Hospitals Serving the Most Patients of Color Have Least Funding for Buildings and Equipment

"This important study uses publicly available data to document why care for many people of color in hospitals with large numbers of Black and Latinx patients may suffer because of inadequate funding. This will continue until we adopt a Medicare for All insurance system protecting everyone equally." - Dr. Sidney Wolfe, founder and senior adviser, Public Citizen's Health Research Group

Hospitals that care for large numbers of Black and Latinx patients have far less to spend on facilities such as buildings and equipment, and offer fewer high-tech services than other U.S. hospitals, according to a new study of hospitals' capital assets and spending. The peer-reviewed study, released ahead of print in the International Journal of Health Services, used data from 4,476 hospitals to determine the total value of each hospital's facilities.

At hospitals serving few people of color, the total value of the facilities available for patient care was 60.2% higher than at the 10% of U.S. hospitals with the highest proportion of Black patients: $8,325 vs. $5,197 per inpatient day in 2017. For the 10% of hospitals with the largest share of Latinx patients, the comparable figure was $5,763. The researchers also found that the hospital asset gap is widening; hospitals serving mostly white patients had about twice as much funding for modernization and new equipment as those serving patients of color ($3,092 annually per patient day at hospitals serving mostly white patients vs. $1,242 at Black-serving hospitals and $1,738 at Latinx-serving hospitals).

The lower spending on facilities translated into more crowding at Black- and Latinx-serving hospitals, which had 35% and 18% less square feet per occupied bed respectively than hospitals with few patients of color. The inequalities in facilities and equipment were not explained by differences in patients' severity-of-illness, or hospitals' size, location or teaching status.

The study also found that 19 of 27 expensive, specialized services were less available at hospitals serving people of color; only 2 were more available. For instance, Black- and Latinx-serving hospitals were about half as likely as other hospitals to offer robotic surgery, cardiac surgery, cardiac catheterization, computer-assisted orthopedic surgery, cardiac rehabilitation and weight-loss surgery.

The researchers used data on the share of Black and Latinx people among Medicare patients at each hospital and calculated the value of (and new spending on) buildings and equipment from 2013-2017 official Medicare Cost Reports. They determined the availability of specific services and hospitals' square footage based on the American Hospital Association's annual survey.

An important determinant of a hospital's current resources for patient care, payer mix, is strongly linked to patients' race. Hospitals have historically collected low payments for the care of uninsured and Medicaid patients (who are disproportionately Black and Latinx), while patients with private coverage are the most lucrative.

Lead author, Gracie Himmelstein, an MD/PhD candidate at Icahn Mount Sinai Medical School and Princeton University's Office of Population Studies, and a Woodrow Wilson Fellow at Princeton commented: "Our study confirms the stark differences between rich hospitals and poor hospitals that I've seen during my training. Many of the doctors and nurses at poor hospitals are terrific, but they're fighting an uphill battle; they care for the sickest patients in the most crowded and difficult conditions. To compensate for decades of unequal health financing we need to invest in hospitals serving Black and Latinx patients, and abandon an insurance system that offers hospitals rich rewards to care for some patients, and less or nothing to care for others."

Co-author Dr. Kathryn Himmelstein, a resident in internal medicine at Massachusetts General Hospital and Harvard Medical School noted, "White Americans were living three and a half years longer than Black Americans even before COVID-19 began ravaging communities of color. If America wants to show that Black lives truly matter, we need to reverse the structural racism that's literally built into our hospitals."

"Inequality Set in Concrete: Physical Resources Available for Care at Hospitals Serving People of Color and Other U.S. Hospitals". Gracie Himmelstein, MA and Kathryn EW Himmelstein, MSEd, MD. Available ahead of print: International Journal of Health Services, 2020

An embargoed copy of the article is available to media professionals on request from ghimmels@princeton.edu.