Medical experts have pointed to the fact that Black and Hispanic people are more likely than the general population to work in service and production jobs that can’t be done from home. They tend to live in large, multigenerational households where the virus is more easily spread and in neighborhoods with more air pollution and fewer places to buy healthy food. And they are more likely to suffer from underlying chronic health conditions like diabetes that make exposure to the virus far more deadly.
But America’s deeply segregated hospital system may have also played a largely unnoticed but outsized role in killing Black and Hispanic Americans.
According to data compiled by the Lown Institute and published in the Washington Monthly, where we are editors, the best-funded and most prestigious hospitals in America, such as the Cleveland Clinic and Massachusetts General, generally avoid treating poor people in their local communities and fill their beds instead with affluent patients blessed with generous health-care plans. Low-income and minority patients, who generally have more meager health insurance or none at all, are forced to use under-resourced safety net institutions such as those owned and operated by municipal governments.
The result is a pattern of de facto hospital segregation that magnifies underlying racial and class disparities in health.
An investigation by the New York Times revealed how these disparities played out in New York City, where patients in wealthy academic medical centers in Manhattan had access to lifesaving treatments like heart-lung bypass machines while underfunded hospitals in the neighborhoods hardest hit by the virus had ventilators that lacked important settings.
Hospital segregation, however, is not isolated to New York but rather a national phenomenon, according to the Washington Monthly data. We found that nearly all of the hospitals that rank in U.S. News & World Report’s top 20 “honor roll” do a terrible job of treating minority and low-income patients. This included hospitals like New York University’s Langone Health and the Mayo Clinic.
Most of these hospitals are chartered as charities, but they focus on providing specialty treatments to the well-to-do at the expense of the poor. Nearly 60 percent of all U.S. hospitals are tax-exempt, including the big-named ones that dominate the U.S. News list. But as of right now, they are not required to show that they are providing real benefits to their surrounding communities or that they meet standards of inclusivity and nondiscrimination like the ones developed by the Washington Monthly and the Lown Institute.
Not all hospitals shirk their responsibilities like this. Institutions such as John Peter Smith Health Network in Fort Worth (JPS), Boston Medical Center (BMC) and Mercy Health West in Cincinnati, achieve strong patient outcomes while treating large numbers of low-income and minority patients.
They pull off these impressive results in myriad ways. At BMC, a safety net as well as a teaching hospital affiliated with Boston University, doctors and nurses can write prescriptions for free food redeemable at the hospital’s food pantry. Mercy Health — West, the only hospital on Cincinnati’s working-class west side that provides specialty care like cardiac procedures, is able to integrate that care with the management of its patient’s chronic diseases. JPS is both a municipally-owned safety net hospital where 70 percent of patients have trouble paying their bills as well as one of the nation’s preeminent teaching hospitals for physicians going into family medicine, a specialty focused on treating common ailments like the flu while helping to manage patients’ chronic conditions.
But relatively few hospitals, achieve, as these three institutions have, strong scores on both patient outcome and inclusivity metrics. Indeed, the Washington Monthly and Lown Institute identified only about 20 nationwide that do so.
A major reason for these shortcomings is because the tax and revenue regimes under which American hospitals operate make it hard for them to do the right thing (treat everyone, regardless of race or need, and treat them well) and easy to do the wrong thing (cherry-pick affluent patients and avoid treating the poor and minorities). Currently, hospitals make the most profits on high-tech procedures, such as heart stents and liver transplants, especially when delivered to patients with private insurance, which tends to pay more. But they barely break even and often lose money when they try to provide the care disadvantaged populations most need, such as the kind of neighborhood-based primary care clinics that hospitals like JPS and BMC operate.
The system might not be racist in intent (the bias toward high-tech procedures and surgeries largely reflects the political power of specialist doctors). But it certainly has a discriminatory impact. As the Lown/Washington Monthly data show, not only do communities of color typically lack access to prestige hospitals even when those institutions are in their own backyards, the hospitals they do have access to are generally underfunded. Making matter worse, these underfunded hospitals typically must deal with patients living in polluted, congested, and otherwise unhealthy environments who typically require more health-care resources than the general population, not less.
The coronavirus pandemic has laid bare how America’s racial inequalities have made the virus worse for Black Americans. But the nation’s injustices have not only made them more vulnerable to contracting the virus. It’s revealed that the care they receive is also deeply unequal and unjust.