Racism as a public health crisis and the economics of urban hospitals

On September 14th, St. Vincent Charity Medical Center announced they will cease to provide emergency and inpatient services, including emergency psychiatric services, in Cleveland. In addition to the impact this will have on the local service delivery landscape, there is also the economic consequences of the loss of 600 jobs in the city’s Center. Ironically, this announcement was made while I was attending the National Academy for State Health Policy conference, where the particular session I was attending focused on the impact of the built environment on disparities in health outcomes. And while there would seem to be little connection between these issues, it may be worthwhile to talk about the association between hospital economics, urban centers and racism as a public health crisis.

Early health care policy and exploitation

Unless you are a wonk like me, you might not understand the policy history between hospitals and cities. To start, we first must acknowledge how the medical industry has a long and dubious relationship in engendering racism and discrimination in our medical institutions. From the closure of Black-led medical schools to experimentation on Black patients without consent, the industry has long exploited Black communities, and their bodies, for direct financial gain, carrying forward the most harmful legacies of our nation’s history of slavery in passive and obscure ways.

As momentum gained in the wake of the labor movement to protect individuals from harm in the workplace, and as a consequence of the rise in employer sponsored insurance in the wake of World War II, policy focus was placed on building access to facilities capable of treating newly covered Americans. In 1946, the Hospital Survey and Construction Act of 1946, commonly known as the Hill-Burton Act, “launched the nation on the most comprehensive hospital and public health construction program ever undertaken”. This legislation, which provided millions of dollars to states and local governments, was designed to build “bed” capacity across the country and was incredibly successful in doing so. It was also very intentionally designed so that the economic benefit of the construction was borne mostly in cities and rural communities, where the deepest public health challenges of poverty were apparent. However, while the availability of coverage and services started to grow, it was not made available for all.

Why provide this history lesson?

The role of government: hospital segregation, Medicare, and Medicaid

Through a disproportionate beneficiary of these resources, southern state Congressional leadership fought against a policy provision that required racial integration in hospitals. Interestingly, this was a provision that was fought for by one of the bill’s main sponsors, Republican Senator (and former Mayor of Cleveland) Harold Burton. Senator Burton was unfortunately unsuccessful, however, and it wasn’t until Simkins v. Cone that the courts affirmed hospital segregation through a “separate-but-equal” standard was unconstitutional. But, like Brown v. Board of Education, the decision largely left it to the states to manage enforcement on a case-by-case basis. In fact, it wasn’t until 1965, with the passage of Medicare and Medicaid by President Lyndon B. Johnson, that hospitals were required to desegregate as a condition of receiving federal funds. So, at this point, you may be asking yourself “why provide this history lesson?

Hospitals have been the disproportionate economic beneficiaries of Hill-Burton, the Medicare and Medicaid Act and the Patient Protection and Affordable Care Act. In essence, it has been government, seeking to develop a meaningful public good, that has created the industry. Its existence, in part, is due to the policy trade-off where the government has subsidized the capital, material and workforce needs of the industry in exchange for health service availability. And that is a good thing. But, with the United States lagging nearly all other industrial nations in outcomes and cost, we are at a point where we should demand more from that investment.

Hospital systems have increasingly shifted their services to the suburbs in a conscious effort to maximize revenue.

Investment, revenue, and economics: hospitals can do better

First, hospital systems have increasingly shifted their services to the suburbs in a conscious effort to maximize revenue. In other words, the business of operating a hospital is often taking precedence over taking care of people in poverty or on Medicaid. And, with poverty and Medicaid coverage disproportionately affecting Black Americans, that inherently contributes to systemic racism in healthcare. Second, hospitals have done more, particularly during COVID, to accommodate service provision through telemedicine. While that can increase access for some, the lack of broadband access in urban centers, coupled with the distrust institutions have engendered, generally, means telemedicine can exaggerate disparities. What’s more, as income taxes from hospitals are often the largest source of revenue for major urban centers like Cleveland, offshoring telemedicine services to far flung geographies can create financial pressure in cities and negatively impact their ability to address basic needs like housing, transit and education.

In other words, it can deepen social risk factors in Black communities by making it harder to establish a foundation of economic security through basic city services. That also contributes to systemic racism. Mind you, locally, we just built the “Opportunity Corridor,” a functional highway, (next to a train line, by the way), so that our hospitals’ workforce, who does not live in the city, can commute home to suburban communities. One would think we would’ve learned our lessons from redlining and urban renewal, but alas.

Third, it’s important to note that hospitals do not pay taxes as a function of being non-profit organizations. And while they have community benefit obligations in federal law, those obligations are deeply flawed and in need of change. If there is a direct economic benefit to these businesses, then we need community benefit policies which have an explicitly anti-racist approach, otherwise we are perpetuating the same specters of our racist past, exploiting communities while doing so with federal and state funds.

We can do it now. We should all expect more.

Three questions to consider when a hospital closes

This is not to say that our hospitals are inherently racist institutions. Far from it. The work of our hospitals to address lead safety, increase staff wages, and build primary care in communities of need are clear examples of an anti-racist approach. But we need to honestly look at our institutions and how they can reform in the direction of justice beyond marketing campaigns, community health need assessment statements and luncheon presentations. Hence why policy proposals which include local government oversight in community benefit are worthy of discussion. So, let’s think about this in the context of the St. Vincent news. With the closure of some services, there are lingering questions about the impact that the loss of a psychiatric emergency department will have on access for individuals in crisis. This is not to say that the very difficult decision made by St. Vincent’s is the wrong one, but rather it should be a signal to the other hospitals, the City and the County to design a response that considers the ways the system can be improved. To that end, here are some recommendations as well as questions to consider that try to synthesize and pull into the foreground the issues outlined above:

1: Center Community-based Services

There will always be a need for a psychiatric emergency department. But, can we minimize the number of people who need that level of care? Why is it that we are still underperforming with our access to the Diversion Center? Why will Emergency Medical Services not transport to the Center and should they, or our city’s doctor, be empowered to provide medical clearance to better integrate in the community? Can we implement a Care Response approach? How can we support more community behavioral health and its workforce?

2: Understand Who Benefits from Closure

There will be less competition for services in the market. That means there will be more market power concentrated in less hands. So, if services are going to be redistributed, where will that happen? In the city or in a suburban facility? Especially because institutional-based approaches in behavioral health have a long history of perpetuating racism, how can we ensure that services offered are done so in the communities where people want to receive services and with the community-based providers that have the relationships clinically meaningful in ensuring success?

How do the programming needs tied to the loss of the emergency department inform the community benefit programs of other institutions and who gets to identify the priorities?

3: Thoughtfully Collaborate

Whatever the individual field or interest, government partners, hospitals, community behavioral health and advocates need to get on the same page about ensuring a successful transition. In looking at St. Vincent’s transition, they are doing what they can to meaningfully stay integrated in the community, but with a different scope and scale. So how can other hospitals support that work? How do the programming needs tied to the loss of the emergency department inform the community benefit programs of other institutions and who gets to identify the priorities? How do levies, relief dollars, opioid settlement monies and Medicaid play a role in ensuring access and equity?

Medicaid Institute on Community Benefit is October 11

And while this is one example, the larger theme of the need to reformat a hospital’s relationship to a community, built around deference to the community in terms of power and resources, still holds. In the coming weeks, The Center for Community Solutions will explore Community Benefit in depth, hosting a Medicaid Institute on Community Benefit with the Lown Institute on October 11. We will be looking at programs in other cities and offer insights into what Ohio cities like Cleveland can do. In the end, if we are serious about ending racial disparities and systemic racism in our institutions, and addressing racism as a public health crisis, we should follow the example of our former Mayor and Senator Harold Burton, and advocate for change. But, unlike Senator Burton, we shouldn’t wait until Medicaid becomes the driving force behind the change. We can do it now. We should all expect more.