Saturday morning, April 17th, the auditorium of Junior High School 22 in the Bronx was crowded with community residents who had gathered for a town hall meeting. Health care reform had passed, but these folks knew that their problems were not over. Ensuring that most Americans have health insurance, while important, will not be enough to eliminate the racial and ethnic disparities that have been dyed deep into the U.S. healthcare system and that reveal themselves, vividly, in the Bronx.
To save black and brown lives and to improve the vibrancy of those lives requires looking beyond access and focusing on quality. It requires, among other things, an examination of the practices of major health care institutions, which deny low-income people of color the highest quality of care they have to offer even when those people have health insurance.
The specific issue that community members had gathered about is this: in New York City, prominent private hospitals–facilities like New York-Presbyterian, Montefiore Medical Center, Mount Sinai–operate two different systems of care for patients with the same kinds of health problems but with different types of insurance. There are, for example, cardiology “clinics” for patients with Medicaid, a public insurance program, and there are cardiology “faculty practices” for patients with private insurance. Sometimes the clinics are right next door to the faculty practices, but Medicaid patients won’t be allowed into the faculty practices, and privately insured patients are not sent to the clinics.
What is more, the hospitals allow valuable and finite resources to be allocated unequally between the two systems of care. For instance, clinics often do not have enough financial support from the hospital to perform basic care coordination tasks like sending notes back to the patient’s primary care physicians, while faculty practices often receive administrative and other forms of support so that such tasks are routinely able to be done.
More significantly, board certified faculty physicians, the top docs, spend only a fraction of their time in the clinics–a mere half a day a week for four months out of the year in one case–even though they are required by law to spend the bulk of their time supervising resident doctors and caring for patients in the clinic setting instead of in the faculty practice. Hospitals do nothing to shift the balance and, as a result, Medicaid patients do not have a single, board-certified physician who is ultimately responsible for their care, whereas privately insured patients do. Here is a chart summarizing some of the main inequalities:
The impact of these differences are felt on the bodies and backs of low-income patients. At the town hall meeting, Medicaid beneficiaries spoke of being bounced from one doctor-in-training to the next within a fragmented clinic system, where fingers and toes were almost amputated and cancer remained undiagnosed until dangerously late. And they spoke of how these outcomes were not race neutral. In New York, people of color are far more likely to have public insurance than whites, which means that when hospitals create two systems of care based on insurance they are also perpetuating a de facto segregation based on race. (For more background and helpful stats on this issue, please see this excellent monograph on medical apartheid in New York City by the Bronx Health REACH coalition, the group that first brought this problem to light.)
Representatives of health care institutions have argued publicly that community residents are missing the point. The source of the problem, they claim, is with the Medicaid program and not with the hospitals. Doctors’ offices are reimbursed at extremely low rates through Medicaid and therefore can’t afford to see publicly insured patients in their faculty practices. The clinics have been set up to provide an avenue for care that otherwise wouldn’t exist.
But it is the hospital representatives who are missing the point. The provision of care to Medicaid patients is not something hospitals are choosing to do out of the goodness of their hearts. Under federal law, hospitals are required to open their doors to Medicaid beneficiaries, and provide them care without discrimination, in exchange for accepting millions of dollars of government funding to modernize and upgrade their facilities.
Moreover, while Medicaid reimbursement rates for doctors’ offices are very low, they are much higher for clinic-based services. In order to integrate care, hospitals could simply shift their resources to the clinic and ensure that all patients, public and private alike, are seen in that setting, instead of siphoning off the privately insured patients to the faculty practices. The increased resources and mixed patient population would help ensure that the quality of clinic care would improve dramatically and that this high-quality care would be accessible to all on equal terms.
Of course, hospitals are choosing not to do this and, given the dubiousness of the financial arguments, one is left to presume that their motives are more suspect: one cannot attract wealthy, white patients from the Upper East Side and Westchester if those individuals will have to sit in the same waiting room as people of a different class or race. The fight to integrate our health care system and to reduce racial and ethnic health disparities is therefore going to be just as messy as the historic battles to integrate our educational system or our housing. But fight is what Bronx residents will do, even in the face of uncertainty and resistance. As one faith leader said at the town hall meeting, quoting a song from the civil rights movement of deep South, we must “run on and see where it ends.”