U.S. HOSPITALS AND OUR BLACK CITIZENS
Strange as it may seem to some entrepreneurs, hospitals weren’t initially established to create wealth. Our nation’s first, Philadelphia’s “Pennsylvania Hospital,” was founded in 1751 “to care for the sick-poor and insane who were wandering the streets.” The facility was the idea of a Quaker who was medically educated in Paris a century before physicians believed bacteria and viruses cause infectious diseases. He wanted to emulate Paris’ Hotel-Dieu, the continent’s second oldest. The Parisian facility was established by Saint Landry in AD 651 “to treat pilgrims and the poor.” By the early 21st century, the facility had become central Paris’ “top casualty and emergency hospital.” It closed in 2013.
During the First World War, 116,000 Americans lost their lives and many were wounded. Four years later, the Veterans Administration was launched and they started building hospitals. By 2020, the VA was operating 170 medical centers and claimed to be the largest integrated health care system in the U.S.
The Indian Health Service is part of a federal agency and operates twenty-six hospitals that are directly and indirectly (through Medicare and Medicaid) federally funded. They help care for the descendants of people Europeans and others decimated and displaced.
Almost a fourth of the hospitals in the U.S. are stock-payer owned. About 1,034 of them belong to one of several for-profit corporations. They have stockholders, earn money, and pay taxes. In 2018, their bottom line was boosted (and government revenues fell) when the corporate tax rate dropped from 35 to 21 percent.
Cook County hospital in Chicago, the caregiver for the poor in our second largest city, is committed to providing “quality care with respect and dignity regardless of a person’s ability to pay.” It gets close to 40 percent of its operating revenue from state and city taxes. A third of the remaining 60 percent of the money comes from Medicaid and Medi care chips in 9 percent, and some of the people treated have private insurance.
After the American Civil War ended, 4 million former slaves were abruptly told they were free to leave, but they had no resources and nowhere to go, no basic shelter. Often cramped together in abandoned buildings, they couldn’t maintain basic hygiene, and many got sick. Privately run institutions for the very poor existed, but there were no hospials. The private shelters wouldn’t accept the newly emancipated. Former slaves died in large numbers. In some places, “their bodies were littering the streets.” At the time, there were 54,000 male and 300 female medical doctors in the U.S., and only a few were people of color.
During Reconstruction, Congress established the Freedmen’s Bureau in the South. It “fed millions of former slaves and poor whites, built hospitals, and provided medical aid.” But its hospitals didn’t have enough beds, linens, or quarantine facilities and there was a smallpox outbreak.
In 1868, four years before Reconstruction ended, the government founded Howard University College of Medicine, an institution where hundreds of black students learned to become “competent and compassionate physicians who provided health care for the medically under served.”
In July of 1872, “responding to the continued hostility of white Southerners,” Congress terminated the Freedmen’s Bureau.
During the subsequent ninety or so years, black physicians often couldn’t get privileges to practice in hospitals dominated by whites. In many of our leading hospitals, people of color were cared for in the basement wards of white hospitals and more than one hundred all-black hospitals were established. One of the facilities, Homer G. Phillips, was affiliated with my medical school. The facility was named for a black lawyer from a small Missouri town who was raised in an orphanage, then by an aunt. He studied law at Howard University and practiced in St. Louis. In 1922, the city put an $87 million bond issue on the ballot. Phillips made sure the measure assigned one million of the dollars to the building fund for a black-run hospital. After the ballot issue passed, it wasn’t easy to get the city to turn over the money, and Phillips spent more than a decade fighting “interests that sought to prevent the hospital’s construction.”
The building’s doors opened in 1937, and by 1961 “Homer G.” had trained the “largest number of black doctors and nurses in the world. It was a leader in developing the practice of intravenous feeding and treatments for gunshot wounds, ulcers, and burns.” It closed in 1979.
During the years when I was a student, St. Louis’ all black hospital, Homer G Phillips had 600 patient beds and was the primary source of health care for the area’s indigent blacks, and a major training center for young black doctors. It was also affiliated with the medical school. White guys like me spent three of our med school weeks at the facility learning how to deliver babies. During my time there the color of my skin was obvious but insignificant. I was treated as just another know-nothing med student.
At the time black physicians, by and large, couldn’t get privileges to practice at hospitals dominated by whites. Ninety six percent of the patient’s in New York’s for-profit hospitals were white and 97% of the people in the city’s private and semi-private not-for-profit hospitals were Caucasian.” Throughout the American South and in many of the Border States black physicians were denied membership in the local medical association, and non members could not get hospital admitting privileges.
As late as 1968, the AMA (American Medical Association) condemned racial discrimination, but allowed its member medical societies to refuse admission to black doctors. Physicians who were not members of the AMA could not get admitting privileges to most U.S. hospitals.
Seemingly politically influential, the AMA is a national conglomeration of physician groups, and it has often been on the wrong side of history. It opposed national health insurance and currently disapproves of the single payer option. For years their journal, the JAMA ran cigarette advertisements that touted the health benefits of filtered cigarettes. They didn’t consider smoking a health risk until 1963, the year before the U.S. surgeon general-- on the basis of more than 7,000 medical articles that were available and that doctors should have read--“concluded”: Cigarettes cause lung cancer, laryngeal cancer, and chronic bronchitis.
Many primary care doctors had separate waiting rooms. Black patients were seen after the white patients were seen. Some of the ill went to county hospitals—where they often sat for hours on wooden benches waiting to be called. In white hospitals they were often bedded in the basement wards.
I grew up in a suburb of St. Louis in a white man’s world and for much of my life had limited exposure to world and the struggles of the black men and women who lived so near yet so far. My awareness went up a few notches after I entered Washington U medical school. My 1958 freshman class contained 75 white men, 8 women and the school’s first black student. His name was James Sweatt and for decades he “had the impression that it was routine for all the professors of the departments in the medical school to sit around and quiz applicants for admission.” At the 25th class reunion he found out that everyone else who was interviewed for medical school had been seen by one person and that was that.” I got a small glimpse into Jim’s world one evening when, after a few hours of study at the library, he was one of the group of med students who went to a local diner for a late night snack. After a series of waitresses bypassed our table we asked the guy in charge why no one had taken our order. “You look like smart guys” he said. “What do you think?”
Dr. Sweatt grew up in Dallas, a town where, in the 1950s,”Whites Only” signs peppered the landscape. Blacks were allowed to buy clothes in the town’s department stores, but they weren’t allowed to try them on.” His mother was an 8th grade teacher, his father a high school principle and he was educated in white schools and at a university where he was one of each institution’s 2- 3 black students.
Officially desegregated in 1947, Washington U had only 2 black medical students during the subsequent decade.
My medical school, Washington U. in St. Louis, didn’t graduate its first black physician until 1962. After Jim graduated he became a thoracic surgeon and practiced in Dallas. In 1995, he became the first African-American president of the Dallas County Medical Society.
The landscape for black Americans started to change in 1956. Two years after the Supreme Court decision, the University of Alabama enrolled the first black student, Autherine Lucy. Then “riots engulfed the campus and she was expelled for “her own safety”. In 1962 demonstrations greeted James Meredith, the first black student to attend the University of Mississippi. (A veteran of 9 years in the U.S. Air Force and a man who felt it was important to make a statement, he was ready.)
Berkeley California became the first sizable city that had a “substantial portion of black students” to voluntarily begin two way bussing. Some white children were transported to schools in black neighborhoods and some black students were bused to schools that were largely white. Their program didn’t start until 12 years after the Supreme Court ruling.
“In 1964, a year before it enacted Medicare, Congress passed the Civil Rights Act. One of its provisions, Title VI, prohibited discrimination on the bases of race, color, or national origin in programs that received federal funding.
The following year when Medicare was being debated there was no mention of Title VI. It didn’t come up and nobody wanted to raise it. “The assumption was that some accommodation would be made that would allow segregation to continue on a separate but equal basis.” The nation’s response to the 1954 Brown v. Board of Education Supreme Court decision had shown that when it comes to race, changes don’t happen very much or very fast. The ruling ordered states to put a stop to segregation in schools with “all deliberate speed.” But “The vagueness about how to enforce the ruling gave segregationists an opportunity to organize resistance.”
“The Medicare law might carry the threat that federal funding could be withheld from any hospital that practiced racial discrimination. That’s what Title VI of the Civil Rights Act “required.” But the Office of Equal Health Opportunity was in charge of federal funding based on the presence or absence of discrimination, and it only had five employees. Swift action seemed unlikely. “Hospitals might have to come up with a plan, but they could presumably proceed gradually and cautiously. Ultimately racial changes wouldn’t get done; hospitals would operate on a business as usual basis.”
Then HEW (Health Education and Welfare) Secretary John Gardner put out a quiet call for volunteers. More than 1,000 people from federal agencies offered to help, along with tens of thousands of Civil Rights organizers. Field inspectors fanned out to hospitals to make sure they were in compliance with the law and eligible for federal funds. As David Barton Smith explained in his book, “They wouldn’t let anybody off the hook,” “The reason they were so successful is that they had this secret army of local civil rights workers and local health workers making sure [the hospitals] complied. Hospitals quickly figured out that they couldn’t fake it.”
The bill Congress passed and President Johnson signed into law created two new programs: Medicare and Medicaid. The entities were funded by a payroll tax; an additional 2.9% of a person’s earnings were taken from each paycheck.
Medicare– paid for the hospital care and some home services for citizens over 65.
Medicaid also covered the care of citizens who were “poor enough”–whose “resources were insufficient to pay for health care” and covers nursing home costs for people who meet the eligibility requirements.
50 to 75% of Medicaid’s costs were paid by the feds and each state paid the rest. States with higher per capita income paid more.
Every state got to limit the amount a family could earn before they no longer qualified. Criteria for inclusion in the “program” have changed over time, so there are variations in Medicaid coverage across the country.1
Additionally—Medicare later established a hospice benefit. Dying people now had help and many could and preferred to manage their pain and problems in their own homes.
As part of The Emergency Medical Treatment and Labor law, hospitals had to provide pregnant women “appropriate medical screenings and stabilizing treatments. Medicaid coverage for pregnant women and infants (up to 1 year of age) was established as a state option for people who earned up to 100% of the Federal Poverty Level (FPL).
“By 2024 More than 300 Black doctors had graduated from Washington University School of Medicine.
“Despite the demand for more black doctors, the number of African-American students at U.S. medical schools has increased at a snail’s pace in recent years. In 1996 there were 3,527 blacks who applied for admission for medical training, the highest level in history. From 1996 to 2003 black applicants to medical school dropped by more than 20 percent to 2,808, and black applications to medical school remain far below the level that prevailed a decade ago.”
https://www.jbhe.com/news_views/55_black_enrollments_med_school.html
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