A landmark Supreme Court ruling, the Civil Rights Act, and Medicare legislation in the early 1960s led to the coerced integration of American hospitals in cities with substantial minority populations.2 After 1965, hospitals had to accept both Medicare and nonpaying minority patients. As a result, hospitals in geographic areas with substantial low-income minority populations became increasingly financially disadvantaged in subsequent years. Many hospitals eventually left inner-city areas because high numbers of uninsured and underinsured patients made these hospitals economically unviable. Similarly, primary care providers and clinics have fled low-income inner-city areas for suburban areas with better payer mix and fewer minority patients. Hospitals and clinics have found that geography determines profitability. As a result, in many communities, hospital segregation has recurred along socioeconomic lines. This important study by Hasnain-Wynia et al3 in this issue of the Archives raises the simple question: Do minority patients sometimes receive lower quality hospital care because of differential treatment by individual providers or because the hospitals that serve minority patients are less capable?
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