Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.

— MLK

 

1. Health inequality started with the nation’s birth

THE HISTORY OF AMERICAN RACIAL HEALTH “DISPARITIES” between whites and blacks begins with some of the former forcing some of the latter onto slave ships. This history is well known: the commodification of black bodies through slave labor bled the health and longevity of these men and women. And even after the abolition of slavery, an amalgam of racist terrorism, social segregation, economic marginalization, and political exclusion carried these health inequalities forward well into the 20th century — indeed, into the present day.[1]

Early on, differentials in medical care presumably played little to no role in health inequalities. Health care in the 19th century (and earlier) was distributed unequally, but, with a few exceptions, this hardly mattered: such care was mostly useless and frequently harmful. The picture changed in the 20th century when medicine gained salutary potential; but even with the rise of so-called “scientific” American medicine, racial health inequalities were not abolished. In fact, they were reproduced.

It’s worth examining this history before returning to the question posed by this article’s title. Consider, for instance, some of the stories compiled by one civil rights group. These stories, of blacks who were denied care in the 1930s through the 1960s, are recounted by the historian Beatrix Hoffman in her indispensible Health Care for Some: Rights and Rationing in the United States Since the 1930s. They include that of a “17 year old Negro girl with a bullet wound in her head” who was turned away by a hospital in Washington in 1932 on account of her race, of a seriously injured man in Texas who — despite a fracture of his pelvis — was rejected from an emergency room (his corpse was later found in an alley), and of a woman named Nonnie Clark who — despite having the majority of her body surface area covered in burns — could not be accommodated by Duke University Hospital because it had no open segregated beds on that particular day.[2]

Early in the 20th century, about 40 percent of all hospitals in the Southeast excluded blacks entirely, and segregation was the rule basically everywhere else, including in hospitals in the North.[3] Even when black patients were admitted, it wasn’t always for the right reasons. In his The Care of Strangers: The Rise of America’s Hospital System, Charles Rosenberg notes that, in large hospitals, blacks were sometimes embraced for their usefulness as compliant bodies in medical education: “[T]he negro,” one observer commented at the time, “is more docile and does not object to being used in clinic for teaching purposes and is one of the most prolific sources in the study of medicine.”[4]

At the same time, the government’s persistent failure to create a public health care system played a foundational role in structuring American health care inequalities, both by class and race. Despite high hopes that the New Deal might realize such a system, Franklin Roosevelt failed to make health reform a priority (among other issues, he wasn’t enthusiastic about the prospects of confronting the rather reactionary doctors’ lobby).[5] At the end of World War II, a major campaign for national health insurance did emerge, backed by both Harry S. Truman and — critically — organized labor.[6] “Our new economic bill of rights,” Truman proclaimed to Congress in 1945, “should mean health security for all, regardless of residence, station, or race – everywhere in the United States.”[7] Yet this bold vision was soon smothered, the victim of a toxic redbaiting campaign pursued by the American Medical Association (AMA).[8] All that survived of it, at least in the short term, was the Hill-Burton Act, a law that funded a massive campaign of hospital-building throughout the nation. But Hill-Burton was permeated with racism from its birth. While in theory it forbid discrimination by race, the law nonetheless made an allowance for “separate but equal” facilities.[9] The implications were clear: explicit medical segregation had received the imprimatur of the law, together with generous public subsidization.

Only through the combined force of the civil rights movement, the Civil Rights Act of 1964, a number of key legal challenges, and the passage of Medicare in 1965 could the rollback of American apartheid medicine begin, as will be discussed in more detail below. For now, it’s worth noting that the impact of the civil rights movement on black health was not insignificant, as demonstrated in a revealing 2013 study by epidemiologist Nancy Krieger and colleagues. In the early 1960s, these investigators found that black infant death rates were significantly higher in “Jim Crow” states (the 21 states, plus the District of Columbia, with racial discrimination on the law books) than in non-Jim Crow states. This is hardly surprising. Yet, during the late 1960s, the death rate of the former group did improve, and by the 1970s the difference had evaporated. This can be touted as evidence that political change can yield real improvements in health over time. But two additional facts complicate this interpretation. First, after 2000, the gap again opened up, albeit to a lesser extent. And, second, regardless of the impact of the Civil Rights movement on disparities among blacks, throughout this period black infant death rates were still twice that of whites.[10]

Meanwhile, in terms of life expectancy, recent years have seen the reduction — but not the elimination — of black-white inequalities. As the Centers for Disease Control reported last November, the difference in life expectancy between the two groups fell from 5.9 years (in 1999) to 3.6 years (in 2013). However, even this may not be entirely goods news. A widely covered study published last fall found a unique and disturbing rise in mortality among middle-aged whites (of lower socioeconomic status) between 1999 and 2013, leading the investigators to conclude that falling white-black mortality disparities in this age group “was largely driven by increased white mortality.”[11]

Moreover, during this same period and on into the present, a series of events have functioned as starkly visible and undeniable examples of ongoing structural health racism. Following the death last year of Freddie Gray while in policy custody, many made note of the enormous chasm in health and mortality between black neighborhoods like his and adjacent wealthier and whiter ones. Other commentators have highlighted “environmental racism,” or inequities in exposure to environmental hazards by race, emblematic of embedded structural inequality. Revealing reporting by the Washington Post, for instance, described Gray’s history of childhood lead poisoning, an exposure that is in part racially patterned. More recently, mass poisoning by lead in Flint, Michigan — the disastrous consequence of dimwitted austerity and structural marginalization — has provided yet more evidence of the downstream health consequences of political exclusion.

Inequalities in criminal justice itself — specifically mass incarceration and police violence — are now being explicitly contextualized within a framework of health.[12] In protest of such inequalities (made starkly visible by the killings of men like Eric Garner and the ensuing “Black Lives Matter” protests), medical students throughout the country have begun to advocate for change — for instance, with a solidarity “die-in” action on December 10, 2014, which in turn led to the formation of a new racial health justice organization (“White Coats for Black Lives”) on Martin Luther King Day in 2015.[13]

Finally, two new books are tackling head-on the problem of racial health inequality, albeit from very different “expert” perspectives — one from within medicine and the other from a legal perspective. Damon Tweedy’s Black Man in a White Coat, released last year, is a thoughtful memoir that explores the nexus of race and medicine through the eyes of a black physician. Law professor Dayna Bowen Matthew’s Just Medicine: A Cure for Racial Inequality in American Health Care, on the other hand, is an integration of legal analysis and social science that culminates in an overarching policy recommendation.

In what follows, I’ll first examine the issue of racism within the medical profession, turning to Tweedy’s experiences and reflections as described in his book. Next, I’ll focus on Matthew’s book, and examine the problem of explicit and implicit medical discrimination historically and in the present — and how civil rights law might be used to combat it. From there, I’ll discuss the place of the health system in the perpetuation of inequalities, and the largely neglected role that health care universalism plays in “health equality.”

Lastly — but most importantly — I’ll explore how health inequities by race and by class intersect. To phrase the question plainly: Does confronting the problem of racial health inequality mean that we must embrace the cause of economic redistribution, as discussed in the first part of this essay? If so, should this economic redistribution proceed within the context of social democracy (or democratic socialism?), or should it — must it — proceed along explicitly racial lines? Is the path to racial health equity paved with “reparations”?

 

2. Black doctors: Discrimination within the profession

The plotline of Steven Soderbergh’s unnerving and beautifully shot series The Knick tackles racism within the medical profession by making it viscerally visible in another era. Set in a downtown Manhattan hospital at the turn of the 19th century, the black, eminently qualified physician, Algernon Edwards (Andrew Holland), is treated with derision and disdain by many of the hospital’s white staff and administrators. At the same time, the hospital turns away black patients from its outpatient clinic; Edwards surreptitiously begins treating them — under rather suboptimal operative conditions — in the hospital’s basement.[14]

But what about after the time period depicted in this series? Into the mid-20th century, blacks were excluded from many medical schools, and those who graduated faced intense discrimination in the course of practice. For instance, even decades after the events depicted in the Knick, black physicians were unable to provide care for their hospitalized patients in the South. This was because physicians needed to gain entry into county medical societies as a prerequisite to hospital-admitting privileges; and, in the South, these societies entirely or almost entirely denied blacks membership. The AMA virtuously professed that it opposed discrimination, and yet excused itself from doing anything, claiming it was impotent to compel integration. It took decades of political pressure to force change. In 1968, the Medical Committee for Human Rights, a health-oriented civil rights group, took matters into its own hands, invading the AMA’s convention at the extravagant Fairmont Hotel in San Francisco. Such actions — in conjunction with the Civil Rights Act and the passage of Medicare — ultimately contributed to the AMA’s vote later that year to expel county societies that excluded black members, at long last forcing their disgracefully delayed integration.[15]

This is, of course, not to say that blacks subsequently gained equal footing within the medical profession. Black representation in US medical schools has remained proportionally low over the decades, especially for men. Indeed, a report from the Association of American Medical Colleges last year showed that the number of black male matriculants in medical school is lower now — in absolute terms — than it was in the late 1970s. Tweedy, now an assistant professor of psychiatry at Duke University Medical Center, was one of these matriculants. In his book, he describes some of the challenges he faced.

In addition to being one of only “a handful of black students” in his class at Duke Medical School, Tweedy came from a working class family, in stark contrast to the majority of his classmates. On the one hand, Tweedy highlights the importance of affirmative action: “So there it was: Not only was I admitted to Duke, when in a color-blind world I might not have been, but I had arrived with a full-tuition scholarship in hand.” On the other hand, his first exchange as a first year student with a medical school professor was markedly inauspicious: the professor approached him to ask if he was there to fix the lights. While he was a medical student, patients routinely queried him about his presumed basketball skills. Far worse was his interaction as a resident with a racist patient and his confederate-flag adorned family (“I don’t want no nigger doctor,” the patient told a nurse). Tweedy’s diligence and persistence ultimately, however, won them over. On another occasion, a black patient rejected him, presuming his medical skills to be inferior and seeing the assignment as evidence of racist mistreatment of him as a patient. Given the insecurities that afflict medical students and trainees in general, we can only imagine the additional strain created by such presumptions and prejudices.

Tweedy’s book is also very much about the experience of black patients. He bears witness to the second-class care they too frequently experience when, for instance, as a medical student he spends time in a makeshift rural clinic, “nestled within a group of dingy trailers and makeshift houses.” The clinic serves poor black patients who cannot afford prescribed treatments. They are likely to see a different doctor at every visit and receive grossly insufficient preventive care. In another chapter, he describes how one black patient, who quite reasonably declines one of his team’s medical recommendations, is dispatched with a punitive psychiatric diagnosis.

Toward the conclusion of his book, Tweedy briefly explores the larger and looming question: what is the cause of racial health inequalities? Early in his medical career, he had assumed — like many others — that genetic differences were the primary factor. And indeed, for years, a huge amount of resources have gone into uncovering the genetic sources of health disparities. However, as Jason Silverstein explains in a revealing article in The Atlantic (“Genes Don’t Cause Racial-Health Disparities, Society Does”), this money may have been better spent elsewhere. He describes a 2015 paper that systematically reviewed the collective evidence thus far for the proposition that genetic factors explain racial cardiovascular disparities. It’s worth quoting from the study’s conclusion:

The results reveal a striking absence of evidence to support the assertion that any important component of observed disparities in these diseases arises from main-effect genetic mechanisms as we currently understand them … Despite the enormous social investment in genomic studies, this research program has not yet provided valuable population-relevant insights into disparities in the most common cause of morbidity and mortality.[16]

Why then, Silverstein asks the study’s lead author, do genomics still get so much attention? The author responds with a sentiment I’ve long suspected: if inequalities are built into the very base pairs of our genetic code, what can we really do to alleviate them? More research? In effect, as the investigator tells Silverstein, the fact is that racism and inequities are let off the hook if our genes are the culprits. Tweedy notes that he came to reject this genetic explanation: even if genetic factors play some role with respect to specific diseases, they explain little of the overall differences in health between races.

In contrast, there are reams of evidence that point to social and economic inequalities as drivers of racial inequalities. In the first part of this essay, I focused on the impact of economic injustices on health: a large body of literature has demonstrated that poverty, for instance, is associated with a panoply of poor health outcomes, and some researchers argue that inequality itself causes worse health for everyone in society (perhaps via increased psychosocial strain as well as other factors).[17] No doubt such socioeconomic factors are a major factor in racial health inequalities, given the tight association between economic status and race.[18] Similarly, differences in health care access associated with race (like being uninsured) are no doubt factors as well.

But what might be said about the role of racially discriminatory treatment itself? This issue has received increased attention since the 2002 publication of an Institute of Medicine evidence report, Unequal Treatment: Confronting Racial Disparities in Health Care. Tweedy quotes from the report’s conclusion: “Although myriad sources contribute to [health] disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of the healthcare providers may contribute to differences in care.” Or, as he puts it, the “doctor-patient relationship itself serves as a catalyst for differing outcomes,” which is in part the result of the fact that “some doctors are prone to hold negative views about the ability of black patients to manage their health and therefore might recommend different, and possibly substandard, treatments to them.”

This issue — namely, the problem of racially disparate treatment — is the central focus of Dayna Bowen Matthew’s book. She explores how “implicit bias,” as she terms it, deforms physician behavior; in her view, it constitutes the most neglected determinant of inferior health among blacks.

 

3. Jim Crow medicine: Past and present

Matthew is a law professor with appointments at both the University of Colorado Law School and the Colorado School of Public Health. Matthew is also one of the founders of the Colorado Health Equity Project, a multidisciplinary organization that works to “remove legal barriers to equal health access and health outcomes for Colorado’s vulnerable populations,” as its website puts it. Her ambitious book lays out a case for a legal remedy for racial health inequality.

Key to her argument is the historical context of civil rights law, which she sees as a swinging pendulum. Hill-Burton, as we’ve seen, legally enshrined the “separate-but-equal” standard — established in the Supreme Court case Plessy v. Ferguson — within the health care system. Legal challenges to this standard were unsuccessful, until Simkins v. Moses H. Cone Memorial Hospital, the “watershed case,” as Matthew puts it, initiated its unraveling. As she recounts it, the case was brought by black practitioners and patients against a discriminatory hospital in North Carolina that received Hill-Burton funds. The Fourth Circuit Court of Appeals decided in favor of the plaintiffs, declaring, as quoted by Matthew, that “Racial discrimination by hospitals visits severe consequences upon Negro physicians and their patients.”

She describes two consequences that flowed from this decision. First, the case helped catalyze subsequent successful health-care related civil rights litigation throughout the country. Second, the decision — which the Supreme Court importantly declined to reconsider — helped lead the way to Title VI of the Civil Rights Act of 1964. According to Matthew, Congress took the Supreme Court’s decision not to accept the case as a signal that it saw hospital segregation as unconstitutional (and, indeed, several legislators explicitly cited the Simkins decision during debate over the bill). Much good came from this: “From 1963 through the early 1990s,” Matthew writes, “Title VI proved an effective weapon against the segregation and discrimination that minority patients and physicians had experienced in American health care since the colonial era.” For instance, the Johnson administration required hospitals to comply with Title VI in order to be eligible for Medicare payment. Few could afford not to, and so the age of explicit hospital segregation finally came to a close.

Yet Matthew asserts that, to an extent, this more auspicious era ended abruptly in 2001, when a more conservative Supreme Court ruled in Alexander v. Sandoval, in a decision written by Justice Antonin Scalia, that Title VI was applicable only in cases of deliberate discrimination; disparate impact was not enough.[19] This new standard precluded a great deal of civil rights litigation because it required that plaintiffs produce tangible evidence that racist health care was intentional, which is made difficult when, as she notes, “few Americans are careless enough to create an evidentiary record of outright bigotry.” Thus, according to Matthew, with respect to health care discrimination, this decision effectively rendered Title VI “a dead letter.” This decision, she argues, must be undone if progress against racial health inequalities is to proceed. In short, unconscious racism in health care must, according to her, be made illegal through an act of Congress and an expansion of Title VI.

This may sound Orwellian to some. Is it meaningful, after all, to talk about outlawing sentiments or attitudes that lie deep within the dark depths of our unconscious? Can we root out biases if we are, by definition, unaware of their very existence? Matthew marshals a body of literature from various disciplines to answer in the affirmative. Conscious racism, she argues, is slowly being replaced by the unconscious variety: “But while overt racism is subject to nearly universal derision, unconscious racism due to implicit bias is hidden, is tolerated, and even excused despite its destructiveness.” She persuasively explores various literatures demonstrating that physicians harbor unconscious negative perceptions of blacks. She cites studies that show that patient race affects which treatments doctors recommend, how much time they spend with patients, “the level of verbal exchange and shared decision-making in which they engage” with patients, and even the manner of their nonverbal engagement. She concludes that there is a sufficient base of evidence to conclude that these implicit biases contribute to disparities, that there is reason to believe that such biases, even though they are implicit, are remediable, and that health care providers — both on the individual and institutional level — can therefore be held legally responsible for the results of their implicit biases.

The “evidence of malleability” is strong, according to Matthew. In other words, she thinks specific interventions can mitigate implicit biases and, as a result, disparate outcomes. The sorts of interventions she envisions, however, seem of mixed applicability and utility. Nonetheless, overall, she makes a strong case that clinicians make racially biased decisions, whether or not they intend to, and that this issue must be directly addressed. People like me — that is to say, white physicians who believe they are immune from racially biased thought and action — have a great deal to gain from reading this book.

That said, it is also important to examine the larger picture. There is no question that more needs to be done to address physician bias. Yet we also have to keep in mind that, in the pre-Alexander v. Sandoval era (when Title VI was, according to Matthew, more robust), there were still large racial inequalities. Litigation may be a useful tool, but it’s a limited, post-facto modality.

More broadly, the recommendations of both Tweedy and Matthew ultimately seem inadequate. Neither gives much credence to the notion that further increasing the universalism of the health system might play an important role in reducing inequalities. Moreover, Tweedy says nothing, and Matthew only a little,[20] about the notion of economic redistribution as a tool against racial health inequalities. In fairness, these concerns are not the focus of their books. However, to my mind, they are crucial considerations in the larger discussion of racial health care justice.

 

4. Health equity and health system universalism

Martin Luther Kings Jr.’s statement on the evils of health inequality is frequently quoted, but not usually in its full form. In his 1966 speech at the annual meeting of the aforementioned Medical Committee for Human Rights, he said, “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”[21] Indeed, studies have shown a statistical association between lack of insurance and mortality. Removing the boundaries between individuals and the health care system is a critical step in the movement toward health care equality.

Tweedy, for instance, sees firsthand the harm inflicted on the uninsured when he works at the rural health clinic described earlier. But, even so, like Matthew, he gives insufficient attention in his book to the fact that, even with the reforms of the Affordable Care Act, we will continue to lack universal health care.[22] For instance, under current reforms, 27 million are expected to remain uninsured 10 years from now, according to an approximation of the Congressional Budget Office. We know that Hispanics and blacks are disproportionately represented among the uninsured.[23] Covering these excluded millions seems critical. Moreover, neither author discusses the fact that the US health care system imposes substantial financial burdens at the “point of use,” in the form of copayments, deductibles, and co-insurance for medical care, which may deter care for those who need it. Some have legitimately suggested that these forms of cost-sharing disproportionately harm minorities, who have lower median income and net wealth.[24] In other words, the potential harm of, say, a $2,000 medical deductible is dependent on your income and assets: those with fewer resources may lose out on important health care. And finally, though Tweedy refers to the shortcomings of Medicaid, neither he nor Matthew emphasizes that a health care system with a separate tier of access for the poor may be inherently unequal.

But would “true” universal health care do much to combat racial health inequalities, if it were, say, a single-payer system that eliminated out-of-pocket expenses and was equally accessible by all, without tiers or walls?[25] Or would it replicate current biases and inequalities? To some extent, the answer is yes to both questions. But even so, a body of research has suggested that, even if these biases persist, a fully universal system might nonetheless be a powerful tool in reducing racial health care inequalities. That evidence comes from what is arguably a quasi-single-payer system located in the US: the Veterans’ Administration (VA). Notwithstanding recent scandals that are indeed of great concern, the modern-era VA has justifiably earned praise for delivering a high — indeed, comparatively superior — quality of health care.[26] There is also evidence that it may indeed effectively reduce, even potentially eliminate, some racial health inequalities.

Last fall, a study published in Circulation, the premier journal of the American Heart Association, received wide coverage in the media for some provocative findings. “The US Veterans Health Administration (VHA),” as the study notes in its introductory section, “is a healthcare system that does not impose the typical access barriers of the US healthcare system that may disproportionately impede enrollment of blacks.” The investigators therefore hypothesized that racial inequalities in cardiovascular outcomes and mortality found in the general population might be reduced in the VA, a “healthcare system that allows enrollment independent of race or socioeconomic status.”[27] Consistent with previous studies, in their analysis of data from the general (non-VA) population, they found racial inequalities much as they expected to find them: blacks had a much higher mortality (after adjusting for various other factors) as compared to whites (indeed, approximately 40 percent to 50 percent higher).[28]

In striking contrast, in the VA population, even though the risk of stroke was either higher or similar among blacks as compared to whites depending on which statistical adjustments were used, the risk of coronary heart disease as well as overall death was actually lower among blacks. This is, of course, only a single study, albeit a rather large one with more than three million subjects. An accompanying editorial concedes that a number of factors may be at play. Nonetheless, the fact is that, as described by the investigators, these findings build on an existing literature consisting of multiple studies that together point to a reduction of racial health inequalities within the VA for critically important outcomes like mortality.[29]

No doubt, there are still discriminatory practices in some or all of these facilities, and we can assume that there are conscious or unconscious biases at work in the minds of some of its clinicians, as there are elsewhere. Indeed, other studies clearly show that, even after the significant reorganization and reform of the VA in the late 1990s, there are still racial disparities in the VA.[30] If we moved to a single-payer system on a national level, such biases would still need to be addressed along the lines Matthew argues. But the point is that a more egalitarian structure of the health care system itself might go even further in reducing them. Indeed, in light of this research, it seems fair to say that health care universalism could be a very powerful tool in combatting ubiquitous racial health inequities. Attaining health care equality, in other words, requires true equality of access. And yet this simple notion is all too often ignored entirely in any discussion of health “disparities.”

 

5. The road to health equality: Is it paved with reparations?

This takes us to the final and most important arena: the issue of economic inequality. The essential point here was made clearly by the scholar Vicente Navarro in a commentary in the Lancet in 1990: “… even if there were no race differentials in mortality, most blacks would still have higher mortality rates than the median or the mean rate in the US population.”[31] The logic of this seemingly paradoxical statement is simple. There is currently a (growing) gradient in life expectancy by income: the wealthy live longer than the poor. Thus, if incomes differ by race (as they do), then life expectancy will differ by race, even if racism were eradicated in its entirety from the health care system.

This is an uncomfortable notion, but it’s an important one. The ongoing rise in economic inequality was — in part — set into motion by a transatlantic political shift that occurred sometime in the 1970s.[32] The political ground may now be shifting beneath our feet, but we are nonetheless very much still living in that same “neoliberal” era, an era in which economic inequality and health inequality are yoked.

For some, an overarching concern with economic inequality might be thought consistent with a “class first” (as its often termed) mentality toward political change, an approach that is currently under great contestation on the left-leaning side of the political spectrum. For instance, Bernie Sanders’s central focus on economic justice has been criticized by the Atlantic’s Ta-Nehisi Coates, who argues that his “rising tide lifts all boats” approach is an amplified version of a longstanding inadequate Democratic approach to racial inequality. For Coates, in contrast, the sine qua non of racial justice is reparations. “[T]reating a racist injury solely with class-based remedies,” he writes, “is like treating a gun-shot wound solely with bandages.” But it bears mention that — in one particular way — Sanders and Coates are both arguing for the same thing: economic redistribution. For Sanders, this redistribution can be colorblind — through greater social welfare programs and progressive taxation — and still benefit minorities; for Coates, it must occur along color lines so as to more directly remunerate the victims of centuries of racist “plunder.” Yet there is, in truth, a great deal of overlap between these views. As The Week’s Ryan Cooper argued in response to Coates, given entrenched economic inequality between races, “[r]ace-neutral redistribution and welfare are by necessity anti-racist.” However, it’s important to recognize at the same time that a redistributive approach that is (at least nominally) neutral with respect to race lacks the symbolism of restitution. I can understand how many might feel that this would therefore fall short of justice.

Then again, a stark theoretical dichotomy between class-based and race-based measures is reflective of neither history nor contemporary reality. The very reason that there are economic inequalities between blacks and whites is, of course, slavery, and the legal and extralegal oppression that followed it. In health, we can disentangle the effects of class and race by using sophisticated statistical tools, but what does it really mean when we say that health disparities are — or aren’t — attenuated when “adjusting” for socioeconomic status? Theoretically, we are trying to measure the “pure” effect of race.[33] But that’s an illusory concept, to some extent: the effects of class and race are intimately interwoven.

In health care, it is at this point clear that we need policies that work to diminish inequalities along the lines of each. A lesson that can be drawn from Tweedy, for instance, is that a health care workforce should reflect the composition of its population. Although he doesn’t make the case quite as strongly in his book, he does so in a New York Times op-ed headlined “The Case for Black Doctors.” For now, this goal requires affirmative action. Matthew, on the other hand, convincingly demonstrates that racial biases are at work — sometimes invisibly — in the minds of physicians, and whatever happens in the realm of economics or on the health system level, those biases will not suddenly wither. They therefore must be addressed, perhaps through the types of legal measures she describes. More broadly, we must aggressively address the host of environmental and public health inequities — and police violence might be considered in this category — that disproportionately afflict communities of color.

Yet these approaches — if carried out alone — would ultimately be inadequate in the struggle against racial inequalities in health. Health system universalism, on the other hand, is a potentially powerful — albeit insufficient — step toward racial health care justice. Likewise, economic inequality — on the rise, bound with race, tightly corresponding to health and death — must also be addressed. This is where the “liberal” and the “left” frameworks toward health inequalities diverge. The liberal framework seeks to ameliorate the health impact of poverty or inequality with an array of interventions and programs and palliatives; the left approach, in contrast, goes a step further, and aims to level the inequalities themselves.

At the moment, the political winds seem to be favoring the latter. For those concerned with combatting the ills of health inequality — of both race and class — this should be seen as an auspicious development. Health inequities are not the product of our genes: they are the consequences of our history, and of the politics of health.

¤

[1] One of the two books reviewed in this essay — Dayna Bowen Matthew’s Just Medicine: A Cure for Racial Inequality in American Health Care — traces the history of health inequalities back to colonialism and the horrors of slavery.

[2] Beatrix Rebecca Hoffman, Health Care for Some: Rights and Rationing in the United States since 1930 (Chicago: University of Chicago Press, 2012), 81-85. The quote is from a document from the Southern Conference Educational Fund, quoted by Hoffman on p. 82.

[3] Stevens note that in 1910, only 60 percent of hospitals accepted any “colored” patients in this region. Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), 50.

[4] Quoted by Charles E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987), 302.

[5] On health reform during the New Deal era, see Daniel S. Hirshfield, The Lost Reform: the Campaign for Compulsory Health Insurance in the United States from 1932-1943 (Cambridge, Mass.: Harvard University Press, 1970). See p. 44 on this specific point.

[6] Regarding labor’s support for national health insurance in this era, see A. Derickson, “‘Take Health from the List of Luxuries’: Labor and the Right to Health Care, 1915-1919491949,” Labor History 41, no. 2 (2000).

[7] Quoted in Alan Derickson, “Health Security for All? Social Unionism and Universal Health Insurance, 1935-1958,” The Journal of American History 80, no. 4 (1994): 1341.

[8] On the Truman campaign and the physician backlash, see Monte M. Poen, Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare (Columbia: University of Missouri Press, 1979).

[9] Hoffman, Health Care for Some, 74.

[10] N. Krieger et al., “The Unique Impact of Abolition of Jim Crow Laws on Reducing Inequities in Infant Death Rates and Implications for Choice of Comparison Groups in Analyzing Societal Determinants of Health,” American Journal of Public Health 103, no. 12 (2013).

[11] Anne Case and Angus Deaton, “Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century,” Proceedings of the National Academy of Sciences (2015). The paper is available here, and my thoughts about it shortly after publication are here. There has subsequently been some discussion about the failure to fully adjust for age in this paper, but the overall thrust of the paper’s findings have held up, as discussed here.

[12] For instance, these scholars contextualize deaths at the hands of law enforcement as a public health issue, arguing that such deaths should be made a “reportable health condition.” Nancy Krieger et al., “Police Killings and Police Deaths Are Public Health Data and Can Be Counted,” PLoS Med 12, no. 12 (2015).

[13] The group recently published a paper describing their origins and aims. Dorothy Charles et al., “White Coats for Black Lives: Medical Students Responding to Racism and Police Brutality,” Journal of Urban Health 92, no. 6 (2015).

[14] I discussed this aspect of the show in greater length in an online article “Just Another Business,” Jacobin, November 21, 2015.

[15] This paragraph relies throughout on John Dittmer, The Good Doctors: The Medical Committee for Human Rights and the Struggle for Social Justice in Health Care, 1st ed. (New York: Bloomsbury Press, 2009), 6-7, 205-07.

[16] Jay S. Kaufman et al., “The Contribution of Genomic Research to Explaining Racial Disparities in Cardiovascular Disease: A Systematic Review,” American Journal of Epidemiology (2015).

[17] The health effects of inequality were presented to a general audience in: Richard G. Wilkinson and Kate Pickett, The Spirit Level: Why Greater Equality Makes Societies Stronger (New York: Bloomsbury Press, 2010).

[18] Moreover, group-level differences in unhealthy behaviors can be seen (in part) as downstream consequences of social, economic, and environmental disparities, and so might also be considered in this category.

[19] However, she notes that “disparate impact” is still sufficient grounds for action by government agencies, though she contends that, practically speaking, these agencies lack sufficient resources for the task.

[20] For example, as Matthew notes in passing, “[c]hanging only the law will not solve the socioeconomic disparities that lie at the foundation of our society and produce the poor health experienced by many people.” She also makes the important point that universalizing access does not solve other racially patterned “systemic inequities” — for instance, in education or housing.

[21] Two articles containing slightly different versions of this quote have recently surfaced. This version is from an AP story headlined “King Berates Medical Care Given NegroesOshkosh Daily Northwestern, March 26, 1966, and is available at: http://www.pnhp.org/news/2014/october/dr-martin-luther-king-on-health-care-injustice (accessed January 26, 2016) The other article with a slightly different version of the quote is available at the same page.

[22] Tweedy acknowledges that the Affordable Care Act “has some good features,” like the expansion of insurance coverage and the prohibition on discrimination based on preexisting conditions. “But whether these and other changes will prove to be fiscally viable over the long term,” he states, “in the face of ever-rising health care costs, remains to be seen.” It’s not quite clear what Tweedy is saying here. Is he calling into question the financial viability of universal health coverage itself? Or is he suggesting that a more robust reform is necessary to cover everybody while also lowering costs? If he means the latter, he does not say it, much less spell it out.

[23] According to this November 2015 report from the Kaiser Family Foundation, the uninsurance rate for whites is 9 percent, for blacks is 13 percent, and for Hispanics is 21 percent.

[24] “[T]he average family deductibles for bronze and silver plans would bring financial ruin to most African American and Hispanic households.” Dominic F. Caruso, David U. Himmelstein, and Steffie Woolhandler, “Single-Payer Health Reform: A Step toward Reducing Structural Racism in Health Care,” Harvard Public Health Review 6 (2015). Available here.

[25] The argument that single payer could be a tool against racial health inequalities has been made before. See Vijay Das and Adam Gaffney, “Racial Injustice Still Rife in Health Care,” CNN.com, July 28, 2015; and Caruso, Himmelstein, and Woolhandler, “Single-Payer Health Reform: A Step toward Reducing Structural Racism in Health Care.”

[26] This study, for instance, compared the extent to which VHA patients receive recommended care for a wide variety of conditions as compared to non-VHA patients. It found that the “… VHA had substantially better quality of care than a national sample.” S. M. Asch et al., “Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample,” Annals of Internal Medicine 141, no. 12 (2004).

[27] The study excluded individuals with reduced renal function, given evidence that genetic factors may play a role in black/white disparities in this population. Kovesdy, Csaba P., Keith C. Norris, L. Ebony Boulware, Jun L. Lu, Jennie Z. Ma, Elani Streja, Miklos Z. Molnar, and Kamyar Kalantar-Zadeh, “Association of Race with Mortality and Cardiovascular Events in a Large Cohort of Us Veterans,” Circulation (September 18, 2015).

[28] 42 percent higher if restricted to those with normal kidney function, and 51 percent higher in the overall population.

[29] For instance, Jha et al. investigated how race affects mortality in those hospitalized at VA hospitals for one of six conditions, and went so far as to conclude that “equal access to care provided by the VA health care system has closed — and perhaps even crossed — the racial gap in health outcomes for common conditions.” Deswal et al. evaluated mortality following admission to a VA hospital among those only with congestive heart failure, concluding that “[i]n the VA healthcare system, a system designed to provide financially ‘equal access’ to care for all enrolled patients, the racial gap in patterns of healthcare utilization in patients with CHF is small. The observation of better survival in black patients after a hospitalization for CHF is not readily explained by differences in healthcare utilization and needs further evaluation.” However, as the investigators’ note, white patients were overall sicker, which might account for their worse outcomes in a manner that could not be adjusted for by the investigators. Still, considered together, the fact that, in some instances, blacks do better than whites in the VA system is striking. However, it should probably be taken with something of a grain of salt given the fact that they do worse everywhere else. Overall, it might seem fair to conservatively conclude from such studies that, at the least, racial health inequalities — like mortality — are substantially attenuated within the VA system as compared to the general population. The papers by Jha et al. and Deswal et al. are cited in the paper by Kovesdy et al. See A. K. Jha et al., “Racial Differences in Mortality among Men Hospitalized in the Veterans Affairs Health Care System,” Jama 285, no. 3 (2001); A. Deswal et al., “Impact of Race on Health Care Utilization and Outcomes in Veterans with Congestive Heart Failure,” J Am Coll Cardiol 43, no. 5 (2004); N. L. Cook and G. A. Mensah, “Eliminating Health Disparities: What Can We Learn from the Veterans Health Administration?” Circulation 132, no. 16 (2015).

[30] For just one example, see Amal N. Trivedi et al., “Despite Improved Quality of Care in the Veterans Affairs Health System, Racial Disparity Persists for Important Clinical Outcomes,” Health Affairs 30, no. 4 (2011).

[31] V. Navarro, “Race or Class Versus Race and Class: Mortality Differentials in the United States,” The Lancet 336, no. 8725 (1990).

[32] On the transatlantic intellectual roots of neoliberalism, see Daniel Stedman Jones’s excellent Masters of the Universe: Hayek, Friedman, and the Birth of Neoliberal Politics (Princeton: Princeton University Press, 2012). Jones emphasizes the “underappreciated real significance of the transatlantic nature of neoliberalism — it didn’t just happen in different places at the same time, it happened across and between them.”

[33] For a very good discussion of this issue, and of how race and class inequities must both be studied and addressed, see Ichiro Kawachi, Norman Daniels, and Dean E. Robinson, “Health Disparities by Race and Class: Why Both Matter,” Health Affairs 24, no. 2 (2005).

¤

Adam Gaffney is a physician and writer whose work has also appeared (either in print or online) in the New Republic, SalonUS News & World ReportJacobin, In These TimesUSA TodayCNN.com, and on his blog at www.theprogressivephysician.net. He is a fellow in pulmonary and critical care medicine at Massachusetts General Hospital. He is also an adviser to the board of the Physicians for a National Health Program. All views expressed are his alone.