Hospitals' “Quiet” Civil Rights Revolution

During the Civil Rights era, hospitals were important, albeit reluctant^{Reference Nash1} leaders in reversing America's egregious history of racial segregation. Until the mid-20th century, hospitals were bastions of American apart-heid with unjust and often tragic consequences.^{Reference Thomson2} A 1957 survey of 721 hospitals in 48 cities reported that 90% of Southern hospitals engaged in the widespread practice of racial segregation, while 83% of hospitals in Northern cities practiced “restrictive integration,” admitting a limited number of “Negro patients … found in overcrowded wards, in basements and in attics.”^{Reference Cornely3} All hospitals routinely excluded non-whites from residency programs and denied black physicians admitting privileges.^{Reference Reynolds4} However, following the water-shed ruling in a hospital desegregation case won by black physicians, dentists, and patients,^{Reference Matthew5} Congress enacted Title VI of the Civil Rights Act of 1964 to broadly prohibit using federal funds to discriminate based on race, color, or national origin.^{Reference Reynolds6} Notwithstanding some instances of doggedly resistance, hospitals for the most part responded to Title VI enforcement^{Reference Reynolds7} with a “quiet revolution” to admit minority patients for treatment on the same basis as whites.^{Reference Nash8}

Thus, hospital desegregation generally provides a marked contrast to the violence that preceded racial desegregation in other aspects of American public life. There were no vicious shows of force to put down marches needed to desegregate hospitals.^{Reference Glass9} History records no massive resistance to hospital desegregation such as the legislative protest to public school desegregation launched from Virginia by Senator Harry F. Byrd, Sr.¹⁰ Instead, history records that most hospital administrators ultimately voluntarily integrated their institutions when they saw that it made economic sense to do so.¹¹ Similarly today, hospital administrators who may need more than moral justification to dedicate themselves and their institutions to holistic care, could serve as lodestars toward health equity care because it makes economic sense to do so. The important next step towards equity in health reform, therefore, is to sustainably finance hospitals' social activities. Medicaid expansion provides this opportunity.

Medicaid Expansion, Hospitals, and Equity

Medicaid expansion increased equitable access to health care. For example, African American uninsured rates dropped by more than a third largely due to Medicaid expansion under the ACA.^{Reference Bailey12} Latinos experienced dramatic reductions in uninsurance rates and increased utilization of preventive care following Medicaid expansion.^{Reference Ortega13} Similarly, people across Virginia — no matter their skin color, race, or ethnicity — will benefit from the Medicaid expansion where 10.3% of Virginians are uninsured.¹⁴

Before the expansion, Virginia's safety net coverage was among the stingiest. A family of three could make no more than $6,700.00 per year to be Medicaid eligible. These limitations disproportionately disadvantaged racial and ethnic minorities. For example, 26% of Virginian Latinos are uninsured¹⁵ though they represent only 9.4% of the population; Medicaid expansion will considerably aid in closing this gap. But Medicaid expansion will also significantly benefit white Virginians. A majority of the estimated 941,300 Virginians who live in poverty, over 442,000 of whom are white, are now within reach of health care. As a consequence, the interests of white and non-white patients in effectively implementing Virginia's Medicaid expansion are aligned. Moreover, increased access to care, presents an opportunity to improve the availability of improved quality of care for all patients as well. Hospitals that take advantage of this alignment to improve the quality of care across the board could reduce health disparities and increase equity even beyond health care. Hospitals represent ideal institutions to assume this leadership role for several reasons.

First, hospitals represent influential “anchor” institutions in the communities they serve. They are large employers¹⁶ and consumers.¹⁷ They serve as a focal point to blend a broad range of stakeholders, services, and funding sources to improve and manage population health. This positioning is especially important in light of evidence that shows population health outcomes are significantly influenced by social health determinants such as the availability of decent, affordable housing and food security.^{Reference Braveman and Gottlieb18} Hospitals are uniquely positioned to use their influence to collaborate outside the health care sector and integrate health care delivery with efforts to reduce social risk factors that adversely affect population health as well as the hospital's “bottom line.”^{Reference Lax19} Hospital leadership toward equitable social interventions is likely to reverberate beyond health care and because a third of payments for the 73.92 million people currently enrolled in Medicaid will be paid to hospitals,²⁰ hospital based reforms are likely to touch communities of greatest need.^{Reference Butler and Diaz21}

Second, the majority of hospitals have already taken initial steps toward innovations that that integrate social and medical care, and these quality improvements are already showing promise. Although comprehensive coordination is lacking, a 2017 survey of 284 hospitals found that 88% now screen for social needs at least on an ad hoc basis.²² Over 50% of hospitals reported they link patients with services to address interpersonal violence issues, transportation needs, utility and employment concerns through referral systems and partnerships with other community providers. Larger hospital institutions are moving beyond referrals, directing significant resources toward social needs. For example, the Corporation for Supportive Housing reports that hospitals have invested nearly $100 million in housing development for people experiencing homelessness and in turn have reduced emergency department visits. Some non-profit hospitals are responding to community health needs assessments by investing community benefit dollars in reducing food insecurity. ProMedica, a health system with hospitals in Ohio and Michigan, allocates $100 million a year to operate “food pharmacies” staffed with dietitians to counsel patients, and chefs who conduct cooking classes in neighborhoods previously designated as food deserts.^{Reference Hostetter and Klein23} Nationally, a growing number of hospitals are forming Medical Legal Partnerships (MLPs) that embed lawyers in health delivery teams to address legal problems related to social determinants that harm patient health. The oldest is at Boston Medical Center, one of 189 general, children's, and VA hospitals nationwide that address unmet legal needs as a social determinant of population health.²⁴ As hospitals leverage their size and influence to comprehensively close racial health disparities, these institutions can significantly contribute to reducing the disproportionate burden that vulnerable patients experience with other social risk factors generally.

Third, hospitals are increasingly using Medicaid flexibility to overcome the lack of systemic, sustainable funding for strategies that can reduce social risk factors that threaten population health. Admittedly, the business case for hospital investments in social services is yet developing. It is clear, on one hand, that the cost of care is adversely affected by social risk factors. On the other hand, hospital activities needed to address social needs require substantial investment and the evidentiary basis to show which investments produce the most meaningful returns is still emerging. Medicaid has proved one of the most promising sources of funding flexibility to allow hospitals and other health providers to deliver integrated care, while proving how well the concept of social service integration works.

Medicaid Section 1115 Research and Demonstration waivers, Section 1915(c) waivers, and Accountable Care Collaborative initiatives allow states to provide some non-medical services to eligible Medicaid beneficiaries. For example, in Colorado, seven Regional Care Collaborative Organizations (RCCOs) manage and coordinate community and social services for Medicaid beneficiaries and reimburse a small permember-per-month (PMPM) add-on for enhanced care management that includes medical legal partnerships. In Vermont, a Global Commitment to Health 1115 waiver invests PMPM funds to support families with children who have disabilities with substance abuse treatment and respite housing. Other states have pooled (or “blended”) Medicaid funds with other state agency funds to offer integrated medical and social services. Wraparound Milwaukee is an example, where Medicaid, child welfare, and juvenile justice funds are blended to cover residential treatment, corrections placement, education, and mental health services.

States can permanently extend Medicaid funding to include social services such as supportive housing for mentally ill patients using Section 1915(i) or State Plan Amendments. Although Medicaid cannot currently use federal funds to directly reimburse housing, employment, education, or other social services, especially where value-based, reimbursement systems are in place, this is the program that has been most widely used to finance a sustainable, public health approach to care for vulnerable populations.²⁵ Perhaps this is part of the reason why polls showed that 83% of Virginians, and 84% of Americans nationwide support keeping the ACA's Medicaid Expansion.

Hospitals are proving particularly adept at managing Medicaid financing, especially in expansion states. Medicaid dollars equal approximately 17% of all national health expenditures paid by governments in 2016, or approximately $565.5 billion.^{Reference Hartman26} Hospitals represent one-third of all Medicaid spending, the largest share of the program.²⁷ Yet hospitals received only 88 cents for every dollar spent caring for Medicaid patients.²⁸ Nevertheless, annual Medicaid spending per-enrollee is slowing,²⁹ due in part to improved cost controls that hospitals have employed.³⁰ In many states, those cost controls include screening for social risk factors, and then connecting patients to social services that can reduce costs and improve outcomes for Medicaid populations. In the thirty-nine states that offer Medicaid through managed care organizations, value-based payment models that allow increased attention to the social determinants of health likely explain improved financial performance.

Hospitals in expansion states saw revenues increase faster,³¹ and uncompensated care costs decrease faster as compared to hospitals in non-expansion states. According to a recent study, the ACA Medicaid expansion was associated with a significant $3.2 million decline in mean uncompensated care costs. Hospitals in Medicaid expansion states also saw steep declines in uninsured hospital visits, and sharp increases in Medicaid covered visits following expansion.^{Reference Antonisse32} As a result, annual Medicaid revenues increased an average of $5.0 million per hospital through 2015, while uncompensated care costs dropped $3.2 million.^{Reference Blavin33} In contrast, hospitals in the states that did not expand Medicaid experienced flat Medicaid revenues and a decrease in uncompensated care of only $1.0 million in 2015. Moreover, growth in per enrollee spending continued to decline in 2016.³⁴ These facts have put hospitals, along with the patients they serve, on the front lines of the effort to protect Medicaid each time Congress considers ACA reform.

Taken together, the features that make hospitals influential leaders in effectively using Medicaid expansion to increase access and improve the quality of health care delivery, also argue in favor of hospitals taking a leadership role in improving health equity — a role which hospitals played historically in response to considerable governmental pressure but could play today on their own. The American opioid crisis provides an illustrative example.

How Hospitals Could Advance Racial Equity in the Opioid Crisis

Many have poignantly written about the racial divide that emerged in America as drug dependence became an increasingly white “public health epidemic” beginning in 1999, rather than the “criminal justice crisis” it was when predominantly black and brown people were victims during the 1970s and 1980s.^{Reference Cohen35} The table below betrays the racialized evolution of the opioid epidemic.

The fact that hospitals are an essential part of the solution to this crisis is evinced by the fact that the most reliable source of these overdose data are hospital emergency departments (ED) which the Centers for Disease Control rely upon to track drug deaths long before they receive data from death certificates.³⁶ Studies have shown that opioid over-prescribing to hospital patients contributes significantly to increasing misuse of opioids.^{Reference Kim, Nolan and Ti37} Moreover, hospitals are a crucial point of contact for opioid victims in crisis. Hospital EDs experienced a 30% increase in the number of visits related to opioid overdoses in 2017³⁸ making the hospital setting an important opportunity for coordinated care linking services from health departments, mental health professionals, community based organization and law enforcement to prevent repeat overdoses.³⁹ Hospitals also have an economic incentive to better manage opioid treatment; the average cost to treat opioid dependent patients admitted to intensive care units was over $92,000 in 2015, a 58% increase in just 6 years.^{Reference Schorsch40} Thus, if hospitals act to innovate by addressing the social risk factors that underlie opioid addiction, they could improve outcomes while reducing treatment costs for this patient population.

Table 1.

Opioid Overdose Deaths by Race/Ethnicity: White, Non-Hispanic & Black, Non-Hispanic & Total, 1999-2016

Because the same social risk factors that have contributed significantly to minority patients' disproportionately poor health outcomes, are also contributing to the overwhelmingly white tragedy of opioid abuse, addiction, and death, although legislators, courts, police and other government officials have erroneously aimed disparate solutions toward substance abuse victims based on their race and ethnicity, hospitals are ideally situated to use Medicaid expansion funds more equitably to effectively treat substance abuse victims of all races. In short, hospitals could lead a second “quiet revolution” in health care by demonstrating that using Medicaid to deliver equitable and just health care can benefit hospitals and their patients regardless of their race, color, or national origin. Indeed, an equitable approach to opioid policy would be revolutionary.

Reversing Racialized Responses to Substance Abuse

The nation began its failed experiment with criminalizing drug addiction during the first opioid epidemic which started in the mid-1800s, and continued through the 1920s. During this first crisis, victims were largely white, native-born, well-to-do women, their prescribing physicians, and Chinese migrant laborers who smoked opioids. While records are not exact, estimates are that more than two million people abused these drugs during and after the Civil War, but by 1920 the epidemic peaked when 80,000 persons were addicted to opiates.^{Reference Courtwright41} Early legal interventions focused on the supply side of the problem. Criminalizing the supply of opiates worked because they reduced drug use by wealthier addicts, but these laws did little for the remaining victims who were lower-income males, often Civil War veterans suffering from what came to be called “morphonism or soldier's disease.”^{Reference Day42} The best evidence suggests that these victims were mostly southern whites as blacks were much less inclined toward opioids during this first epidemic. Regardless of race, the opioid victims left behind in the first epidemic shared much in common with the victims of the nation's second opioid epidemic: they were young males, poorly educated, and exposed to violent trauma early in life.

America's second opioid epidemic extended from approximately 1970 until 1985. This crisis was concentrated in the nation's city centers which were also severely affected by increased violent crime rates that accompanied this period of poverty and desperation.^{Reference Cooper and Smith43} The New York Times reported in 1986 that there were 500,000 heroin addicts in the United States, 200,000 of whom lived in New York City.⁴⁴ While national statistics on the second heroin epidemic are difficult to compile, New York City numbers are representative. By the mid 1970's, the New York City Health Department reported in excess of 650 heroin-related deaths a year. Data from hospitals showed that in 1981 51.5% of heroin users who presented in EDs were in their 20s and 35.5% were in their 30s.^{Reference Kerr45} David Courtwright estimates the number and ratio of black and white heroin users in treatment peaked around 1970 when just under 6,000 whites and nearly 8,000 blacks entered treatment.^{Reference Courtwright46} The epidemic's largely black and Hispanic victims were treated as a public safety rather than public health concern. They landed in prison when, predictably, their untreated drug addiction led to spikes in crime.^{Reference Langan47} Importantly, however, even the white victims of this second drug crisis, many of who were Vietnam War veterans, shared much in common with victims of the first epidemic. All, whether white, black, or Latino, were predominately young males, poorly educated, and suffered exposure to violent trauma.

The tragic and unprecedented death toll affecting predominately white victims of America's current and third opioid epidemic are well known. Current data confirms that social determinants are key roots of the crisis.^{Reference Galea and Vlahov48} History teaches that effective opioid treatment must address unemployment, low wages, and poor educational attainment, three social determinants highly correlated with opioid deaths for all races, during all three epidemics. The fact that these determinants affect all races presents an opportunity for health providers to increase equitable health treatment for all.

Improving access to employment that pays living wages is an example of one equitable opioid policy that hospitals could help drive. As a county's unemployment rates increase by 1 percentage point, opioid death rates rise by 3.6%, regardless of the race or ethnicity.^{Reference Betz and Jones49} Wage growth is also a predictor of overdose death.⁵⁰ These correlations persist today among predominately white workers,⁵¹ just as they did among blacks and Latinos during the second opioid epidemic. Between 1972 and 1980, blacks as a proportion of the nation's employed workforce remained unchanged at 9.4% while white employment rose by 18%.⁵² Between 1970 and 1981, the real median income for black families decreased by 8.3% and the ratio of black to white median family income declined steadily to 55%.⁵³ Educational attainment improved for all races but blacks were under-represented compared to non-blacks at each stage of the educational pipeline; they represented a lower percentage of all high school graduates, college freshmen, and college graduates in 1979 than they did in 1972.⁵⁴ Low income, employment, and wages increased heroin dependence among minorities just as similar conditions are associated with whites' opioid abuse today. Hospitals that pay workers well and collaborate with job training and education sectors to address these social needs will make an enormous impact on the opioid crisis for communities, regardless of race or ethnicity.

The confluence of racial unrest and Medicaid expansion in Virginia can inspire a national reimagining of health care aimed at equalizing health and social outcomes for all. The urgent need for innovative opioid intervention presents a fertile proving ground. We know that health outcomes are worse for all where racial division is greatest.^{Reference Leitner, Hehman, Ayduk and Mendoza-Denton55} We know also that Medicaid covers almost 4 of 10 non-elderly adults with opioid addiction.⁵⁶ Hospitals, therefore, could employ Medicaid expansion to once again revolutionize health care and equity in America.