Hospital Care in Black and White: How Systemic Racism Persists
Covid-19 has exposed, once again, the fact that Black New Yorkers suffer more disease and earlier death than their neighbors. Blacks are twice as likely as Whites to be hospitalized for the virus and twice as likely to die. These stark differences are not new to Covid-19. Virtually every measure of health and longevity shows the city’s Black residents faring worse.
It has long been noted that social and economic inequality contributes to these dismal health outcomes, but structural racism in our healthcare system has received less attention. Our research shows that skin color helps to determine where a patient receives hospital care. Two-thirds of White New York City patients are treated by hospitals that are part of the five major citywide networks (Montefiore, Mount Sinai, Northwell, NYU Langone, and New York-Presbyterian), according to the most recent publicly available data from the State of New York. In contrast, most Black patients sought care at public hospitals or at private, non-affiliated hospitals located in low-income communities and caring for many uninsured and Medicaid insured residents.
One legacy of discrimination is self-imposed restraint. Many Black people do not trust and thus avoid medical care from White providers and institutions. Medicine, to its lasting shame, provided a rationale for slavery by claiming Black people had less intellectual ability and more capacity for hard labor. A recent study correlated revelations about the Tuskegee Syphilis experiment, in which Black men went untreated for decades to provide a control group, with increased death and disease among a more current generation of Black men suspicious of US health care and less willing to seek care.
Indeed, racism is built into the very protocols that determine the treatment of patients. On June 17, 2020, the New England Journal of Medicine published an article which identified standard treatment protocols in cardiology, nephrology, obstetrics, and urology that are premised on racist assumptions. For example, seriously ill Black kidney patients are routinely downgraded on kidney transplant wait lists because a race adjustment added points to kidney function lab test results to account for the “fact” that Black patients had larger muscle mass.
Most racist constraints, however, are situational and institutional. It is claimed that White people get care at private hospitals because they have private insurance, which is more desirable because it pays more than Medicaid. But insurance coverage does not sort neatly by color. Data from New York City hospitals shows that substantial numbers of every racial/ethnic group have each of the main insurance types: 20 percent of privately insured patients were Black and 21 percent of Medicaid patients were White.
This disparity is not explained solely by insurance coverage, hospital location, or the type of care sought. In fact, any reasonable person would conclude that what is also at play is discrimination, plain and simple that undermines the health of Black Americans.
This would suggest that in private network hospitals one-fifth of privately insured patients at would be Black; in actuality only 16 percent are. Black patients are concentrated in non-network hospitals regardless of whether they have private insurance or Medicaid. Not so for White patients; only eight percent use public hospitals.
Nor does geography alone explain these discrepancies. NYU Langone Medical Center and the venerable public Bellevue Hospital sit side-by-side on the East Side of Manhattan. They are similar in bed size, number of inpatient discharges, and total outpatient visits. Three-quarters of patients in each come from the five boroughs. Yet only nine percent of NYU Langone’s 2016 discharged patients were Black compared to 26 percent from Bellevue – percentages that hold for both city and non-city patients.
Two renowned specialty hospitals – Memorial Sloan Kettering, the city’s premier cancer hospital, and the Hospital for Special Surgery (HSS) which treats orthopedic illnesses and injuries – present extreme examples of racial disparity. Only nine percent of patients at Memorial and five percent at HSS were Black. Only seven percent of privately insured patients were Black. It is even tougher to gain entry if you are poor and Black; 49 (0.3%) of HSS’s 14,000 patients were Black men and women covered by Medicaid. At Memorial it was just two percent.
Our laws prohibit discrimination based on color. The biggest hammer is in the hands of federal authorities that control Medicaid and Medicare. But states and local jurisdictions have tools, too. The State of New York can examine whether any hospital violates its ban on discrimination and may impose significant fines. The City can order hospitals to care for more poor and Black patients, or it can deny permits and zoning variances, remove or reduce the $800 million in property tax waivers it gives private nonprofit hospitals, and issue fines. If additional remedies are needed, City and State legislatures can enact the necessary laws. New York’s City’s local authorities have an obligation to do something.
Congress amended the Social Security Act 55 years ago to create Medicaid and Medicare. Passage closely followed enactment of the 1964 Civil Rights Act. Credited with ending hospital segregation, it did not accomplish this passively. Robert Ball, then the commissioner of Social Security Administration, noted that “At one point the Social Security Administration and the U.S. Public Health Service each had 500 people inspecting hospitals, mostly in the South. Before a hospital could be certified for Medicare, it had to do more than have a plan to end discrimination: It had to demonstrate nondiscrimination.” Desegregation of US hospitals happened in four months.
Government at every level can act. Failure to do so is complicity with a racist system. It is long past time to ensure equality.