The lasting impact of hospital segregation

This blog was first published in the Anti-Racism Daily on March 17, 2022.

Hospitals are an essential part of our health system, providing routine, specialty, and emergency care for millions of people each year. That’s why addressing ongoing racial segregation in hospitals is so urgent. Persistent hospital segregation in U.S. cities means that not all hospitals are equally accessible. 

A new analysis from the Lown Institute shows what hospital segregation looks like in major cities. Some prestigious hospitals serve mostly patients from whiter, wealthier areas, despite being just as close to communities of color. At the same time, patients from Black and Brown communities are concentrated in “safety net” hospitals, which often have fewer resources and lower quality of care.

For example, at the Netflix-famous Lenox Hill hospital in New York City, 67% of their Medicare patients were white in 2020. However, 47% of patients within their surrounding community who could come to the hospital were white. On the other hand, at the Metropolitan Hospital, a public hospital less than two miles away, 34% of their Medicare patients were white in 2020. The average Medicare patient income at Lenox Hill is $61,000 — double the patient income at Metropolitan. 

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.”

Dr. Vikas Saini, president of the Lown Institute (Medpage Today)

Racial segregation in hospitals is not a new phenomenon. Research has shown that people of color are 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. 

Drivers of segregation

Most hospitals in the U.S. are nonprofits that receive billions in tax breaks for fulfilling their charitable mission. But the way we pay hospitals does not incentivize them to care for the patients most in need. 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.

To do this, some hospitals advertise their elective services in white, wealthy neighborhoods. Others even relocate to white neighborhoods in search of privately insured patients. The fact that we have a two-tiered insurance system rather than universal coverage is not an accident. It’s a policy choice driven in large part by racism.

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

Dr. Mary T. Bassett (The Lown Institute)

Historical and cultural factors also impact racial segregation in hospital markets. Many of the hospitals that were welcoming to people of color in the past still serve these populations. For example, the Chinese Hospital in San Francisco was built out of necessity when Chinese Americans were unable to access care at other hospitals, and is still a mainstay in the community. People of color may prefer to go to hospitals where the doctors and staff look like them and avoid hospitals where they have been mistreated or felt unwelcome. 

Addressing the “slow pandemic”

However, there is some good news — hospitals have shown that they can be more inclusive when they have to be. For example, in 2020, most hospitals served COVID-19 patients demographically similar to their surrounding communities, rather than patients from whiter and wealthier areas.

It is encouraging that hospitals’ COVID-19 admissions were more representative of the Black and Brown communities disproportionately harmed in the pandemic. Yet chronic conditions such as high blood pressure, asthma, and HIV/AIDS that occur at much higher rates in communities of color often go untreated. These disparities can be thought of as a “slow pandemic” — they’re not as visible as COVID-19 but just as impactful for health.

The COVID-19 pandemic is an emergency. So are preventable deaths from lack of access to quality health care. We need incentives for hospitals to prioritize addressing the slow pandemic of untreated illnesses killing Black and Brown people rather than focusing on elective procedures for wealthier patients. This means paying hospitals the same reimbursement rates for all patients, whether they have public or private insurance. Hospitals should also expand their diversity, equity, and inclusion efforts to include culturally-conscious training, translation services, and large investments toward training and supporting more Black and Brown medical students

Lastly, patients and communities can hold hospitals accountable for including all patients, not just the most privileged, and amplifying community voices on hospital boards. For example, the Chicago Health Equity Coalition organized for community representation on the board of their local hospital when it was taken over by new owners. You can also join the Community Advisory Board of your local hospital, if there is one. 

In 2020, hospitals pledged to address racism in healthcare. If they want to make good on this promise, addressing hospital segregation is a necessary step.