The legacy of racism in American medicine persists

Black Minnesotans and Black Americans suffer worse outcomes than whites

Protesters supporting “Medicare for All” hold a rally outside PhRMA headquarters April 29, 2019 in Washington, DC. Photo by Win McNamee/Getty Images.

A Black woman is 22% more likely to die from heart disease than a white woman, 71% more likely to die from cervical cancer and 350% more likely to die from pregnancy or childbirth. 

Studies suggest that health care workers are less likely to believe Black women when they express symptoms, and they tend to undervalue their pain. A high-profile example is that of tennis star Serena Williams, who suffered shortness of breath after a C-section and struggled to get hospital staff to take her complaints seriously. 

Being a Black woman in America is itself a risk factor. 

And it’s not just Black women. The evidence that Black Americans receive worse health care is overwhelming and has been for decades. The 2003 Institute of Medicine report, “Unequal Treatment—Confronting Racial and Ethnic Disparities in Health Care,” indicated  that U.S. racial and ethnic minorities are less likely to receive preventive medical care than whites — and receive lower-quality care. 

Most alarming, the analysis found that even after taking into account income, neighborhood, illnesses and health insurance type — factors used to explain racial disparities — health outcomes among Black people were still worse than whites. 

Set aside your Minnesota exceptionalism, because the situation is not better here: People of color receive suboptimal cancer screening, diabetes and asthma care compared to whites. We are aware of this because Minnesota requires health care providers to track racial and ethnic disparities in treatment. This tracking should be mandatory in every state, and publicly reported so performance can be measured, compared and inequities addressed. 

Systemic racism in U.S. health care started with slavery and was institutionalized along the way. Consider the 1946 Hill-Burton Act, the first significant federal health care legislation. It addressed the inadequate number of hospitals by providing construction grants to communities that could demonstrate need. Southern Democrats would support the legislation only if they could continue the practice of racially segregated hospitals, meaning they were using federal money to support Jim Crow laws. The bill gave the responsibility for assessing health needs to the states —allowing mostly white officials to decide where the money went. At the time fewer  than half of the nation’s hospitals served Black and white patients equally, while one-third of hospitals in the South would not admit Black Americans — not even for emergencies. The southern hospitals that did admit Black patients had segregated wards, cafeterias, staff and blood banks. 

As recently as the mid-1960s one did not need to look to the developing world for examples of inadequate health care — you could find it in the South, where blacks suffered from disease, malnutrition, polluted air and water, low life expectancy and high infant mortality rates. The value of life was far from equal between Black and white Americans. 

Until desegregation, 85% of all Black physicians were educated at two schools, Howard University and McHarry Medical College. They had to finish their training at segregated hospitals. Black physicians were barred from county medical societies and did not have admitting privileges to local hospitals. The American Medical Society — at the time, no ally of Black physicians — refused to end these discriminatory practices. 

In 1962, George Simkins, a dentist from North Carolina, along with other Black dentists, physicians and patients filed a lawsuit alleging that federal support for a hospital serving only white patients was unconstitutional. The plaintiffs lost in district court but appealed to the Supreme Court. In Simkins v. Moses H. Cone Hospital, the justices ruled that segregation was illegal in institutions receiving federal funds — the case started the desegregation of hospitals throughout the South. U.S. Attorney General Robert F. Kennedy sided with the plaintiffs and supported the final decision — making the separate but equal clause unconstitutional. 

Even as de jure segregation collapsed, health disparities and lower life expectancies of African Americans continued. Some of it can also be attributed to their documented distrust of the health system — today, one in three do not trust the U.S. public health system. 

The biggest driver of this distrust was likely the Tuskegee study — from 1932 to 1972 the Public Health Service tracked about 600 low-income African-American men in Tuskegee, Ala., about 400 of whom had syphilis. The men were never treated, passed the disease on to family members, suffered and died. As one scholar put it, the Tuskegee study “revealed more about the pathology of racism than it did about the pathology of syphilis.” This distrust has led to many failed public health efforts — including slowing the spread of H.I.V., containing tuberculosis and providing preventive care.

Health policy is to blame for much of the continued health disparities we see today. 

The uninsured rate among Black Americans is almost twice as high as whites, (9.7 vs. 5.4%). Black Americans account for 12.2% of total population but 14% of the uninsured, while whites account for 64% of total population but only 46% of the uninsured. For  Black Americans, the average annual cost for private health care premiums is almost 20% of their average household income. 

The Medicaid program, covering about 68 million people (pre-COVID) is an important program for  Black Americans, who account for 20 percent of enrollees. In states that have not expanded Medicaid under the Affordable Care Act, Black and Latino people make up 48 percent of all Americans who fall within a coverage gap — their earnings are too high to qualify for Medicaid and are not eligible for premium subsidies. As a result, they are forced to go without insurance, buy substandard insurance or spend a significant portion  of their income for coverage. 

Medicaid work requirements — a policy pending or enacted in many states — disproportionately affect people of color. Many states exempted residents from the work requirements if they reside in counties with high unemployment rates — mostly rural and white areas — with no relief for residents of urban areas, with higher proportions of people of color. 

Besides health policies, there are examples of racial bias in health care tools used by providers. In 2019, algorithms used by U.S. hospitals were systematically discriminating against Black people. The formula used total health care costs — a proxy for health — to assign risk scores to patients. Those with higher scores received specialized care. Because Black patients had less utilization of health care and lower total health care costs — likely because they could not afford adequate health care — they were less likely to get specialized care. But in reality they needed  significant specialized care. Only 17.7% of patients that the algorithm assigned to receive specialized care were Black. The researchers calculated that the proportion would be 46.5% if the algorithm were unbiased. Race is incorporated into many other medical decision-making tools and formulas that doctors use to treat a range of conditions, including heart disease, cancer and maternity care resulting in less care for black patients. 

Racial disparities in health care also extend to the composition of health care administrations. Despite many of the nation’s hospitals pledging to increase diversity, hospital C-suites and boards remain overwhelmingly white, even as minorities are an increasingly larger part of the patient population. Only 11% of hospital executive leadership positions, 14% of hospital board members and 9% of CEOs are minorities, according to the most recent study by the American Hospital Association’s Institute for Diversity and Health Equity. 

Racism is deeply rooted in past and present U.S. health care. We need to use policy to dismantle inequity, first by valuing all people equally. We need to optimize the conditions in which people are born, grow, live, work, learn and age. Policymakers need to work in all sectors to address the factors that influence health, including employment, housing, education, health care, public safety and food access. Equity is often referred to as the forgotten aim in health care — the triple aims being cost, quality and access. Now, more than ever, we need to make equity a priority.