America's Health Segregation Problem

Has the country done enough to overcome its Jim Crow health care history?

A doctor's office in Merigold, Mississippi in 1939 (Marion Post Wolcott / Library of Congress)
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Sixty-two years ago Tuesday, the Supreme Court passed down its decision in Brown v. Board of Education, finding that “segregation is a denial of the equal protection of the laws.” That decision, pertaining to de jure segregation in public schools, became the groundwork for dismantling many of the formal systems of racial segregation that pervaded both the South and the North in the century following the Civil War. Brown v. Board was a key milestone in the civil-rights movement, and a key weapon for that movement’s future successes.

Ever since, the anniversary of Brown v. Board has provided an opportunity for assessing just how far the country has come since the Jim Crow days of naked segregation. The results have been, at best, mixed. Last year, one such assessment detailed the rise of “apartheid schools” that are virtually all black, and the corresponding re-emergence of de facto segregation in public education. Some schools, such as those of Cleveland, Mississippi, still face new court orders to integrate. In other policy areas, the “new Jim Crow,” inspired by Michelle Alexander’s book of that name, has come to be used as an apt categorization of broad disparities in criminal-justice policy. Housing segregation is still rampant, and segregation of black people in areas of concentrated poverty has only accelerated in the past decade. But one of the most enduring—and least noticed—areas of racial segregation even after Brown v. Board has been health care.

Segregation is baked into the way people and institutions discuss health care at its most basic levels. Racial differences in almost every health outcome—from infant mortality to life expectancy––are obvious and pronounced, especially between white people and black people. Perhaps because of the sheer size of the evidence of health disparities, all sides of health-policy debates acknowledge their existence, a consensus that has yet to be achieved in debates about education or criminal justice. Yet segregation in health care is rarely discussed in those terms, and its importance in shaping the larger narrative of race in America is often ignored.

Like other forms of segregation, health-care segregation was originally a function of explicitly racist black codes and Jim Crow laws. Many hospitals, clinics, and doctor’s offices were totally segregated by race, and many more maintained separate wings or staff that could never intermingle under threat of law. The deficit of trained black medical professionals (itself caused by a number of factors including education segregation) meant that no matter where black people received health-care services, they would find their care to be subpar compared to that of whites. While there were some deaths that were directly attributable to being denied emergency service, most of the damage was done in establishing the same cumulative health disparities that plague black people today as a societal fate. The descendants of enslaved people lived much more dangerous and unhealthy lives than white counterparts, on disease-ridden and degraded environments. Within the confines of a segregated health-care system, these factors became poor health outcomes that shaped black America as if they were its genetic material.

The sweeping tide of Civil Rights papered over the fissures that were built into Jim Crow-era health-care, but progress was slow and proved much more difficult to assess than progress in education or housing. Generations of strict geographical segregation left hospitals that served black people deeply segregated, understaffed, and under-resourced. The number of black physicians has never come close to matching their demographic share of the total population. Unlike the temporary integration gains in education, there is no real high-water mark for the state of health-care integration.

The 2010 passage of the Affordable Care Act aimed to set that mark. The ACA functioned as a stealthy civil-rights achievement of the Obama presidency, promising to make health care less of a financial burden, end disparities in health-care coverage, ease barriers to access for people of color, and subsidize preventative health-care services that proved especially lacking in black neighborhoods.

Although the ACA has undoubtedly succeeded at some of those metrics and is still being evaluated for some others, the Supreme Court’s 2012 decision in NFIB v. Sebelius seriously weakened its most key provision. The broad Medicaid expansion to poor people was effectively turned into a state opt-in, and state decisions to expand Medicaid have so far been largely based on ideological grounds. Southern conservative governors and legislatures opposing the ACA on party lines or concerns about expanded federal authority and the costs of the program have formed most of the resistance to the ACA. And many of their states have large black populations. Seven of the ten states with the highest black populations chose not to expand Medicaid. Overall, more than half of the people who are now categorically unable to access any affordable health coverage are people of color. Thirty percent of people without affordable coverage options are black.

The ACA could still be the rising tide that lifts all ships. The law has resulted in record lows in uninsured rates, a development welcome in communities of color, where rates are dropping the fastest. Black people were also historically vulnerable in the states that chose to expand Medicaid, and provisions for community health centers, preventative care, and physician training might end up reducing segregation in purely utilitarian terms. It is also very early in the history of the ACA, and its true impacts are likeliest to be felt—and best measured—over decades.

But even at its best, the ACA alone probably can’t solve all of the problems posed by health-care segregation, and coverage exclusions could engender a whole new class of problems. Neighborhood segregation is still correlated with the likelihood of hospital closings, and the safety-net hospitals that often serve black people have been under extraordinary financial stress, which shows up in outcomes and quality of care. Neighborhood segregation is generally linked to poor health outcomes and less extensive treatment options from physicians. Health care providers are less likely to provide certain screening options for black patients, even with an increased focus on preventative health in the ACA. Despite shortages of doctors of color, these understaffed physicians’ offices are more often than not responsible for sicker patients of color. And with the racialization of exclusion from affordable coverage, in essence the health of people who are already healthier is subsidized while those who have historically needed coverage the most are left out.

Over six decades after desegregation kicked off in earnest with Brown v. Board, America has not traveled far in its journey to escape health-care segregation. At every turn of life, black people and the greater community of color are still beset with a minefield of health-care dilemmas that don’t always exist for everyone else, as they have always been. The ACA represents a crossroads, and the fulfillment of over a half-century of integration rhetoric depends on how future policies embrace its spirit of change. The health-policy debate over the next several years will help answer the most basic question at the heart of every debate about segregation: Just what does America want to be?