Segregation in Health Care: The Rule more than the exception

        As the new administration continues to encourage what many of us view as discriminating policies, the discussion of segregation, discrimination and division repeatedly emerges. Unfortunately, segregation is not limited to residential communities but rears its ugly head in the healthcare system as well, contributing to health disparities and inequalities.  Segregation of patients in healthcare facilities remains a persistent problem and the methods include segregation by location, by insurance status and segregation by social risk.

People go to health care providers that are closer and accessible. In this way, health care facilities including private practices, clinics, hospitals and nursing homes largely cater to different populations because of residential segregation. The motives for opening a practice or clinic in certain neighborhood fuels the separation. Health administrators interested in attracting wealthier clients will open in predominately white neighborhoods. Conversely, those looking for cheap rent and less restrictions will open in underserved minority communities.  Because racial and ethnic segregation is largely linked to economic class and finances, segregation is largely connected to quality.  For example, in NYC, majority of African American and Latino patients are rarely serviced by private academic medical centers, instead a significant portion of these patients get treatment public city hospitals.  

These facilities have less funding, reduced resources and lack specialty services crucial to minority communities such as social work or nutritionist. Optimally speaking, when health care facilities attract specific populations due to location, it would be best to tailor services to that population, this includes cultural competence, translation services, targeting health condition that predominant in that population and hiring minority physicians. Unfortunately, there are no real provisions by local or federal government to mandate this.

Segregating patients by type of insurance is the second most common method. Patient with no health care coverage or Medicaid (subsidized ) are assigned to specific clinics and practices. It is standard practice for hospitals to separate their practices (including doctors, location), with private offices servicing private insured patients and their Medicaid patients serviced by physicians-in-training in outdated, overcrowded hospital clinics . Similarly, rehabilitation facilities and nursing homes by the same corporation and umbrella organization, will separate these patients. Typically, the services again are not equal.

Probably the most egregious is segregation by social risk. In this case, clients or patients with certain “undesired” social risk or issues are diverted (through referrals) to specific facilities including clinics or rehab facilities. These “social risks” can range from homelessness to history of substance abuse, history of mental health issues, or undocumented immigration. Patient with these factors are specifically diverted to only identified places, and like racial segregation, the purpose is to separate them from what is considered the “respectable paying public”. This practice should not be confused with specialty clinics or facilities that target specific vulnerable populations such HIV clinic, healthcare for homeless or clinic for refugees. With the latter, the facilities are specifically designed and structured to address the needs and challenges of the targeted population. However, under most circumstances these “high risk patients” are not going to a specialty clinic and patients with the most challenging social, physical and emotional health needs are shuffled together into identified programs or facilities, without the necessary resources. The facilities are not equipped with extra social workers, nor mental health providers, nor other specialty service. This type of segregation contributes to further social isolation of certain vulnerable groups and may encourage unhealthy behaviors. Think of the substance user in remission who is only allowed to go to places servicing other person suffering with substance use disorder and how relapse increases in these settings.

Most of the above-mentioned scenarios do not occur in isolation, but instead overlap. Large medical practices and hospital with multiple locations or campuses are typically the most guilty,  having  the convenience and means to designated which location /center will service who.

If segregation in health care persist so will health disparities, the solutions are difficult. For one this country has not been able to reverse residential segregation despite multiple policies and laws implemented to change things. The capitalistic culture favors dividing services based on pay. And social status and risk continues to divide. Here are some ideas however, that may improve things:

• ·        Stop the hospital segregation of Medicaid patients to clinics with only medical students and residents. If health training is crucial then doctors-in-training should be equally exposed to both private and Medicaid patients. Conversely, regardless of insurance, all patients should have an equal or access to see and be treated by attending physicians.  
• ·         Accreditation organizations and surveyors should monitor for signs of segregating referral practices by hospital administrators or social workers.   
• ·         Facilities in minority communities should be reimbursed or be incentivized in a way that support investment of more resources and specialty services that optimize health care to minority populations such as social workers, community health workers and cultural competency training and resources.   
• ·         Maintain credentialing criteria in hiring health care providers in all health care settings regardless of population served.
• ·         Assess business health care facilities opening in minority communities and inquire what is their process to address the needs of the community. 

    Hopefully we can push our policymakers to implement these changes