Unfortunately, racial disparities in health care outcomes have persisted over many decades in the United States, largely due to historical social and structural injustices leaving minoritized groups at long term disadvantage in health care access and high-quality care. My academic interest lies in the intersection of health care policy and health disparities, and I am a strong believer that policy can be an effective lever to help curb disparities in care. As history often rhymes, it is important for disparities researchers to understand the history of health care discrimination in the US. Today, I wanted to highlight some historical context about racial segregation in hospital care and the major legal and policy steps that helped end it.
First, it is important to provide some context. At the end of World War II in 1945, there was a shortage of hospitals in the US. Few hospitals were built during the Great Depression and World War II and many existing hospitals had closed.1 To help correct this shortage, the Hospital Survey and Construction Act (or the Hill-Burton Act) of 1946 was passed by Congress and signed by President Truman.2 This provided federal grants to states to aid with hospital construction. Initially, Hill-Burton funds were tied to a non-discrimination clause, but to get the act passed, a compromise was struck to allow for “separate but equal” facilities and the funds were mostly left for the states to control. Notably, this was the only federal law passed in the 20th century with a separate but equal provision specifically codified.3 After passage, the overall hospital shortage decreased as more hospitals were constructed in the US, but pre-existing segregation of hospital care remained. While not exclusively a problem of Southern hospitals, hospital segregation was much more pronounced in the South. Only 6% of Southern hospitals offered Black patients services without restrictions. Black patients were either denied admission altogether (31% of Southern hospitals) or admitted to separate floors (47% of Southern hospitals) – often basement or attic wards.4 Black physicians also struggled to obtain privileges to admit patients at these hospitals.3
One of the first major legal steps to desegregation of hospitals came from Simkins v Moses H Cone Memorial Hospital, which struck down the separate but equal clause of the Hill-Burton Act. In 1962, Dr. George Simkins, a dentist from Greensboro, North Carolina, sued Moses H. Cone Memorial Hospital for refusing to admit a Black patient suffering from a molar abscess. Simkins argued that because the hospital had received federal funds under the Hill-Burton Act, they are beholden to the Fourteenth Amendment’s Equal Protection Clause. While the local courts initially sided with the hospital, Simkins (represented by the NAACP, and supported by then Attorney General Robert F. Kennedy) won the case in the Fourth Circuit appeals court, thus overturning the separate but equal clause of the Hill-Burton Act. The Supreme Court declined to hear an appeal, cementing the ruling in place.3
Despite the ruling, there was no real mechanism to compel the integration of hospitals similar to integration of public schools following Brown v Board of Education
However, two major legislative achievements passed during this time. First, the Civil Rights Act of 1964 made it illegal for any program receiving federal funds to discriminate based on race, color or national origin and allowed individual federal agencies to enforce the policy.
Second, the Medicare program was passed into law by President Lyndon Johnson in 1965. The Medicare/Medicaid programs were monumental legislative achievements. With Medicare, millions of older adults were now guaranteed health insurance which was a financial win for hospitals who would be reimbursed for their care. With Medicare passage, the federal government now had leverage to enforce desegregation of hospitals, as they could withhold Medicare funding to hospitals that did not comply, thus withholding a substantial portion of hospital revenue.2 One major hurdle was that the federal government now had to certify thousands of hospitals as compliant with the Civil Rights Act in the 1 year between the passage of Medicare in 1965 and implementation in 1966. The Department of Health, Education, and Welfare (precursor of the Dept of Health and Human Services) enlisted an army of personnel from their office and the Social Security Administration to conduct a desegregation campaign throughout 1965 and 1966. They formed inspection teams in conjunction with local volunteers and civil rights leaders/organizations- particularly in the South where initial compliance was estimated to be <20% among hospitals- to inspect and file complaints against segregated hospitals. This would then put hospital Medicare reimbursement at-risk.1
The strategy worked well. The day before Medicare took effect, 92% of hospitals were compliant, and 6 months later, 98% of hospitals were compliant. However, it was not a perfect process. Several hundred hospitals in the deep South who did not receive federal funds chose to opt out of Medicare and remain segregated.1
Although Medicare implementation and hospital desegregation did not eliminate racial disparities, it did help. It is difficult to study the direct contribution of hospital desegregation, but some estimate this helped the Black infant mortality rate fall by 30% in the deep south in the first 5 years after Medicare implementation.1
Clearly, the job remains unfinished. Black Americans have a 5-year shorter life span than White Americans, infant and maternal pregnancy-related mortality are also higher among Black patients than White patients.5 Notably for surgeons, a large body of literature has consistently documented pervasive racial disparities in surgical access and outcomes.6
The implementation of Medicare serves as a landmark example of how policy can affect disparities. Although a politically contentious proposal in the current landscape, I would hypothesize that public reporting of disparities measures and establishing disparity-related outcomes as quality standards hospitals need to meet for reimbursement may help further reduce disparities. If I learned anything in Economics 101, it is that humans (and hospitals) respond to incentives.
P.S.:
This is only a brief summary of a bigger, more fascinating story. I did not cover the contributions of many other Black physicians and civil rights leaders during this time. I would encourage reading the full articles by Burrows and Burney1, Beardsley7, and Largent2 cited below if you are interested in learning more.
- Burrows V, Berney B. Creating equal health opportunity: How the medical civil rights movement and the Johnson administration desegregated U.S. Hospitals. J Am Hist. 2019;105(4):885-911. doi:10.1093/jahist/jaz004
- Largent EA. Public health, racism, and the lasting impact of hospital segregation. Public Health Rep. 2018;133(6):715-720. doi:10.1177/0033354918795891
- Reynolds PP. Professional and Hospital Discrimination and the US Court of Appeals Fourth Circuit 1956-1967. Am J Public Health. 2004;94(5):710-720. doi:10.2105/AJPH.94.5.710
- Cornely PB. Segregation and discrimination in medical care in the United States. Am J Public Health. 1956;46(9):1074-1081. doi:10.2105/ajph.46.9.1074
- Artiga S, Hill L, Presiado M. How Present-Day Health Disparities fo Black People Are Linked to Past Policies and Events. KFF. https://www.kff.org/racial-equity-and-health-policy/issue-brief/how-present-day-health-disparities-for-black-people-are-linked-to-past-policies-and-events/. Published 2024. Accessed February 7, 2025.
- Haider A, Scott V, Rehman K, et al. Racial Disparities in Surgical Care and Outcomes in The United States: A Comprehensive Review of Patient, Provider and Systemic Factors. J Am Coll Surg. 2013;216(3):482-492.
- Beardsley EH. Good-Bye to Jim Crow: The Desegregation of Southern Hospitals, 1945-70. Bull Hist Med. 1986;60(3):367-386.
Joshua Herb
