"What Works: A Fifty Year Retrospective,"by David Barton Smith September/October 2004 issue of Poverty & Race
Three watershed events in the struggle to end divisions by race in the United States are marking major anniversaries: the 1954 Brown v. Board of Education decision, the Civil Rights Act of 1964 and the 1965 Medicare-Medicaid legislation. While we have fallen far short of the vision of the movement that produced these events, what has worked? I list concrete examples of five general strategies that have given good returns on investments.
1. Visibility: Nothing happens until the inequities and disparities are made visible. The Medicare-Medicaid legislation was passed only after disparities in access to care by race and income began to be documented by regular national surveys. Since the 1989 revisions of the Home Mortgage Disclosure Act of 1975 (HMDA), residential mortgage lenders are required to publicly report detailed information, including the race of loan applicants. Nationally, loan approval rates, unadjusted for risk, are substantially lower for blacks than whites. The Federal Reserve Bank of Boston in 1992 did the first “risk adjusted” study. The study concluded that minorities in the Boston Area were rejected for loans 56% more often than equally creditworthy whites. After scathing headlines, heated industry rebuttals and lending agency efforts to improve the fairness of their loan application processes, the number of loans approved nationally for blacks has increased and rejection rates have declined. Public disclosure reports by race for individual lending institutions are available both in hard copy and from the web site of the Federal Financial Institutions Examination Council (www.ffiec.gov). As a result, lenders concerned about their public image have a strong incentive to demonstrate good faith by following such best practice loan fairness guidelines.
2. Testing: Making disparities visible, however, rarely forces change. There are just too many more comfortable, moralistic and victim-blaming alternative explanations. Randomized testing varying only the race of the testers clears away this ideological underbrush. By the 1970s, testing was being used by fair housing agencies to determine the validity of housing discrimination complaints. In 1979, the Department of Housing and Urban Development sponsored the first national testing study of discrimination in housing markets. The study demonstrated the feasibility of such surveys and the persistence of a high degree of discrimination in the housing market. This has been followed by a series of regular testing studies that have kept pressure on and have documented progress in reducing the level of discrimination. Perhaps reflecting these pressures,the Census documents a modest decline in residential segregation in most metropolitan areas over the last 20 years.
3. Gold: The golden rule in America is that those that have the gold rule. Title VI of the Civil Rights Act attempted to impose the condition of integration and non-discrimination on all organizations receiving federal funds. Unwavering commitment to this principle in implementation of the Medicare program worked. Almost 1,000 hospitals integrated their accommodations and medical staff in a period of a few months. The visible symbols of Jim Crow in the nation’s hospitals disappeared almost overnight, and gross racial disparities in access to services gradually disappeared over the next decade.
4. Regionalism: Patterns of geographic and residential segregation limit the ability to reduce unequal treatment. Treatment may be integrated and equal within school districts or health systems but unequal between. The more affluent and predominantly white suburban areas do better. Health systems and school districts that don’t overlap such boundaries can do little to reduce the overall level of segregation and are limited in their ability to address treatment disparities. For a brief period in the 1970s and 1980s, federal regional health planning certificate of need requirements forced integration of specialized health services in many metropolitan areas. Metropolitan areas that had been operating under city-suburban court-ordered desegregation have achieved a greater degree of integration. In general, metropolitan areas whose schools or health systems are regionalized have fewer disparities and better overall outcomes.
5. Universality: “Freedom of choice” was the rallying cry of the segregationists in the 1960s and is embedded within market/competitive solutions to schools and healthcare. The initial success of the Medicare program in integrating hospitals was based on a single universal program (all persons over 65) and a restructuring of the hospital system to restrict consumer choice. This meant one entrance, one waiting room and race-blind room assignment. The goals of desegregation and equity trumped individual consumer choice. Choice was viewed as the wolf in sheep’s clothing that would undermine the goal of integration.
These five general strategies have worked because the majority of Americans believe (or at least can be shamed into saying they believe) in equal opportunity and that segregation and discrimination should not be tolerated. Yet, the sheep’s clothing arguments of the wolf of segregation have blunted the effectiveness of each of these strategies. Visibility has been fought with privacy objections, testing by raising the specter of costly government intrusion, regionalization by the rhetoric of community empowerment and entrepreneurship, and universality by appeals for consumer choice and competition. The vision of the Civil Rights Movement will be realized to the extent that the wolf is named for what it is and the long-term impact of such alternatives on the cost and quality of life for all citizens made clear.
David Barton Smith is Emeritus Professor, Program in Health Management and Policy, Temple University and Research Professor, Dornsife School of Public Health, Drexel University. A documentary film related to this story (produced by Barbara Berney, working title "The Power to Heal" and supported by the National Endowment for Humanities) is currently in the editing process and tentatively scheduled to air on PBS stations later this year. dbs36@ drexel.edu
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