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Ruqaiijah Yearby from Saint Louis University joins Health Affairs' Editor-in-Chief Alan Weil to discuss how structural racism is embedded in US health policy.
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
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Hello and welcome to A Health Policy. I'm your host, Alan Weil. Members of racial and ethnic minority groups have long suffered from health inequities in the United States. These inequities result in large part from racial and ethnic minority populations inequitable access to health care, which persists because of structural racism in health care policy. Racism includes a complex array of social structures, interpersonal interactions, and beliefs by which the group in power categorizes people into socially constructed races and creates a racial hierarchy in which racial and ethnic minority groups are disempowered, devalued and denied equal access to resources.
Speaker 1:Now, the words I just read are from the opening paragraphs of 1 of 4 overview papers in the February 2022 issue of Health Affairs, an issue devoted entirely to the topic of racism and health. How structural racism is embedded in US health policy is the topic of today's episode of A Health Policy. I'm speaking with Rekhaia Yerbi, a professor in the Center For Health Law Studies at Saint Louis University School of Law and executive director of the Institute For Healing Justice and Equity at Saint Louis University. Miss Yerby and coauthors published a paper in the February 2022 issue of Health Affairs describing structural racism within US health care policy today and in the past. They describe structural racism as an integral component of US health policy dating back to the Jim Crow era.
Speaker 1:Today, structural racism has created a tiered system of care with racial and ethnic minorities experiencing poorer access and lower quality care than white Americans. We'll discuss these topics in today's episode. Miss Hirby, welcome to the program.
Speaker 2:Thank you. Thank you for having me. I'm excited to talk about a paper that I coauthored with professor Breanna Clark at Loyola Los Angeles School of Law and doctor Jose Figueroa of Harvard University. You're,
Speaker 1:the 3 of you, and I appreciate you acknowledging your coauthors, describe structural racism as embedded in US health policy. So I just wanna make sure we're all starting from the same place here. Tell me what you mean by structural racism and tell me what you mean when you say it's embedded in US health
Speaker 2:policy. So structural racism refers to the ways that laws and policies are used to structure systems in a manner that advantages white individuals and disadvantages racial and ethnic minority individuals. Here, we discuss about the ways that US health care policy has been used to structure the health care system in a manner that advantages whites and disadvantages racial and ethnic minorities, particularly in terms of health care coverage, financing, and quality. And to be clear, structural racism is embedded in US health care policy because our health care policies shape the system, access to insurance, access to coverage, access to quality health care in a way that disadvantages racial and ethnic minorities, but it's just one form of discrimination embedded within US health care policy. We see the same as true for those who are poor, for those who have different gender identity and sexual orientation, as well as people with disabilities as well.
Speaker 1:So we've all read about disparities, inequities, health indicators being worse for certain groups and others. And your the point you're making in this paper is those disparate outcomes are tied to structural aspects of the health care system. And as we have our conversation, I'd like to walk through some of the domains that you explored in the paper as you just introduced. But do I have sort of the right framing here? I just wanna make sure we're approaching this the way, you think a a listener ought to.
Speaker 2:Correct. Oftentimes, when we think about disparities in health care, we primarily focus on physician bias or health care bias without considering that it is the way that the system is structured which requires people often to have access to health insurance which plays a large part in those disparities as well.
Speaker 1:Okay. So let's start with, coverage. You actually go back to the Hill Burton Act, Kerr Mills. These are familiar to long time health policy analysts, but maybe not to everyone who's listened to them. When you think of them generally, you think of them as big investments in health care.
Speaker 1:So how is it that they embody structural racism?
Speaker 2:Correct. They were big investments in health care that actually has built the health care system that we see today, but they provided advantages for whites while disadvantaging racial and ethnic minorities and I just want to go back really quickly. Before the Hill Burton Act, we see the federal government primarily providing funding for private health care facilities which cause a disparity because most racial and ethnic minorities receive their health care in public institutions. So with the Hillburn Act funding public health care institutions, you think that it's going to actually benefit racial and ethnic minorities, but it didn't because within that act, it explicitly said that states could fund health care facilities and construct racially separate and unequal health care facilities. The same was true with the CURE Mills Act, which was the precursor to Medicare, which provided funding for elderly who were poor.
Speaker 2:But, again, it was the fund the program was underfunded, and few states participated in state especially states with large portions of Black Americans, and we see that same problem today with Medicaid, and the focus about who's going to expand Medicaid being really tied to who we believe it's gonna cover. And if we think it's gonna cover racial and ethnic minorities, we tend not to expand Medicaid.
Speaker 1:So here are a number of examples where the federal government says we have a goal of expansion, expanded access, expanded facilities, But in one instance, you describe it actually supports the development of segregated facilities and the other is a common practice we have of delegating the actual application for funds to a lower level of government, in this instance, states and states making decisions on the basis of the racial politics of their state. So this is an investment, but it's a distorted investment. Now you brought up that, Kerr Mills is a precursor to future programs. I do think it was really interesting in the paper you talk about Medicare and Medicaid as both addressing certain racial disparities, but also embodying racist policies. And it does seem like that tension or or pairing actually shows up in quite a few places.
Speaker 1:So so tell me a little bit about what is it about Medicare and Medicaid that reduce disparities, but what is it that actually then, creates structures that, continue?
Speaker 2:Yes. So we know Medicare is a federal health care program that primarily covers the elderly and disabled, whereas Medicaid is a federal state joint run program that covers the poor. Medicare funding was central to the racial desegregation of hospitals because it was the leverage to get hospitals to actually desegregate. It also encouraged physicians and other providers to serve underserved communities, which included racial and ethnic minority communities. But, again, we didn't fully require people, to integrate.
Speaker 2:So as long as nursing homes made a good faith effort to use nondiscriminatory language and marketing materials, the government certified those homes to participate in Medicare and Medicaid even though they continue to use discriminatory practices to deny admission to racial and ethnic minority individuals, which we still see today. We also see, again, as we've touched upon earlier, leeway given to Southern states who were resistant to civil rights gains. The federal government gave tremendous flexibility that allowed the states to underfund Medicaid or to limit Medicaid eligibility, which still persists today. In fact, there's a federal law requiring Medicaid reimbursement to be sufficient to ensure equitable access to quality health care for Medicaid beneficiaries, but time and time again, the federal government has rubber stamped cuts, that tend to disproportionately harm people of color. And most recently, there was a 2017 lawsuit filed by Medicaid beneficiaries in California that challenged these rates, not only because they've limited access to health care, but also because they believed that it created a separate and unequal health care system for the Latino population.
Speaker 1:So here we have a federal government that in order to get these laws passed has to make political compromises. Part of that compromise is to allow states to make major decisions. And of course, you've focused on Medicare and Medicaid, but this runs throughout the Social Security Act, where you have income thresholds for cash assistance and other benefits also set at the state level designed to, in the positive framing, meet the needs in the local conditions. But in the negative framing, allowing racialized policies or racially disparate policies or racist policies to be pursued without really any federal check on them because that's the bargain we cut to get these programs created.
Speaker 2:Yes. And I do wanna just jump in. What you've noted is that we have done this in a racially neutral way, understanding the impact that it will have on racial and ethnic minorities because, historically, we've seen the same thing happen again where they've had limited access to health care, but also, as you mentioned, it doesn't just stop at racial and ethnic minorities. Right? It negatively impacts the poor, people with disabilities as well, and so we're just focusing on one aspect of it to try to shine light of how it harms, most Americans.
Speaker 1:But I'm really glad you brought that up. I mean, part of the challenge and importance of studying structural racism is that you're not looking for the word black or white or Latino, Latina in the statute. It's not that you write these laws targeting one group or another. It's that the way we've designed the decisions that different levels of government, and we'll get to it in a moment, private sector entities entities make, has a disparate impact. And it you can draw the line directly, but not because of the words in the law.
Speaker 2:Exactly.
Speaker 1:I do want before we leave Medicare and Medicaid, you had a I thought a really interesting point about the allocation of disproportionate share hospital funds, which to some may seem obscure but is a central element in the Medicaid statute for the federal government to give funds designed to serve institutions, hospitals that are serving a disproportionate share of underserved people, which, again, you would think would have a racially equalizing effect. But you comment on how the fact that the allocation of those funds is left to the states can undo some of that. Can you say a little more about that?
Speaker 2:Yes. So professor Beata Clark, brought in her expertise on this area, which really focuses on the lack of oversight, that disproportionate share hospital payments are intended to subsidize uncompensated care provided by hospitals that serve a large number of low income individuals, but we are not tracking where that money actually goes. And so oftentimes, that money is not necessarily going, to the hospitals that need it most, but if it is, sometimes it's directed to state and local run hospitals, and that money goes back into, the state budget to sometimes offset other things. And so we need to do a better job ensuring that the money that is set aside to address structural racism or gaps and access to health care is actually used for that purpose.
Speaker 1:Well, we've gotten off to a strong start talking about mostly coverage. We should talk also about financing and quality and access. We'll do that after we take a short break.
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Speaker 1:And we're back. I'm speaking with Rukia Yerbi about structural racism in the past and today in health care policy in the United States. Before the break, we were focusing on coverage programs, particularly public programs. I thought it was very interesting that you also point out the role that employer sponsored insurance private coverage plays in the structures that lead to the disparate outcomes that we observe. So we think of employer sponsored insurance as a good benefit that you get from a good job and doesn't really have anything to do with race.
Speaker 1:You describe it as part of a 2 tier system and, that there are aspects of employer sponsored insurance that actually do reflect structural racism. Can you say a little more about that?
Speaker 2:Sure. So when we think about employer sponsored health insurance, we have to think about it in 2 ways. First, that not everyone actually gets insurance through their employers. And so, historically, low wage jobs, jobs that racial and ethnic minority individuals tend to work in do not provide health insurance, and that continues even to this day. As of 2019, 66 percent of white workers were covered by employer sponsored health insurance compared with 40% 47% of black, 43% of Latinos, and 37% of American Indian and Alaska Natives.
Speaker 2:2nd, if low income racial and ethnic minority workers are insured, they are disproportionately covered by employer sponsored plans that provide poor coverage, leaving them with higher out of pocket cost. And this is true even though their Affordable Care Act exchange plans, They are not allowed to go and use, those plans. They do not receive federal subsidies offered as part of those plans, and they are not eligible to switch to Medicaid. And so if they are able to get employer sponsored health insurance, oftentimes, it's more expensive and does not provide the same level of access to health care as other workers.
Speaker 1:So we have a multi $100,000,000,000 annual subsidy from the tax exclusion of employer sponsored insurance. And what you're saying is that the actual allocation of those dollars contributes to both the higher rates of of employer sponsored coverage for whites but also the tendency for white employees to have more comprehensive plans. So here's another federal investment that's in one sense expanding access but doing it in ways that structurally contribute to the inequities that we observe. It does seem a little parallel to what we were talking about on the public program side that, again, here is sort of a a race neutral policy, and what we're focused on is how it plays out. Are there elements of the design of that system that would could be addressed that would make it less of an or not contribute, as you say, to a structurally racist system?
Speaker 2:Yes. And so one area that doctor Jose Figueroa mentioned in the paper was taking in consideration the structural determinants of health and how they limit people's access to health sometimes make them more unhealthy, but when we think about value based payments or incentives for providers providing care to these patients, we do not take that into consideration, and we should. Things that were not in the paper that we wanted to include, but, we were not able to, though, is to really begin to think about, changing the system and doing it in an intentional way that incorporates the principles of health justice, which provides a community based systems level approach to reform. And, really, the key points are patient and community empowerment, truth and reconciliation, and structural remediation. And I can just give you one example, particularly of community empowerment that racial and ethnic minority individuals must be engaged as patients, caregivers, and community leaders in transforming health policy and coverage financing and the provision of quality care.
Speaker 2:One example would be involving them in the oversight of tax exemptions and incentives to minimize the use of funds meant for their benefit. So bringing them into discussions about the disproportionate share hospital payments, also discussions about, not being able to receive subsidies if you have or if you are a low wage worker, and also about incentives for providing care to them.
Speaker 1:I wanna spend more time on the solutions here. But before we fully focus on that, I wanna make sure we cover the last dimension of the paper which is quality. There's of course quite an extensive literature on the poorer health outcomes for black Americans, for Hispanic Americans, But that again has origins in policies, and I wonder if you could talk a little bit about that side of it, not just where we see disparities, but how it ties to the existence of structural racism.
Speaker 2:Yeah. So when you think about quality disparities, again, we often think about the interaction between patient and physician, but it is much broader. And so when we look at, say, nursing home care, there's been decades worth of research showing that black patients have poor quality outcomes even when they're in homes with other white patients, when they are in predominantly, segregated nursing homes, we see they have poor quality of care, and that has been linked to lower staffing levels and bigger for profit urban facilities. And so, again, that goes back to the decisions about financing, the decisions about oversight, the decisions about not requiring the same level of care in predominantly white and predominantly, black nursing homes. We can also see that in where hospitals and health care services are located.
Speaker 2:There have been studies showing that actually there was a there were a lot of hospitals that moved from a predominantly black neighborhoods to predominantly white neighborhoods. And oftentimes, the the reasoning given for that was really financial, but the research shows that it's more correlated with race than financial. So as the population of, racial and ethnic minorities increases, you tend to see closures of hospitals moving to predominantly white neighborhoods, which doesn't lower cost because now you have too many hospitals in one area and not enough hospitals in another.
Speaker 1:And even if it is for financial reasons, in addition to the racial factors you described, those financial conditions are tied to some of the policies we've been discussing earlier that the payment rates in public programs that disproportionately serve racial and ethnic. Minority populations are lower than they are for commercial insurance. And and so you can make a perfectly rational financial decision if that's what it is, and it can have these highly disparate racial effects, even though again even if I should say race isn't a direct consideration of the institution. I do want to come back to your starting the conversation about solutions. It seems to me there's sort of a combination of inside health care and outside health care.
Speaker 1:So you described, what I gather is a little bit more of a participatory approach to health policy and health decision making of health enterprises. You do, at the end of the paper, say existing reforms have not remedied this this problem, and that's the problem of disparities because the eradication of structural racism in health care policy has not been a primary goal. So I wonder if you could expand on that both, as I say, within the health sector, but also more broadly how we would embrace the goal of eradicating structural racism and, what that might look like.
Speaker 2:Thank you. So as I mentioned, definitely patient and community empowerment, but, also, we have to change the way we operate as health care institutions and as a government regulating the health care system. One way is to adopt a truth and reconciliation process that acknowledges the existence of racism and health policy and our health care system. We've already seen this a little bit in the health care system where they have adopted a process to to address medical malpractice by having providers apologize for their mistakes. And so building on this on this restorative justice movement, to do the same thing with patients, to listen to their experiences of racism, and to move forward.
Speaker 2:Work with them to move forward to create solutions for that beyond just the acknowledgement of provider bias, but actually looking at what the institution is doing, but we also have to include healing in that. And so offer people opportunity for counseling sessions, therapy, but being able to move past this trauma. The last one is to really aim at reforming the system and restructuring the system. And so one example that I mentioned before about low income racial and ethnic minority workers not having great employer sponsored plans, about giving them the same protections as those in the ACA the ACA exchanges that provide immediate financial relief against high out of pocket cost. It really means taking into consideration the disproportionate impact on these groups when you're moving forward with the policy, to continue to track that as the policy is in place, and to remediate any harm that is caused by it.
Speaker 1:So I'm really struck by you invoking the, the approach to malpractice of disclosure and compensation. We've, of course, published a few papers on this topic in health affairs and it's quite transformative. It's hard to do and it's a real culture change for organizations that are accustomed to sort of circling the wagons and denying all responsibility to saying we're going to open up to hearing and acknowledging that we made a mistake. But I can't help and of course you're trained as a lawyer, as am I, I can't help but note that that transformation and malpractice occurs against a backdrop of potential very large liabilities against the hospital if there is a negative finding on malpractice. And so there's sort of a there's a financial reason for them to come to the table and to maybe experiment with something quite different than what they're used to.
Speaker 1:So I'm trying to envision this in a broader structural racism context, truth and reconciliation, and thinking, if we're gonna get folks to the table, maybe some of it will come out of a desire to do things differently in goodwill. But what's the equivalent of the threat of a really big, high publicity malpractice decision that you want to avoid, what's the equivalent of that when it comes to issues of structural racism?
Speaker 2:I would say the same thing that push people to desegregate hospitals, the loss of Medicare and Medicaid financing. But, also, let me talk about the impact that it's not only having on patients but on providers because throughout our article and this discussion, we've only focused it on, the patient's perspective, but there are a lot of health care providers who are experiencing this same structural racism. And so I think if you mobilize both those providers and what they're experiencing during COVID 19, and other issues with the patients, then that would be a move to get the health care systems to actually do that. And that's what you see in lots of the Medicaid lawsuits, that it is the providers joining with the beneficiaries to challenge the system and to try to change the structure of the system.
Speaker 1:Well, I think that's a good place for us to close, and I'm glad you brought in the role of the provider and the goodwill and desire on the part of so many providers to improve the system. After all, once we begin talking about racism, there are those who view this as an attack and immediately just resist the attack. But as you've described in the paper, these are structures that have been in place for quite some time and they were created by people and the only way to alter those structures is to have people redesign them. And if people of goodwill, who see the role that structural racism plays in the disparities that that they aim to reduce, if they can see a way to tackle those structural precursors, I think there's a possibility there. It's certainly not easy but that may just because it's not easy, it probably is the only way to do this.
Speaker 1:And so if we're serious, we really do have to go back to the structural roots.
Speaker 2:Yes.
Speaker 1:Well, Ms. Yerby, thank you for the paper, for the conversation, for helping our listeners understand the deep roots of structural racism in U. S. Health policy. Thank you so much for being my guest on Health Policy.
Speaker 2:Thank you. Thank you for having me.
Speaker 1:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.
Speaker 3:Health Policy is produced by Health Affairs, the leading journal for health policy research. The team behind the show includes Patty Sweet, Jeff Byers, Julia Vivolo, Sarah Calk, and Sue Ducat. Like the show? Subscribe to a Health Policy on Apple Podcast, Spotify, Stitcher, Google, or wherever you listen to your favorite podcasts. Thanks for listening, and have a great morning day or evening.