 275 8%
African 241 7%
Black and American Indian / 145 4%
Native American / Indigenous

Afro-Caribbean 88 3%
Afro-Latinx 34 1%
Of African Descent 8 <1%
AGE

18 to 24 64 6%
25 to 34 339 10%
35 to 44 554 17%
45 to 54 607 18%
55 to 64 700 21%
65 to 74 555 17%
75 and older 276 8%
GENDER

Women 1,829 48%
Men 1,235 47%
Gender Nonconforming / Nonbinary 20 <1%
REGION

Los Angeles County 1,393 36%
Inland Empire 364 15%
Other Southern California 339 10%
San Francisco Bay Area 704 20%
Central Valley 194 9%
North 259 2%
Central Coast 49 7%
Far North 19 1%
INCOME, BY FEDERAL POVERTY LEVEL (FPL)

<200% FPL 630 28%
200% to 399% FPL 814 25%
2400% FPL 1,292 30%

 

Notes: Ns are unweighted, %s are weighted (see page 38 for details).

Prefer not to say is not shown.

Source: Listening to Black Californians, statewide survey conducted by

EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health
Significant numbers of both women (21%) and men
(18%) report a disability of any type (e.g., mobility,
cognitive, visual, or sensory). One-fourth (25%) of
LGBTOIA+ respondents indicate having a disability.
Of those with a disability, 65% also report a serious
health condition and 47% report a mental health
condition. Among those with a disability, 34% are
covered by private insurance, 32% by Medicare,
and 30% by Medi-Cal.

Most respondents have health insurance (90%).
Five percent are uninsured. Forty-four percent have
employer-provided coverage, 17% have Medi-Cal,
and 15% have Medicare (Figure 1).

Figure 1. Health Insurance Coverage, by Type

 

Do you currently have health insurance?
Which of the following is your main source of coverage?

Tricare/CHAMPVA (2%)

Prefer not
to say

8%

Soles Le-col) Employer-provided

Covered CA 6% Vy

Medicare
15%

Medi-Cal
17%

 

Notes: Sample includes 3,325 Black California residents age 18 and older.
CHAMPYVA is the Civilian Health and Medical Program of the Department
of Veterans Affairs.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

SECTION 1

Black Californians'
Health Behaviors and
Utilization

"This survey dispels the narrative that Black
people don't care about their health, when
actually, they are very intentional."

- Connie Stewart, Listening to Black Californians
Advisory Group Member and Executive Director
of Initiatives, Humboldt State University

Both the qualitative and quantitative phases of the
Listening to Black Californians study reveal a high
level of engagement with improving physical and
mental health. Although survey participants vary
by age, ethnicity, gender, income, insurance cover-
age, and education, as a whole, the survey findings
demonstrate a strong commitment to health.

Black Californians are highly
intentional about maintaining
and improving their health and
regularly engage in healthy
behaviors.

Listening to Black Californians interviewees and
focus group participants uniformly described the
close attention they pay to managing their personal
health. Survey respondents corroborate these views
and demonstrate a prevailing focus on engaging in
healthy behaviors. More than three in four Black
Californians report putting a great deal or quite
a bit of effort into getting appropriate screenings
or preventive care (77%). Over 7 in 10 put a great
deal or quite a bit of effort into tracking health indi-
cators, such as blood pressure, cholesterol, and
sleep patterns, and working to reach or maintain a
healthy weight (71%). Fifty-seven percent of Black

 

California Health Care Foundation

www.chcf.org 8
Californians put a great deal or quite a bit of effort
into exercising during leisure time (Figure 2).

Figure 2. Things to Maintain/Improve Personal Health

 

Here are things that some people do because they think
that these things will help them maintain or improve their
health. For each one, please tell me how much effort, if
any, you put into doing it.

THOSE WHO ANSWERED "A GREAT DEAL / QUITE A BIT"

Speaking up about your concerns when you go to the doctor
(even when they do not ask)

85%

Getting appropriate screenings or preventive care

ah

Tracking indicators of personal health or symptoms
(i.e., blood pressure, glucose, cholesterol, and sleep patterns)

Tab

Working to reach or maintain a healthy weight

Ab

Exercising during your leisure time

Ya

Notes: Sample includes 3,325 Black California residents age 18 and older.
Prefer not to say is not shown.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Most respondents (85%) speak up a great deal or
quite a bit about their concerns when they visit a
doctor, even when not asked. Nearly 9 in 10 women
(89%) speak up a great deal or quite a bit, com-
pared to 8 in 10 men (81%). Eighty-eight percent of
respondents with a disability and 88% with a mental
health condition speak up a great deal or quite a bit
about their concerns during a visit.

Black Californians across all types of insurance
coverage engage regularly in healthy behaviors.
Almost all the survey respondents (90%) are cov-
ered by health insurance. The majority of Black
Californians across all types of insurance coverage
devote a great deal or quite a bit of effort to a vari-
ety of healthy behaviors. More than two-thirds of
Black Californians with Medi-Cal coverage make a
significant effort to speak up about concerns (84%),
get appropriate screenings (78%), track indicators
of personal health (72%), and work to reach or
maintain a healthy weight (69%) (Figure 3, page 10).

"| work out. | have a little workout regimen |
do. And | walk, ride my bike, and meditate.

| try to eat right. | try to eat healthy. | try to
stay away from fast food and stuff as much
as possible. Limit my alcohol intake . . . just
in general, try to stay on the healthier side
of things."

- 54-year-old Black man, San Diego

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 9
Figure 3. Things to Maintain/Improve Personal Health,
by Insurance Coverage Type

 

any, you put into doing it.

THOSE WHO ANSWERED "A GREAT DEAL / QUITE A BIT"

Speaking up about your concerns when you go to the doctor
(even when they do not ask)

86%
sto
84%
hey

Getting appropriate screenings or preventive care
83%

ako

78%

o
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BS

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(i.e., blood pressure, glucose, cholesterol, and sleep patterns)

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Exercising during your leisure time

54%

fo}
le Medicare (n = 497)
56% Mi Employer (n = 1,449)
5 HE Medi-Cal (n = 572)
add M@ Uninsured (n = 154)

Notes: Sample includes 3,325 Black California residents age 18 and older.
Prefer not to say is not shown.

Black Californians view their
health holistically and actively
attend to their mental health.

"Everything in our life influences our health;
the provision of health care is an important
aspect."

- Oliver T. Brooks, MD, Listening to Black
Californians Advisory Group Member and
Chief Medical Officer, Watts Healthcare

Many Black Californians who participated in the
qualitative phases of the study held a holistic view
of health that encompasses physical and men-
tal health. Interview and focus group participants
emphasized their efforts to attend to their whole
health and well-being. Survey respondents are also
highly intentional about addressing factors that
affect their mental health.

Just under 8 in 10 survey respondents (79%) devote
a great deal or quite a bit of effort to focusing on
their mental health. A large majority (80%) of survey
participants say they actively work to reduce stress a
great deal or quite a bit. Respondents also see spiri-
tual health as an integral component of health, with
approximately two-thirds (66%) praying or engag-
ing in some other spiritual activity a great deal or
quite a bit (Figure 4, page 11).

 

California Health Care Foundation

www.chcf.org 10
Figure 4. Things to Maintain/Improve Mental Health,
by Level of Effort

 

Here are things that some people do because they think
that these things will help them maintain or improve their
health. For each one, please tell me how much effort,

if any, you put into doing it.

A great deal Ml Quite abit Bi Some Ml Very little I None

Focusing on your mental health

57% 22% 14%

. . 4% 2%
Actively trying to reduce stress

56% 24% 14%

4% 2%
Praying or engaging in some other spiritual activity

50% 16% VR amma

Meditating or deep breathing

28% vA 27% 13% 11%

Notes: Sample includes 3,325 Black California residents age 18 and older.
Prefer not to say is not shown. Segments may not sum to 100% due to
rounding.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

"| think of health as being the totality of well-
being, so that means being in good physical
condition, but it also means mental health is
an important part of your health. In my case,
how | feel determines everything else. If |
don't feel good, I'm not going to exercise
or eat right. It's all connected for me. ...

I think, also, the spiritual component of well-
being and feeling connected to the universe,
to God, to community [is] an important
element in being healthy and having healthy
relationships, family relationships."

- 66-year-old Black woman, San Diego

The degree of effort put into mental health
declines with age. Respondents age 18 to 34 pay
more attention to mental health than all other age
groups, with 84% focusing a great deal or quite a
bit on their mental health. By contrast, 73% of those
age 75 and older say they put a great deal or quite
a bit of effort into focusing on their mental health
(Figure 5).

Figure 5. Focusing on Mental Health, by Age

 

Please tell me how much effort, if any, you put into
focusing on your mental health.

THOSE WHO ANSWERED "A GREAT DEAL / QUITE A BIT"

18 to 34 (n = 403)
84%

35 to 44 (n =554)
ha

45 to 54 (n= 607)

VEY

55 to 64 (n = 700)

LN

65 to 74 (n= 555)
74%

75 and older (n = 276)

EY

 

Overall: 79% ©

Notes: Sample includes 3,325 Black California residents age 18 and older.
p < .05 for differences between 18 to 34 and all other age groups.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 11
Black Californians who are uninsured or covered
by Medi-Cal focus more on mental health than
other Black Californians. Those who are uninsured
(83%) and those with Medi-Cal (83%) are more likely
to put a great deal or quite a bit of effort into focus-
ing on their mental health. Those who are covered
by employer-provided insurance (78%) and those
on Medicare (77%) are less likely to do so (Figure 6).

Figure 6. Focusing on Mental Health, by Coverage Type

 

Please tell me how much effort, if any, you put into
focusing on your mental health.

THOSE WHO ANSWERED "A GREAT DEAL / QUITE A BIT"

Uninsured (n= 154)

83%

 

Medi-Cal (n = 572)

 

Employer-Provided (n= 1,449)

    

Vhs

Medicare (n= 497)

 

ih

 

Overall: 79% @

Notes: Sample includes 3,325 Black California residents age 18 and older.
p <.05 for differences between Medi-Cal, Employer-Provided, and Medicare.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Black Californians seek
alternative and non-Western
approaches to health care.

One key finding from the qualitative research was
that many Black Californians use alternative and
non-Western approaches to medicine, and many
more expressed interest in increased access to
these types of care. The survey confirms this high
level of interest in alternative medicine.

Many Black Californians put effort into seeking
out alternative care, especially women and those
with lower incomes. Four in ten respondents (40%)
put a great deal or quite a bit of effort into seek-
ing out alternative or non-Western approaches to
health care. Women (45%) are more likely to put a
great deal or quite a bit of effort into seeking alter-
native types of care than men (33%).

"| do a lot of acupuncture and massage. |
take supplements, and it's because | had

a doctor tell me that he wanted to put

me on a chemo-like pill for inflammation.
When | researched it and found out it was
a chemo pill, | refused to take the pill. | did
my own research, and after six months, my
inflammation went away. The doctor told
me, 'Well, you keep that up.' | asked, 'Why
wouldn't you suggest | do [my alternative
treatment] from the start?' His answer was,
'I practice medicine.' | said, 'Did you know
that this was an alternative?' He said again,
'I practice medicine.' He practices giving
medication to solve any and every problem
instead of giving an alternative."

- Black woman, focus group participant, LGBTOIA+

 

California Health Care Foundation

www.chcf.org 12
The degree of effort put into seeking alternative
approaches to health care is inversely correlated
with income. Forty-five percent of Black Californians
with lower incomes put a great deal or quite a bit
of effort into seeking out alternative approaches
to health care compared to 34% of those with an
income =400% FPL (Figure 7).

Figure 7. Sought Alternative/Non-Western Approaches
to Health Care, by Gender and Income

 

Please tell me how much effort, if any, you put into
seeking out alternative care.

THOSE WHO ANSWERED "A GREAT DEAL / QUITE A BIT"

Women (n = 1,829)

45%

Men (n = 1,235)

Ry

< 200% FPL (n = 630)
45%

200% to 399% FPL (n = 814)
42%

2400% FPL (n = 1,292)

34%

 

Overall: 40% @

Notes: Sample includes 3,325 Black California residents age 18 and older.
FPL is federal poverty level. p < .05 for differences by gender and for
>400% FPL compared to other income groups.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

FIGURE 8:

Notes: Sample includes 3,325 Black California residents age 18 and older.
p <.05 for differences by insurance coverage. Values within ovals represent
the percentage of those who were covered by this type of insurance.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Black Californians actively engage
with the health care system.

"For me, health involves the ability to have a
doctor, a practitioner . . . [then] the ability to
go to the doctor, the ability of the doctor to
monitor your health, and if you have issues,
to be able to go to the right party, the right
doctor, the right agency to correct it."

- 61-year-old Black man, Los Angeles

Most Black Californians, especially those with
insurance, have a regular health care provider.
More than 8 in 10 Black Californians (83%) have a
regular doctor or health care provider for illness,
routine care, or care for a specific condition. Nearly
all Black Californians with Medicare have a regular
provider (94%), as do 86% of those with employer-
covered insurance and 81% of those with Medi-Cal.
In contrast, only 4 in 10 uninsured Black Californians
have a regular health care provider (Figure 8).

Figure 8. Regular Doctor or Health Care Provider,
by Insurance Coverage Type

 

Do you have a regular doctor or health care provider that
you see when you are sick, for routine check-ups, and/or
care for a specific condition?

THOSE WHO ANSWERED "YES"

Medicare 15%

ZN

Employer-Provided 44%

86%

Medi-Cal 17%
81%

Uninsured © 5%

 

40% Overall: 83% @

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 13
Respondents without a regular doctor or health care
provider go to the emergency department (48%) or
an urgent care facility (20%) when they need care.

A vast majority of Black Californians have
received health care recently. Almost all respon-
dents (92%) have either seen a doctor or health care
provider in person, by phone, or by video in the
last 12 months, with a median number of three visits
(Figure 9).

Figure 9. Number of Health Care Visits in the
12 Months Prior to the Survey

 

During the past 12 months, about how many times have
you seen a doctor or health care provider either in person,
by phone, or by video?

Prefer not to say (1%)

 

More than 10
nhs

 

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

More than 7 in 10 Black Californians have received
a routine checkup (75%) or a routine and/or preven-
tive health screening (73%) since 2021. More than
one in three have received treatment at a hospital
(39%) or at an emergency room or urgent care facil-
ity (37%) since January 2021 (Figure 10).

Figure 10. Care Received Since January 2021,
by Type of Care

 

Since January 2021, have you done any of the following,
either in person, by phone, or by video?

THOSE WHO ANSWERED "YES"

Routine checkup

75%

Routine and/or preventive health screening

EY

 

Treatment at a hospital, outside of emergency room care

Ria

 

Treatment at an emergency room or urgent care facility

Seo

 

Treatment for a chronic illness

cb

 

Treatment at a community clinic

Yea

 

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

California Health Care Foundation

www.chcf.org 14
Black Californians with insurance are more likely
to receive routine checkups and health screen-
ings. Only half of uninsured Black Californians (50%)
have received a routine or preventive health screen-
ing since 2021, and fewer than half (47%) have
received a routine checkup since 2021 (Figure 11).

Figure 11. Routine Care Received Since January 2021,
by Insurance Coverage Type

 

Since January 2021, have you done any of the following,
either in person, by phone, or by video?

THOSE WHO ANSWERED "YES"

Routine and/or preventive health screening

 

Overall: 73%

Routine checkup

 

Overall: 75%

HE Medi-Cal (n = 572)
Uninsured (n = 154)

Medicare (n= 497)
Hi Employer (n= 1,449)

Notes: Sample includes 3,325 Black California residents age 18 and older.
p <.05 for differences for differences between uninsured and the other
groups, and between employer and the other groups for routine checkup.
p <.05 for differences between uninsured and the other groups, and
between Medi-Cal and the other groups for health screening.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

SECTION 2

Black Californians'
Experiences with the
Health Care System

"What stands out from the survey results was
the way that people identified themselves
and how the impact of health care diverged
depending on the individual. The Black
community is not homogeneous."

- Danté Allen, MA, Listening to Black Californians
Advisory Group Member and Executive Director,
CalABLE Act Board, California State Treasurer's Office

Although many Black Californians report satisfac-
tion with their health care, there is widespread
agreement that the health system is not provid-
ing the care that Black people need and deserve.
Unacceptably large numbers of Black Californians
experience racism, discrimination, and inadequate
treatment when accessing health care. These
experiences are more common among the most
disenfranchised segments of the Black population.

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 15
Satisfaction with health care is
generally high, with important
exceptions.

In general, many Black Californians report satisfac-
tion with their health care, with 44% reporting being
very satisfied and 40% being somewhat satisfied
with their main source of care (Figure 12).

Figure 12. Satisfaction with Main Source of Care

Satisfaction with care increases with age. Ninety-five
percent of Black Californians age 75 and older and
90% of those age 65 to 74 are very or somewhat
satisfied with their main source of care. In contrast,
80% of those ages 18 to 34 are very or somewhat
satisfied (Figure 13).

Figure 13. Satisfaction with Main Care Source, by Age

 

How satisfied or dissatisfied are you with your
main source of care?

Don't know /
Prefer not to say (2%)

ed
5%)

  
  

Very dissatisfi
(

 

Very satisfied
cr

Somewhat
satisfied
40%

Notes: Sample includes 3,325 Black California residents age 18 and older.
Segments do not sum to 100% due to rounding.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

How satisfied or dissatisfied are you with your
main source of care?

Dissatisfied:
Mi Somewhat Ml Very

Satisfied:
HiVery Mi Somewhat

18 to 34 (n = 403)

 

 

 

 

 

33% 47% 12% 6%
35 to 44 (n= 554)
36% Uy a ae.
45 to 54 (n= 607)
42% 42% Th5%
55 to 64 (n=700)
bibs 36% 6%
4%
65 to 74 (n= 555)
60% 29% 6%
4%
75 and older (n= 276)
ohh 26%

3% 2%
Notes: Sample includes 3,325 Black California residents age 18 and older.
Segments may not sum to 100% due to rounding.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

California Health Care Foundation

www.chcf.org 16
While only 13% of respondents overall report being
somewhat or very dissatisfied with their care, some
subsets of Black Californians are much more likely
to express dissatisfaction. Specific groups more
likely to report higher levels of being somewhat or
very dissatisfied with their main source of care are:

> 31% of those who are uninsured

> 27% of women with Medi-Cal coverage

> 22% of those with Medi-Cal coverage

> 22% of those with a mental health condition
> 19% of those with a disability

> 18% of those age 18 to 34

Many Black Californians report
being treated poorly by health
care providers due to their race
or ethnicity.

"It is a tragedy that Black Californians don't
feel they can trust the health care system,
a tragedy that it's viewed as a place to go
when you're at the end of your rope."

- David M. Carlisle, MD, PhD, Listening to Black
Californians Advisory Group Member, President
and Chief Executive Officer, Charles R. Drew
University of Medicine and Science

Many Black Californians who participated in the
qualitative phases of the study described experi-
ences of racism, discrimination, and mistreatment
when seeking health care for themselves and their
family. The survey validates these experiences.
Almost one-third (31%) of respondents, or 1,095
Black Californians, report being treated poorly by a
health care provider because of their race or ethnic-
ity. This is higher than those who have been treated
poorly because of their perceived ability to pay
(22%), weight or body type (15%), or age (13%).

Figure 14. Experience with Being Treated Poorly
Because of Race/Ethnicity

 

Have you ever been treated poorly by a doctor, dentist,
nurse, or other health care provider because of your race
or ethnicity?

Does not apply (1%) « e Prefer not to say (1%)

Don't know
ay

 

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

More women than men _ experience poor
treatment by providers and report negative
interactions with the health care system. Four in
10 Black women in California (40%) report being
treated poorly by a health care provider because
of their race or ethnicity, compared to just over 2
in 10 men (22%). In addition, 26% of women report
poor treatment due to perceived ability to pay and
23% due to their weight or body type (Figure 15,
page 18).

By significant margins, more women than men
report negative experiences with the health care
system, including not having their symptoms taken
seriously (51%), being prescribed medications they
did not feel were needed (38%), and not being
treated with respect (37%) (Figure 16, page 18).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 17
Figure 15. Reason for Being Treated Poorly,
by Gender

Figure 16. Adverse Experiences with Health Care Visits,
by Gender

 

 

Have you ever been treated poorly by a doctor, dentist,
nurse, or other health care provider because of your...?

THOSE WHO ANSWERED "YES"

Race or ethnicity
40%
Ya

Perceived ability to pay
26%
18%

Weight or body type
RW
es

WTS
8%

Age

Gender or gender identity
14%

 

Sexual orientation

HE Women (n= 1,829)
i © Men (n= 1,235)

FIGURES 15 and 16:

Notes: Sample includes 3,325 Black California residents age 18 and older.
p< .05 for differences by gender.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Thinking more generally about your experiences with
health care visits, have any of the following ever
happened to you?

THOSE WHO ANSWERED "YES"

Symptoms were not taken seriously
a
28%

Prescribed medication you didn't feel you needed
38%
Vay)

Not treated with respect
Rye)

YW

Provider did not believe you were telling the truth

34%

20%

Provider refused to order test or treatment you felt you needed
Ya
yA

Other patients were unfairly prioritized ahead of you
27%
Was

Provider suggested that you were to blame for health problem
26%
Wa

Privacy was not respected
Wa
an

Subjected to medical harm
16%

roy HE Women (n= 1,829)

© Men (n= 1,235)

 

California Health Care Foundation

www.chcf.org 18
"| feel like Black voices aren't as loud. They
are not taken as seriously. In this case, |
wasn't listened to, and it ended up being
a very serious, actually life-threatening
problem. But the doctor, | told him | was
short of breath, and he told me, 'You are
out of shape." | was like, 'I have been out of
shape for a long time, [and] | wasn't out of
breath. [But] I'm out of breath now.' And he
told me, 'You just need to lose weight and
exercise more.' And it ended up being that
| was severely anemic and had to have two
blood transfusions."

- Black woman, focus group participant,
private insurance - urban

The most marginalized segments of the Black
California population report especially high rates
of poor treatment by providers due to their race
or ethnicity. More than 4 in 10 respondents with
a mental health condition (47%) and those who
identify as LGBTOIA+ (43%) report being treated
poorly because of their race or ethnicity. Reports
of mistreatment are also high for respondents with
a disability (40%) and for Medi-Cal enrollees (37%)
(Figure 17).

Figure 17. Experience with Being Treated Poorly
Because of Race/Ethnicity, by Select Groups

 

Have you ever been treated poorly by a doctor, dentist,
nurse, or other health care provider because of your
race or ethnicity?

THOSE WHO ANSWERED "YES"

Respondents with a mental health condition (n = 771)

 
      
    
    

LGBTOIA+ respondents (n = 330)

Respondents with a disability (n = 663)

Medi-Cal enrollees (n = 572)

Overall: 31%

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 19
Many LGBTQIA+ respondents report being
treated poorly by a health care provider.

Overall, LGBTOIA+ respondents are more likely to
report being treated poorly by a provider because
of their race or ethnicity, weight or body type, gen-
der or gender identity, or sexual orientation than
other respondents. More than 4 in 10 LGBTOIA+
respondents (43%) report being treated poorly by
a health care provider because of their race or eth-
nicity, compared to 3 out of 10 straight-cisgender
respondents (30%). LGBTOIA+ respondents (19%)
are also more than twice as likely to experience
poor treatment because of gender or gender iden-
tity than non-LGBTOIA+ respondents (9%), and are
five times more likely to experience poor treatment
based on sexual orientation (Figure 18).

"Because if you're LGBT, for example, and
you don't know who your doctor is, and
you get in there, you may feel like the
doctor may try to kill you or try to give

you something or not give you the right
medication because they don't like LGBT
people. And that's a constant thing that's on
your mind when you're LGBT when you go
see the doctor... Oh my god, is this person
going to hurt me or help me? Sometimes
you would rather just not even go."

- 48-year-old Black gender-nonconforming person,
Inland Empire

Figure 18. Reason for Being Treated Poorly,
by Sexual Orientation

 

Have you ever been treated poorly by a doctor, dentist,
nurse, or other health care provider because of your...?

THOSE WHO ANSWERED "YES"

Race or ethnicity
43%
30%

Weight or body type
25%

eye

Gender or gender identity
ha
a)

Sexual orientation

15%
Mi LGBTQIA+ (n = 330)
§ Straight-Cisgender (n = 2,995)

|

%

Notes: Sample includes 3,325 Black California residents age 18 and older.
p < .05 for differences between groups.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

California Health Care Foundation

www.chcf.org 20
Many Black Californians
experience inadequate
treatment for pain.
"| used to work in a hospital, and | saw how
some doctors - if a Black patient came
in - they would poke and prod them. The
patients would cry out in pain and say,
'What's the matter? Why are you doing that
to me, Doctor?' It was as if the doctor felt
like they didn't feel any pain."

- Black man, focus group participant,
Medi-Cal/uninsured

Respondents in all phases of the Listening to Black
Californians study emphasize inadequate treat-
ment for pain as a singular example of how the
health care system negatively affects Black people.
Interviewees and focus group participants described
instances when their pain was ignored or inade-
quately treated during a health care visit.

Black Californians report alarmingly high rates of
inadequate treatment for pain, especially certain
segments of the population.

"Pain control is a metaphor for the
performance of the health care system."

- Dr. David M. Carlisle, Listening to Black Californians
Advisory Group Member

Across the state, nearly 4 in 10 respondents (38%)
say that their pain was not treated adequately by
a health care provider. Specific groups within the
Black California population experience even higher
instances of insufficient pain treatment, with more
than half of respondents with a mental health con-
dition (58%), LGBTQIA+ respondents (54%), and
women with Medi-Cal coverage (52%) reporting
inadequate treatment for pain (Figure 19).

Figure 19. Inadequate Pain Treatment, by Select Groups

 

Has there ever been a time when your pain was not
treated adequately by a health care provider?

THOSE WHO ANSWERED "YES"

Respondents with a mental health condition (n = 771)

bys)

LGBTOIA+ respondents (n = 330)

Women enrolled in Medi-Cal (n = 383)

    
    
 

Women (n = 1,829)

Medi-Cal enrollees (n = 572)

San Francisco Bay Area (n = 704)

<200% FPL (n = 630)

 

Overall: 38%

Notes: Sample includes 3,325 Black California residents age 18 and older.
FPL is federal poverty level.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 21
Many Black Californians avoid
care due to concerns about
not being treated fairly or
with respect.

More than one in four Black Californians (26%)
avoids care due to concerns they will not be treated
fairly or with respect. The tendency to avoid care
varies by insurance coverage. More than one in
three Medi-Cal enrollees (35%) and 3 in 10 unin-
sured respondents (31%) report avoiding care due
to concerns about being treated fairly (Figure 20).

"As far as going to the doctor and hospitals,
it makes it hard for me to even tell myself to
go make an appointment, because | know
that I'm going to get discriminated against
in some form or fashion. Even when people
hear my name as [an African American-
sounding name], like . . . they see my weight,
they see my name. . . . | am resistant to
getting help unless | feel comfortable with
the person who may or may not look like me.
But | also have been discriminated against a
lot from Black physicians as well. It makes it
pretty challenging. | am hesitant to go, which
| know affects my health."

- 33-year-old Black woman,
San Francisco Bay Area

Figure 20. Avoided Care Due to Concerns About
Fair and Respectful Treatment,
by Insurance Coverage Type

 

Have you ever avoided going to a doctor or hospital
because you felt you would not be treated fairly or
with respect?

THOSE WHO ANSWERED "YES"

Medi-Cal (n = 572)

Rhy

Uninsured (n= 154)

Rub

Employer-Provided (n= 1,449)

PLY

Medicare (n= 497)

vA

 

Overall: 26% @

Notes: Sample includes 3,325 Black California residents age 18 and older.
p < .05 for differences between Medi-Cal and employer-provided and
Medicare, and between uninsured and Medicare.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Specific subgroups of the Black population report
avoiding care at higher rates than the overall pop-
ulation. One concerning finding is the high rate
of avoidance among those who have previously
experienced poor treatment when seeking health
care: 57% of respondents who say they have been
treated poorly because of their race or ethnicity
avoid care, as do 49% of respondents who say their
pain has not been treated adequately.

 

California Health Care Foundation

www.chcf.org 22
Equally concerning is the high rate of avoidance
among respondents who may need regular health
care, including Black Californians with a mental
health condition (40%) and those with a disability
(38%). In addition, 42% of women age 35 to 44 and
41% of LGBTOIA+ respondents report avoiding
care due to concerns they will be treated unfairly
(Figure 21).

Figure 21. Avoided Care Due to Concerns About Fair
and Respectful Treatment, Select Groups

 

Have you ever avoided going to a doctor or hospital
because you felt you would not be treated fairly or
with respect?

THOSE WHO ANSWERED "YES"

Treated poorly because of race/ethnicity (n = 1,095)

Pain not treated adequately (n = 1,280)

a

Women, age 35 to 44 (n = 340)

|

LGBTOIA+ respondents (n = 330)

Respondents with a mental health condition (n = 771)

40%

Respondents with a disability (n = 663)

 

Overall: 26%

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Many respondents deliberately

take steps to mitigate negative
health care experiences.

"| feel people judge appearance[s], so |
always make sure my kids are in nice, neat
clothes, something appropriate for the
doctor. | always make sure | give them a bath
before the doctor, so they can look their very
best. | make sure | brush their teeth before
they see the dentist - just little things like
that to protect myself from being treated
unfairly and [to prevent] people looking at
my kids sideways. And | always make sure |
have everything | need: doctor's cards, their
social [security cards], my ID, immunization
cards - | just keep all that stuff ready. | pack
7 diapers and wipes because | don't want

to be embarrassed about them not being
changed. ... | protect myself because | don't
want people to judge me, because it makes
me feel uncomfortable."

- 24-year-old Black woman, Antelope Valley

In interviews and focus groups, Black Californians
described the efforts they make prior to any health
care visit to decrease the chance of being treated
poorly or being discriminated against. The sur-
vey corroborates the widespread use of these
approaches.

Some of these strategies, such as researching a con-
dition or concern prior to the visit (used by 66% of
Black Californians), are commonly used by people
of all races and ethnicities before accessing health
care. Other approaches represent more defensive

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 23
strategies adopted by Black Californians to prevent
mistreatment and discrimination. Just over 4 in 10
(41%) signal to providers that they are educated,
knowledgeable, and/or prepared to hold the pro-
vider accountable. Over one in three (35%) tailor
their speech and/or behavior to make providers
feel at ease. And one in three (33%) have a com-
panion accompany them in the exam room during
an appointment.

"First and foremost, just keep in mind that
I'm a Black American male. My actions will
probably be looked at and applied to the
whole race, especially if my actions are
negative. And especially if they are perceived
as aggressive [or] unnecessarily aggressive.
So in case | run into a situation like that...

I try to find a way to disarm things. But it
depends, though. If something comes off
the wrong way, I'm not going to be that
diplomatic. But | try first and foremost to
understand that, right or wrong, people are
going to look at me like I'm every Black man
out there. And if | look like a fool, then I'll
probably reinforce some negative thing that
they've learned in life. If | conduct myself in
a way with some dignity, hopefully, they will
learn that too."

- 72-year-old Black man,
Los Angeles

One strategy, minimizing questions and con-
cerns to avoid being perceived as difficult, can
potentially prevent the receipt of needed care or
lead to adverse outcomes. Over one in four Black
Californians overall (27%) and one in three women
(32%) use this strategy (Figure 22).

Figure 22. Strategies Used to Increase Chances of
Being Treated with Respect

 

Next is a list of things some people may do to increase
the chances that they will be treated with respect when
seeking health care. For each one, please indicate if you
have ever used that approach/strategy when seeking care.

THOSE WHO ANSWERED "YES"

Researched a health condition or concern before meeting with
a provider

66%

Signaled to providers that you are educated, knowledgeable,
and/or prepared to hold them accountable

Ca

Tailored your speech, and/or behavior, to put providers
"more at ease" or to avoid being off-putting

Rhy

Took a companion with you into the exam room
during an appointment

33%

Paid special attention to how you were dressed

32%

Minimized questions and concerns to avoid
being perceived as "difficult"

27%

Recorded interactions

a

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

California Health Care Foundation

www.chcf.org 24
Respondents who have been treated poorly due
to race or ethnicity regularly use strategies to
mitigate negative health care visits. The majority
of those who were treated poorly because of race
or ethnicity prepare for health care visits with prior
research (82%), signal to providers that they are
educated (64%), and tailor their speech or adopt
other behaviors to make the provider feel more at
ease (63%). Half of Black Californians (50%) who
have been treated poorly minimize questions and
concerns to avoid being perceived as "difficult"
(Figure 23).

"A lot of times | go to Google, before |
get going [to a doctor's appointment]. |
go to Google and look up [my concerns],
read up as much as | can....1 try to go
in with as much information so that if
they try to dismiss me, I'll say, 'Hey, well,
what about this, | read this online.' You
know, to try to back it up... . I'm not
just coming in complaining, !m actually
doing some research."

- 39-year-old Black woman,
Sacramento

Figure 23. Strategies Used to Increase Chances of
Being Treated with Respect, Among Those
Who Reported Being Treated Poorly Due to
Race/Ethnicity

 

Next is a list of things some people may do to increase
the chances that they will be treated with respect when
seeking health care. For each one, please indicate if you
have ever used that approach/strategy when seeking care.

THOSE WHO ANSWERED "YES"

Researched a health condition or concern before meeting with
a provider

82%

Signaled to providers that you are educated, knowledgeable,
and/or prepared to hold them accountable

for

Tailored your speech, and/or behavior, to put providers
"more at ease" or to avoid being off-putting

oy

Paid special attention to how you were dressed

ho

Minimized questions and concerns to avoid
being perceived as "difficult"

50%

Took a companion with you into the
exam room during an appointment

Lbey

Recorded interactions

We

Notes: Sample includes 3,325 Black California residents age 18 and older.
Data are presented for the 1,095 respondents who report being treated
poorly due to race or ethnicity.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 25
Black Californians consider strong
relationships with providers to be
central to quality health care.
"| mentioned the doctor [who gave me] the
best level of care that | ever received. He sat
down quietly, looked at me in my face...
wasn't looking around. Talked to me about
my life. [He explained,] 'We're going to do
blood tests on everything.'. .. And that was
the best care | received. And that's what
| envision it would look like... a doctor
saying, 'Anything else you want to ask me?,'
because | [didn't] ever feel like | got to ask
the questions, and if | did, maybe | was just
too spooked to ask because of how | felt
inside about not being believed. . . . That's
how it would look for me to receive great
care. And | received it once, so | keep going
back to this doctor."

- 35-year-old Black man, Central Valley

In interviews and focus groups, Black Californians
consistently described what high-quality care means
to them: care that is centered around the patient,
encompasses the patient's experiences, and recog-
nizes the patient's knowledge and desires. Survey
respondents corroborate this view.

Virtually all Black Californians consider it extremely
or very important to have a provider who listens
to them (98%), spends the time needed to answer
questions (97%), and discusses specific health goals
(93%) (Figure 24).

Figure 24. Importance of Provider Relationship

 

When it comes to health care, how important are each
of the following to you?

HAVING A PROVIDER WHO...

Listens to you

98%

Spends the time needed to answer all your questions

1% 1%

 

Talks to you about specific goals for your health

93% 5%

 

2%
Important:

Mi Extremely/Very [ll Somewhat

Not important:
BB Not too / Not at all

Notes: Sample includes 3,325 Black California residents age 18 and older.
Don't know / Prefer not to say is not shown.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

"My doctor is Black, which | think is a plus.
So if | ever go through anything, | don't feel
[a Black doctor] will [dismiss] it. . .. Having
a Black doctor, or somebody that looks like
me at least to some degree, feels more
comfortable than not having one."

- Black woman, focus group participant, age 18 to 21

Many respondents prefer a Black / African
American doctor.

Research studies have shown that patients often
benefit from having a physician of the same race or
ethnicity. A recent Urban Institute study, Improving
and Expanding Programs to Support a Diverse
Health Care Workforce, sponsored by CHCF,
cited findings that "when the race or ethnicity of
a patient matches that of their physician, patients
have greater satisfaction with and trust in them,

 

California Health Care Foundation

www.chef.org 26
and in some cases receive more effective care."°
In California, only 3% of physicians are Black, com-
pared with 6% of the overall population.*

Responses from the interviews, focus groups, and
survey amplify that research, with participants across
the study expressing high levels of interest in having
Black physicians. Nearly half of Black Californians

(47%) say it is extremely or very important to have a
Black or African American doctor. Across all age cat-
egories, women are more likely to express a strong
preference for a Black doctor than men, except for
the 75+ age group. Two-thirds of women of child-
bearing age (66% of those age 18 to 34 and 69%
of those age 35 to 44) say it is extremely or very
important to have a Black doctor (Figure 25).

"The first day that | was in the hospital, | did have a Black pediatrician, which was amazing.

It made all the difference because she was talking about things, educating me about things.
If there was a minor issue, she [reassured me that] it was nothing to worry about. | felt great.
She listened to me. She heard me. She was there only one day, and another person came who
was the pediatrician [on duty], and that all went out of the window. If | asked any questions,
they told me, 'We have other patients that we have to see.'"

- Black woman, focus group participant, Medi-Cal/uninsured

Figure 25. Importance of Having a Black Doctor, by Gender and Age

 

When it comes to health care, how important is having a Black or African American doctor?

Mi Extremely/Very important

cL 12% 42% 19% Bh 34%

ee

Women Men
45 to 54

Women Men
35 to 44

Women Men
18 to 34

M8) Somewhat important

 

Women Men

HE Not too important / Not important at all

  
  

22% ff 38% 24% ff 39% 44% Be ai%

PLoy
ab

36%
Rab

Women Men
75 and older

Women Men
65 to 74

55 to 64

Notes: Sample includes 3,325 Black California residents age 18 and older. p <.05 for differences between female and male for each age group. Don't know /

Prefer not to say not shown.

Source: Listening to Black Californians, statewide survey conducted by EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 27
Half of LOBTOIA+ respondents consider it
important to have a doctor who identifies as
LGBTOIA+.

In the qualitative research, many LGBTOIA+ partici-
pants discussed the difficulty of finding providers
who respect them and provide care to them without
bias. In the survey, having a doctor who identifies
as LGBTOIA+ is extremely important to 21% of
LGBTQIA+ respondents, very important to 11%,
and somewhat important to 27% of LGBTOIA+
respondents (Figure 26).

Figure 26. Importance of LGBTQIA+ Doctors to
LGBTQIA+ Respondents (n = 330)

 

When it comes to health care, how important is having a
doctor who identifies as LGBTQIA+?

Don't know /
Prefer not to say (1%)

ane TAIN

Not at all '
important

important

21% aU

A Ta7

important
Not too cE

important
uty

Somewhat
important
Va

 

Notes: Sample includes 3,325 Black California residents age 18 and older.
Segments do not sum to 100% due to rounding.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

"In addition to being multiracial, I'm part of
the LGBTO community. So, | do try to find
doctors that are LGBTQ friendly. That is
one thing | do look for, for sure. Because |
do know that can be an issue with a doctor
treating you and I'd rather not have to deal
with potential ramifications of anyone's
beliefs in my medical care."

- 25-year-old Black man,
Inland Empire

SECTION 3

Black Californians'
Recommendations for
Addressing Racism
and Discrimination in
Health Care

Although the Listening to Black Californians study
reveals many differences in the health care expe-
riences of Black Californians, survey respondents
universally recognize that the health care sys-
tem requires transformative change to improve
the health and well-being of Black residents. This
shared belief in the need for change is grounded
in a strong sense of Black identity and linked fate,
the sense that what happens to one Black person
affects all Black people.

 

California Health Care Foundation

www.chcf.org 28
Black identity is central to the
lives of Black Californians and
informs their views on how to
improve the health care system.
To establish a context for Black Californians' views
on health and health care, survey respondents
were asked whether they feel being Black is an
important part of their identity. Across every major
demographic category, around 90% of respondents
strongly or somewhat agree that "being Black is an
important part of my identity" (Figure 27).

Figure 27. Importance of Black Identity, by Gender

 

To what extent do you agree with this statement?:
"Being Black is an important part of my identity."

Hi Strongly agree 'Ml Somewhat agree

Women (n= 1,829)

86% 11%

Men (n = 1,235)

79% 12%

Overall (n = 3,325)

82% | 11%

Notes: Sample includes 3,325 Black California residents age 18 and older.
p <.05 for differences by gender for total who agree. Somewhat agree,
strongly agree, and don't know / prefer not to say are not shown.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

Nearly all respondents hold a belief in linked fate,
the sense that what happens to one Black person
affects all Black people. More than 9 in 10 Black
Californians overall (92%) believe in linked fate.
Those with incomes under 200% FPL (95%) and
women (94%) express an especially strong belief
in linked fate (Figure 28). The belief in linked fate
is reflected in the universal recommendations that
survey respondents endorse to improve the health
care system.

Figure 28. Belief in Linked Fate, by Gender and Income

 

Do you think that what happens to Black people in this
country affects you and what happens in your life?

<

es: No:
HA lot Mi Somewhat M Not very much Ml Not at all

Women (n= 1,829)

vhs 24%
3% 2%
Men (n= 1,235)
63% 26% 6%
4%
Overall (n = 3,325)
CY il 25% 5%

5% 3%
Under 200% FPL (n = 630)

LN VPA

2% 1%
200% to 399% FPL (n= 814)

Na 24% 5%

2%
2>400% FPL (n = 1,292)

62% BVA

3% 2%

Notes: Sample includes 3,325 Black California residents age 18 and older.
FPL is federal poverty level. p <.05 for differences by gender except for
yes, somewhat. p <.05 for yes, a lot and no total between <200% and other
groups. Don't know / Prefer not to say are not shown. Segments may not
sum to 100% due to rounding.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 29
Black Californians

universally endorse specific
recommendations to address
racism and discrimination in
health care.

Participants in the interviews and focus groups
offered many recommendations for addressing
and preventing racism and discrimination in health
care. Survey respondents were asked to weigh in on
these recommendations, and a strong majority think
these solutions are extremely or very important for
addressing racism and discrimination in health care.

Recommendations are grouped into four major
categories:

1. Increasing Black representation among health
care leaders and providers

2. Expanding community-based education and
advocacy

3. Training providers and holding the health care
system accountable

4. Developing more holistic approaches to
health care

"Black people need to be educated that
they have a right to proper health care... .
You have to be willing to demand it, and
if you don't get it, you have to be willing
to file a complaint. . . . [If] a doctor gets
enough complaints, it will affect his license,
his board certification, and practice in that
state. [If there are no repercussions and
consequences,] a person... is not going
to change behavior toward you. ... So we
have to educate ourselves and be willing to
do what it takes to cause repercussions and
consequences .. . when we're mistreated
[because of] discrimination or bias."

- 55-year-old Black man,
Los Angeles

 

California Health Care Foundation

www.chcf.org 30
1. Increasing Black representation among
health care leaders and providers

"In systems with diverse leadership,
you can see the change."

- Dr. David M. Carlisle, Listening to Black Californians
Advisory Group Member

"[To reach Black men,] it's helpful to use
data and have messages come from
a Black male physician to another
Black man."

- Dr. Oliver T. Brooks, Listening to Black Californians
Advisory Group Member

A common criticism among Black Californians
who were interviewed or participated in the focus
groups was the lack of Black representation across
the health care system, from a lack of Black doctors
and other providers to a lack of Black individuals
leading health care organizations, clinics, and hos-
pitals. Survey respondents overwhelmingly endorse
increasing Black representation in the health care
leadership ranks (85% say this action is extremely
or very important) and among providers (80% say
this action is extremely or very important) to help
address racism and discrimination in health care. In
addition, 80% say it is extremely or very important
to expand the number of Black-led, community-
based clinics and medical practices (Figure 29).

Figure 29. Increasing Black Representation to Address
Racism in Health Care

 

| am going to read you a list of suggestions made to
address racism and discrimination in health care. After
each suggestion, please tell me if you believe the item
to be extremely important, very important, somewhat
important, not too important, or not at all important
when it comes to addressing racism and discrimination
in health care.

THOSE WHO ANSWERED "EXTREMELY/VERY IMPORTANT"
Increasing the number of...

Black health care leaders

Slob

Black doctors, nurses, and other health care providers

s10y/

Black-led, community-based clinics and medical practices

80%

Note: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

"| feel like we need more Black doctors, we
need more Black nurses. We need more
Black [people] on boards, politicians, stuff
like that. So if my kids can be the next doctor
or the next nurse, or the next practitioner, I'll
take that, if that's what it takes for us to get
our people out. I'm definitely with that."

- 34-year-old Black man,
Sacramento

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 31
2. Expanding community-based education
and advocacy

"| think more assistance and advocacy at the
street level [are needed] rather than [with]
the bureaucracy and going through social
services. Put the help where people need
it... . [We need] advocates who support
dignified health care for people who are
poor and homeless."

- 74-year-old Black woman,
Los Angeles

More than 8 in 10 Black Californians (84%) say it is
extremely or very important to expand community-
based education on how to navigate the health care
system and advocate for high-quality care. Three
in four (77%) say it is extremely or very important
to expand the number of Black community health
advocates and medical chaperones available to
patients (Figure 30).

Figure 30. Expanding Community-Based Resources to
Address Racism in Health Care

 

| am going to read you a list of suggestions made to
address racism and discrimination in health care. After
each suggestion, please tell me if you believe the item
to be extremely important, very important, somewhat
important, not too important, or not at all important
when it comes to addressing racism and discrimination
in health care.

THOSE WHO ANSWERED "EXTREMELY/VERY IMPORTANT"

Expanding community-based education on how to navigate
the health care system and advocate for high-quality care

84%

Expanding the number of Black community health advocates
and/or medical chaperones available to patients

Notes: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

California Health Care Foundation

www.chcef.org 32
3. Training providers and holding the health
care system accountable

"Acknowledge that there are race issues
among medical professionals in the medical
system. Acknowledge it. The data is there
... of doctors giving more care to a White
patient than to a Black patient who's
suffering the same issues. . . . What is that
about? How do we explain that? We have

a problem. And we need to address it
collectively, together. . . . It just needs to
be taken head on. Because once again, [the
medical system] is a matter of life and death
for many Black people."

- 58-year-old Black man,
Los Angeles

A majority of survey respondents agree with recom-
mendations to hold the health system and providers
accountable. Over 8 in 10 Black Californians (82%)
believe it is extremely or very important to ensure
there are financial consequences and other
accountability measures when incidents of racism
or discrimination occur. There is similarly high sup-
port (80%) for requiring that providers and other
health care professionals receive implicit bias train-
ing (Figure 31).

Figure 31. Training Providers and Creating
Accountability to Address Racism
in Health Care

 

| am going to read you a list of suggestions made to
address racism and discrimination in health care. After
each suggestion, please tell me if you believe the item
to be extremely important, very important, somewhat
important, not too important, or not at all important
when it comes to addressing racism and discrimination
in health care.

THOSE WHO ANSWERED "EXTREMELY/VERY IMPORTANT"

Ensuring that there are financial consequences and
other accountability measures when incidents of
racism or discrimination occur

82%

Requiring that doctors, nurses, and other health care
professionals receive implicit bias training

80%

Broader recognition of the history and existence of
racism in medicine

VES

Tying accreditation for doctors and hospitals to improvements
in health disparities and ratings of patient experiences

ey

 

Notes: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 33
4. Developing more holistic approaches to
health care

"The focus on wellness and alternative
medicines in the study is key. .. . It is
imperative to incorporate this into
medical training."

- Dr. Oliver T. Brooks, Listening to Black Californians
Advisory Group Member

Throughout the study, participants expressed
interest in broadening the definition of medicine
to include holistic and alternative approaches to
care. The survey findings echo comments from
participants in the interviews and focus groups
who thought holistically about their health and the
connections between mind, body, and spirit, and
those who turn to alternative approaches for care
or medical treatment. Approximately 7 in 10 Black
Californians think it is extremely or very important
to develop more holistic approaches (73%) and
to expand access to non-Western or alternative
approaches to care (69%) (Figure 32).

Figure 32. Increasing Holistic Approaches to Address
Racism in Health Care

 

| am going to read you a list of suggestions made to
address racism and discrimination in health care. After
each suggestion, please tell me if you believe the item
to be extremely important, very important, somewhat
important, not too important, or not at all important
when it comes to addressing racism and discrimination
in health care.

THOSE WHO ANSWERED "EXTREMELY/VERY IMPORTANT"

Developing more holistic approaches that consider the
connection between mind, body, and spirit

 
 

73%

Expanding access to non-Western or alternative
approaches to care and/or medical treatment

Notes: Sample includes 3,325 Black California residents age 18 and older.

Source: Listening to Black Californians, statewide survey conducted by
EVITARUS (March 5 to May 8, 2022).

 

California Health Care Foundation

www.chcf.org 34
Conclusion

The Listening to Black Californians study shows that
Black Californians are actively engaged in the pur-
suit of health and are consistent users of the health
care system. They have health insurance, get pre-
ventive screenings, prepare for doctor visits, and
monitor their physical health, often at higher rates
than other racial and ethnic groups.' In addition, they
exert great effort to tend to their mental health and
seek holistic medicine and alternative approaches
to care. Yet, while the average Californian lives
to be 81, the average Black Californian lives only
to 75. In this study, Black Californians share their
experiences of how California's health care system
- public and private - is failing them, and offer
specific recommendations for how to improve the
health care system for them.

Although Black Californians share many similar atti-
tudes toward health and similar experiences in the
health care system, there are important differences
by gender, socioeconomic status, health status, and
sexual orientation. In many cases, this study finds
that the greatest burden is borne by those most in
need of health care.

An unacceptably high proportion of the Listening
to Black Californians study respondents (31%), or
more than 1,000 people, has been treated poorly
by a health care provider because of their race or
ethnicity. In addition to experiencing racism and
discrimination, too many Black Californians report
inadequate treatment for their pain, not having their
symptoms taken seriously, and not being treated
with respect. Although alarmingly widespread, this
mistreatment is most likely to be experienced by
women who are enrolled in Medi-Cal, people with
low incomes, uninsured individuals, people with
mental health conditions and/or physical disabili-
ties, and people who identify as LGBTOIA+.

The effects of this mistreatment are costly to Black
Californians and to the health care system. This sur-
vey finds that Black Californians who have received
poor treatment are much more likely to avoid care
altogether or to engage in understandable defen-
sive behaviors during health care appointments,
both of which may prevent timely diagnosis and
treatment.

"The missing piece is that there's still not
quality care... . [I]t isn't about knowing what
to do as a provider; it's about not doing it.
And at this point, | don't see any other way
to change that behavior other than to add an
uncomfortable sense of accountability."

- Dr. Venise C. Curry, Listening to Black Californians
Advisory Group Member

There is broad agreement among survey respon-
dents on pragmatic approaches to making the
health care system work better for Black people.
At the core of their recommendations is devel-
oping strong patient-provider __ relationships.
Overwhelmingly, Black Californians want providers
who listen to them, spend time with them, speak
respectfully with them about health goals - pro-
viders who are partners and advisors. Eight in ten
Black Californians agree that it is extremely or very
important to have more Black doctors and health
care providers, as well as more clinics staffed by
Black health care workers in their communities.

Survey participants also want health systems to
be held accountable for delivering equitable
care. Whether through accreditation or financial
consequences, they want to see good behavior
incentivized and bad behavior penalized.

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 35
Black Californians already play an active role in their
own health and health care, and their responses
suggest that many are ready to become more savvy
users of health care systems. More than 8 in 10
respondents want more information about navigat-
ing the health care system so they can advocate for
themselves and their families (84%). Over three in
four want more community advocates to help and
support them (77%).

The diverse voices of participants speak loudly
through Listening to Black Californians. They tell
us that eliminating the detrimental effects of rac-
ism and discrimination on their health is within our
grasp if we are willing to listen to Black Californians,
build trust and partner with them, and hold the
health care system accountable for equitable care.

 

California Health Care Foundation

www.chcf.org

36
Appendix. Methodology

CHCF's Listening to Black Californians statewide
survey was conducted from March 5 to May 8,
2022, by EVITARUS, a Black-owned public opin-
ion research firm, using multiple-frame sampling
to achieve a total sample of 3,325 adults who self-
identify as Black or African American. This included
an oversample of 330 Black Californians who
identify as LGBTOIA+. The survey is one of the larg-
est-scale surveys to date focused on the health care
experiences of Black Californians. The survey was
administered by phone (landline and cell phone;
n = 738) and online (n = 2,587). Opinion Services
administered the survey by phone using a team of
live interviewers who identify as Black or African
American. EVITARUS administered the survey
online, including distribution of invitations to par-
ticipate via text and email. All survey respondents
were offered an incentive for completing the survey.

The research and sampling design of this study was
developed to help ensure that as many California
residents who identify as Black and/or African
American as possible had at least some probability
of inclusion in the survey sample. According to the
2020 US Census, the Black population in California
is less than 10% of the population. California's Black
population is also becoming increasingly geo-
graphically dispersed, as is apparent when census
estimates are compared over time. Both factors, in
combination with the general decline in response
rates for general population studies, present chal-
lenges to efficiently and effectively reaching a
sample of Black Californians large enough to reflect
the geographic and demographic diversity of the
population.

A multiple-frame sampling design was used to
maximize coverage of the study's target population
and overcome some of the limitations that might be
associated with relying on a single sample source or
a single-frame approach. The sampling frames were

composed of a combination of probability and non-
probability samples, including the following:

>» A probability sample based on cell phone billing
addresses drawn by Dynata (n = 388), to capture
known California cell phone numbers most likely
belonging to residents who currently live in the
state, increase coverage of the target population,
and minimize bias that might be associated with
the listed sample frames included in the design

> A probability sample of registered voters
obtained from Political Data Inc. (n = 2,090), to
maximize the likelihood of reaching the target
sample size of 3,200 respondents

> Anonprobability sample of nonregistered voters
drawn by Catalist (n = 420), to increase coverage
of the nonvoting population

> A nonprobability sample drawn from a propri-
etary panel of self-identified Black Californians
maintained by EVITARUS (n = 427), to increase
coverage of the nonvoting population and
enhance the efficiency of reaching self-identified
Black Californians with predetermined willing-
ness to participate in research

Both the EVITARUS panel and the Catalist database
were screened against the full file of California regis-
tered voters maintained by the California Secretary
of State, to help ensure that these two sampling
frames included only persons who were not regis-
tered to vote or who were registered to vote but did
not have a phone number or email address associ-
ated with their registration and would therefore not
be captured by the registration-based sample. For
each sampling frame, live interviewers first called
records containing a phone number (landline or
cell), then followed up with invitations to nonre-
spondents by text, email, or both text and email,
depending upon the contact information available.
Records that contained only an email address were

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health 37
sent an email invitation to participate in the survey
online.

Poststratification weights were applied using a rak-
ing procedure to align the distribution of the data
with the adult population of Black Californians by
gender, region, insurance status, insurance type,
percent living below the FPL, and education, and to
account for the oversampling of those who identify
as LGBTOQIA+. The weights were calibrated using
the following sources:

> 2020 US Census data for the regional distribution
of Black Californians and levels of education

> 2019 American Community Survey for popula-
tion estimates by age, gender, and percentage
below the FPL

> 2020 California Health Interview Survey (CHIS)
for population estimates for rates of insurance
coverage and insurance type reported among
self-identified Black adults over the age of 18

> 2019 American Community Survey data analyzed
and reported by the Williams Institute at UCLA
for population estimates of the percentage of
Black Californians who identify as LGBTOIA+

The weighted percentages included in Table 1,
page 7 were calculated using the above procedure.

Research and sampling design, implementation,
weighting, tabulation, and data analysis were con-
ducted by EVITARUS.

 

California Health Care Foundation

www.chcf.org

38
Endnotes

1.

Megan Thomas and Allison Valentine, 2021 Edition - Health
Disparities by Race and Ethnicity in California, CHCF,
October 22, 2021.

. "Advancing Black Health Equity," California Health Care

Foundation (CHCF), accessed August 19, 2022.

. Nicole Torres, "Research: Having a Black Doctor Led Black

Men to Receive More-Effective Care," Harvard Business
Review, August 10, 2018. Cited in Kima Joy Taylor et al.,
Improving and Expanding Programs to Support a Diverse
Health Care Workforce: Recommendations for Policy and
Practice, Urban Institute, May 2022.

. Janet M. Coffman, Emmie Calimlim, and Margaret Fix,

California Physicians: A Portrait of Practice, CHCF,
March 2021.

. Health Disparities by Race and Ethnicity in California, CHCF.

 

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health

39