Author’s disclosure: with three classmates and fellow advocates, Terence M. Hughes is a co-author on one of the 13 articles published in the American Medical Association Journal of Ethics January 2023 special edition, entitled “Medical Student-Driven Efforts to Incorporate Segregated Care Into Their Curriculum.”
For many readers, directly linking segregation and the US health system may be new. We have been taught to conceptualize segregation as being in the past — to be learned about in the ‘pre-Civil Rights era’ chapters of our history books. Dr. Rojas Marquez and Dr. Hazel Lever, co-editors of the American Medical Association’s January 2023 Journal of Ethics “Segregation in Healthcare” special edition, challenge this assumption: while “legally sanctioned racial segregation in hospitals ended with the Civil Rights Act of 1964… practices such as sorting patients by insurance status still perpetuate de facto racial and class segregation.”
This highlights the question: what is de facto racial segregation in healthcare?
Unlike peer countries, America has a multi-tiered insurance system in which employed adults are most often covered by employer-sponsored private insurance, while low income adults typically receive coverage via public insurance — Medicaid and/or Medicare. Because class and race are intimately correlated due to America’s history of exploitative capitalism, a system segmenting by income and employment status also segments by race. As a result, a disproportionate percentage of patients of color receive insurance through Medicaid. For example, of New York state’s Medicaid beneficiaries, 21% are white, 38% Black and 42% Hispanic compared to 69%, 18% and 20% of the state’s population, respectively.
A multi-tiered insurance system matters because it leads to separate and unequal care. For example, location of care differs by race and insurance status. Patients of color are more likely to receive care in public hospitals than their white counterparts. In New York City, the public hospital system sees 39% Hispanic, 33% Black and 8% white patients compared to 29%, 23% and 40% of the citywide population, respectively. Patients with Medicaid are also more likely to be cared for by resident physicians — doctors who are still in training — than their privately insured counterparts.
Different care experiences by race and insurance status correlate with disparate health outcomes. Studies demonstrate that patients cared for primarily by residents are less likely to receive cancer screenings and reach chronic disease management milestones compared to patients cared for by full attending physicians. Infant mortality is significantly higher for Black and Hispanic births, and pregnancy-related mortality is nearly three times higher for Black patients than their white counterparts. The impact of inequitable outcomes like these is cumulative: 2021 life expectancy for Black Americans was 70.8 years, strikingly less than 76.4 years for white Americans.
Discourse framing health inequity as a product of healthcare segregation is not new. In 1994, the New York Times reported that New York state was investigating whether two New York City hospital maternity wards were segregated by race. In 2006, The Bronx Health REACH Coalition published an investigation finding that differences in care directly resulted in disparate outcomes, termed “medical apartheid.” They subsequently filed a civil rights complaint to the New York Attorney General in 2008, calling out segregation at three academic medical centers in New York City.
In writing this piece, I hope for medical student perspectives to be particularly impactful to Dartmouth students interested in health careers. These perspectives are crucial, given trainees’ proximity to segregation as they enter the health system and learn to practice medicine. One survey found that over 50% of medical students learning in the clinical environment witnessed separation of or differences in patient care by insurance status.
Learning medicine in a segregated health system unquestionably impacts a student’s education. On one hand, medical students are well positioned to advocate for change. We enter the system as outsiders, granting a fresh perspective through which we can question how things should be done, rather than how they have been done before.
On the other hand, learning medicine in a segregated system perpetuates burnout and normalizes systemic injustice. For example, in medical school, students are encouraged to learn about health equity while simultaneously entering a system that is deeply flawed and inequitable. The coexistence of these seemingly incompatible realities results in dissonance between how students want to act, and how they are able to act within the system’s limitations. This drives moral injury and has been increasingly cited as causing sharp increases in rates of physician burnout.
Further, student authors reflect that current models of pre-medical and medical education normalize our health system as is, thereby perpetuating its systemic injustices. Specifically, students fear subconsciously internalizing unacknowledged injustices as “truth” — for example, that it is “normal” for low-income patients to be disproportionately treated in public hospitals with fewer resources.
These realities of medical education are not inevitable. They beg the question, what can be done?
Heightened political pressure to end America’s multi-tiered insurance system through passage of universal health coverage is critical. Interestingly, today’s public and political rhetoric focuses on phrases like “universal coverage” and “single payer,” but discourse around desegregation is often absent. Re-framing our conversations about US healthcare to explicitly call out segregation has the potential to shift our collective consciousness and thereby move the political needle toward passing impactful, equity-oriented legislation like Medicare for All.
While advocating for these sweeping changes, however, much can be done to minimize the harms our current system perpetuates. Pre-medical and medical students can provide peer-to-peer education, ranging from informal conversations to formalized curriculums calling out healthcare segregation. Students should feel empowered to push their institutions to design curriculum that equips them to be physician-advocates instead of bystanders, capable of removing systemic inequity from the inside.
The editors of the Journal of Ethics “Segregation in Healthcare” special issue call for dialogue as a first step to imagining and enacting a more just health system. I echo their sentiment in striving to bring both dialogue and action about healthcare segregation to the Dartmouth community.
Terence M. Hughes ’17 is a fourth-year medical student at the Icahn School of Medicine at Mount Sinai. He is an incoming emergency medicine resident physician at Elmhurst Hospital and Mount Sinai Hospital in New York City. Outside of clinical work, he strives to be an advocate and researcher, with focuses on desegregating care, health equity, medical education and harm reduction.
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