Health Care Divided: Race and Healing a Nation (review)

David Barton Smith. Health Care Divided: Race and Healing a Nation. Ann Arbor: University of Michigan, 1999. 400 pp. $32.50 cloth.

David Barton Smith's Health Care Divided provides a thoughtful synthesis of a critical issue in American health care--the history of racial segregation and its long-term implications into the late twentieth century. Smith's study draws heavily on existing historical and policy analyses, on oral interviews with participants in particular events, and on discussions of key controversies such as the passage of Medicare and Medicaid legislation in 1965. In doing so, he weaves an evolving portrait of the "choices that produced the health care civil rights struggle" in the early and mid-twentieth century. Smith then turns his attention to the disturbing "legacy of a divided health care system" for black and white patients in the United States which, he argues, has remained a defining feature of health care into the end of the century.

Smith's text is organized clearly, retracing terrain that will be familiar to students of the history of race relations and the history of health care but may be new to policy makers and students of the recent politics and sociology of health care. Smith begins with a discussion of the early-twentieth-century attitudes toward African American mortality rates and the use of African Americans in research and examines their broad implications for maintaining a divided health care system. The separate but equal system began to be questioned as early as the 1930s in debates between the National Medical Association (NMA, the organization of African American physicians who benefited in part from the system) and the NAACP, which sought the destruction of the system. But it was federal government activism after World War II (beginning with the Hill-Burton hospital construction act of 1946 and peaking with the Supreme Court case of Simkins v. Moses Cone Hospital in Greensboro, North Carolina, in 1964) that began most effectively to erode the walls of this divided health care system. This era, Smith argues, was the pinnacle of the movement. What has followed, he suggests (based on his analysis of the history of federal agencies such as the Office of Equal Health Opportunity in the 1960s and the Office of Civil Rights in the 1970s and 1980s), have been decades of federal retreat from the pursuit of health care civil rights.

In the second half of his book, Smith turns to three discrete areas of the health care system in order to address "what happened and what didn't" in the wake of the demise of formal segregation. He finds a disturbing "persistence of [informal] racial segregation in health care" and draws upon recent studies of segregation under Medicare, of long-term care, and of prenatal care to document its features. First, he argues that "the greatest irony in the post-Medicare transformation of health care. . . was that Medicare, the same program whose implementation forced the racial integration of hospitals, also enabled hospitals to adapt and massively subsidize separation" by encouraging the building of new facilities which, in turn, promoted division (229). He also documents--using case studies of Philadelphia nursing homes--the continuing racial divide in long-term care. Finally, Smith discusses prenatal care policy in a chapter organized around the discussion of Philadelphia's Health Start Initiative and the Medical University of South Carolina's (MUSC) controversial policy of testing pregnant women (most of whom were African American) for use of crack cocaine.

The book concludes with a number of important observations about this time frame, among them some historical lessons for contemporary policy makers. He argues that focusing on creating better indicators and report card accountability (for evaluating institutional developments and measuring equality today) often misses the mark. His historical study suggests that the "brief period of aggressive enforcement of civil rights compliance between 1964 and 1968 is instructive of what...