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Segregated care, write the authors in an article published in AMA Journal of Ethics, is care that is segregated by insurance status, and therefore, in effect, by race. As an example, the authors explain that in New York State, nonelderly Black adults are more likely than their white counterparts to be enrolled in public insurance options like Medicaid. Another illustration of how segregated care manifests as health insurance inequities, write the authors, includes public insurance eligibility restrictions, which restrict Black Americans from coverage at a rate of two times the rate of white Americans. Groups that are vulnerable to these exclusions include undocumented patients, patients with incomes less than 50 percent of the federal poverty level, and adult patients without dependent children. The authors further explain that differences in insurance status have numerous implications on patient care and outcomes – impacting, for instance, wait times and the locations where patients are most likely to receive care.
Their article was published in a special AMA Journal of Ethics theme issue devoted to the topic of racial segregation in health care today, edited by Icahn Mount Sinai alums Denisse Rojas Marquez, MD, MPP, and Hazel Lever, MD, MPH. In their introduction to the issue, Drs. Marquez and Lever describe their aim to use the publication to open an academic dialogue on segregated care while underlining their view of shared responsibility. They write, “The act of dismantling racism in health care requires all health care staff to recognize their own complicity in a racist health system—despite the fact that they did not create it.”
Commenting on the scarcity of academic literature devoted to the topic of segregated care, David Muller, MD, FACP, Dean for Medical Education, Icahn Mount Sinai, said, “I am so proud that Icahn Mount Sinai graduates and current students are openly sharing their experiences to inform the long-overdue and long-neglected conversation about segregated care. The editors rightly point out the responsibility we all share to fix this crisis in human rights that has long been the norm in American medicine.”
Speaking on the AMA’s podcast “Ethics Talk,” fourth-year medical student and co-author Ruhee Shah explains, “The environments that we train in shape our view of health care and what health care should look like. So there is a lot that we are exposed to that can normalize injustices.”
Ms. Shah, in collaboration with her three co-authors, fourth-year Icahn Mount Sinai medical students Lindsay Clark, Terence M. Hughes, and Ashesh Trivedi, helped lead efforts to develop a student-led curriculum to provide extracurricular peer-to-peer education about segregated care. Their work builds on earlier work from 2014, when student leaders at Icahn Mount Sinai founded the Segregated Care Student Workgroup
The authors’ model, described in detail in the article, includes mandatory curricular presentations to first-year and second-year medical students designed to prepare them for the experience of segregated care. To reinforce their presentations, the students also developed optional extracurricular opportunities, including a session on “Chats for Change” (a Mount Sinai Health System-wide interactive discussion format) and opportunities to participate in the Segregated Care Student Workgroup.
The student-led curriculum model created a framework with a detailed definition of segregated care, contextualizing it within both New York City and the Mount Sinai Health System. To provide detail to illuminate the extent of segregation, the students tapped quantitative data detailing the percentage of patients by insurance status and race nationally and locally. They also described segregation in quantitative measures, culling survey data from Icahn Mount Sinai students and residents about their observations of how segregated care had impacted the delivery of care. By beginning with this data, the students laid the groundwork for robust discussion sessions with their audiences to elicit further engagement with the curricular material.
The student leaders’ orientation for first-year medical students included a peer-to-peer presentation in which students were asked to closely examine the intersection of their social identities, their roles as students, and the health care system. In the curricular presentation to second-year students, the student leaders provided a peer-to-peer presentation focused on recognizing segregated care that students would likely experience in their third-year clerkships. Action items intended to engage these students included reflections on clinical role models who challenged the status quo and sharing how the experience of segregated care had impacted both their education and well-being. The student leaders collected feedback from their fellow students to elicit input on how to strengthen their curricular model.
In 2020, the authors helped lead an effort, built on their original extracurricular model, to pitch the idea of a formal medical school curriculum to school leadership. “Segregated care, which exists widely in health care including in our own hospitals, is one of the key reasons for race-based disparities in health outcomes in our clinics, hospitals, and even pharmacies. School leadership not only applauds the work of our students but supports their efforts to create a lens through which we can see clearly what is right under our noses,” says coauthor Leona Hess, PhD, senior director of the Strategy and Equity Education Program at Icahn Mount Sinai. “The students’ recommendations are perfectly aligned with Icahn Mount Sinai’s medical education program objective, ensuring that every student can demonstrate approaches to mitigate the manifestations of racism and social inequities.”
About the Icahn School of Medicine at Mount Sinai
The Icahn School of Medicine at Mount Sinai is internationally renowned for its outstanding research, educational, and clinical care programs. It is the sole academic partner for the
eight member hospitals* of the Mount Sinai Health System, one of the largest academic health systems in the United States, providing care to a large and diverse patient population.
Ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges, Icahn Mount Sinai has a talented, productive, and successful faculty. More than 3,000 full-time scientists, educators, and clinicians work within and across 34 academic departments and 44 multidisciplinary institutes, a structure that facilitates tremendous collaboration and synergy. Our emphasis on translational research and therapeutics is evident in such diverse areas as genomics/big data, virology, neuroscience, cardiology, geriatrics, and gastrointestinal and liver diseases.
Icahn Mount Sinai offers highly competitive MD, PhD, and master’s degree programs, with current enrollment of approximately 1,300 students. It has the largest graduate medical education program in the country, with more than 2,600 clinical residents and fellows training throughout the Health System. In addition, more than 535 postdoctoral research fellows are in training within the Health System.
A culture of innovation and discovery permeates every Icahn Mount Sinai program. Mount Sinai’s technology transfer office, one of the largest in the country, partners with faculty and trainees to pursue optimal commercialization of intellectual property to ensure that Mount Sinai discoveries and innovations translate into health care products and services that benefit the public.
Icahn Mount Sinai’s commitment to breakthrough science and clinical care is enhanced by academic affiliations that supplement and complement the School’s programs. Through Mount Sinai Innovation Partners (MSIP), the Health System facilitates the real-world application and commercialization of medical breakthroughs made at Mount Sinai. Additionally, MSIP develops research partnerships with industry leaders such as Merck & Co., AstraZeneca, Novo Nordisk, and others.
The Icahn School of Medicine at Mount Sinai is located in New York City on the border between the Upper East Side and East Harlem, and classroom teaching takes place on a campus facing Central Park. Icahn Mount Sinai’s location offers many opportunities to interact with and care for diverse communities. Learning extends well beyond the borders of our physical campus, to the eight hospitals of the Mount Sinai Health System, our academic affiliates, and globally.
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* Mount Sinai Health System member hospitals: The Mount Sinai Hospital; Mount Sinai Beth Israel; Mount Sinai Brooklyn; Mount Sinai Morningside; Mount Sinai Queens; Mount Sinai South Nassau; Mount Sinai West; and New York Eye and Ear Infirmary of Mount Sinai.
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