5 Ways the Health-Care System Can Stop Amplifying Racism
Instead of reducing disparities, the industry makes them worse. Here’s how to change that.
The coronavirus pandemic didn’t create the health disparities among Americans, but it has exposed once again how stark the problem is. Black and Latino patients are two to three times as likely as white patients to be diagnosed with COVID-19, and more than four times as likely to be hospitalized for it. Black patients are more than twice as likely to die from the virus. They also die from it at younger ages. COVID-19 has exacerbated long-standing trends: Black and Latino Americans have lower rates of insurance coverage, a higher prevalence of chronic diseases, worse health outcomes, and a lower life expectancy. People in the health-care world sometimes speak of these patterns as if they are inevitable facts of life—something the industry is powerless to change. More doctors and hospitals need to acknowledge and address how the U.S. health-care system is rife with structural racism. For decades, American medicine has discriminated against people of color.
The health-care system, by one estimate, is responsible for only about 10 to 15 percent of preventable mortality in the United States. Socioeconomic factors, such as housing, food, and education, have a greater overall impact. Policies that effectively address these factors will be required to significantly reduce disparities in health outcomes for Black and Latino people. Nevertheless, many choices that health-care professionals commonly make—such as not accepting Medicaid patients, having fewer staff members at facilities in minority neighborhoods, and blaming patients for not taking their medicine and for poor overall outcomes—perpetuate disparities and even amplify them.
These health gaps are not immutable. Concrete changes to public policy, industry practices, and medical education could turn the health-care system into a force for greater equality. Here are five such changes:
First, when states are indifferent to whether their Black and Latino citizens have health coverage, the federal government should step in. According to research published earlier this year, 9 percent of white adults were uninsured in 2018, compared with 14 percent of Black adults and 25 percent of Latino adults. The coronavirus recession is making the coverage gap worse. Already, as many as 12 million Americans have lost insurance sponsored by their employer or a family member’s employer. Black, Latino, and other workers of color have faced especially steep declines in employment.
The Affordable Care Act did reduce disparities in insurance by setting up insurance exchanges and making more Americans eligible for Medicaid, but some states opted out of the latter—with terrible consequences for disadvantaged minorities. Indeed, an estimated 46 percent of Black working-age adults live in the 15 states that refused to implement the ACA’s expanded Medicaid benefits, leaving low-wage workers with no way to pay for their family’s care. The disparity rises when joblessness grows: Medicaid covers 36 percent of unemployed adults in states that expanded eligibility for the program, but only 16 percent in states that did not.
So far, federal inducements have not been enough to persuade states such as Texas, Georgia, and Florida to expand Medicaid. The next president and Congress can solve that problem by federalizing Medicaid and removing its administration from states. Such a change could yield universal enrollment standards and greatly reduce the racial health-insurance gap.
Second, policy makers can make insurance coverage meaningful by having Medicaid pay physicians and hospitals more. Having health coverage is necessary, but not sufficient, for patients to obtain good health care in a timely manner. Because Medicaid pays doctors less than Medicare or private insurance does, many doctors refuse to see—or delay appointments for—Medicaid patients. A 2014–15 survey showed that only 68 percent of family-practice physicians accepted new Medicaid patients, while 91 percent accepted those with private insurance. Some doctors did not accept new patients at all or didn’t accept insurance. Only a third of psychiatrists accepted new Medicaid patients.
In 2013 and 2014, the ACA temporarily raised Medicaid payments to primary-care doctors. This fee bump improved patients’ access to doctors. Just as predictably, when states returned to lower fee levels, Medicaid enrollees had more trouble making appointments. The lesson is clear: The federal government needs to permanently raise Medicaid payments to doctors. For hospitals, payment reforms should penalize poor performance on measures of health equity. For example, higher payments to hospitals could be tied to improvements in emergency-room wait times—which have often been found to be longer for Black patients than white ones.
Third, hospitals—which often anchor a community’s health-care system—must address social factors that affect health outcomes. Hospitals that do so could see benefits in the long run. In the mid-2000s, for example, Boston Children’s Hospital began a community-outreach program for low-income Black and Latino children who, based on previous information, seemed likely to be hospitalized with asthma. Case workers worked with families and community groups to reduce the prevalence of conditions that lead to asthma attacks. The result: Unnecessary readmissions, emergency-room visits, missed school days by students, and lost workdays among parents all fell. The program generated $1.73 in benefits for every dollar spent. At a variety of other hospitals, initiatives to address the social determinants of health have led to a fall in readmissions.
The government has leverage over hospitals. In return for avoiding substantial federal and state taxes, nonprofit hospitals are required to provide community benefits. Many hospitals count discounted care to Medicaid and uninsured patients as community benefits. Instead, state and federal policies should specifically encourage hospitals to invest in community health—for instance, in anti-hunger programs or “nurse-family partnerships” that assist low-income mothers. Many hospitals also receive extra funds because they operate in low-income communities, make less money from private insurance, and provide a disproportionate share of their services to patients without the ability to pay. These government payments should be tied to investments that address social determinants of health.
Fourth, increasing diversity among physicians and nurses is vital. In an experiment in Oakland, California, the researchers Marcella Alsan, Owen Garrick, and Grant C. Graziani found that the involvement of Black doctors could reduce the cardiovascular mortality gap between Black and white men by 19 percent. Yet only 5 percent of American physicians are Black, compared with 13 percent of the general population. Latino and Indigenous physicians are similarly underrepresented. Structural barriers, including the excessive cost of attaining a medical or nursing degree and bias in the admissions process, substantially contribute to this lack of diversity. Many states already offer loan-repayment services and other incentives for physicians to work in underserved areas, but expanding these programs could recruit even more underrepresented minorities to the medical field. Not all the obstacles to diversity are economic, of course. Minority students are also more likely to experience discriminatory comments and public humiliation during their medical training. Medical schools and hospitals need to enforce serious disciplinary measures for such behavior, while ensuring that students who complain are not labeled as “troublemakers.”
Finally, all health-care workers could also benefit from a curriculum that specifically addresses implicit bias and the historical roots of racism in the medical system. To this day, medical textbooks still depict mostly white skin tones. Many medical students hold empirically false beliefs about race-based physiological differences—including the notion that Black patients have a higher tolerance for pain than white patients. These beliefs affect the kind of decisions that doctors make. One analysis early in the pandemic found that doctors were less likely to refer symptomatic Black patients for testing than they were to refer white ones. Educating aspiring doctors about these dynamics will improve the care that patients receive.
These five steps won’t cure America’s health disparities, but they outline a course of action. Reducing racial bias in health care will have broad benefits: A country whose residents have fewer chronic conditions, better access to care, and longer lives has a greater capacity for happiness and prosperity. As America faces a national reckoning with structural racism, leaders in the health-care system must confront the role we play and assume responsibility for solving the problem.
Amaya Diana and Aaron Glickman contributed research to this article.