Eliminating Disparities in Treatment and the Struggle to End Segregation
David Barton Smith, Ph.D.
Segregation was the central issue facing the civil rights challenges and achievements of the 1950s and 1960s—specifically, the Brown vs. Board of Education decision, the Civil Rights Act of 1964, and the implementation of the Medicare program. However, current efforts to eliminate racial and ethnic disparities in health care treatment fail to address the effect of segregation on disparities. By reviewing the history of the civil rights era efforts to integrate health care in the United States and assessing its accomplishments, this report offers lessons of this experience for current efforts to eliminate disparities in health care treatment. Progress can best be achieved by making the reduction of health care segregation a measurable goal, reinvigorating regional planning, taking a more critical view of the impact of "consumer-driven" choice in the organization of care and health plans, and transforming health care reform into a civil rights issue.
Segregation was the central issue of the civil rights challenges and achievements of the 1950s and 1960s—specifically, the Brown vs. Board of Education decision and the Civil Rights Act of 1964, with the implementation of the Medicare program dealing a further blow to the institution. Current efforts to eliminate racial and ethnic disparities in health care treatment, however, fail to address the effect of segregation on disparities. Segregation is simply not part of the current vocabulary of clinicians, health care executives, policymakers, or advocacy groups in their discussions of racial disparities in treatment or health. To address this omission, this report aims to:
The Struggle to Integrate Health Care
- review the history of the early efforts to integrate health care in the United States;
- assess the trends and effectiveness of the strategies used for reducing segregation; and
- outline the lessons of this experience to assist current efforts in the elimination of disparities in health care.
Unlike the more visible, protracted battles that took place over the integration of public accommodations, housing, and schools during the civil rights era, the parallel struggle in health care was brief, quiet, private, and incomplete. At the time of the Brown decision in 1954, health care was sharply divided along racial lines. This separate care system represented a double-edged sword: while marginalizing black physicians and dentists, it provided insulation from white control and allowed some practitioners, particularly in the South, the freedom to act as advocates for their patients and their communities.
In 1954, at the time of the Brown decision, the vast majority of black and white health professionals saw little promise that there would ever be any significant change. In most communities, racial integration in hospitals and health care was too difficult an issue, and efforts instead focused on the integration of schools and public accommodations, which seemed easier to achieve. Yet, a small network of activist black physicians and civil rights lawyers coalesced after the Brown decision and began to map out a campaign to accomplish what most felt was impossible. This resulted in the inclusion of Title VI in the Civil Rights Act of 1964, which prohibited the provision of federal funds to organizations or programs that engaged in racial segregation or other forms of discrimination. The first significant test of Title VI enforcement came with the implementation of the Medicare program in 1966. More than 1,000 hospitals quietly and uneventfully integrated their medical staffs, waiting rooms, and hospital floors in less than four months.
However, outside the hospital, the rest of the health care system was never directly affected by the Medicare integration efforts. No effort to inspect nursing homes for compliance was ever mounted. Physicians were specifically exempted from compliance with Title VI. Until the recent resurgence of interest in health disparities, health care has been left to drift, unrestrained by concerns about segregation and responding only to changing market forces.Current Patterns of Segregation in Health Care and Strategies for Eliminating Treatment Disparities
There are four main conclusions regarding the reduction of segregation in health care:
Reinventing Health Care's Civil Rights Struggle
- In spite of progress in eliminating disparities, health care remains quite segregated and may be becoming more so. The civil rights era in health care produced impressive and lasting accomplishments. However, substantial segregation remains. Data on Medicare discharges from hospitals by elderly beneficiaries suggest both wide variation and the persistence of segregation in hospital care in the United States. Racial segregation is also a factor for outpatient care and nursing home care.
- How health care is regulated and financed shapes the degree of segregation and disparities in treatment. In the 1980s, a fundamental shift took place in the planning and financing of capital projects in health care. Federal support for regional health planning was abandoned and most states chose to terminate or greatly reduce the scope of their Certificate of Need programs. By eliminating the federal program, providers in most states were then freed of any external planning constraints on decisions concerning new services or capital projects. Capital projects and service expansions were viewed strictly as business, rather than social investments.
- Segregation produces a health system that increases the cost and reduces the quality of care for everyone. Unburdened by the restrictions of the pre- and early post-Medicare periods, providers have expanded profitable services in areas with the most advantageous payer mix. This has tended to increase services in predominantly white, affluent suburban areas and reduce services in less affluent, predominantly minority, inner-city areas. By increasing racial and economic segregation, everyone loses in terms of cost and quality.
- Segregation exaggerates disparities. One of the most socially destructive and stigmatizing effects of segregation in health care, as in other areas of American society, is the exaggeration of differences. For instance, minorities in most metropolitan areas have relied more heavily on medical schools, teaching hospitals, and public clinics that tend to routinely screen for sexually transmitted diseases and for drug use and, consequently, tend to report a higher rate of positive findings for these conditions.
Racial segregation in health care not only distorts and contributes to disparities; it increases the cost and reduces the quality of care for everyone. The lessons of the past half-century's efforts to desegregate health care suggest four possible strategies for reducing racial, ethnic, and economic disparities in treatment:
- Make the reduction of health care segregation a goal. Include measures of segregation in the health care quality and disparity report cards of providers, plans, regions, and the nation as a whole. Reducing segregation will reduce disparities and total costs and will improve the overall quality of care.
- Reinvent regional planning. Make obtaining a Certificate of Need contingent on providing convincing evidence of a reduction in the racial and economic segregation of care.
- Do not confuse market-driven reforms for real choice. When health plans and providers are more driven by market conditions, care becomes more fragmented and segregated by race and income. Consumer-driven choice, when applied to retirement security or access to medical care, amounts to an abdication of public responsibility.
- Transform health care reform into a civil rights issue. Medicare was passed as a civil rights bill. Health care became a right under this universal entitlement program, which was driven to creation by the most powerful grass roots social movement this country has ever experienced. The time has come to return to the basic premises of this movement.
Eliminating Disparities in Treatment, David Barton Smith, Ph.D., The Commonwealth Fund, August 2005