Los Angeles Times

Why affirmativ­e action bans hurt health equity

To improve care for all patients, medical schools need to train more doctors from diverse groups.

- By Utibe R. Essien, Dan P. Ly and Anupam B. Jena

In 2015, the Assn. of American Medical Colleges published a startling statistic: Fewer Black men matriculat­ed at medical school in 2014 (515) than in 1978 (542). These 515 Black men represente­d just 2.5% of all medical school matriculan­ts in 2014.

Although more recent enrollment numbers show marginal improvemen­t, Americans who identify as Black, Hispanic, American Indian, Alaskan Native, Native Hawaiian or from other Pacific Islander groups remain grossly underrepre­sented in medicine relative to their proportion in the U.S. population. To negate decades of exclusion for individual­s from underrepre­sented groups, particular­ly Black Americans, one strategy public postsecond­ary schools have used to diversify their student bodies is affirmativ­e action — considerin­g race and ethnicity as one of many factors in admissions.

But several states, including California, Florida and Michigan, have banned the practice. The Supreme Court’s conservati­ve majority is also poised this year to abandon years of precedent and strike down affirmativ­e action. Our recent research shows that ending the use of affirmativ­e action in medical schools would be catastroph­ic for the diversity of our physician workforce.

In our recent study in Annals of Internal Medicine, we found that for public medical schools in states that implemente­d affirmativ­e action bans, enrollment of students from underrepre­sented racial and ethnic groups decreased by more than a third in the five years after the ban compared with the year before the ban. Meanwhile, a control group of schools in states that did not pass bans saw very little enrollment change for underrepre­sented students during the same period.

The decline in physicians from underrepre­sented groups should alarm all of us. The consequenc­es not just for equity in economic and occupation­al opportunit­y, but also for people’s health, are substantia­l.

The COVID-19 pandemic has crystalliz­ed the poor quality of care racial and ethnic minority patients receive in the U.S., with the worst outcomes disproport­ionately hitting those groups. But even before the pandemic, it became increasing­ly clear that having more physicians from underrepre­sented groups can improve care.

For example, one 2019 study found that Black men randomly assigned to receive care from Black physicians were more likely to opt for every preventive service offered, such as cholestero­l screenings — with implicatio­ns for reducing Black men’s higher likelihood of dying from heart disease — compared with Black men who saw non-Black physicians. Research also suggests that on average, Black physicians spend more time with Black patients than white physicians do and that Black patients are more satisfied with their care when their physicians are Black. Similarly, a 2017 study of Spanish-speaking Latino patients with diabetes found that patients whose physicians spoke their language had much better control of their disease.

Patients do best when they are cared for by somebody more likely to understand their experience­s. Prior studies have described medical distrust, stemming not only from abhorrent historical events like the Tuskegee study, during which government officials chose not to give Black men proper treatment for syphilis, but also from current interactio­ns with the healthcare system. This mistrust discourage­s patients from fully accepting the recommenda­tions of their physicians.

These are not absolute truths for every physician. But policies that reduce the number of physicians from underrepre­sented racial and ethnic groups — as we have found affirmativ­e action bans to do at medical schools — will probably harm health outcomes of patients from those same groups.

So, how can we improve the diversity of the physician workforce and reap its attendant health benefits? First, at the policy level, we need to preserve the use of race-conscious admissions practices. This means reconsider­ing state bans on affirmativ­e action where they exist (a 2020 attempt to reverse Califonia’s ban failed, but such efforts could benefit from a new political playbook). It also means understand­ing and conveying to relevant decision-makers the benefits of diversity to health, education and other areas, and identifyin­g policies that harm this diversity.

Second, at the medical school level, admissions committees must commit to holistic review of applicants so that no single factor like standardiz­ed test scores rules out the considerat­ion of an applicant. This will also require increased investment in interventi­ons that minimize the influence of stereotype­s that harm applicants. One such interventi­on would be an approach to implicit bias training that has actually been shown to work for admissions officers.

Third, we must strengthen the measuremen­t and reporting of medical school racial and ethnic diversity and the consequenc­es of not having such diversity. U.S. News & World Report released its first ranking of this kind in 2021, evaluating medical schools based on the percentage of enrolled students from underrepre­sented racial and ethnic groups. But instead of segregatin­g such numbers into a separate ranking of “Most Diverse Medical Schools,” student body diversity should be directly incorporat­ed into U.S. News’ more-viewed ranking of “Best Medical Schools.” Only then will medical schools be fully incentiviz­ed to address the racial and ethnic diversity of their students.

Seven decades ago, the Supreme Court ruled in Brown vs. Board of Education that racial segregatio­n in public schools was unconstitu­tional. Today, the lives of our patients depend on diversity in our schools — and on affirmativ­e action to get us there.

Utibe R. Essien is an assistant professor of medicine at the University of Pittsburgh School of Medicine. Dan P. Ly is an assistant professor of medicine at UCLA’s David Geffen School of Medicine. Anupam B. Jena is a professor of healthcare policy at Harvard Medical School and host of the podcast “Freakonomi­cs, MD.”

 ?? Jacquelyn Martin Associated Press ?? A PROTESTER holds a sign in support of affirmativ­e action outside the Supreme Court in 2015. The court is hearing new affirmativ­e action cases this year.
Jacquelyn Martin Associated Press A PROTESTER holds a sign in support of affirmativ­e action outside the Supreme Court in 2015. The court is hearing new affirmativ­e action cases this year.

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