Just Medicine: A Cure for Racial Inequality in American Health Care

In Chapter 1, Matthew argues that racism is a root cause of health disparities in America, and that legal systems have historically reinforced this inequality. Since racism is currently unconscious for most health professionals and middle-class US citizens, it is very difficult to make a case against with material data. Matthew sets out to show how the legal system in the US is permeated by racism and discrimination. She examines four key historical periods, starting with colonial laws that equated BIPOC individuals to property, and continuing through the 20th century, when racism in healthcare was legally sanctioned.

Although the civil rights era brought some progress, current antidiscrimination laws have failed to address implicit biases that perpetuate these disparities today. Matthew emphasizes the need for legal reform to reduce health inequality and improve outcomes for BIPOC populations.

In the section of Chapter 1 called “The Colonial Period: The Hegemonic Role of Law,” Matthew illustrates how the legal system, starting in colonial times, facilitated racial subordination by passing property laws that enabled the seizure of Native American lands. Similarly, laws allowed enslaved Africans to be treated as property, which resulted in their health being disregarded unless it impacted their ability to work. Historical documents reveal that medical care for slaves was often minimal and only provided by the owner when it benefited their financial interests.

In the section titled “Seeds of Segregation: Legalized Racism,” Matthew discusses how, during the 19th-century Industrial Revolution, American law played a central role in denying working immigrants access to the resources needed for good health. Laws governing housing, labor, and immigration promoted racial segregation, confining racially marginalized communities to unsanitary ghettos that became breeding grounds for disease. Immigrants, particularly Chinese, Mexican, and Irish workers, faced legal discrimination that isolated them in hazardous living and working conditions. Meanwhile, Black workers were subjected to “Black codes” (17) that restricted their employment options and access to healthcare. Public health laws in the early 20th century further institutionalized racism, as BIPOC patients received inferior medical care in segregated hospitals. Despite the promise of equal protection under the Constitution, courts often upheld segregationist policies, denying BIPOC patients proper medical care. Matthew argues that this discriminatory legal framework directly contributed to the health disparities that persist among BIPOC populations in America today.

In the Chapter 1 section titled “The Civil Rights Era: Legal Attacks on a Divided Healthcare System,” Matthew discusses the landmark case Simkins v. Moses H. Cone Memorial Hospital—a significant civil rights victory that challenged hospital segregation under the Hill-Burton Act. The Hill-Burton Act, a bill passed in 1946, provided federal funding for hospital construction and modernization but allowed segregation in healthcare by permitting “separate-but-equal” facilities for different racial groups (21). Although initially upholding segregation, the law was later revised in 1979 to remove these discriminatory provisions. The plaintiffs, which were African American medical professionals and patients, successfully argued that the law’s separate-but-equal provisions were unconstitutional. This case laid the foundation for Title VI of the Civil Rights Act of 1964, which prohibited racial discrimination in any organization receiving federal funding, including healthcare institutions. From the 1960s to the early 1990s, Title VI was instrumental in dismantling segregation and discrimination in healthcare, addressing issues such as unequal access to medical care, exclusion of BIPOC physicians, and discriminatory treatment policies. However, by the late 20th century, the effectiveness of Title VI began to decline as courts increasingly rejected challenges to subtle forms of racial and ethnic discrimination in healthcare.

The section “The Law of Post-Racial America: Intentionality, Causation, and Health Disparities” discusses the deterioration of the Title VI, which was rejected repeatedly by courts in the 90s. Matthew exemplifies this tendency with cases like Bryan v. Koch and N.A.A.C.P. v. Wilmington Medical Center, which failed due to a lack of proof of discriminatory intent. By 2001, the Supreme Court’s decision in Alexander v. Sandoval severely weakened Title VI, limiting plaintiffs to cases of intentional bias. Consequently, contemporary racial and ethnic health disparities remain unaddressed, as legal protections against subtle discrimination are mostly ineffective.

The chapter’s final section, titled “The Legal Legacy: A Persistent Gap between BIPOC and White Health and Healthcare in America,” discusses how marginalized racial and ethnic groups in the US, including African Americans, Latinos, Asians, and Native Americans, consistently receive inferior medical care and experience worse health outcomes compared to whites. Matthew states that the legal structures historically contributed to these disparities, and that health inequalities are worsening. She gives the example of a study by Dr. Kathleen Harris, which shows that health disparities between BIPOC patients and whites increase with age, independent of socioeconomic status. Mental health disparities, particularly for Hispanics, have also worsened. Matthew calls for legal action to address and regulate unconscious discrimination in healthcare.