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The Role of HBCUs in Ensuring a Diverse Health Care Workforce
Research shows that existing racial inequities in health outcomes in the U.S. can be mitigated by racially concordant care. But this type of care is only possible with a diverse healthcare workforce.
a Century Foundation feature
On June 29, 2023, the U.S. Supreme Court effectively ended the use of race-conscious affirmative action in higher education when it ruled that the admissions processes at Harvard University and the University of North Carolina at Chapel Hill were unconstitutional. Not only did this decision ignore precedent, but it also disregarded the realities of racial discrimination and inequality baked into the very structure of American society and ignored the immediate harmful impacts striking down affirmative action would have.
Existing studies conducted in states such as California and Michigan—which eliminated affirmative action well before the Supreme Court’s decision at the federal level—clearly show that the enrollment of Black students in higher education can be expected to decline, which will have devastating impacts on racial equity.
Not only is this decision deeply concerning for racial equity in the world of higher education, but also, the ripple effects will be far-reaching, impacting other areas such as health equity. Research shows that existing racial inequities in health outcomes in the United States can be mitigated by racially concordant care. But this type of care is only possible if there is diversity within the health care workforce—diversity that is only achievable if institutions of higher education such as medical and nursing schools are able to admit students that reflect the U.S. population as a whole.
When it comes to current levels of diversity in medical and nursing education, gaps persist. In the 2022–23 class, approximately 6.7 percent of the 20,920 U.S. MD-granting medical school graduates identified as Black or African American. In the 2020 graduating class of all registered nurses, 10.6 percent of the 167,612 graduates identified as Black or African American. This is in contrast to the general American population, of which 13.6 percent identify as Black. With race-conscious admissions policies now off the table, these already-low percentages are expected to decline.
The implications of the Supreme Court’s decision only further highlight the need to shore up resources and support for the institutions that, year after year, have had an indispensable role in training the next generation of Black doctors and nurses: Historically Black Colleges and Universities (HBCUs). Making greater investments in HBCUs is critical if the country is to ensure a diverse talent pipeline for medical education, create a psychologically safe and culturally inclusive health care workforce, and make progress toward health care equity.
Health Care Workforce Diversity Improves Health Outcomes and Equity
The United States has long suffered from racial inequities in health outcomes, even when controlling for relevant sociodemographic variables. The COVID-19 pandemic has only worsened racial disparities in health outcomes, taking a toll on communities of color. The pandemic has also depleted the health care workforce in a way that has required rethinking how the country can better support the pipeline of doctors and nurses.
Much of the blame for these racial disparities in health outcomes can be placed on structural as well as interpersonal racism and implicit bias in the health care system. Racism and biases can worsen health outcomes for Black people in many ways, such as a lack of equitable access to high-quality health care or when providers rely on their racial biases to develop care recommendations. History also shows that there has been hesitancy in the Black community when it comes to seeking health care, even for something as simple as getting vaccinated, due to events like the traumatic and heinous Tuskegee Experiment and the unethical maltreatment of Henrietta Lacks. Because of decades of distrust, innovative strategies to diversify the health care workforce are vital to serving communities that have historically been marginalized, improving their health outcomes, and working toward health equity.
One way that workforce diversity improves outcomes is by increasing the prevalence of what is known as racially concordant care. Research has supported patient/provider racial concordance as a mitigating factor against poor outcomes, with patients’ perceived personal similarity with their provider associated with higher ratings of trust, satisfaction, and intention to adhere to medical advice and treatment recommendations. Professional organizations in medicine, such as the Association of American Medical Colleges and the American Medical Association, have underscored the benefits of racial diversity in the health care workforce.
A relevant case study highlighting the importance of racially concordant care can be seen in maternal health. With policymakers, health care professionals, and families across the country growing increasingly alarmed by the disproportionately high rates of maternal mortality and the racial inequities within this crisis, many experts have been calling for change, pointing to research that highlights the benefits of expanding and diversifying the perinatal workforce, including the midwifery workforce. Compared to other models of care, the midwifery model of care - a client-centered approach with a holistic framework that aims to support the physical, psychological, and social well-being of the birthing individual before, during, and after birth - is associated with higher levels of satisfaction and fewer medical interventions, including decreased odds of cesarean sections.
Fortunately, the number of credentialed midwives in the United States more than doubled between 1991 and 2012, and has only continued to grow steadily, with universities expanding their course offerings and new students enrolled in accredited midwifery programs growing from 1,006 in 2014 to 1,214 in 2018. However, while the workforce has been expanded, it has not been sufficiently diversified: 14 percent of the U.S. birthing population identifies as Black, yet Black people make up only 6.3 percent of nurse midwives in the U.S. perinatal workforce (see Figure 1). This lack of Black representation is especially unjust considering that the practice of midwifery itself has origins in West African traditions brought to the United States by enslaved people. Through deliberate policy choices, however, Black midwives were systematically excluded from the increasingly medicalized field of obstetrics over the course of the twentieth century, and that systemic racial exclusion persists today.
Having access to racially concordant providers improves health outcomes for patients of color and having access to midwifery care improves health outcomes for women and birthing people. The lack of Black nurse midwives is a racial equity problem that, if solved, has the potential to ameliorate the Black maternal health crisis.
The Role HBCUs Play in Diversifying the Health Care Workforce
HBCUs have long been a talent pipeline for Black students who go on to enter careers in health care. Not only do HBCU medical and nursing schools graduate large numbers of doctors and nurses of color every year, but also, many of these students’ first experience with higher education is at an HBCU, long before they decide to pursue health care. With race-conscious affirmative action now out of the higher education picture, HBCUs will become the school of first choice for an increasing number of college-bound Black students.
Research shows that the top three U.S. institutions in terms of graduating Black doctors every year are all HBCUs: Meharry, Howard, and Morehouse School of Medicine. These three schools, along with the predominantly Black medical school, Charles R. Drew University of Medicine and Science, now produce half of the country’s Black doctors. New HBCU medical schools are also now being established at Morgan State University and Xavier University of New Orleans, as a direct response to the nation’s physician shortage.
The need to expand the pipeline for Black doctors is clear—the current HBCU medical schools are only four of the 155 allopathic (MD-granting) medical schools in the country. The resulting disparity between the number of Black doctors practicing and the number of Black patients is glaring, making things like concordant care impossible. However this was not always the case. At the height of the Reconstruction Era, there were fourteen HBCU medical colleges that were focused on the health and wellbeing of formerly enslaved people. Unfortunately due to the rise of systemic racism during Jim Crow, the Flexner report called for reforms to funding medical education and devaluing the role of Black medical colleges and Black medical students, thus limiting the breadth of medical care to Black patients. This report further pushed the narrative that only two medical colleges, Howard and Meharry were worthy of investment. However, the racial inequities in health and health care during the COVID-19 pandemic showed that the need for Black medical colleges to graduate more Black doctors is critical and necessary for public health.
Expanding the pipeline for Black doctors will take significant new investment. Fortunately, Bloomberg Philanthropies is still holding fast to their commitment of $100 million to provide support to the nation’s four historically Black medical schools over the next four years, but increasing the number of Black doctors in the United States will take more than philanthropic support.
The number of HBCU nursing schools or nursing programs is significantly higher than that of medical schools, numbering in the dozens. While more numerous, HBCU nursing schools and programs still face significant challenges, such as a lack of resources due to decades of HBCU underfunding, and so expanding the pipeline for Black nurses will require creative approaches. For HBCUs that don’t currently have the resources to offer midwifery training, for example, partnering with nursing schools that have such programs is a potential solution. An example of this can be seen in a partnership between New York University’s Rory Meyers College of Nursing and Howard University, which since 2021 has worked to raise the necessary funds to support midwifery training for Howard students and alumni.
What Can Be Done to Invest in HBCUs and Improve Health Equity?
The structural barriers that Black people face in gaining access to higher education and breaking into the medical field are glaring, and the recent Supreme Court decision on affirmative action has created yet another obstacle. These barriers are deeply connected to how the country values the contributions of Black people in health care.
With Black enrollment in many universities expected to decline in the coming years, the nation must do all it can to support institutions that are likely to enroll more Black students, not fewer: Historically Black Colleges and Universities. And if the country—specifically, Congress—is committed to achieving health equity while improving public health, they should take action to increase national investment in the HBCUs that educate students pursuing careers in health care.
If all problems were treated like public health problems, we would have a much healthier society. The lack of Black doctors and nurses is a public health problem that will take reform and reimagining in higher education unlike what’s been done before.
Investing in Aid for Medical and Nursing Graduate School Programs
One of the biggest hurdles to gaining a medical degree is the cost. While some may say that graduate education is a privilege and not a right, medical and health care education is something that serves everyone: a diverse, well-educated health care workforce improves public health. And so while the scarcity of aid to support graduate education is a challenge that many in the higher education community struggle with, investing in the next generation of health care providers should be a no-brainer.
Currently, the average medical or nursing school student can accrue $30,000 to over $100,000 in debt while in pursuit of their degrees. Black student loan borrowers in particular carry a disproportionate debt burden compared to their white counterparts, which raises concerns about racial equity. Congress certainly can consider expanding programs like the Federal Supplemental Educational Opportunity Grant (FSEOG) and Pell grants, to assist students that have a greater need across all of higher education. But if Congress wants to target assistance that would help create a more diverse health care workforce, one way to do this would be to invest in the endowment of the medical and nursing colleges that are educating the next generation of Black doctors and nurses, such as HBCUs. Supporting HBCU endowments would not only support the institutions but would also allow them to draw down 4 percent from the endowment annually—a reasonable spending rate for colleges and universities—which would give them more resources to provide merit-based and need-based aid.
Lifting Up the Expanding Medical Education Act
While the public health emergency (PHE) has been declared over, the plain fact is that COVID-19 is still here, placing strain on the health care system at large. And while the ravages of the pandemic spared no one, COVID-19 was and continues to be catastrophic to the Black community. At this point in time, it is important to think about the future of medical and nursing education in the context of developing and supporting a health care workforce that is better prepared to ensure national public health.
The pandemic has placed Black medical colleges and nursing programs in a position to educate, treat, and vaccinate the Black community, for example—but they would need funding support to launch such programs. Expanding enrollment to achieve greater diversity in the health care workforce so that concordant care is more accessible would also require greater investments.
In 2021, Senator Tim Kaine (D–VA) reintroduced a bill called the Expanding Medical Education Act, which focuses on developing medical schools and health care centers in underserved areas. This legislation is imperative for the nation to expand access to medical schools and health care centers specifically that serve and support communities that have been marginalized and represents an opportunity for HBCUs to expand their programs. For example, if this legislation were to pass, it could support institutions such as Morgan State University and others that are interested in expanding their campus footprints to serve a need in their local communities. The House has reintroduced their version of this bill in the 118th Congress, thanks to lead sponsor Representative Jim Costa (D-CA), but it still has yet to be reintroduced in the Senate.