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

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 around 0.67 on MIMIC-CXR-JPG, 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.

Foundation Model of Electronic Medical Records for Adaptive Risk Estimation

We developed the Enhanced Transformer for Health Outcome Simulation (ETHOS), an AI model that tokenizes patient health timelines (PHTs) from EHRs. ETHOS predicts future PHTs using transformer-based architectures. The Adaptive Risk Estimation System (ARES) employs ETHOS to compute dynamic and personalized risk probabilities for clinician-defined critical events. ARES incorporates a personalized explainability module that identifies key clinical factors influencing risk estimates for individual patients. ARES was evaluated on the MIMIC-IV v2.2 dataset in emergency department (ED) settings, benchmarking its performance against traditional early warning systems and machine learning models. We processed 299,721 unique patients from MIMIC-IV into 285,622 PHTs, with 60% including hospital admissions. The dataset contained over 357 million tokens. ETHOS outperformed benchmark models in predicting hospital admissions, ICU admissions, and prolonged hospital stays, achieving superior AUC scores. ETHOS-based risk estimates demonstrated robustness across demographic subgroups with strong model reliability, confirmed via calibration curves. The personalized explainability module provides insights into patient-specific factors contributing to risk. ARES, powered by ETHOS, advances predictive healthcare AI by providing dynamic, real-time, and personalized risk estimation with patient-specific explainability to enhance clinician trust. Its adaptability and superior accuracy position it as a transformative tool for clinical decision-making, potentially improving patient outcomes and resource allocation in emergency and inpatient settings. We release the full code at github.com/ipolharvard/ethos-ares to facilitate future research.