UCSF

Despite more than sixty years of civil rights legislation prohibiting racial segregation, pregnancy care in the United States remains segregated by insurance, and de facto by race, ethnicity, and socioeconomic status. While previous research has documented racial segregation in hospitals and its consequences for health outcomes, less attention has been paid to the organizational processes that produce and sustain segregated pregnancy care or the role of academic medicine in these practices. This study examined how law, health care financing, and academic medicine co-constructed and sustained segregated pregnancy care in the United States. It also elucidated the experiences of health care providers and trainees who witness and participate in a system that stratifies care and resources based on race, ethnicity, and socioeconomic status. Drawing on genealogy, institutional theory, critical legal theory, the theory of racialized organizations, and biopower, I conducted a qualitative study of two academic medical centers with different models of prenatal care delivery: one that sorts pregnant patients by insurance into the resident and faculty practices and one that blinds insurance at intake and assigns patients to providers based on clinical risk. Data included 94 interviews with obstetricians, midwives, trainees, administrators, and national experts; 190 hours of observation of clinical settings and professional meetings and events; and review of legal, archival, and institutional documents. I argue that payer segregation is produced through reinforcing legal, financial, and administrative structures and operationalized through organizational processes that sort pregnant patients into different providers, clinical spaces, and standards of care based on insurance. These routine sorting processes reproduce racial and economic segregation through the delivery of pregnancy care. Health care providers and trainees reported experiencing moral injury as they witnessed and participated in segregated systems. This study contributes to medical sociology by identifying payer segregation as a mechanism through which racial and economic segregation are reproduced in health care settings and by theorizing patient sorting as the organizational process that operationalizes payer segregation in everyday clinical practice. It shows how seemingly race-neutral laws, policies, and organizational practices sustain segregation long after the end of de jure segregation. I conclude by proposing health system and organizational reforms to dismantle payer segregation and advance equity in pregnancy care.