A decision made by the Trump administration earlier this year should be concerning for people involved in admissions for medical schools and higher education. This arrangement reflects one of the many ways this administration is supporting policies that make it harder for minorities to achieve health equity.
In April, the Wall Street Journal revealed that the Texas Tech University System had signed an agreement with the US Department of Education (DOE) to stop using affirmative action as part of the admissions process at the medical school after a 14-year investigation.1 The probe started after a complaint filed by the anti-affirmative action advocacy organization Center for Equal Opportunity. During the course of the DOE’s Office on Civil Rights probe, the system stopped using affirmative action in its admissions considerations at its pharmacy school and undergraduate college.
Texas Tech was unable to demonstrate they reviewed their admissions policies annually and whether race-neutral strategies could achieve a diverse student body. In the first agreement of its kind involving the Trump administration, Texas Tech agreed to stop the use of affirmative action. This decision occurred after the Department of Justice supported the Asian-American plaintiffs who sued Harvard University over affirmative action quotas.
When medical schools intentionally make racial and ethnic diversity an admissions goal and students perceive a positive environment for interracial interactions, students are more likely to feel prepared to care for minority populations, and white students are more likely to have strong favorable attitudes toward health equity.2 Additionally, nonwhite physicians care for a larger percentage of minority and non-English-speaking patients compared to white physicians, a finding that has not changed in more than 20 years.3 Furthermore, patients of nonwhite physicians are more likely to report fair or poor health.3 Underrepresented minority (URM) health care professionals are not the only people who can or should care for diverse populations, but they can teach non-URMs about better communication styles for different patients as the country’s population becomes majority minority.
A diverse health professional workforce improves cultural competency and health equity, and diverse clinicians and researchers can serve as role models and problem solvers. Blacks, Latinos, and Native Americans are underrepresented among medical students as well as medical school faculty.4 If there are fewer role models among medical school faculty and leadership, potential URM applicants may self-select out of medical careers before they give them a chance. The more diverse academic medicine is, the better the diversity of ideas and viewpoints, innovation, brainstorming, and decision-making in tackling disparities in health care.5,6
While this DOE agreement affects only Texas Tech, the Trump administration’s moves against affirmative action are worrisome because affirmative action is an important tool for schools to use to create diverse student bodies. The US Supreme Court (SCOTUS) has previously clarified the role of affirmative action in higher education. In the landmark case of Regents of University of California v Bakke, the court opined that schools cannot exclude anyone on the basis of race, but they could use race as a “plus” factor weighed along with other details for admission consideration.7 Later in Grutter v Bollinger, the Supreme Court found that the University of Michigan Law School had a compelling interest in creating a diverse student body and its use of race as a “plus” factor did not violate the Fourteenth Amendment.8 More recently, in Fisher v University of Texas-Austin (UT), the Supreme Court upheld that UT’s race-conscious admissions program did not violate the Equal Protection Clause of the Fourteenth Amendment.9 In general, SCOTUS has ruled that schools can use affirmative action as long as there was no quota system.
Some states have passed propositions to ban race-based admissions policies, with adverse effects on diversity. After the Fifth Circuit Court’s 1996 decision in Hopwood v Texas, the state banned affirmative action. Texas tried to implement a race-neutral admissions policy, but it did not help increase underrepresented minority students at flagship public colleges.10 After two decades with Proposition 209 in California, college enrollment by black and Latino students was lower than before the proposition was passed.11 These affirmative action bans in Texas, California, and other states have decreased matriculation of URMs in medical schools.12 Meanwhile, theoretical models have not found successful race-neutral alternatives to affirmative action in achieving diversity while maintaining applicant quality.13-15 Students admitted under affirmative action and special consideration over 20 years at one institution had “no difference in completion of residency or evaluation of performance by residency directors.”16
Notably, while much affirmative action research has focused on black and Latino URMs, lack of disaggregated data makes it difficult to observe impacts on different populations. URMs do not usually include Asian-American and Pacific Islanders (AAPI), but this category includes many ethnic communities. Similarly, the Latino population in the United States. includes people from many different countries with different socioeconomic and settlement patterns. Because they are combined, it is unclear how well represented specific groups are within AAPI and Latino communities.
The selective admissions program that should end is the one that benefits applicants with familial relationships to alumni and from wealthy families. According to a 2018 survey, 42% of admissions directors at private colleges and universities and 6% at public institutions use legacy as a factor in admissions decisions.17 Despite less competitive grades and test scores, some students are accepted to schools after their families pledge large donations or pay for new buildings.18,19 Some wealthy parents are willing to pay up to $6.5 million for college preparation organizations to take standardized tests on behalf of their children or bribe coaches to admit their children as recruited athletes regardless of their skills.20
Until there is another way to achieve a diverse student population while maintaining the quality of future health care professionals, admissions committees can continue to use affirmative action as a factor in admissions. Our nation’s health depends on a diverse health care workforce. This is not the first time this journal has emphasized the importance of diversity in medical education, and it won’t be the last.21
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