How do we desegregate the hospital system?

Hospitals aren’t allowed to reject patients based on their race, income, or insurance status. But years of research shows that in practice, hospital markets in many cities are still segregated, with some hospitals caring for disproportionately more low-income people and people of color than others.

For example, the New York Times recently reported that NYU Langone Hospitals pressured emergency department doctors to prioritize “VIPs” for treatment, while shuttling poor and homeless patients to Bellevue, a public hospital with fewer resources.

The pattern of segregation–driven by redlining and other housing policies, unequal hospital reimbursements, and bias in medical culture–is deeply rooted in our healthcare system. But there are ways that clinicians, hospital leaders, medical educators, and policymakers can take action to make healthcare more equitable. A new series of articles on healthcare segregation in the American Medical Association’s Journal of Medical Ethics provides a call to action and a way forward for all actors in the healthcare system looking to improve racial and economic equity.

Why desegregation matters

Healthcare segregation means that people of color are often concentrated in certain hospitals, usually public or safety net hospitals (hospitals with the mission to provide health for everyone, regardless of their ability to pay), while elite academic medical centers are often out of reach. 

This leads to disparities in access and quality of care. For example, Black and Indigenous individuals are deeply underrepresented in clinical trials of new cancer drugs, in part because they have less access to the hospitals that run these studies. Lower-quality care at some safety net hospitals also contributes to higher rates of COVID-19 mortality and life-threatening birth complications for Black people. 

The role of medical education

In the AMA Journal of Medical Ethics, Lown Institute president Dr. Vikas Saini along with AMA health equity leaders discuss how medical education contributes to healthcare segregation and how academic medicine can promote anti-racism. The authors point out that many academic health systems disproportionately funnel Black, Latinx, and Indigenous patients and low-income white patients into safety net centers and resident clinics, while keeping faculty-only clinics within the same system exclusive.

Medical education itself also fails to teach students about structural racism in our society that created and perpetuates segregation–in part because people of color, particularly Black and Indigenous physicians, have been systematically excluded from leadership roles in medical education, the authors write.

How can medical educators begin to fix healthcare segregation? They can start by learning about the issue, listening to others, and acknowledging structural inequities with students when they occur. Academic medical centers should adopt curricula that address the structural racism and other systems of power and oppression (many residency programs are already doing this). Finally, leaders of academic medical centers must address segregation of employees within the hospital itself by hiring and retaining diverse faculty, committing to paying a living wage to all employees and contractors, and creating new career development pathways for low-wage hospital workers.

Payment reform

However, it will take more than actions from individual academic medical centers to desegregate hospitals. That’s because the incentives to treat patients differently based on their race or income is embedded within the healthcare payment system.

Hospitals get paid the most to perform high-tech elective surgeries for patients with private insurance but barely break even on preventive or routine care for patients with Medicare or Medicaid. This means their financial success often depends on attracting wealthier patients with private insurance, patients who are more likely to be white.

In another article in the AMA series, Kimberly A. Singletary and Marshall H. Chin at UChicago Medicine provide recommendations for antiracist payment reform. The two main policy changes they suggest are around healthcare coverage and quality improvement. Ideally we would eliminate our 2-tiered healthcare system and ensure access to quality health insurance for all. Smaller steps include providing more incentives for hospitals to care for patients with Medicaid or uninsured patients, increasing insurance coverage for interventions that address patients’ social needs,

To improve equity in health quality and outcomes through payment, the authors recommend:

• requiring Medicaid managed care plans to implement racial equity impact assessments and other antiracism measures,
• boosting payments to safety net hospitals that serve more patients at high social risk,
• rewarding hospitals that reduce health disparities through alternative payment models
• using the nonprofit hospital tax exemption as a tool to expand care to marginalized populations and invest in community health

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