Kermena Ishak

Honors Interdisciplinary Seminar

Dr. Yeo

12/06/2022

Medical Inequity in Nashville

The healthcare crisis in the world, and Nashville specifically, has always been present.

However, after Covid-19, concerns regarding medical inequality surfaced as some groups of

people were prioritized before others when receiving the vaccine or testing. Health Inequity

alludes to disparities in health levels that are typically avoidable between various communities or

individuals. Unbalanced allocations of societal, geographical, and economic factors within

cultures cause such inequities. These factors influence people's chances of being sick, their

capacity to control illness, and appropriate medicines/treatment availability. Expanding diversity

in the hospital workplace could limit health inequities that have generated a significant disparity

in the level and treatment that the LGBTQ community, the Black community, ethnic minorities,

and disabled individuals acquire in Nashville, TN.

Inequality in healthcare is not just discrimination in hospitals but the causes, impacts, and

consequences of health differences between communities. Social determinants of health (SDQH)

refer to the environments in which people live and their influence on health. Socio-economic

status, education, unemployment rate, poverty, health insurance coverage, access to healthy

resources, preventable hospitalization, infant mortality, Covid-19, and homicides. All topics are

disparities in health risk and promoting behavior. Based on a 2021 Metro Nashville Health

Equity report by Peters Matthew, typically and statistically, ethnicity and race play a tremendous

role in such health disparities. Tennessee now has the poorest healthcare results in the country.

Before the passage of the Affordable Care Act (ACA) in 2010, the U.S. healthcare system was in

disarray. It had severe accessibility, cost, and performance issues, making millions of Americans
unable to pay medical expenses without health insurance. Unaffordable insurance premiums and

limited provider networks made it difficult for numerous individuals to obtain the treatment they

required, resulting in an extensive patchwork system of government-run programs such as

Medicaid and the Children's Health Insurance Program (CHIP) that provided care to several of

society's vulnerable groups but was unavailable to numerous others. The ACA responded to

these problems by enacting several changes that enhanced coverage accessibility. Nevertheless, it

also generated new challenges by demanding that all individuals receive coverage and innovating

different marketplaces where people can buy individual policies. These reforms were a start in

the proper direction, but much work remains to be taken to guarantee that every American has

access to affordable, high-quality healthcare. The ACA did not address the most serious concerns

confronting Americans. Private health insurance is too costly for several families and

individuals. One-third of the population is uninsured, with countless more facing significant

out-of-pocket expenses due to high copayments and deductibles.

Limited access to adequate treatment, hostile providers to LGBTQ+ patients, and

unwarranted discrimination within the healthcare system are all obstacles that substantially

influence the lives of the LGBTQ+ community. Such structural impediments often result in

overlooked diagnoses. The uninsured rate in Nashville is greater than the state average, and

insurance rates for LGBTQ+ individuals are lower than the general population. According to

Gilbert Gonzales' recent study on Nashville's LGBTQ population, over 70% of the city's LGBTQ

residents were uninsured; bisexual women were 13.8% uninsured, while straight women were

3.9% uninsured. Similarly, roughly half of Tennessee's trans males are uninsured. Due to

prejudices, unemployment is prevalent, leaving numerous LGBTQ+ individuals without

insurance. This indicates significant discrepancies in education, housing, and medical care.

Living in the city and having a better socioeconomic status could provide greater access to
medical resources (Gonzales). Healthcare benefits such as transgender-inclusive healthcare and

prescription contraceptives are also limited.

Tennessee constructs challenges for the LGBTQ population to receive equal treatment in

hospitals. The TN Justice Center reminded Tennesseans that the state "does not prohibit

conversion therapy, does not prohibit health insurance providers from excluding coverage for

transgender-specific care, and does not prohibit private health insurance companies from

discriminating based on sexual orientation or gender identity. Tennessee is one of 12 states that

officially restricts access to Medicaid coverage for gender-affirming care." It is lawful for

healthcare practitioners to refuse care if they believe your gender contradicts their perception of

what gender "should" be. Furthermore, doctors can deny treatment if they suspect the patient of

homosexual behavior. Based on a 2017 Harvard School of Public Health poll, approximately

40% of LGBTQ respondents reported discrimination in medical treatment. With this lack of

respect, many LGBTQ+ individuals avoid medical care when ill for fear of prejudice from health

practitioners. This makes LGBTQ+ people more vulnerable to illnesses, including HIV,

depression, hepatitis, higher death rates, and other chronic health issues.

The approach to treating LGBTQ+ people for coronavirus testing has been disgraceful.

While LGBTQ+ individuals are encouraged to be tested, medical staffs are frequently inattentive

to the concerns of LGBTQ+ patients during the screening procedure. Despite having the

resources to do so, Nashville General Hospital did not examine members of the LGBTQ+.

Several hospitals around the U.S., including Vanderbilt University Medical Center, rejected

LGBT patients during the crisis, ignoring that their health issues were critical and they were

previously isolated. LGBTQ patients were dismissed from emergency care as well. As a

response, several LGBTQ individuals used online support organizations and media platforms to

communicate and locate resources that could assist them.

 Nashville's medical community has attempted to address these discrepancies, but much

work remains. Inclusive clinics are offered, such as the Vanderbilt transgender clinic; however,

such clinics are not common in rural areas. Moreover, many healthcare staff are uninformed

about the needs of LGBTQ+ patients. They may unintentionally contribute to these inequities by

neglecting to offer proper treatment or raising unsuitable inquiries that may place them in danger.

The LGBTQ community may be subjected to discriminatory visiting policies as well. To

effectively accommodate the requirements of LGBTQ+ patients, healthcare institutions must

consider expanding the diversity of their workforce to ensure that more health workers recognize

their patients' situations and can fulfill their needs. The Metropolitan Government of Nashville

and Davidson County have a collaborative effort to combat health inequities through the

Meharry-Vanderbilt Alliance on Community Engaged Research (MAVERE) to enhance the

health of our community members through innovative research and educational training. To

assist LGBTQ+ patients, healthcare employees must undergo training to develop their cultural

competency.

Death rates within racial and ethnic minority communities among Nashville residents

have increased since 2012. According to Matthew's 2021 Metro Nashville Health Equity report,

Black and Hispanic individuals are more inclined to be impoverished, consume tobacco, eat

poorly, and lack medical coverage. These socioeconomic determinants are critical in affecting

health outcomes. They are also avoidable. Addressing disparities starts with a comprehension of

the core cause. For example, a Tennessee Health News study indicates that Black and Latino

patients were significantly more likely to obtain high-cost heart disease care in 2017. African

American males are three times more likely to die from a heart attack, while African American

women experience twice the mortality rate of white women during childbirth. Similarly, Latinos

were nearly three times more likely than whites to be hospitalized for a high-cost treatment.

These percentages are greater than other states in the U.S., notably Mississippi and Alabama,
which are known for having poor health performance in minority groups. This is attributable to

their inferior population health and a history of racism in our state. Due to such circumstances,

most racial minorities in Tennessee are far more likely to be uninsured or reside in disadvantaged

regions without local hospitals.

African Americans in the state are significantly affected by the epidemic since their rates

of heart disease, high blood pressure, and diabetes is higher. Access to medical care is a struggle

for many colored individuals in this state; the prevalence of insurance coverage among those

residing at the federal poverty line is extremely low. TN healthcare workers revealed through

NEJM Innovations in Care Delivery that African-Americans comprise just 17% of the

population, yet they account for 32% of Covid-19-related deaths. African Americans are also

reported to have a higher hospitalization rate. Furthermore, patients in Nashville with Language

English Proficiency (LEP) had a greater positive rate than patients who spoke English as their

first language. A recent Vanderbilt University School of Medicine report indicates that just 18%

of African Americans have received Covid-19 vaccination (NEJM). This difference is partly

attributable to a deficiency of vaccination distribution and African-descent distrust of

government and public medical institutions. Considering their high poverty rates and the

frequency of health difficulties, it is hardly unexpected that the coronavirus adversely impacts

Tennessee's racial minorities. We are witnessing a severe epidemic, yet we have neglected to

offer appropriate access to healthcare and medications.

Tennessee must address the disparities in our medical system and implement essential

changes to guarantee that every patient receives fair treatment. Before all else, we should seek to

remove the long-standing racial and ethnic inequities in our healthcare system. Only then could

we establish a proper universal system that benefits all. Programs or organizations collaborating

with medical schools like Vanderbilt to increase racial diversity can be the first step. Increasing

the number of Black doctors or ethnic minority groups will encourage patients to find comfort in
hospitals. Collaboration with community groups to ensure that the requirements of vulnerable

members of society are fulfilled is also critical for a more equitable health care delivery. Public

health workers can help detect at-risk individuals and engage them with psychological assistance

programs, dietary guidance, and healthcare education. They can work with medical practitioners

to guarantee that individuals in their areas receive proper treatment.

In Tennessee, the healthcare system is inequitable and unattainable to the disabled.

Between 2010-2014, Nashville's disability rate grew slightly and stayed unmoved. This is due, in

part, to demographic shifts and an increase in chronic diseases. Nashville 2019 data from Centers

for Disease Control and Prevention suggest, "disabled individuals have less access to health care,

have more depression and anxiety, engage more often in risky health behaviors such as smoking,

increased risk of diabetes and heart diseases, and are less physically active." These inequities

result from insufficient state and federal financing and a limitation of Medicaid expansion under

the ACA. Merely 2% of Medicaid funding in Tennessee is spent on long-term medical care for

disabled individuals when 10% of the populace has a disability. While it is true that the ACA

extended the availability of health coverage and offered to finance community-based resources

for individuals with developmental and intellectual disabilities, various local and state

governments are reducing Medicaid programs to cover the loss of federal funds. Several states

that did not adopt the Medicaid expansion provision, such as Tennessee, had significant financial

limitations for treating people with disabilities.

Limited access to transportation in rural locations is one of the most significant obstacles

that individuals with intellectual or physical disabilities face. Transportation is frequently

required for medical appointments; however, the Individuals with Disabilities Education Act

(IDEA) forbids schools from offering transportation services unless it is necessary for academic

purposes. This places an additional strain on families, which is challenging if the family does not

possess a car or afford the expenses. Transportation is also an issue in rural areas where public
transportation is minimal. According to the U.S. Census Bureau, 19% of the U.S. population

resides in rural regions, whereas disabled individuals compensate for 25% of those living in rural

regions. Most rural communities lack essential hospital services, forcing patients to commute

vast distances for treatment. This can cause treatments to be postponed, leading to repercussions

or avoidable deaths. Furthermore, rural residents experience worse health than urban populations

and are less likely to be insured. Such variables generally result in increased infant death rates

and reduced life expectancy. This city also has a vastly greater rate of uninsured disabled

individuals than the overall population. These findings emphasize the pressing need for enhanced

medical care in the Nashville district.

Due to Covid-19, the issue concerning care accessibility for disabled people has become

increasingly urgent. Throughout Covid-19, the disabled in Nashville were reported to be at high

risk for death and hospitalization due to pre-existing medical issues and other Covid-19-related

variables. The elevated likelihood of severe sickness or death among specific groups of disabled

people throughout this virus underlines the necessity of providing access to quality healthcare for

all Nashvillians. Numerous disabled individuals cannot get the medical attention they require due

to closure and quarantine. During Covid-19, relatives are also less likely to assist disabled

individuals. It is more critical than ever to guarantee that people with pre-existing medical

illnesses obtain access to the health services they require.

Disabled individuals require direct legal attention. Based on WHO records, disabled

individuals in Nashville have immense poverty rates and lower employment than the general

public. All city residents can have equitable access if a new program is created to overcome such

obstacles and support the needs of disabled people in Nashville. The city council could pass a

resolution promoting federal legislation, such as the Disability Integration Act, that could secure

disabled Americans' rights and simplify the process for them to receive health care and other

public services. Moreover, hiring additional healthcare providers who are educated to engage
with disabled individuals can enhance the functionality of healthcare services. Expanding

government financing for services that notably address the issues of individuals with disabilities

and making public spaces more functional are two more options. Likewise, Nashville can

promote public understanding of people with disabilities and advocate greater inclusive laws

within the city administration.

Racism and discrimination are the foundation of almost all health inequalities; minorities

are constantly at a disadvantage. While some hospitals and organizations are taking action, only

a few are accessible. Because of this underlying tension, promoting diversity in medical schools

is the first step toward combating maltreatment in the medical setting. Enforcing a diverse

representation of people of color, non-Americans, and LGBTQ people in medical schools and

hospitals could benefit all future patients. Furthermore, by mandating health workers to receive

training to meet the requirements of disabled people and other minority groups, the health system

will become considerably more accessible. A social media campaign managed by current

Tennessee Health workers who are members of minority groups could educate administrators,

the public, as well as other organizations and agencies about health inequities, their causes, and

evidence-based approaches, such as the one outlined above, for effectively addressing specific

issues within minority groups of high-risk health.

 Resources

Peters, Matthew. "2021 Metro Nashville Health Equity Report."

“Impact of the Affordable Care Act (Obamacare) in the United States (2009-2017).” Ballotpedia,

https://ballotpedia.org/Impact_of_the_Affordable_Care_Act_(Obamacare)_in_the_Unite

d_States_(2009-2017).

Gonzales, Gilbert, et al. "Health Disparities among Lesbian, Gay, Bisexual, and Transgender

(LGBT) Adults in Nashville, Tennessee." Southern Medical Journal 114.5 (2021):

299-304

TJC. “Health Equity.” Tennessee Justice Center, 13 Oct. 2022.

https://www.tnjustice.org/health-equity/.

Vanderbilt Health. “LGBTQ Focus on Cancer.” Program for LGBTQ Health,

https://www.vumc.org/lgbtq/lgbtq-focus-cancer.

Harvard T.H. Chan School of Public Healt, Robert Wood Johnson Foundation. “Poll Finds a

Majority of LGBTQ Americans Report Violence, Threats, or Sexual Harassment Related

to Sexual Orientation or Gender Identity.” Hsph.harvard.edu, 21 Nov. 2017,

https://www.hsph.harvard.edu/news/press-releases/poll-lgbtq-americans-discrimination/.

Mensah GA. Cardiovascular Diseases in African Americans: Fostering Community Partnerships

to Stem the Tide. Am J Kidney Dis. 2018 Nov;72(5 Suppl 1):S37-S42. doi:

10.1053/j.ajkd.2018.06.026. PMID: 30343722; PMCID: PMC6200348.

Consuelo H. Wilkins, MD, et al. “A Systems Approach to Addressing Covid-19 Health

Inequities.” NEJM Catalyst Innovations in Care Delivery, 1 Jan. 2021,

https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0374.

Shimizu, WHO. “Disability and Health.” World Health Organization, World Health

Organization, 24 Nov. 2021, https://www.who.int/news-room/fact-sheets/

detail/disability-and-health.
“Disability & Health U.S. State Profile Data: Tennessee.” Centers for Disease Control and

Prevention, Centers for Disease Control and Prevention, 18 May 2022,

https://www.cdc.gov/ncbddd/disabilityandhealth/impacts/tennessee.html.

“Health Equity for People with Disabilities.” Centers for Disease Control and Prevention,

Centers for Disease Control and Prevention, 23 Sept. 2022,

https://www.cdc.gov/ncbddd/humandevelopment/health-equity.html.