Algorithms Trained on Normal Chest X-rays Can Predict Health Insurance Types

Chi-Yu Chen, Rawan Abulibdeh, Arash Asgari, Sebastián Andrés Cajas Ordóñez, Leo Anthony Celi, Deirdre Goode, Hassan Hamidi, Ned McCague, Laleh Seyyed-Kalantari, Thomas Sounack, Po-Chih Kuo

Keywords: spurious correlation, health insurance, medical images

Abstract: Artificial intelligence is revealing what medicine never intended to encode. Deep vision models, trained on chest X-rays, can now detect not only disease but also invisible traces of social inequality. In this study, we show that state-of-the-art architectures (DenseNet121, SwinV2-B*, MedMamba) can predict a patient’s health insurance type, a strong proxy for socioeconomic status, from normal chest X-rays with significant accuracy (AUC $\approx$ 0.70 on MIMIC-CXR-JPG, $\approx$ 0.68 on CheXpert). The signal persists even when age, race, and sex are controlled for, and remains detectable when the model is trained exclusively on a single racial group. Patch-based occlusion reveals that the signal is diffuse rather than localized, embedded in the upper and mid-thoracic regions. This suggests that deep networks may be internalizing subtle traces of clinical environments, equipment differences, or care pathways; learning socioeconomic segregation itself. These findings challenge the assumption that medical images are neutral biological data. By uncovering how models perceive and exploit these hidden social signatures, this work reframes fairness in medical AI: the goal is no longer only to balance datasets or adjust thresholds, but to interrogate and disentangle the social fingerprints embedded in clinical data itself.

Primary Subject Area: Fairness and Bias

Secondary Subject Area: Integration of Imaging and Clinical Data

Registration Requirement: Yes

Reproducibility: https://github.com/altis5526/Predicting-Insurance-Type-from-Normal-Chest-Xrays

Visa & Travel: No

Read CFP & Author Instructions: Yes

Originality Policy: Yes

Single-blind & Not Under Review Elsewhere: Yes

LLM Policy: Yes

Submission Number: 10