During the Supreme Court oral arguments about affirmative action in October 2022,
Justice Elena Kagan asked, “[I]f you’re a hospital and you serve a diverse group of
patients, is it super important to you to have a diverse set of doctors?” Justice
Kagan’s question raises whether the Supreme Court, poised to end affirmative action,
may diminish the diversity of health providers in the United States. Two affirmative
action lawsuits facing the court—against the University of North Carolina (UNC) and
Harvard University—will likely have severe ramifications for medical training and
health equity. Given the likelihood that the Supreme Court will end affirmative action,
medical institutions must plan how to further diversity without incurring liability.
More broadly, the cases follow a pattern of judicial intrusion into the affairs of
medicine and health. As with abortion, contraception, health insurance, and COVID-19,
the Supreme Court has encroached on the field of medicine, denying expert guidance
on what is required in order to achieve a healthy and equitable society. The affirmative
action cases are emblematic of a high court intent on opposing racial progress and
other forms of social change.
The affirmative action cases before the Supreme Court follow a recent pattern of judicial
intrusion into the affairs of medicine and health. Image credit: Shutterstock/ProStockStudio.
Race in Admissions
The lawsuits, filed in 2014, allege that both universities impermissibly use race
as a factor in admissions, amounting to racial discrimination. Medical schools are
indirectly in the crosshairs of this litigation, given that most medical schools today
use race in admissions to help secure a racially diverse student body. However, consideration
of race in admissions has been increasingly subject to legal challenge, the first
in a parade of cases being Regents of the University of California v. Bakke. Allan
Bakke, a White male, was denied admission twice to the University of California Davis
(UC Davis) School of Medicine and challenged the school’s practice of reserving 16
spots each year for racially or ethnically diverse medical students (1). The Supreme
Court invalidated this program as an impermissible racial quota, but said schools
could still consider race as a plus factor. Perhaps because this litigation was so
successful (and landed Bakke a spot at UC Davis’s medical school), White applicants
denied admission have continued to press challenges to affirmative action for more
than 30 years, leading to decisions that have further narrowed consideration of race
in admissions.
In Grutter v. Bollinger (2003), the Supreme Court decreed that consideration of race
must be part of a holistic review, and racial quotas are impermissible. Medical schools
have taken the Supreme Court’s charge and shifted toward a more holistic assessment
of their applicant pools, with the support of the Association of American Medical
Colleges (AAMC) Holistic Review Project (2).
Despite the resiliency of medical school admissions, the Supreme Court has narrowed
affirmative action to a small corner of consideration in admissions processes—which
may soon also become illegal.
As of 2015, there is estimated to be a deficit of about 114,000 Black and 81,000 Hispanic
doctors compared to what one would expect from proportions of the US population (3).
This dearth is at least partially historical: Racial and ethnic minorities were excluded
from attending medical school and joining medical organizations, such as the American
Medical Association (AMA). In 1900, 11.6% of the US population was Black, compared
with 1.3% of physicians. In 2018, 12.8% of the population was Black, but only 5.4%
of physicians (4). Over 120 years, then, the fraction of Black physicians has increased
by only 4 percentage points. This lack of representation emphasizes why the fate of
affirmative action is essential to securing a racially and ethnically diverse physician
body in the United States.
Affirmative action helps compensate for systemic inequities throughout childhood and
young adulthood that impede the significant steps required to apply to and be admitted
to medical school (5). The current biggest gatekeeper to medical school admission
is the Medical College Admission Test® (MCAT®), whose notable racial and ethnic disparities
are well documented (5
–7). As of 2022, Black and American Indian/Alaska Native medical school applicants
have an average MCAT® score of 497.4 and 498.7, respectively, which is about one standard
deviation below the average score for White applicants of 507.9 (8). Although these
disparities do not mean that the test makers intentionally discriminate by race, they
reflect the systematic disadvantage facing racial and ethnic minorities applying to
medical school.
Using the natural experiment from states banning affirmative action, researchers have
found that affirmative action significantly impacts medical school diversity. A 2022
study found that states with affirmative action bans saw a 4.8 percentage point decline
in underrepresented racial and ethnic minority students in public medical schools.
In contrast, control states saw an increase of 0.7 percentage points (9). These data
forecast what could happen at the national level should the Supreme Court issue a
pronouncement broadly prohibiting consideration of race in medical school admissions.
Pivotal Lawsuits
The lawsuits allege that UNC has violated the Constitution’s “Equal Protection Clause,”
which bars states from denying any person “the equal protection of the laws.” However,
this clause only applies to governments. So for Harvard, the lawsuits use Title VI
of the Civil Rights Act of 1964, which prohibits any person in the United States from
being subject to discrimination under any program receiving federal funding*. The
Supreme Court has interpreted Title VI to bar the same conduct as prohibited by the
equal protection clause. Together, these two cases reach most educational institutions,
which is likely why they are being pursued at the same time.
These suits were brought by Students for Fair Admissions (SFFA), a group founded by
Edward Blum. Blum has been the key driver of anti-affirmative-action lawsuits to assist
White applicants denied admission. However, his intent on this go-round was to move
from White plaintiffs to Asian-American plaintiffs to build public support for the
idea that affirmative action is racially discriminatory (10). The strategic positioning
of Asian Americans in the lawsuit may seem odd, as any discrimination in a university’s
admissions does not necessarily impugn affirmative action as a broad program. But
for the Supreme Court, the lawsuit has successfully created an association between
consideration of race in admissions and potential discrimination against Asian Americans.
Most legal commentators believe the Supreme Court will end affirmative action in education.
At oral argument, many of the more conservative-leaning justices seemed openly skeptical
of the program. Most likely, the decision would not be confined to admissions, but
would invalidate any consideration of race in educational programs, such as for scholarships,
financial aid, and leadership positions. This restriction would apply to the education
of the next generation of physicians, physician assistants, nurses, nurse practitioners,
and other providers. More broadly, it may become more challenging to seek diverse
hospital administration without going afoul of non-discrimination laws. This is especially
ironic because, historically speaking, Title VI was instrumental for forcing hospitals
to desegregate by law (11).
But because the Supreme Court may now deem consideration of race itself to be discrimination—even
when it would benefit a racial group and society as a whole—the Supreme Court may
stipulate a rule with far-reaching effects across the US healthcare industry. This
would not be the first Roberts Court decision to re-interpret civil rights laws as
protective of White people, as opposed to the subordinated groups these laws were
meant to protect. For example, in Parents Involved in Community Schools v. Seattle
School District (2007), the Supreme Court held that voluntary school desegregation
plans in Seattle, WA, and Louisville, KY, violated the Equal Protection Clause. Although
this clause was created to help remedy racial discrimination after the Civil War,
the Supreme Court used it to impede efforts to address systemic racism (12). In this
case, Chief Justice Roberts famously quipped, “The way to stop discrimination on the
basis of race is to stop discriminating on the basis of race,” thereby imparting a
“color-blind” reading on a clause aimed at racial progress. The Roberts Court’s belief
that color-blindness will end racism overlooks the more structural and systemic forms
of racism that are likely the biggest propagators of disadvantage today (13). At the
same time, the color-blind approach invalidates policies aimed at racial progress
like affirmative action, thus entrenching the benefits of Whiteness.
Ending consideration of race could place medical schools in a difficult position.
According to Liaison Committee on Medical Education (LCME) Standard 3.3, medical schools
must have “effective policies and practices” aimed at achieving the “inclusion … of
persons from different racial, ethnic, economic, and/or social backgrounds” (14).
Medical schools may be torn between their duties for accreditation and the law of
the Supreme Court. It may be that LCME standards will have to change. But in the meantime,
schools may violate the current standards if they are not sufficiently diverse. This
tension between law and medicine is striking and highlights the impact of our current
judiciary on attaining a core objective of medicine: diverse providers that can care
for a diverse populace.
Affirmative action’s loss may result in medicine and healthcare that look substantially
less diverse. And any loss of diversity could be self-perpetuating. Through their
presence and contributions, racial and ethnic minorities help make spaces more accommodating
and inclusive to people from differing backgrounds. For example, testing of implicit
bias using the well-validated Implicit Association Test has revealed that African-American
physicians have far less implicit bias than White physicians (15). Racial and ethnic
prejudice, prolific throughout medicine, impact physician–patient communication, treatment
decisions, and patient outcomes (16
–18). A less racially diverse pool of providers could bring heightened bias toward
racial and ethnic minorities, leading to a spiral effect, in which medical spaces
become less varied across the board (19).
Losing racial and ethnic minority physicians may also seriously affect health equity.
Racial concordance between provider and patient is associated with improved communication,
lower emergency department use, and better outcomes (20). Although that does not necessarily
militate in favor of assigning physicians to patients by race, it raises serious questions
about healthcare inequity should the physician body look less like America in all
its diversity. There are also unique health concerns, given the legacy of injustice
affecting certain racial and ethnic groups—concerns that diverse providers may be
better able to notice and address. And because medicine is an enriching and lucrative
career, everyone should have a fair chance to apply, regardless of race or ethnicity.
Maintaining and Improving Diversity
The possible downfall of affirmative action threatens to worsen an already difficult
situation at medical institutions in the United States. They should therefore prepare
now for a potential Supreme Court loss.
The first consideration is whether the rulings would even apply. The existence of
lawsuits against both Harvard and UNC suggests that the prohibition on using race
will apply to state and private institutions. However, Title VI applies to private
institutions only when they accept federal funds. Unfortunately, most medical schools
depend on federal funds, including federal financial aid, federal grant money for
research, the Medical Science Training Program, and Medicare and Medicaid funds for
healthcare activities. To the extent that a private institution can avoid taking federal
money, it may be wise to do so in order to avoid the direct impact of these rulings.
Delegation can help separate admissions activities from the acceptance of federal
funds. Medical schools can set up organizations that conduct specific admissions assessments
involving race. The schools can then use any metrics and recommendations second-hand.
Such structuring is common for tax purposes, for separating nonprofit from political
activities (i.e., 501(c)(3) vs. 502(c)(4)), and for reducing tort liability. Medical
schools should consult with attorneys as soon as possible to plan organizational offshoots
that can consider race.
Many medical schools will be driven to alternative metrics, or proxies, to attain
racial diversity. Such proxies could include family history, experiences of discrimination,
socioeconomic status, and geography. However, proxies are limited for at least two
reasons. First, they may poorly approximate race. For example, experiences of discrimination
may seem to correlate with race, but they have frequently been claimed by White applicants,
including in the Supreme Court’s historical affirmative action cases. And, second,
the upcoming decision may prohibit not only consideration of race, but also similar
metrics. At oral argument, an attorney for SFFA stated that it should be impermissible
to consider whether a student descended from enslaved people because that would be
a “pure proxy for race.” All told, given the state of de facto segregation in the
United States, geography is likely a decent proxy.
Another option is pathway or recruitment programs, which aim to fold racial and ethnic
minorities into educational environments from which a portion of students are chosen.
These programs can also provide support for standardized tests and preparing applications—which
can be daunting to prospective students and a barrier to diversity.
Ultimately, asking larger questions about the relationship between law and medicine
is imperative. Across numerous domains over the past 30 years, judges have sidelined
medical expertise and issued decisions that obstructed medicine’s core mission. Supreme
Court decisions have made obstetrics and gynecology practice more difficult by curtailing
access to contraceptives and abortion (21); invalidated COVID-19 protective measures,
including a vaccine requirement and an eviction moratorium; and weakened the Affordable
Care Act and Medicaid expansion, to name a few examples. At the same time, the Court
has moved the law to be fairly hostile toward discrimination lawsuits (except in the
affirmative action context). These trends co-occur with a fall in US life expectancy,
particularly among racial and ethnic minorities, and increased burnout in medicine.
They also raise serious concerns about medicine’s ability to function alongside a
judiciary that is increasingly aggressive in limiting racial progress and other forms
of social change.
The affirmative action cases before the Supreme Court raise serious questions about
the future of a diverse medical profession and the integrity of healthcare itself.
In advance of the decision, medical programs that value diversity and accept federal
funds (or are government institutions) would be wise to consider alternative paths
to create a racially diverse student body without explicitly considering race. With
some strategizing, they can preserve some racial diversity while keeping to the letter
of the law.