How hospital segregation contributes to racial health disparities

Legal segregation of hospitals by race ended in 1967, but de facto hospital segregation still exists. As much as hospitals would like to believe they are “colorblind,” some hospitals disproportionately serve patients from Black and Brown communities while other hospitals draw their patients from whiter, wealthier communities.

The results of the Lown Institute Hospitals Index includes a new metric that measures inclusivity of Medicare patients by race and socioeconomic status. We found that in many cities, hospitals that rank in U.S. News & World Report’s top 20 “honor rolldo a poor job of treating minority and low-income patients. On the other hand, safety net hospitals are disproportionately serving patients from communities of color.

In a recent op-ed in The Washington Post, Paul Glastris and Philip Longman, editors of the Washington Monthly, provided a few possible explanations for why these patterns of segregation persist, and discussed the impact on health. (The Monthly published the “Best Hospitals For America” ranking based on the Lown Index.)

“Hospitals barely break even and often lose money when they try to provide the care disadvantaged populations most need.”

Paul Glastris and Phil Longman

A big reason behind hospital segregation is because of the way hospitals are reimbursed in our fee-for-service system. “Currently, hospitals make the most profits on high-tech procedures, such as heart stents and liver transplants, especially when delivered to patients with private insurance, which tends to pay more. But they barely break even and often lose money when they try to provide the care disadvantaged populations most need, such as the kind of neighborhood-based primary care clinics,” Glastris and Longman write. Hospitals also get higher reimbursements for patients with private insurance than patients with Medicare or Medicaid, and Black and Latinx people are more likely to be covered by a government program or to be uninsured. Beyond reimbursement, people of color may avoid certain hospitals because they have been mistreated or felt unwelcome there.

This de facto system of hospital segregation may be exacerbating racial health disparities, Glastris and Longman argue, because the safety net hospitals that serve more people from communities of color are often underresourced, even though their patients are more likely to have underlying chronic conditions than those at elite hospitals. Racial disparities in deaths from heart attacks and childbirth complications have been linked to quality issues at hospitals that primarily serve Black communities.

And with Covid-19, these differences can be deadly. For example, in New York City, patients at elite academic medical centers had access to new drugs like remdesivir, but underfunded hospitals in the neighborhoods hardest hit by the virus lacked basic treatments and were low on staff.

Although most hospitals are tax-exempt nonprofits, these hospitals “are not required to show that they are providing real benefits to their surrounding communities or that they meet standards of inclusivity and nondiscrimination,” like the ones on the Lown Index, write Glastris and Longman.

Existing patterns of hospital segregation are deeply rooted, but they must change. Without policy changes and more dedicated attention to this issue, we will continue to have separate and unequal systems of health care.