The harms of hospital segregation

The creation of Medicare in 1965 helped desegregate hospitals by making equal access to hospitals a requirement for new federal funding. But in many American cities, hospitals are still segregated by race, data from the Lown Institute Hospitals Index shows. In cities like Chicago, NYC, Newark, Philadelphia, Detroit, and others, most hospitals in the area either overwhelmingly serve white patients or people of color.

“If you arrived from another planet and saw two airports a mile apart, one for Black people and another for whites, you’d think this is some kind of weird apartheid. We don’t do that for airports, but somehow that’s where we’ve ended up with hospitals, and everyone knows it.”

Vikas Saini, president of the Lown Institute

This hospital segregation causes serious harms, because often the hospitals serving Black patients and the hospitals serving white patients have significant differences in quality of care. On the Lown Index, we found that safety net hospitals, which tend to serve poorer patients and more people of color, have worse scores on patient outcomes, even when adjusting for patient conditions.

New research from the University of Pennsylvania also finds this pattern in Covid-19 mortality trends. They analyzed Medicare data from 44,000 Covid-19 patients at more than 1000 US hospitals. Black patients with Covid-19 had 11% greater risk of 30-day inpatient mortality or discharge to hospice compared to white patients, even after adjusting for sociodemographic and clinical characteristics. However, when researchers controlled for hospital differences, the mortality difference went away, indicating that hospital quality issues played a large role in the racial disparities in Covid-19 deaths.

To understand why hospitals serving Black patients have worse clinical outcomes, we have to look at structural inequalities in our health system–particularly how hospitals are paid. Our health care system sets up safety net hospitals for failure, because they are paid less to care for patients with public insurance like Medicaid, and not paid at all to care for uninsured patients. This leaves safety net hospitals with fewer resources to improve their quality of care. For example, Covid-19 patients at MLK Community Hospital, a safety net hospital in Los Angeles, did not have access to a antibody therapies, external lung machines (ECMO), or other specialized care that wealthier hospitals had available.

“This is a consequence of being in a society where Black and Brown bodies are undervalued.”

Dr. Mary T. Bassett

We expect hospitals to serve everyone who needs care, regardless of their race or insurance status. But high levels of residential segregation from decades of redlining and discrimination are still perpetuated in our hospital system, and there is little incentive for hospitals to change. We have to end our unequal reimbursement system, so that all hospitals are compensated equally for the patients they serve. At the same time, hospitals caring for communities of color need more support to provide quality of care on par with wealthier hospitals.