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Affirmative Action Matters in Public Health

Shannon Sweetnam
by Karol Dean, PhD, Ronisha Edwards-Elliott, MSW, and A. Gita Krishnaswamy, MEd, MPH
Contributors: Mia Hayford, Mia Bonds, and Jessica Coffee

A year has passed since the Supreme Court’s decision on affirmative action in college admissions, and its impacts on community health are becoming increasingly apparent. This ruling has significant implications for the diversity of health care providers and the quality of care in under-resourced communities. At Health & Medicine, we nurture the college students (through our AHEC program) and the graduate students (through our Schweitzer Fellowship program) who will be affected by this decision. As we engage with these students to build a workforce committed to health equity, the Supreme Court’s affirmative action decision will shape the demographic makeup of future health care workers, potentially limiting the representation and cultural familiarity needed to effectively address inequities in health care delivery and health outcomes.

It may be hard to imagine how a Supreme Court decision about college admissions would relate to the health of under-resourced communities. The connection between access to education and physical health was described by the Center on Society and Health, indicating that an individual’s pursuit of education creates opportunities for better health for that person through multiple pathways.1  These include 1) increased income and financial resources, 2) reduced stress and improved social skills and networks, 3) increased understanding and implementation of healthy behaviors, and 4) likelihood of living in healthier neighborhoods that make available primary care physicians, accessibility to higher quality schools and supermarkets, while reducing exposure to crime and pollution. However, the 2023 Supreme Court decision requiring race-blind admissions decision-making for institutions of higher education will have a broader effect on communities of color. Initially, the decision will reduce the pipeline of students of color pursuing health careers, as studies done at the University of California and elsewhere indicate that enrollment of students of color predictably declines in the aftermath of changes to these policies.2,3  The broader implication is that the Supreme Court’s action will likely reduce the quality and experience of health care in communities these students would have served.

Supreme Court Decision (Students for Fair Admissions Inc. v. President & Fellows of Harvard College, Students for Fair Admissions Inc. v. University of North Carolina)

Before the Supreme Court’s decision, admission procedures at most higher education institutions included considering an applicant’s race as one element among many factors reviewed. The Supreme Court ruled in June 2023 that institutions may not consider race as part of admissions decisions, as the Supreme Court’s interpretation deemed this a violation of Title VI of the Civil Rights Act of 1964 and the Equal Protection clause of the Fourteenth Amendment.4  Chief Justice Robert’s majority opinion indicated that universities’ affirmative action goals did not provide evidence of successful enrollment of under-represented students. Additionally, the ruling stated that universities’ admissions decisions effectively used race against probable candidates. Other concurring opinions asserted that race-conscious admissions programs do not increase the overall number of students of color admitted, that they have the effect of increasing racial polarization, or that there are other legal remedies to address discrimination that exist.

The effects of the Supreme Court’s decision will apply nationally to students who apply for admission in 2024. The “race-blind” approach required by the ruling means that colleges can consider race only when considering its impact on an individual applicant’s life specifically related to how the applicant would contribute to the institution as the result of skills or knowledge the applicant has developed.  Academic institutions are left to re-consider how to recruit and admit students from a wide range of backgrounds without utilizing race as a factor.

Effects of Eliminating Affirmative Action

To understand the likely outcome of this decision affecting public and private institutions throughout the U.S., we can review evidence from states that have eliminated the use of affirmative action in college decisions over the last 27 years. These states are California, Idaho, Arizona, Florida, Nebraska, Michigan, New Hampshire, Washington, and Oklahoma. The elimination of affirmative action led to a significant decline in Black, Hispanic, and Native American student enrollment in these states.5

We can use the state of California as an example, as it has the longest history of operating without affirmative action in its public institutions.  California eliminated the use of race as a factor in admissions in 1996 through Proposition 209.  According to a report by Zachary Bleemer for the University of California, https://cshe.berkeley.edu/publications/affirmative-action-mismatch-and-economic-mobility-after-california’s-proposition-209effects were initially observed in a decline of an estimated 1,000-1,200 undergraduate applications from under-represented groups (defined as Black, Latinx, Pacific Islander and American Indian groups) in the first year the policy was in effect.2  Of the students who did apply from underrepresented groups, they were less likely to be admitted and to enroll. Declined students then enrolled at less selective institutions but because there are typically fewer resources for support at these institutions, the students were less likely to complete their undergraduate degrees or pursue and complete graduate degrees.  The most selective campuses within the University of California had the most profound initial impact, with a 40% decline in Black and Latinx enrollment at UC Berkeley and at UCLA.  Importantly, within the UC system, Black and Latinx students were less likely to enter STEM fields, commonly associated with entry to health care professions. Despite extensive outreach efforts and modifications of admissions criteria, Proposition 209 continues to distort the admissions process so that UC enrollments do not reflect the pool of available high school students in California, and the system has not met its diversity goals more than 25 years later.6  Nationally, affirmative action bans enacted in other states have had a similar effect, with some projecting a nationwide reduction of 10% in admissions of Black and Latinx undergraduate students in the coming years as one result of the Supreme Court’s decision.7

The affirmative action ban impacts graduate and professional training in two ways. Liliana Garces found a decline in the already low numbers of graduate students who were Black, Latinx and/or Native American in her 2012 study.3 When examining graduate enrollment in four states that had eliminated race-conscious admissions, she found a decline of 12% in enrollment across all graduate fields studied, with stronger effects observed in natural sciences (19%) and social sciences (15.7%) that fuel research in health care.  Given the already dismally low numbers of under-represented graduate students the declines are striking.

A second study by Garces in 2015 specifically addressed medical school matriculation in six states that had banned affirmative action.8  She found that the number of Black, Latinx and/or Native American students admitted to medical schools in these states declined from 18.5% to 15.3%, which represents a 17.2% decline in the proportion of underrepresented medical students.  In addition to anticipated immediate shifts in graduate enrollment as the result of the change in their admissions processes, the number of undergraduate students who can move into graduate and professional training will decrease over time when there are fewer Black and Latinx students to draw from in the graduate and professional applicant pool.

The pipeline of health professionals of color in the US

Although geared toward ending racial discrimination in higher education institutions, eliminating affirmative action will ultimately negatively impact the number of trained minority health care providers. Currently, 13.6% of the US population is Black, and 19.1% is Latinx (US Census Bureau)  In two health care professions that require undergraduate training as a minimum requirement for practice, medical doctors and nurses of color are already underrepresented.9  According to the National Medical Association only 5.7 percent of medical doctors in the United States are African American, while only 2.4 percent are Latinx.10 Similarly, 10% of nurses indicate that they are Black, and 4.8% are Latinx, according to Minority Nurse.11  The small proportion of health providers of color in the United States is a concern for public health as the US Census Bureau projects that the percentage of Black and Latinx people will increase in the coming years.12

Effects on Health Outcomes of Communities of Color

Why does the percentage of Black and Latinx health care providers matter? Recent research indicates that health outcomes improve for communities of color when racial concordance exists between health providers and patients.  That is, when there is shared racial or ethnic identity between a patient and a physician, patients perceive their care to be better quality.13 Racial concordance has demonstrable positive effects on chronic conditions such as cardiovascular disease, hypertension, and many other illnesses. Data collected from more than 600,000 patients with hypertension from a study conducted over a 3-year period showed a correlation between positive hypertension outcomes and racial concordance in patient-provider relationships.14  Racial concordance also improves preventive medicine, as a study that paired Black men with Black doctors found that Black men were more likely to engage with Black doctors and even agree to cardiovascular screenings, which improve life expectancy.15 Conversely, literature on racial concordance indicates that people of color are at increased risk of having poorer health outcomes and receiving less effective care when they do not have access to care from physicians who look like them.13 These studies demonstrate a profound negative impact on the health outcomes of people of color, as well as increased health care costs for delayed or ineffective care.

In a remarkable study by Snyder and colleagues in 2023, racial concordance made a difference in the life expectancy of people of color.16 The researchers used longitudinal data from 2009, 2014, and 2019 to measure the association between racial concordance of Black doctors and patients and the mortality and survival rates of Black people in more than 1600 US counties. The study revealed that a 10% increase in Black doctors was associated with a 30.6-day average increase in life expectancy for Black patients.17 There was also a reduction in mortality by 12.7 deaths per 100,000 Black people, and Black/White disparity in mortality decreased by 1.2%. Ultimately, racial concordance had the strongest association with life expectancy in counties with high poverty. This is significant as African American men have the lowest life expectancy in the United States when compared with all demographic groups.18     

There are many ways that the experience of patients of color receiving care from providers of color supports improved health outcomes.  Practically, patients sharing the same language and cultural background as their care providers are likely to have improved communication.18 Additionally, physicians of color are more likely to treat patients of color and locate their practices in underrepresented communities, improving patient access to health care.19 Building on the vital relationship between providers and patients, trust and communication are easier in medical settings staffed by providers with similar cultural backgrounds.18 This may be due to patients’ reports that they feel more respected by health care providers of color.  Because of the relationship developed, physicians of color can detect and treat illnesses based on shared-decision making and patient-centeredness.  Outside of the immediate treatment setting, patients of color report increased adherence to medical treatment and advice.20

Conclusion

Communities of color experience substantial negative effects from disparities that exist in the US health care system.  These disparities result in decreased likelihood (as compared to their Caucasian counterparts) of receiving appropriate care for acute and chronic illnesses, which leads to lower quality of life due to health concerns.  Structural and social determinants of health create health inequities that decrease longevity in communities of color, even within the same region. The city of Chicago’s longstanding gap of up to 30 years in life expectancy between neighborhoods primarily populated by Black and white citizens is one salient example of how disparities affect the health of communities.21  Clearly there are many structural barriers to health for communities of color that must be addressed.

Drawing on HMPRG co-founder John McKnight’s Asset-Based Community Development model, we can start to build on the strengths of the community to address health disparities among communities of color.22  Research on the benefits of racial concordance demonstrates that patients of color are seeking medical care, pursuing diagnostic and preventive testing, adhering to treatment plans, and generally experiencing improved health outcomes as one result of interacting with health providers of color.  When patients are seen by providers that share their cultural backgrounds, they are more likely to address health concerns proactively and to have better health outcomes.

Therefore, the need to provide educational and career pathways for providers of color is vital to community health. Ensuring that those drawn to health care careers from all racial and ethnic groups are admitted to and thrive in educational programs is the responsibility of the full educational system.  Race-conscious admissions support diversification in the health care sector, and the Supreme Court’s decision is likely to reduce admissions of diverse students in higher education. This is a significant step backwards in our collective journey and commitment to health equity.  Without this effective approach to supporting students of color in health care pathways, higher education institutions will need to explore alternate (and to date) less effective methods of ensuring that diverse enrollment leads to increased multiculturalism, improved biomedical research, and representation in underserved communities.

 

References

  1. Center on Society and Health. Why education matters to health: Exploring the causes. Published February 15, 2015. Accessed April 4, 2024. Available from: https://societyhealth.vcu.edu/work/the-projects/why-education-matters-to-health-exploring-the-causes.html#gsc.tab=0.
  2. Bleemer Z. Affirmative Action Mismatch and Economic Mobility after California’s Proposition 209. Center on Society and Health. Available from: https://cshe.berkeley.edu/publications/affirmative-action-mismatch-and-economic-mobility-after-california%E2%80%99s-proposition-209
  3. Garces LM. The Impact of Affirmative Action Bans in Graduate Education. UCLA: The Civil Rights Project / Proyecto Derechos Civiles; 2012. Available from: https://escholarship.org/uc/item/6np398tm
  4. Supreme Court of the United States. Syllabus. Students for Fair Admissions, Inc. v. President and Fellows of Harvard College. Certiorari to the United States Court of Appeals for the First Circuit. No. 20–1199. Argued October 31, 2022—Decided June 29, 2023*.
  5. Colin E, Cook Future of College Admissions Without Affirmative Action. Urban Wire. Available from: https://www.urban.org/urban-wire/future-college-admissions-without-affirmative-action
  6. Burke M. University of California affirmative action: a cautionary tale. Berkeleyside. Available from: https://www.berkeleyside.org/2023/06/29/university-of-california-affirmative-action-cautionary-tale
  7. Meyer K, Pita A. How will the Supreme Court’s affirmative action ruling affect college admissions? Brookings Institution. Available from: https://www.brookings.edu/articles/how-will-the-supreme-courts-affirmative-action-ruling-affect-college-admissions/
  8. Garces LM, Mickey-Pabello D. Racial Diversity in the Medical Profession: The Impact of Affirmative Action Bans on Underrepresented Student of Color Matriculation in Medical Schools. J Higher Educ. 2015;86(2):264-294. doi:10.1353/jhe.2015.0009
  9. United States Census Bureau. QuickFacts – United States. Available from: https://www.census.gov/quickfacts/fact/table/US/PST045222
  10. Howard, J. National Medical Association. Only 5.7% of US doctors are Black and experts warn the shortage harms public health. Available from: https://www.nmanet.org/news/632592/Only-5.7-of-US-doctors-are-Black-and-experts-warn-the-shortage-harms-public-health.htm
  11. Minority Nurse. Nursing statistics. Published April 13, 2016. Accessed April 4, 2024. Available from: https://minoritynurse.com/nursing-statistics/#:~:text=9.9%25%20of%20RNs%20are%20black,as%20black%20.
  12. Vespa J, Medina L, Armstrong D. United States Census Bureau. Demographic Turning Points for the United States: Population Projections for 2020 to 2060. Available from: https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf
  13. Ku L, Vichare A. The Association of Racial and Ethnic Concordance in Primary Care with Patient Satisfaction and Experience of Care. J Gen Intern Med. 2023;38(3):727-732. doi:10.1007/s11606-022-07695-y
  14. Adriano F, Burchette RJ, Ma AC, Sanchez A, Ma M. The Relationship Between Racial/Ethnic Concordance and Hypertension Control. Perm J. 2021;25:20.304. Published 2021 Aug 6. doi:10.7812/TPP/20.304
  15. Huerto R. Michigan Medicine Health Lab. Minority Patients Benefit From Having Minority Doctors. That’s a Hard Match to Make. Available from: https://www.michiganmedicine.org/health-lab/minority-patients-benefit-having-minority-doctors-thats-hard-match-make
  16. Snyder JE, Upton RD, Hassett TC, Lee H, Nouri Z, Dill M. Black Representation in the Primary Care Physician Workforce and Its Association With Population Life Expectancy and Mortality Rates in the US. JAMA Netw Open. 2023;6(4):e236687. doi:10.1001/jamanetworkopen.2023.6687
  17. Peek ME. Increasing Representation of Black Primary Care Physicians—A Critical Strategy to Advance Racial Health Equity. JAMA Netw Open. 2023;6(4):e236678. doi:10.1001/jamanetworkopen.2023.6678
  18. Aksan M, Garrick O, Graziani GC. Does Diversity Matter for Health? Experimental Evidence from Oakland. National Bureau of Economic Research (NBER). Available from: https://www.nber.org/papers/w24787. DOI: 10.3386/w24787
  19. Cantor JC, Miles EL, Baker LC, Barker DC. Physician service to the underserved: implications for affirmative action in medical education. Inquiry. 1996;33(2):167-180.
  20. Hammond WP, Matthews D, Mohottige D, Agyemang A, Corbie-Smith G. Masculinity, medical mistrust, and preventive health services delays among community-dwelling African-American men. J Gen Intern Med. 2010;25(12):1300-1308. doi:10.1007/s11606-010-1481-z
  21. NYU Langone Health. Large Life Expectancy Gaps in US Cities Linked to Racial, Ethnic Segregation by Neighborhood. Available from: https://nyulangone.org/news/large-life-expectancy-gaps-us-cities-linked-racial-ethnic-segregation-neighborhood
  22. DePaul University. Asset-Based Community Development (ABCD) Institute. Available from: https://resources.depaul.edu/abcd-institute/Pages/default.aspx.

 

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