That’s the conclusion of a newly published study we authored in JAMA Network Open. In it, we look at data from 44,000 patients hospitalized with the disease from January through Sept. 21, 2020. Unlike prior studies based on single health system data, our study examined a diverse set of nearly 1,200 hospitals across 41 states and D.C.
Conventional wisdom holds that these survival differences arise because Black Americans have higher rates of chronic health conditions and social risk factors than White Americans. It is true that hypertension, diabetes and poverty are more common in Black patients, and that each increases the risk of covid-related mortality. But even when we account for these health risks, we still find that Black patients die more often from covid-19 than their White counterparts.
Our study reveals why: Black patients have higher covid-19 mortality because they go to different hospitals than White patients. It’s not that some hospitals give worse care to Black patients compared with White patients; it’s that some hospitals have worse outcomes for both Black and White patients. And Black patients disproportionately go to the hospitals where the outcomes are worse for all.
Many forces combine to create this situation, but the common thread is racism. Decades of racial residential segregation have concentrated Black people in some areas and White people in others. Redlining, which limited mortgages in Black neighborhoods during the last century, reinforced and worsened residential segregation. Inequities in school funding, which is largely based on property taxes and other local resources, amplify the effects of this segregation. The result is economic deprivation and lack of upward mobility in racially segregated Black neighborhoods that persist to this day.
We see these effects in health care, too. Poor neighborhoods have proportionately more people who are uninsured or insured by Medicaid, which has payment rates that are often too low to cover the costs of care. People tend to seek health care near home. As a result, hospitals that are located in poorer neighborhoods have less to work with, and often lack the resources needed to provide optimal health care. In effect, doctors and hospitals in the United States are paid less to take care of Black patients than they are paid to take care of White patients. When we talk about structural racism in health care, this is part of what we mean.
These structures are deep, but there are ways to undermine them. When we expanded health insurance to uninsured Americans through the Affordable Care Act, we took an important step toward health equity. President Biden’s proposal to shore up the ACA and extend affordable coverage to more people would be another important step.
But more is needed. Medicaid, upon which a lot of the ACA is built, underpays hospitals compared with Medicare and commercial insurance. Hospitals that see a disproportionate number of Black patients also rely heavily on Medicaid, leaving them strapped for cash with little to invest in quality, patient care and social needs. Increasing Medicaid payment levels to Medicare levels would help address this structural inequity.
We should increase our investment in the health-care safety net, which relies heavily on hospitals. Hospitals receive partial support through supplemental payments for uncompensated care to uninsured individuals. These payments are essential to keep these hospitals afloat, but they are not large enough or targeted well enough to alleviate the financial burden under which these hospitals operate. As a result, safety-net hospitals still have worse financial performance and worse quality of care. They also struggle to meet the needs of the patients they serve.
Centuries of racism got us to this level of segregation and to these inequities in payment structure. Those enduring effects have played out in the setting of the covid-19 pandemic, and they are no longer a mystery. These effects are predictable. But they are not inevitable. We can stop the cycle of disadvantage that perpetuates these inequities by adopting policies that directly invest in these communities and their hospitals.
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