Author discusses health system inequities

Photo of a Zoom screen reading "Anti-Black racism and the threat to American health"
Anti-racism activist Camara Jones said there are four forms of racism: structural, institutional, individually-mediated and internalized. (Xiangyuan Chi | Daily Trojan)

Brian Smedley, an equity scholar at the Urban Institute and the author of the book “Unequal Health: Anti-Black Racism and the Threat to American Health,” discussed the ingrained racism within the United States healthcare industry during a webinar miniseries at USC’s Center for Health Journalism.

Smedley began by presenting a definition of racism provided by Camara Jones, a renowned epidemiologist and anti-racism activist, in her study “Confronting Institutionalized Racism.”

“Racism is a system of structuring opportunity and assigning value based on phenotypic properties (i.e., skin color and hair texture) associated with race,” Jones wrote. “There are four forms of racism, structural, institutional, individually-mediated and internalized.” 

In its 2003 seminal report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” Smedley’s team at the Institute of Medicine concluded that “racial and ethnic minorities experience a lower quality of health services, and are less likely to receive even routine medical procedures than are white Americans.”

Twenty years later, the U.S. has “not made significant progress toward eliminating these healthcare disparities,” Smedley said.

“Unfortunately, for many patients, this is a matter of life and death,” he said.

Smedley cited the Agency for Healthcare Research and Quality’s 2021 National Healthcare Quality and Disparities Report. Since 2000, disparities “have narrowed for only about 8% of measures of American Indian and Alaska Native populations, 2% of measures for Asian populations, 3% of measures for Black populations, 4% of measures for Hispanic populations, and 10% of measures of Native Hawalian/Pacific Islander populations,” according to the report.

The report also mentioned that patients of color are less likely than white patients to receive preventive care and kidney transplants.

Smedley concluded that there are multiple factors associated with healthcare inequity, including the separate and inequitable healthcare system in which people of color are disproportionately under-resourced.

“People of color are disproportionately concentrated in lower tier, under-resourced, lower quality health care systems, safety net institutions and other systems that struggle to provide high-quality care,” Smedley said.

Smedley also discussed the ways tiered health insurance and differences in provider reimbursement contribute to the inequity.

“Patients who are covered by Medicaid, for example. Medicaid continues to struggle to provide the level of reimbursement necessary to attract providers to provide these services to patients,” Smedley said. 

Implicit clinician biases, stereotypes and prejudice against patients of color also contributed to the disparity, the study found. As people become socialized into their culture, these feelings and beliefs become increasingly ingrained that they are often triggered automatically.

“Even if you as an individual find those beliefs abhorrent, no doubt you are aware of those broad societal beliefs, and you may even find that those belief systems infect your thinking in ways that you are not consciously aware of,” Smedley said.

A persistent lack of diversity among healthcare professionals is closely linked to the lingering racism in the healthcare system. According to a AHRQ study, only 5% of physicians nationwide identify as African American.

“What I’m suggesting is that increasing diversity among our healthcare workforce can increase the capacity of U.S. healthcare systems overall, to better address the needs of a growing and diverse U.S. population,” Smedley said.

All of these factors combined created the “Medical Apartheid,” which refers to the separate and inequitable care for patients of color.

Smedley proposed interventions to tackle these factors that contribute to healthcare inequality, such as improving diversity among physicians. In a 2005 report at the Institute of Medicine, Smedley suggested de-emphasizing standardized tests which could negatively affect the ability of students of color to matriculate into health professional programs. He also discussed stopping the inappropriate use of patient race in medical diagnoses and treatments.

Michelle Levander, moderator of the webinar and founding director of the Center for Health Journalism, said the conversation was “inspiring and illuminating” and led a Q&A session at the end of the webinar. Smedley said that healthcare inequalities hurt all Americans through social, economic and environmental costs.

“We as a society have a moral imperative to ensure that healthcare is equitable and just for every patient,” Smedley said. “Widespread disparities should not exist and, in fact, are antithetical to our beliefs as a nation in terms of egalitarian ideals.”