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Is healthcare for all? A qualitative questionnaire study of systemic racism in healthcare and the perception among stakeholders of U.S. healthcare corporations: an exploration of moral disengagement..

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Is healthcare for all? A qualitative questionnaire study of systemic racism in healthcare and the perception among stakeholders of U.S. healthcare corporations: an exploration of moral disengagement..

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Is Healthcare for All? A Qualitative Questionnaire Study of Systemic Racism in Healthcare
and the Perception Among Stakeholders of U.S. Healthcare Corporations: An Exploration
of Moral Disengagement and Interest Convergence in Healthcare Delivery

Maria D. Flowers

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2023

© Copyright by Maria D. Flowers 2023
All Rights Reserved

The Committee for Maria D. Flowers certifies the approval of this Dissertation

Alan Green
Ronald Wyatt
Brianna Hinga, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
This study sought to understand why disparate healthcare between White Americans and
minoritized populations has been allowed to persist despite decades of research about unequal
treatment. It is widely proven and accepted that systemic racism drive health disparities yet
disparate health outcomes continue to rise for minoritized populations. Healthcare organizations
and professionals should operate to improve the health and well-being of all patients. The pursuit
of profits and the underlying biases rooted in the foundations of systemic racism will continue to
perpetuate without increased organizational accountability. The United States government needs
to protect vulnerable patients by changing policies that inject greater accountability for
organizations to provide safe and equitable care. Patient Safety legislation reform is needed for
patients to increase the reporting of preventable events that lead to disparate outcomes. Medical
education organizations should provide standardized curriculum on the promotion of equitable
care that is introduced at earlier levels of medical training. The perspectives of stakeholders
representing US healthcare organizations contributed to the results and recommendations in this
study.

v

Dedication
To Mary L. Baity, and Annie Belle Harris, my grandmothers.
To Brenda J. King, my mother.
To Adrianna Ford, Dawn Ford, Alexis Flowers, and Brianna Flowers, my nieces. This degree is
in honor of the past, in celebration of the present, and an inspiration for the future.

vi
Acknowledgments
First and foremost, I thank my Lord and Savior, Jesus Christ. What was impossible in my
mind, became possible through HIS strength. Next, I thank my husband, Anthony L. Flowers,
who selflessly picked up the slack and supported me through many ups and downs to help me
finish this dream; thank you. To my son, Anthony G. Flowers, Mommy did it!!
Dr. Ronald Wyatt, I am humbled that you agreed to support me as a member of my
dissertation committee, and I am forever grateful for all of your time, wisdom, and input to this
project. Dr. Alan Green, thank you for stepping in at the ninth inning to help me bring this home.
Dr. Briana Hinga, thank you, thank you, thank you for everything.
Dr. Marc Pritchard and Dr. Doug Lynch, thank you for your encouragement and
mentorship along this journey; I am very thankful to you both. Dr. Erin Marsano, thank you for
your help with structure and editing along this journey. Dr. Adibe, I finished.
I cannot leave out the entire OCL cohort 18. You all are the best human beings I have
ever had an opportunity to work with. The most intelligent, creative, and fun people. I hate that
we were not able to be physically around each other more. I am so excited to see all of the
awesome changes that are going to come about from the beautiful people in this group. I will
truly miss Wednesday nights without you.
I must acknowledge my mentor, coach, Soror, and friend Dr. Cheryl Polote-Williamson;
words cannot express my gratitude to you for being you.
Last, I thank the countless friends and family for understanding why I wasn’t as present
as I usually am, I appreciate your grace.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgments.......................................................................................................................... vi
List of Tables ................................................................................................................................. ix
List of Figures ................................................................................................................................ xi
Chapter One: Introduction to the Study ...........................................................................................1
Context and Background of the Problem .............................................................................2
Purpose of the Project and Research Questions ...................................................................3
Importance of the Study .......................................................................................................4
Overview of Theoretical Framework and Methodology .....................................................5
Methodology ........................................................................................................................5
Definitions............................................................................................................................6
Organization of the Dissertation ..........................................................................................7
Chapter Two: Literature Review .....................................................................................................9
Creating Systems of Racism ................................................................................................9
Overview of the United States Health System ...................................................................20
History of Disparate Health Outcomes ..............................................................................30
Conceptual Framework ......................................................................................................44
Chapter Three: Methodology .........................................................................................................52
Research Questions ............................................................................................................52
Overview of Design ...........................................................................................................52
Validity and Reliability ......................................................................................................60
Ethics 61
Chapter Four: Results or Findings .................................................................................................63

viii
Participants .........................................................................................................................63
Data Validation ..................................................................................................................71
Results or Findings for Research Question 1 .....................................................................73
Results or Findings Research Question 2 ..........................................................................89
Summary ..........................................................................................................................104
Chapter Five: Recommendations .................................................................................................105
Limitations and Delimitations ..........................................................................................115
Recommendations for Future Research ...........................................................................117
Conclusion .......................................................................................................................117
References ....................................................................................................................................119
Appendix A: Survey Questions ...................................................................................................149
Introduction ......................................................................................................................149
Research Questions ..........................................................................................................149
Consent ............................................................................................................................149
Consent Checklist ............................................................................................................150
Demographics Section .....................................................................................................151
Perception ........................................................................................................................153
Expectation ......................................................................................................................154
Experience........................................................................................................................154
Appendix B: Survey Questions With Response Count................................................................155
Research Questions ..........................................................................................................155
Perception ........................................................................................................................155
Expectation ......................................................................................................................156
Experience........................................................................................................................159

ix
List of Tables
Table 1: Bandura’s Eight Forms of Moral Disengagement Across the Four Loci of Moral
Agency 46
Table 2: Demographics Data: Race and Ethnicity 64
Table 3: Demographics Data: Gender 64
Table 4: Demographic Data: Age 65
Table 5: Demographic Data: State of Residency 66
Table 6: Demographic Data: Stakeholder Role 67
Table 7: Demographic Data: Organization Size 67
Table 8: Demographic Data: Organization Type 68
Table 9: Demographic Data: Salary 68
Table 10: Demographic Data: Education 69
Table 11: Comparison of Participants to U.S. Healthcare Workers Demographics: Gender 70
Table 12: Likert and Open-Ended Response Count 73
Table 13: Perception 1 Likert Results 76
Table 14: Perception 1 Likert Participants by Stakeholder 77
Table 15: Experience 1 Likert results 79
Table 16: Experience 1 Likert Participants by Stakeholder 80
Table 17: Expectation 2 Likert Results 82
Table 18: Expectation 2 Likert Participants by Stakeholder 83
Table 19: Expectation 3 Likert Results 87
Table 20: Expectation 3 Likert Participants by Stakeholder 88
Table 21: Perception 2 Results 93
Table 22: Perception 2 Likert Participants by Stakeholder 94
Table 23: Experience 2 Likert Results 97

x
Table 24: Experience 2 Likert Participants by Stakeholder 98
Table 25: Experience 3a Likert Results 99
Table 26: Experience 3a Likert Participant by Stakeholder 101
Table A1 Consent Checklist 150

xi
List of Figures
Figure 1: State Map Comparison: Slave Verus Free States, Jim Crow America, States
Refusing Medicaid Expansion 27
Figure 2: Social Determinants of Health 32
Figure 3: African Americans and People of Color Fare Worse for Overall Health Status 34
Figure 4: Moral Disengagement and Interest Convergence Conceptual Framework Depiction 50
Figure 5: Perception 2 Results 92
Figure 6: Health Equity Curriculum Across the Physician Education Timeline 111

1

Chapter One: Introduction to the Study
Chronic disease represents a significant source of morbidity and mortality for the U.S.
healthcare system. Nearly half of the U.S. population lives with some form of preventable
chronic disease (Centers for Disease Control and Prevention [CDC], 2022a), and over 40% of the
American population lives with at least two preventable chronic diseases, such as cancer, heart
disease, or diabetes (CDC, 2022a). In a study comparing the healthcare and general health of
high-income nations and their citizens, the United States ranks the lowest (Schneider et al.,
2021). Compared to Whites, African Americans’ health statistics are worse (Baciu et al., 2017;
Schneider et al., 2021; Smedley et al., 2002; Walensky, 2021). African American women are
three times as likely to die from childbirth (Centers for Medicare and Medicaid Services [CMS],
2022b). African American life expectancy is consistently lower than Whites, with an average
difference of 6 fewer years (Johnson et al., 2022).
In 2002, the Institutes of Medicine released the keystone report Unequal Treatment,
which connected disparities seen in minority populations to the impact of racial discrimination in
the United States (Smedley et al., 2002). The prevalence of health inequities has been related to
historical differences in the socioeconomic status of African Americans and recognized by
government agencies such as the National Institutes of Health (Baciu et al., 2017), Institute of
Medicine (Smedley et al., 2002), and the CDC (Walensky, 2021). These persistent health
inequities persist for African Americans regardless of socioeconomic differences (Baciu et al.,
2017; Smedley et al., 2002; Walensky, 2021). Despite the evidence and statistics about disparate
health outcomes, 42% of healthcare organizations do not see health equity as a top priority
(Institute for Healthcare Improvement, 2021). While health disparities and their root causes
surfaced during the COVID-19 pandemic, healthcare organizations made record profits (Paavola,
2

2022). According to Becker’s Healthcare (Paavola, 2022), seven of the United States’ largest
healthcare organizations reported earnings of over $1 billion each. In 2022, healthcare spending
represented over 18% of the U.S. gross domestic product (Paavola, 2022). However, the U.S.
healthcare system ranks last among wealthy nations in access to care, equity, and healthcare
outcomes (Schneider et al., 2021). The purpose of this study was to understand the extent to
which healthcare organizations have allowed racism and greed to influence healthcare outcomes
in the United States and aimed to explore solutions to advance equitable quality care.
Context and Background of the Problem
Many scholars have studied the connection between racism and poor health outcomes for
minorities. A report by the Institutes of Medicine suggests potential solutions, forecasting results
if healthcare organizations fail to act (Smedley et al., 2002). Two decades after Smedley and
colleagues’ publication, a global pandemic juxtaposed with social injustices exposed inequities
long felt by African Americans, causing the nation to revisit the paradigm of systemic racism
(Andrews, 2021). The COVID-19 pandemic highlighted economic disparities typically ignored
by healthcare organizations (CBPP, 2022). In addition, several major healthcare organizations
boasted their most significant recorded profits due to concessions provided by the U.S.
government through the Coronavirus Aid, Relief, and Economic Security Act (2020).
This enlightenment about the condition and quality of healthcare, the increased revenues
of healthcare conglomerates, and increased salaries for healthcare workers ignited continuing
political and academic debates. For example, one major healthcare organization boasted over $ 1
billion in earnings for 2021 and provided a salary of just over $20 million for their CEO, which
is 338 times the annual amount of the average employee (Framingham Source, 2021; Muoio,
2022; Tenet Healthcare, 2022). Nevertheless, during one of the highest earning years, that same
3

organization reduced available beds and turned away patients who were unable to pay due to a
nursing staff strike in response to a demand for higher pay (Framingham Source, 2021; Muoio,
2022; Tenet Healthcare, 2022).
According to Spector (2014), racism does not seek to oppress another race solely due to
the differences between human beings; racism seeks to identify a specific group that one can
control and exploit for one’s benefit. Wilson (1996) described racism and systems of race as the
basis of a capitalistic society fueled by greed. For example, privatized healthcare corporations
which operate like major corporations, have transformed healthcare into a business and the
health and well-being of the general population into a commodity (Matthew, 2015; Starr, 1982;
Stevens, 1989). These social determinants of health (SDOH) demonstrate that African
Americans suffer from disparate conditions at younger ages than Whites (CDC, 2017). The
SDOH, such as nutrition, education, environment, and access to healthcare, are socioeconomic
drivers that impact one’s general well-being (WHO, 2022). African Americans experience
negative social factors such as unemployment and poverty at almost double the rate of Whites
and at earlier ages, which puts African Americans at a greater risk for poor health (CDC, 2017).
Purpose of the Project and Research Questions
This study assessed how healthcare workers, healthcare administrators, and patients
perceive how healthcare organizations have contributed to systemic racism and examined these
organizations’ role in perpetuating racism. The goal of the study was to understand how racism
and greed have influenced healthcare delivery in the United States and explore solutions. During
data collection, I included the perspectives of administrators, patients, and healthcare workers
affiliated with major healthcare delivery systems in the United States. The results aim to assist in
developing methods to insert equitable practices across the care continuum, from the
4

government, the board room, and the bedside. The research questions guiding this study were as
follows:
1. What are the differences in the perceptions of systemic racism in healthcare between
the stakeholders of large healthcare organizations (i.e., patient vs. provider vs.
administrator)?
2. What role does the healthcare organization play in promoting health equity across
minoritized patient populations?
Importance of the Study
Daily exposure to certain conditions influences an individual’s health and well-being
(World Health Organization [WHO], 2022). Social determinants of health are societal factors
that include where one is born and raised, the education available to one, where one works, and
how one will age (WHO, 2022). According to the WHO (2022), SDOH can account for as much
as 35% of health outcomes. Historically, systemic racism in the United States resulted in African
Americans experiencing prolonged exposure to adverse conditions impacting SDOH (Whitman
et al., 2022). These negative influences include disparate health outcomes in African Americans
(Whitman et al., 2022). Prior to the COVID-19 pandemic, a publication from the CDC (2017)
revealed inequities in numerous social factors demonstrating increasingly significant health risks
for African Americans compared to Whites. In this same study, the CDC found that African
Americans are more susceptible to early death than Whites (CDC,2017).
Five years later, after increased inequities highlighted by the COVID-19 pandemic, the
life expectancy of non-Hispanic Black people fell by almost two times that of Whites (Andrasfay
& Goldman, 2022). During the pandemic, leading health and medical organizations and several
municipalities across the nation declared systemic racism as the cause of health inequities and a
5

public health threat in the United States (Andrews, 2021). Today, given the ongoing economic
fallout from the aftermath of the pandemic, the health risks and impact on SDOH continue to
impact African Americans unequally (Centers on Budget and Policy Priorities, 2022).
Overview of Theoretical Framework: Critical Race Theory and Social Cognitive Theory
This study relied on two theoretical frameworks as a guide: social cognitive theory’s
(SCT) moral disengagement and critical race theory’s (CRT) interest convergence. Social
cognitive theory, developed by Bandura (1986), posits that one’s environment influences
behavior. The theory of moral disengagement expounds upon the SCT to specify the actions an
individual, organization, or society may take in opposition to a moral agency when those actions
deem to benefit the more significant part of society (Bandura, 2016). Legal scholars Derrick
Bell, Alan Freeman, and Richard Delgado developed CRT, which declares systemic racism as an
integral part of the U.S. social structure, which bears consideration when interpreting the law in
legal proceedings (Demaske, 2009). Bell, Freeman, and Delgado conceived CRT as a framework
to aid in advancing civil rights in legislation (Demaske, 2009).
Interest convergence further explains CRT in suggesting that the interests of the minority
race only warrant promotion as they endorse those of the race and class of those in power
(Demaske, 2009). This study leveraged these two frameworks to expose the root causes of health
inequities in U.S. healthcare organizations and the conditions necessary to elicit progress toward
health equity.
Methodology
This study employed a qualitative questionnaire to research the practice problem and
investigate a potential solution. I constructed the questionnaire based on an existing survey
instrument used to study major healthcare organizations and the degree to which their practices
6

promote anti-racism and dismantle health inequities (Just Capital, 2022). The questionnaire
surveyed stakeholders of large healthcare organizations to determine equitable organizational
practice through the perceptions, expectations, and experiences of patients, employees, leaders,
and board members. Upon completion, I analyzed the open-ended question responses to identify
mechanisms of moral disengagement and interest convergence concepts.
Definitions
Anti-racism: The policies and ideologies are antithetical to racism in all its forms (Kendi,
2019; NMAAHC, 2022).
Capitalism: The economic system in which private people and entities have the enterprise
to own and control property as it aligns with their private interests to make a profit (Jahan &
Mahmud, 2015).
Critical race theory (CRT): a transdisciplinary method of racial equity emerged from
legal studies that posit racism as a societal norm (Ford & Airhihenbuwa, 2010).
Culturally and linguistically appropriate services (CLAS): Healthcare services seek to
identify, understand, and respond appropriately to the diverse cultural and linguistic needs of the
patient in a specific care encounter (Office of Minority Health, 1999).
Health disparities: The preventable differences in health conditions, chronic diseases, and
general well-being experienced by marginalized groups. (Centers for Disease Control, 2022).
Health equity: When every person may “attain his or her full health potential,” and no
one is “disadvantaged from achieving this potential because of social position or other socially
determined circumstances” (Centers for Disease Control, 2022).
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Institutional racism: synonymous with the terms systemic or structural racism.
Institutional racism speaks to how institutional systems and structures perpetuate racism. This
term can also refer to the racism perpetuated within a specific organization (Kendi, 2019).
R.E.a.L. data: Racial, ethnic, and linguistic attributes of existing data used to stratify
clinical data and health outcomes (Institute for Healthcare Improvement, 2019).
Social cognitive theory (SCT): a theoretical framework created by Bandura. It explains
human accomplishments and well-being in terms of the interplay between individuals’ attributes,
their behavior, and the influences in their environment. According to this view, people contribute
to their life circumstances, not just their products. Several basic capabilities characterize them.
These include cognitive, vicarious, self-regulatory, and self-reflective capabilities that play a
significant role in human self-development, adaptation, and change (Rogelberg, 2017).
Social determinants of health (SDOH): the conditions in the environments where people
are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning,
and quality-of-life outcomes and risks. These determinants impact five domains of healthcare:
economic stability, access to quality education, access to quality healthcare, healthy and safe
neighborhoods, and social and community support (Healthy People 2030, 2022).
Systemic racism: Systemic and structural racism are forms of racism embedded in the
systems, policies, practices, laws, beliefs, and attitudes that perpetuate the unfair and unequal
treatment of people of color. Systemic racism involves the whole individual system and the
structures that uphold the systems (Braveman et al., 2022; Du Bois & Anderson, 1899/1996).
Organization of the Dissertation
I organized this dissertation into five distinct chapters. The five-chapter dissertation
model originated in the early 1990s as an epistemological methodology approach to a thesis that
8

allows for presenting multiple theoretical perspectives (Love, 2001; Perry, 1995). Chapter One
introduces the problem and gives an overview of the study. Chapter Two is an extensive review
of the literature. Chapter Three describes the methodology used for research. Chapter Four
summarizes the results of the research, and Chapter Five is a summary and conclusion of the
entire study.

9

Chapter Two: Literature Review
This review of the literature discusses how systems of race and capitalism in healthcare
organizations contribute to poor health outcomes for African Americans. To demonstrate the
connection between racism, capitalism, healthcare organizations in the United States and poor
health outcomes in African Americans, this literature review analyzes the foundations of
systemic racism in the United States and examines how it connects to disparate health outcomes.
Limited empirical evidence on systemic racism in the 18th, 19th, and early 20th centuries exist;
therefore, this review relies on historical texts combined with more recent research to establish
the validity of the problem of systemic racism. Likewise, healthcare organizations did not exist
before the early-mid 20th century. Therefore, historical texts are necessary to describe the origins
of the U.S. healthcare system and the evolution of the healthcare organization. Since this
research assesses the perpetuation of systemic racism, an account of the history of the United
States is fundamental to understanding the roots of systemic racism and how that system
continues to impact healthcare organizations and disparate health outcomes. Additionally, this
review of the literature briefly explores the concept of capitalism to show the motivation behind
systems of race and racism. Finally, this chapter will cover how systemic racism came to be, an
overview of the U.S. healthcare system, and how it negatively impacts the health of African
Americans, as seen in disparate health outcomes.
Creating Systems of Racism
In recent years, the term systemic racism has gained popularity, yet to understand it, one
must understand history. Feagin (2000) introduced the phrase “systemic racism” as a deeply
rooted and constructed system of race with the seminal goal of establishing and perpetuating
White supremacy. Feagin and McKinney (2005) expounded upon this definition, where he
10

expresses that systemic racism is foundational to the development of the United States, not as an
ideology, but as a reality conducted in the policies and procedures that make up the nation and
many of its major institutions. Many use the term “systemic racism” interchangeably with
institutional racism and structural racism (Braveman et al., 2022). Sociologists often intertwine
these definitions as they involve an intricate arrangement of racially motivated discriminatory
practices present in all aspects of American society, including political, economic, educational,
judicial, organizational, and health (Braveman et al., 2022; Bonilla-Silva, 2015; Du Bois &
Anderson, 1899/1996; Feagin, 2000; Williams & Mohammed, 2008). While the terms may vary,
the meaning of systemic racism is evident in the nation’s history. What was planted as seeds by
the founding leaders of the United States in the establishment of the slave trade (Hannah-Jones,
2019) took root and sprouted through the reconstruction era and bloomed during the Jim Crow
era (Du Bois & Anderson, 1899/1996; Gates, 2019), persisted beyond the civil rights era
(Alexander, 2020), and thrives today in what some now refer to as a post-racial society (Kendi,
2021).
Slavery and the Founding of the United States
The structure and systems of racism began with the institution of slavery. The tentacles of
systemic racism pre-date the founding of the United States (Wilkerson, 2020). The colonists
brought stolen Africans to New World soil to exploit their labor and their docile disposition to
cultivate commodities that allowed these colonists to become independent from the sovereign
nation of Great Britain (Hannah-Jones, 2022; Wilkerson, 2020). The legal institution of slavery
in the United States differed from the slavery of ancient civilizations and indentured servitude in
western European countries (Wilkerson, 2020). Genetic studies reveal the physical and sexual
abuse experienced by those subjected to slavery in the United States to be more heinous than the
11

conditions of slavery experienced by those in Latin American and European slavery systems
(Kenneally, 2020). The convention of the concept of the inhumanity and inferiority of Africans
made slavery possible in the United States (Feagin, 2006). Before 1830, there were more than 2
million African Americans in the United States, around 90% of whom were born on North
American soil (Du Bois, 1935/2017).
The forefathers of the United States birthed an economy centered around and dependent
upon the lives of enslaved Africans, controlled by a belief in racial superiority (Feagin, 2012).
The work of the enslaved African Americans grew the American commerce of sugar, rice,
tobacco, and cotton; this increased the need for more land and labor, which established the newly
formed nation into a global center of commerce and an economic empire (Du Bois, 1935/2017).
Bonds and Inwood (2016) posited that White supremacist belief sanctioned human enslavement
and genocide as a means of wealth accumulation and through the production of systems of
racism that continue to persist in modern times. According to an early study by Du Bois
(1935/2017), the contrariety of the notion of a supreme race in a nation that declares the equality
of all men is a blemish against U.S. democracy.
Establishing White Supremacy
The period immediately following slavery, known as reconstruction, presented what the
newly freed African Americans perceived as a perfect opportunity to achieve parity in American
society (Wilkerson, 2020). However, according to Du Bois’s (1935/2017) study on
reconstruction states, the victory of the Union over the Confederacy marked the beginning of
serfdom for newly freed African Americans. Scholars of Abraham Lincoln suggest his stance on
slavery and thoughts of White supremacy were points of personal contention used by Whites in
the south to advocate for legal segregation by race (Du Bois, 1935/2017; Feagin, 2012;
12

Fredrickson, 2008). According to Du Bois (1935/2017), Whites did not consider formerly
enslaved people to be a permanent fixture in American society after the Civil War; the sentiment
was that they would emigrate back to their native continent or die off from disease. In 1865, a
senate bill created the Freedman’s Bureau, previously known as the Bureau of Refugees,
Freedman, and Abandoned lands, a government-funded organization providing rules, wages, and
protection for the formerly enslaved people who now found themselves with nowhere to go, and
no provisions for livelihood (Du Bois, 1901). By 1869, the United States discontinued the
Freedman’s Bureau, which had cared for over 500,000 patients, due to dwindling funds; the
program expended over 20 million dollars throughout its operation (Du Bois, 1901).
Van Evrie (1870) conducted a study on White supremacy and Negro subordination which
suggested that if the Black man were to rise to the same level of societal power as the White
man, it would be a frightful cruelty that would end in the extinction of the Black race. Studies by
Logan (2020) show that during the Reconstruction Period of 1866–1880, the now-freedmen
occupied approximately 1,300 elected offices ranging in responsibility from school board
member to governor. According to an account by Dunning (1907), the growth of African
Americans’ political prowess and enfranchisement led to a campaign by conservative southern
White voters to reverse Black suffrage. Gates (2019) described this as a deliberate campaign to
dismantle the progression of power attained by the newly freed African Americans and redeem
the power and order of White supremacy in the southern states.
The redemption campaign involved violence and terrorism by groups like the Ku Klux
Klan and White southern elitists (Feagin, 2006; Gates, 2019). Between 1865 and 1876, the Equal
Justice Initiative reported approximately 2,000 documented lynching events, 34 of which were
mass lynching events (Equal Justice Initiative, 2022). According to studies by Du Bois (1901,
13

1935/2017) and Feagin (2006, 2012), and confirmed in contrasting studies by Van Evrie (1870)
and Dunning (1907), the general sentiment of the southern White and some northern Whites
during this time was that the Black person was not humanly equal to the White person. Accounts
by Gates (2019) suggested that the abolitionist who held the sentiment of anti-slavery did not
simultaneously believe in the equality of the Black person and the White person. The
normalization of the sentiments about the former enslaved and the success of this campaign to
disenfranchise them led to the local and federal establishment of laws segregating Blacks from
Whites and restored the center of power to the former slaveholding class (Du Bois, 1935/2017;
Dunning, 1907; Feagin, 2006). The providence used to kidnap and enslave the Africans is the
same providence used to keep African Americans subject to a lower role in American society.
Jim Crow
The segregationist laws established in the United States were known as Jim Crow, which
was a reference to a caricature of an enslaved Black man who danced and sang songs, used in a
pejorative manner to coincide with the White sentiment about all Black people during that time
(Equal Justice Initiative, 2022). Lawmakers founded and maintained these laws primarily in
northern states before the Civil War (Feagin, 2012). Southern states adopted Jim Crow laws after
the reconstruction to enforce segregation between the formerly enslaved and Whites (Equal
Justice Initiative, 2022). The Jim Crow laws segregated all aspects of day-to-day life (Feagin,
2012); locations such as schools and residences were in separate geographical areas (Du Bois &
Anderson, 1899/1996; Feagin, 2006, 2012; Klarman, 2006). Establishments not separated
geographically, like public transportation and movie theaters, had separate entrances and seating
areas for Black and Whites (Du Bois & Anderson, 1899/1996; Feagin, 2006, 2012; Klarman,
2006). According to Klarman (2006) and Mohamed (2021), the U.S. Supreme Court decision in
14

Plessy vs. Ferguson (1896) inculcated the legality of an apartheid system of separate but equal
accommodations (Mohamed, 2021). Justice commentary included the relevance of White
identity and social rights equal to property that the court could not deprive access to the White
man nor grant the Black man (Mohamed, 2021). For several decades to follow, that court ruling
sealed any hope for true freedom and parity for African Americans.
Convict Leasing and Sharecropping
The Jim Crow laws deprived African Americans of societal freedoms and the opportunity
to achieve financial advancement. Convict leasing was one of the institutions used against the
newly freed person (Muller, 2018). Convict leasing was a program in which prisons legally
leased convicted felons to corporations by the prisons to provide labor for free; in exchange, the
corporations only needed to provide housing, food, and clothes and keep them guarded from the
rest of society (Muller, 2018). According to the literature, this practice started immediately
following the Civil War (Muller, 2018). The state penal system paid some of these corporations
to take on the convicts as laborers (Lynch & Cass, 2021). According to Muller (2018), 15 years
after the Civil War had ended, courts continued to convict Black people at rates 12 times higher
than Whites. Jim Crow laws allowed for the arrests and convictions of Blacks for whatever
Whites deemed a criminal infraction. Those in power leased those incarcerated to former
slaveholders to work at plantations just as they had before the end of slavery (Stabler, 2020).
According to Lynch and Cass (2021), the popularity of this practice caused an issue with
unskilled laborers competing for the same type of work but for wages. An alternative institution
used to perpetuate the conditions of slavery and White supremacy in the United States is known
as sharecropping (Baker, 2022). Sharecropping is a program like serfdom or indentured
servitude, where a person lives on land owned by a landlord and pays through the labor and
15

revenue from each harvest (Stabler, 2020). Accounts by W. E. B. Du Bois (1935/2017) and
Marler (2004) describe sharecropping as a form of peonage where formerly enslaved people
often performed the same tasks and worked for their former enslavers, incurring debt from the
use of tools and goods needed to sustain a family. The harvests were either just enough to break
even or not enough to bring them out of debt (Stabler, 2020). According to Conrad et al. (2005),
in 1933, sharecroppers in the southern states averaged $105 as their annual cash income. This
practice of sharecropping continued in some southern states until the late 1960s and early 1970s
(Stabler, 2020). Bad harvests, failed markets, and the mechanization of agriculture led to the
decline of sharecropping. Many of these African Americans left the south to seek better
opportunities for wages in northern and western states, hoping for a better tomorrow (Conrad et
al., 2005; Stabler, 2020). However, outside of the south, there would be different obstacles to
overcome.
Tactics of Economic Deprivation
African Americans sought better opportunities in other states to escape the terror and
control of the Jim Crow Laws in the south. From the end of World War I until the 1970s,
approximately 6 million southern-born Black people would leave the south and spread across to
other states north and west (Wilkerson, 2010). As referenced by Tolnay (2003), in his review of
an earlier study, the motivation behind this movement varied, as did the type of African
American that chose to migrate. The literature provides multiple examples of occupational
segregation and economic deprivation as positional motivating factors (Eichenlaub et al., 2010;
Tolnay, 2003; Wilkerson, 2010). This migration shifted Black populations to cities like Detroit,
Chicago, New York, Philadelphia, and Los Angeles (Tolnay, 2003; Wilkerson, 2010). In these
cities, African Americans met economic deprivation and occupational segregation of a different
16

type. A racial caste system restricted job opportunity, relegating African Americans to lower job
roles and unstable employment (Eichenlaub et al., 2010; Tolnay, 2003).
Organized labor unions excluded or segregated African Americans from opportunities
with seniority, and complaints of discrimination from Black workers went unresolved or left
pending (Hill, 1959). Additionally, residential areas between the Black and White populations of
cities remained segregated. Whites used covenant restrictions, terrorism, and redlining to control
the residential freedom of Black people (Tolnay, 2003). As Boilard (2020) defined, redlining
refers to the discrimination against African Americans by mortgage insurance and lending
companies that exclude the ability to purchase or lease property in certain areas of a city,
restricting them from living there altogether. According to a study on American apartheid by
Massey (1990), racial segregation in residential areas created a concentration of poverty. The
societal elements accompanying poverty, such as crime, family instability, and drug use, affect
residents’ mental, social, and physical well-being in those communities.
In addition, economic and residential segregation resulted in educational segregation,
where the public schools in majority African American areas were poorly funded and lacked
resources equal to schools in majority White neighborhoods (Clotfelter, 2004; Rouse, 2006). The
inequality of the school systems between Black and Whites led to the historic Supreme Court
decision in the Oliver Brown et al. v. Board of Education of Topeka, Kansas (1954) case, where
the ruling decreed the ‘separate but equal’ doctrine inapplicable to public education (Brown v.
Board of Education, 1954; Kizer, 2017). Nevertheless, legally sanctioned segregation persisted
in the United States for over 80 years (Feagin, 2006). Although declared illegal, segregation and
the campaign toward systemic racism continued to persist.

17

Capitalism and White Supremacy
The study would be remiss to discuss racism without addressing the connection to
capitalism, as the founding and perpetuation of racism drive capitalism (Feagin & Ducey, 2019).
The tenets of capitalism encapsulate the ideal of private interest and control of enterprise for
profit (Jahan & Mahmud, 2015). In simpler terms, capitalism is an unregulated opportunity to
seek unlimited wealth for one’s benefit; it is greed (Oxford English Dictionary, 2022). Racism
intersects with capitalism as a desire for profit and greed obtained through the exploitation of one
racial or ethnic group for the advancement of another racial or ethnic group (Feagin & Ducey,
2019; Wilson, 1996).
According to Wilson (1996), racism and capitalism in the United States are fueled by the
subjugation of the once enslaved African and now free African Americans for the promotion and
preferment of the supremacy of the White race. Wilson (1996) expounded on his explanation to
describe the corporation's role in the nation as one that seeks to increase wealth, not as an effort
to support the communities they serve nor for human necessity; gaining wealth is the sole
purpose of capitalism. Spector (2014) argued that racism is a socio-political construct designed
to exploit African Americans for the benefit of the White. Evidence of exploitation manifests in
the systemic oppression of African Americans in politics, economics, violence, discrimination,
and genocide (Spector, 2014). Advocating for a White supremacist society in the United States,
Dunning (1907) posited the importance of the subjugation of the formerly enslaved as paramount
to the economic and political success of the nation.
Conversely, after the success of the Civil Rights Act of 1964, Dr. Martin Luther King, Jr.
(1967) emphasized economic equality in his address at the Southern Christian Leadership
Conference. King’s final focus and word leading to his assassination was the challenge of abject
18

poverty and economic injustices across the United States (Dellinger, 2018; King, 1967).
According to accounts by Dellinger (2018) and Klaber (2022), Whites saw King’s rise to
leadership and ability to unite the African American race as a political threat to the economic
structure of the United States, which led to his killing at the hands of the U.S. Federal Bureau of
Investigation. Scholars posit that after King’s death, there has been an increasingly aggressive
tug of war between the African American struggle to overcome exploitation and oppression and
the reinforcement of systemic racism and White supremacist ideals (Douglas & Loggins, 2021).
Toward a Post-racial America
After the Brown v. Board of Education (1954) decision, African Americans assumed a
fight toward freedom while some White Americans continued to fight to maintain the status quo
of the social hierarchy (Kizer, 2017). In 1955, the murder of a young boy named Emmett Till,
killed in Mississippi by Whites while visiting family for allegedly whistling at a White woman,
impelled a wave of activism against Jim Crow laws, starting what is now known as the Civil
Rights Movement (Clayton, 2018; History House, 2022; Onwuachi-Willig, 2018; Tyson, 2016).
While the intent of the Brown v. Board of Education (1954) decision was to integrate (Brown v.
Board of Education, 1954), the legislature effectuated a movement by Whites to preserve a
segregated society (McGhee, 2021; McMillen, 2007; Van Delinder, 2008). The opposition to
desegregation was extreme in southern states where most African Americans resided (Kizer,
2017). Over 100 members of the U.S. Congress and 19 members of the U.S. Senate representing
former Confederate states penned the Declaration of Constitutional Principles and is commonly
known as the Southern Manifesto, which was an attempt to galvanize other states to reject the
Supreme Court’s decision of Brown v. Board of Education (1954; Brown Henderson & Brown,
2016; U.S. Senate, 1956). The Civil Rights Movement marked Black activism through boycotts,
19

marches, sit-ins, and campaigns against racism and segregation (Klaber, 2022; Onwuachi-Willig,
2018; Seals, 2003). Police and local militia groups met these with resistance with bombings,
arrests, terrorist threats, and killings (Brückmann, 2019; Klaber, 2022; Levingston, 2020).
President Lyndon B. Johnson signed the Civil Rights Act of 1964 to make inequality and
unequal treatment based on race illegal throughout the United States (Johnson, 1964).
Nonetheless, systemic racism and efforts to maintain White supremacy continue to persist
to the present day, as evidenced in the unequal and mass incarceration of African Americans
(Alexander, 2020; Tucker, 2017), police brutality (Loyd, 2012; Peeples, 2020), the racial wealth
gap (Bell, 2005; Yeung & Conley, 2008), and education (Bell, 2005; Noguera, 2016). In 2020,
the unjust killing of an African American man named George Floyd by a Minneapolis police
officer highlighted the continuance of racial injustices. Consequently, in the summer of 2020,
social uprisings occurred across the United States, resulting in a presidential executive order on
the advancement of racial equity (The White House, Office of the Press Secretary, 2021). Today
the concept of racial parity is more mainstream in the United States than before; the U.S.
Congress and Senate have acknowledged and apologized for a history of systemic injustices
(Feagin & Ducey, 2019). However, to date, the U.S. Congress has taken no formal action to
repair the damage created by slavery and racial oppression (Feagin & Ducey, 2019).
Systemic Racism: Conclusion
In conclusion, systemic racism and White supremacy founded on the atrocities of the
African slave trade persist as a norm in contemporary society on a different scale. This historical
account of how systemic racism came to be, intends to serve as foundational information for this
study. There are differing opinions on the presence of racism in the United States, as even an
African American senator has denied its existence (Scott, 2021). However, a Center for
20

American Progress study shows worsening racial disparities, increased economic hardship,
heightened food insecurities, housing instability, and unequal healthcare access (Maxwell, 2020).
To quantify the cost of racism in the United States, leading economist Dan Peterson estimated a
price tag of approximately 16 trillion dollars over the past 20 years (Payne, 2021). Still, no U.S.
president has offered a formal apology or passed legislation for reparations for the history of
racism and its long-lasting impact on the African American community (Feagin & Ducey, 2019;
McGhee, 2021). The unwillingness of the nation’s highest leaders to accept accountability and
make reparations for the systems of racism underscores its impermeability in every aspect of
American life.
Overview of the United States Health System
Internationally, hospitals have evolved from meager beginnings to technologically
sophisticated establishments. The earliest hospitals in the United States were modest yet
disorganized almshouses (Bradley et al., 2013). Healthcare delivery originated as a charity by
volunteer providers through non-profit organizations for the indigent (Bradley et al., 2013).
Unlike other civilized nations, the present-day U.S. hospital and healthcare system is separate
from the social welfare system (Bradley et al., 2013). During the Civil War, the demands for
medical care brought advancements in biomedical science and progressed the overall profession
of medicine (Bradley et al., 2013). Shi and Singh (2017) posited that the advancement of medical
technology during the Civil War ushered in an era of growth for medical education and
alternative medical delivery settings. Today, the hospitals and healthcare systems in the United
States are corporate enterprises, some of which operate on a global scale (Shi & Singh, 2017).
The corporatization of healthcare in the United States minimized access to care for all citizens.

21

Separate and Unequal Hospitals
The late 1890s marks the expansion of medical care provided through hospitals
nationwide. According to Gamble (1995), the early model of healthcare had an advantage for the
formerly enslaved, as their primarily indigent status created opportunities for charitable medical
services. The nation addressed the question of care for the newly freed population through the
Freedman’s Bureau, which by 1867, owned and operated as many as 45 hospitals specifically for
this sector of the population (Gamble, 1995). In comparison, by 1875, general hospitals
nationwide numbered nearly one dozen (Shi & Singh, 2017). Studies of Freedman’s Bureau
hospitals declare that in 1868, only 11 of the hospitals remained, and by 1872, only the
institution in Washington, DC remained. However, by 1900, general hospitals grew
exponentially to around 4,000 and, by 1913, added another 1,000 facilities (Anderson, 1990;
Falk, 1999; Shi & Singh, 2017; Wright, 1997).
With the failure of the Freedman’s Bureau hospitals, responsibility for the care of
formerly enslaved people shifted from the federal to the local level (Downs, 2012). African
Americans received healthcare in the same manner as most other services were during that time,
in partially or entirely separate facilities, usually at unequal levels of care (Gamble, 1995).
According to Gamble (1995), this prompted African Americans to establish their own medical
facilities serving as care centers for African American patients and training centers for African
American nurses and doctors (Gamble, 1995). The American Medical Association (AMA),
founded in 1847 to advance the professional and financial status of the physician member, did
not accept Black physician members (Baker, 2014; Gamble, 1995; Shi & Singh, 2017). In 1895,
in response to an urgent need for parity and justice in healthcare delivery, Black physician
leaders founded The National Medical Association (NMA, 2022). The progression of the
22

medical industry in the United States excluded the progression of African Americans, as the
NMA also noted inequities in the quality and quantity of medical training sites for African
Americans (National Medical Association, 2022).
Separate and Unequal Medical Education
As the medical industry progressed, so did the need for quality standards in education and
practice. The pre-Civil War version of medical education resembled that of trade school, with an
academic length of 4 to 6 months and minimal guidelines on curriculum and graduation
qualifications (Bradley et al., 2013; Shi & Singh, 2017; Starr, 1982). In the late 19th century,
medical schools began to affiliate with universities (Shi & Singh, 2017). Harvard University and
Johns Hopkins University are two institutions raising the standards of medical education by
increasing the time for matriculation and establishing a college degree as the entrance
requirement (Shi & Singh, 2017). In a landmark account of American medicine, Starr (1982)
cited the establishment of the AMA as the organization that corralled the industry toward
organized medicine. In the early 20th century, the Carnegie Foundation for the Advancement of
Teaching solicited Abraham Flexner to conduct a study on medical education in the United
States and Canada (Flexner, 1910); today, researchers and medical professionals refer to the
report as the Flexner report. The text, backed by the AMA, investigated the quality of and
created a rating system for medical schools in North America (Bradley et al., 2013). This led to
limitations in African American lead medical school programs.
According to scholars (Bradley et al., 2013; Shi & Sigh, 2019), the widespread
acceptance of the Flexner report spurred further advances in the quality of medical education and
medical care. The new standards elevated the medical profession and medical institutions to
greater heights in quality of care (Bradley et al., 2013; Shi & Singh, 2017) while forcing
23

providers and facilities that did not meet them out of the medical industry (Gamble, 1997; Shi &
Singh, 2017). These standards brought forth by the Flexner report elevated the prestige of the
medical profession and subsequently limited the education options for African American medical
students (Bailey et al., 2017; Laws, 2021). Laws (2021) reported that prior to the release of the
Flexner report, there were seven medical schools for aspiring African American physicians; after
its release, the report deemed only two of these schools suitable for African American medical
training.
According to Raup and Williams (1964), there were few White medical schools open to
African Americans. Those that accepted African American students allowed for a maximum of
one to two students per year. By 1948, African American students represented 3% of students
enrolled in a medical school program in the United States (Gamble, 2019). Flexner’s report
further marginalized African American physicians’ opportunities by curtailing funding to
historically Black medical schools (Bailey et al., 2017; Laws, 2021). According to Laws (2021),
the purpose of the Black physician was not to ascend to the height of the profession but to
concentrate on the public health needs of the African American population as it related to the
needs of the White population. Flexner opined that if the Freedman’s Bureau program began
funding the two African American medical schools, it would always be necessary (Flexner,
1910), resulting in a shortage of African American physicians for the African American
population. Starr (1982) noted that, in 1930, one Black doctor was available for every 14,634
Black persons in Mississippi. The Flexner report is an example of how philanthropic lobbying,
regulatory agencies, and policy impacted the U.S. healthcare system, and it would not be the last.

24

The Corporatization and Politicizing of the Healthcare Organization
For the more significant part of the past century, policy and politics drove access to
healthcare. Across 15 presidencies and 9 decades, the United States has unsuccessfully attempted
to establish universal healthcare in various forms (Morone, 2010). Access to healthcare at the
dawn of the 20th century was based on public health and driven by urbanization. As more of
America’s population moved to cities, doctors and hospitals provided medical treatment for
disease prevention (Starr, 1982). At the turn of the 20th century, the Wharton family
commissioned the groundbreaking study on The Philadelphia Negro, by W. E. B. Du Bois. This
was one of the first sociological studies on the African American experience in an urban
American city, out of a concern for the impact of the presence of Negros on White
Philadelphians (Anderson & Du Bois, 1996). However, early on, the connection between
economics and medical care became apparent as doctors realized that free care provided for
public health was a lost revenue opportunity (Starr, 1982). As a result, some states took measures
to criminalize unnecessary or excessive use of public health services (Starr, 1982).
Following World War I, access to medical care and preventative medicine emerged as a
benefit for soldiers who served through the Veterans Administration and large companies as a
benefit for their employees. The earliest concept of health insurance emerged from an effort to
raise funds for Baylor University after the Depression (Bradley et al., 2013). The Blue Cross
insurance plan, which covered hospital care for Baylor University faculty occupational-related
injuries, rapidly grew to cover over one million Americans across the United States (Bradley et
al., 2013). A decade later, the Blue Shield plan emerged to provide coverage for preventative
physician services for mining and lumber workers in Northern California (Bradley et al., 2013).
25

In 1935, the Social Security Act, coordinated by the administration of Franklin D.
Roosevelt, sought to include provisions for universal healthcare, but the then-powerful AMA
was in fierce opposition, comparing the offering akin to communism (Bradley et al., 2013; Social
Security Act, 1935). President Lyndon B. Johnson made a subsequent attempt toward universal
healthcare with the Medicare and Medicaid Act, which provided healthcare coverage for the
elderly (Medicare and Medicaid Act, 1965; Morone, 2010). Nixon’s attempt resulted in the
passing of the Health Maintenance Organization Act (HMO ACT, 1973), which inserted the
healthcare organization as the physician’s employer, insurance owner, and final decision maker
on qualifying healthcare.
The HMO plan evolved from an insurance plan offered by a construction company
owned by the Kaiser Family after WWII; this same family owns what is now known as the
Kaiser Permanente healthcare system (Cutting & Collen, 1992). By 2005, over 97% of the
healthcare industry was under a managed care plan (Bradley et al., 2013). The Affordable Care
Act (ACA) of 2010 created provisions for healthcare coverage to extend to more Americans by
providing tax credits and subsidized premiums for individuals with lower income levels (ACA,
2010). The ACA led to the passing of the Medicare Access and Children’s Health Insurance
Program Reauthorization Act of 2015, which linked payments under the Medicare program to
the quality and value of care instead of the quantity of care (Medicare Access and CHIP
Reauthorization Act of 2015). Many states rejected this and found loopholes to not comply with
the ACA’s Medicare Expansion component, which provides each state with federal funding to
offer healthcare coverage through Medicaid programs; presently, 12 states refuse to adopt the
expansion provision (Kaiser Family Foundation [KFF], 2022). Eight of those states are southern
26

states, and a map representative of those refusing to adopt mirrors a map of slaveholding and the
Jim Crow states, as shown in Figure 1.
The depiction of these maps is notable as the ACA came to fruition during the
administration of Barack Obama, the first U.S. President of African descent. As his presidential
administration’s first act, President Joseph Biden created an executive order encouraging
government organizations to promote equitable practices (The White House Office of the Press
Secretary, 2021). Today, the provisions of the Medicare Access and CHIP Reauthorization Act
of 2015 plan have expanded to include various quality programs that hold healthcare
organizations accountable for healthcare outcomes. A recent press release from the CMS
announced the intention to include a policy to advance health equity in the upcoming program
years (CMS, 2022). If the CMS enacts the proposed policy as a final rule, payment penalties will
be assigned to hospitals that do not comply with the specific measures to advance health equity
(CMS, 2022).
Figure 1 depicts the persistence of racist ideals and their impact on current healthcare
affairs. The map on the top left provides a picture of the slaveholding states at the start of the
Civil War, the map on the top right shows the states enforcing Jim Crow laws after the
reconstruction period, and the map at the bottom highlights the states in opposition of the
financial allowances granted by the ACA (Columbia Public Schools, 2022; Kaiser Family
Foundation, 2022; Midwest Center for Holocaust Foundation, 2022). There is a visual
correlation between the sentiment of race relations from over 150 years ago to the social welfare
extended to minorities seen in the present-day (Columbia Public Schools, 2022; Kaiser Family
Foundation, 2022; Midwest Center for Holocaust Foundation, 2022).

27

Figure 1
State Map Comparison: Slave Verus Free States, Jim Crow America, States Refusing Medicaid
Expansion

Note. This figure demonstrates the geographical comparison of states that legalized slavery and
Jim Crow laws to modern-day states that refuse Medicaid expansion dollars.

Major Healthcare Corporations
Much of the literature surrounding the impact of racism and its impact on health
disparities concentrates on the agency of the patient, the provider, or government policy (Ansell
et al., 2021; Coe et al., 2020; Copper, 2012; Santry & Wren, 2012; Serchen et al., 2020; Smedley
et al., 2002; van Ryn, 2019; Williams & Mohammed, 2008; Williams & Wyatt, 2015).
Researchers note gaps in identifying the contributions of the healthcare organization. As
addressed earlier in this review, the healthcare organization in the United States has grown from
28

small singular hospitals to global corporations, some with thousands of patient care facilities
boosting the care of millions of patients (Matthew, 2015). This section reviews some of these
organizations to highlight activities perpetuating systemic racism and health disparities.
HCA-Healthcare, formerly known as Hospital Corporation of America, is the largest
healthcare system in the United States. The HCA has facilities across 40 states and three
countries with over 35 million annual patient encounters (Frist, 2021). HCA began in the deep
south shortly after the passing of the Civil Rights Act as a franchise model for hospitals
fashioned after a fast-food chain business model and a low-budget hotel corporation (Kelman,
2018). HCA is based in Nashville, Tennessee, which many consider the healthcare capital of the
United States. Healthcare corporations based in Nashville own or operate over 15% of America’s
hospitals (Frist, 2021). Nevertheless, Young (2020) noted an account of health disparities, with
over 40% of the state’s counties without obstetric providers. The author identified the state as
one that has rejected the federal funding available to expand Medicare coverage under the ACA,
resulting in over 60% of low-income African Americans in Tennessee without insurance and
unable to receive regular care from a primary care physician (Young, 2020). Tennessee reports
that participation in the Medicaid expansion would bring in over 1.4 billion dollars into the state
for medical care that would eventually go to the large healthcare organizations headquartered in
the state, creating additional jobs and revenue and decreasing health disparities (Frist &
Churchwell, 2020; Young, 2020).
Major consulting firm McKinsey released a report before the pandemic that exposed the
need for healthcare organizations to target SDOH to improve health outcomes (Coe & Cordina,
2020). A later study by McKinsey suggested that healthcare organizations can start promoting
health equity by transforming workplace culture (Cordina et al., 2021). The C-suite of healthcare
29

organizations is primarily White and male (Livingston, 2018). In 2015, only 11% of healthcare
organization executives were minorities (Livingston, 2018). The number of African American
executives is likely much less, as the term “minorities” in this study represents women and all
people of color (Livingston, 2018). Minorities account for over 30% of patients, and by 2044, the
minority population will likely be over 50% in the United States (U.S. Census Bureau, 2014;
Livingston, 2018). The rise in the minority population should emphasize the need for healthcare
organizations to find reasonable solutions to promote health equity, especially those responsible
for large swaths of the current population.
Health System: Conclusion
Healthcare in the United States, once seen as a charitable effort, is now a major
contributor to the value of the U.S. economic power (Schneider et al., 2021). A contemporary
report by executives at the Commonwealth Fund (2021), an independent healthcare research
firm, compared healthcare quality in the United States to other wealthy countries across the
globe, and findings ranked the United States last in access to care, health equity, and health
outcomes. Between 1950 and 2010, the U.S. healthcare industry grew from $1 billion to $847
billion, representing over 16% of the Gross Domestic Product (Bradley et al., 2013; Schneider et
al., 2021). Each year, the top 10 healthcare systems accrue over $226 billion of net patient
revenue and collectively manage over 20% of American hospitals (Schneider et al., 2021). In a
study conducted through the Institute for Healthcare Improvement, Wyatt et al. (2016) posited
that the business case for improving health equity is a barrier to organizational implementation.
However, now that the business case is clear, political will might be the new barrier to
meaningful change.

30

History of Disparate Health Outcomes
Disparate health outcomes emerged as a direct correlation to systems of race and racism
and the exploitation of wealth in the United States and the country’s healthcare delivery system
(Yearby, 2020). This section of the literature review explores existing discourse about SDOH or
those societal factors that control poor health outcomes. Subsequently, there is a discussion of
current statistics of disparities seen in the U.S. population and a description of implicit bias and
how it impacts healthcare delivery.
Social Determinants of Health
The society one lives in drives their health and well-being, and SDOH are the
characteristics of one’s society. Attributes such as residence, neighborhood, wealth, employment,
education, nutrition and access to food, and socioeconomic status are all components but not an
exhaustive list of SDOH. The CDC defined SDOH as “the conditions in the places where people
live, learn, work, and play that affect a wide range of health and quality-of life-risks and
outcomes” (2020). These social and environmental factors account for as much as 60% of the
disparate adverse health outcomes experienced by marginalized groups in the United States
(Hill-Briggs et al., 2021). Systemic racism thus breeds implicit biases, which cause SDOH and
lead to disparate health outcomes, also known as health disparities. Braveman and Gottlieb
(2014) highlighted the need to look at the root causes of SDOH stemming from socioeconomic
influences. Earlier studies by Ahnquist et al. (2012) posited that low social status and poor
economic capital correlate to adverse health outcomes. When both statuses are present, the
probability of poor health exponentially increases. A meta-analysis by Paradies et al. (2015)
called out racism as a determinant of health. As suggested by Paradies et al. (2015), racism
impacts the underlying factors that drive SDOH:
31

1. Reduced access to employment, housing, and education, as well as increased
exposure to risk factors (e.g., avoidable contact with police)
2. Adverse cognitive/emotional processes and associated psychopathology
3. Allostatic load and concomitant pathophysiological processes
4. Diminished participation in healthy behaviors (e.g., sleep and exercise) along with
increased engagement in unhealthy behaviors (e.g., alcohol consumption) either
directly as a stress coping or indirectly, via reduced self-regulation
5. Physical injury because of racially motivated violence
Similarly, the KFF (2020) developed a figure demonstrating the various SDOH and how
systemic racism and discriminatory practices contribute to adverse outcomes. In Figure 2, there
is a horizontal listing of different societal categories across the top row of the diagram, separated
by a row showing racism and discrimination as a reagent resulting in the attributes of health
determinants listed underneath that led to disparate health outcomes. This diagram is essential as
it visually represents the impact of systemic racism on health in discussing socioeconomic status
as an SDOH. Williams and Wyatt (2015) suggested that disparate health outcomes persist even
when education and income are equal. However, current policy efforts to address health status
have not targeted the underlying root causes of health disparities in the African American
population (Entress & Anderson, 2020; Kaye, 2019; U.S. Department of Health and Human
Services, 2015). Systemic racism in the United States has caused a public health crisis evidenced
by health disparities experienced in the African American population (Wright et al., 2020).
Furthermore, this has contributed to the overall well-being of African Americans.

32

Figure 2
Social Determinants of Health

Note. This figure depicts socioeconomic areas that impact a population’s health outcomes. The
grey line shows how racism and discrimination act as a filter for access and experience which
lead to health outcome disparities.

Health Disparity Statistics
Studied extensively over the years, healthcare disparities, their relation to racism, and
recent events in the world have found what scholars have long suspected. In 2020, the disparate
cases and deaths from the COVID-19 pandemic in the African American population highlighted
the link between systemic racism and health (Gay et al., 2020). Studies conducted early in the
pandemic reveal COVID-19 infection rates of as much as 925 per 100,000 for African
Americans and 389 per 100,000 for Whites, demonstrating a disparity of over 81% (Gay et al.,
2020). Coronavirus death rates follow a similar pattern as the infection rates, with African
Americans dying at a rate of 1,883 per 100,000 and Whites at 93 per 100,000 (Gay et al., 2020).
33

Scholars have aligned historical racial discrimination with the increased susceptibility to
chronic health conditions and novel viruses seen in African Americans (Wright et al., 2020).
Wright et al. (2020) provided empirical evidence that points to exposure from chronic stress and
trauma due to racism as an intergenerational root cause of poor health outcomes, citing studies
that prove decreased autoimmune response in pediatric and adult African American patients
exposed to chronic stressors of systemic racism. Pre-pandemic studies conducted by the KFF and
depicted in Figure 3. demonstrate the propensity for people of color and African Americans
specifically to fare worse in health status across multiple outcome measures related to maternity,
chronic conditions, life expectancy, and general health and well-being (2020). Research from
Williams and Mohammed (2008) states that 100,000 African Americans die annually from
preventable causes due to disparate health outcomes stemming from perceived racial
discrimination. Their research was a meta-analysis of 115 publications on racial disparities and
concluded that African Americans have higher death rates than Whites (Williams & Mohammed,
2008).
Moreover, in this same study, African Americans present higher outcomes of the leading
causes of death in the United States. This study found that Black people receive poor treatment
for cardiac disease and cancers by as much as 35% more than White patients, even when there is
parity for insurance coverage, economics, and disease severity. Dovidio et al. (2016) noted that
healthcare disparities exist between Black people and Whites regardless of socioeconomic status
and educational background. Iton and Ross (2016) revealed that the residue of redlining
practices, which legally enforced housing segregation, directly correlates to life expectancy
disparities. Bailey et al. (2017) maintained that residential segregation is like that of 1940 and
cited exposure to environmental toxins, risk of chronic diseases, homicide, and limited
34

employment opportunities as some of the direct and indirect ways that structural racism impacts
health. Despite the heightened awareness of systemic racism in the United States, scholars and
policymakers have not settled on a solution.

Figure 3
African Americans and People of Color Fare Worse for Overall Health Status

Note. People of color refers to all non-White identifying races. The health status measures are
maternal and infant mortality, chronic illness, and general well-being, including behavioral
health. These data are from pre-pandemic data sets.

35

Chronic stress from racism is a root cause of many health outcomes experienced in
disparate proportions by African Americans (Trent et al., 2019). Furthermore, Trent et al. (2019)
stated that systemic racism exposes the African American population to a chronic stress
environment, resulting in inflammatory reactions causing chronic health conditions. In separate
qualitative analyses, Lucas et al. (2016) and Sue et al. (2007) found that, on a daily basis, African
Americans experience racism in some form. The constant exposure to racism leads to heightened
stress responses by Black people (Moreland-Capuia, 2021). Additionally, microaggressions and
social injustices result in adverse psychological harm (Moreland-Capuia, 2021). Pascoe and
Richman (2009) further prove that even the perception of bias and discrimination led to adverse
health outcomes. Their meta-analysis on perceived discrimination links heightened stress
responses to poor physical and mental health, unhealthy behavior, and the avoidance of health
behaviors. Health disparities experienced by African Americans as a stress response to racism
leave the population vulnerable for conditions to worsen from a public health crisis to an
emergency.
Today, the synergistic epidemic of racism and COVID-19 pose an even more significant
threat to the health outcomes of African Americans. According to Wright et al. (2020), the
African American population is more susceptible to illness and death from SARS-COVID-19
due to racial disparities. Unconscious attitudes have placed African Americans at greater risk in
the COVID-19 pandemic as medical professionals determine whom they will evaluate and
downplay related symptoms (Wright et al., 2020). Gravlee (2020) explained that a pandemic
tends to reveal and highlight health inequities. Age-adjusted data links place African Americans
at higher susceptibility to COVID-19 and unnecessary hospitalizations, with a death risk as high
as nine times greater than Whites. Additionally, SDOH disparities exacerbate the impact of the
36

current pandemic (Watson et al., 2020). The lack of medical care access, food insecurities,
inadequate housing, and poverty rates experienced in Black communities heightened because of
COVID-19. Given the conditions of health disparities in this country, there is an urgent need to
find a novel approach to address racial biases among healthcare providers.
Implicit Bias and Providers
As early as 2002, the U.S. government acknowledged health disparities and the need for
improved research (Smedley et al., 2002). In the acknowledgment of the 20th anniversary of the
landmark research conducted by the Institute of Medicine to confront racial and ethnic disparities
in healthcare, a presentation of the facts has yet to move the moral needle required to drive
change (Smedley et al., 2002). The Stanford Encyclopedia of Philosophy supplies a fourfold
definition of implicit bias, which incorporates attitudes, measures, processes, and behaviors,
albeit subconscious, as prejudiced actions (Brownstein, 2019). Recent research found that
healthcare providers mirror the implicit bias in the more significant population (FitzGerald
Hurst, 2017). Empirical evidence links implicit bias experienced daily to psychosocial stressors,
clinical disease, and poor health behaviors (Williams & Wyatt, 2015). FitzGerald and Hurst
(2017) emphasize the need for individual health practitioners to embrace and address the role of
implicit bias in healthcare settings. Their research suggests that providers show added
discrimination toward conditions considered caused by patient lifestyles, such as obesity and
drug use (FitzGerald & Hurst, 2017). This thought among providers also extends to the broader
population, as shown by the inability to find a universal healthcare solution (Dickman et al.,
2017).
Although the United States attempted to extend access to healthcare, the Supreme Court
subverted this ruling in 2012, allowing individual states with a large population of uninsured,
37

low-income, and minority populations to opt out of the expansion (Dickman et al., 2017).
Refusing to accept the funding available to extend access to healthcare for millions of
underprivileged citizens allowed disparities in health outcomes to persist (Dickman et al., 2017).
The rejection of universal healthcare as a solution to remove barriers to healthcare access as an
SDOH is yet another failed attempt to eliminate discriminatory healthcare practices (Gay et al.,
2020). Policymakers and citizens must be aware of implicit biases and support anti-racist
legislation to support the elimination of health inequities (Gay et al., 2020).
Implicit racial biases are systemic in the healthcare industry. According to Serchen et al.
(2020), healthcare institutions such as the American College of Physicians (ACP) have a history
of exclusion. The first African American member joined the American College of Physicians in
1947, and ACP remains underrepresented by Black internal medicine physicians in its leadership
and general membership (Serchen et al., 2020). Evidence shows that clinicians’ pre-existing
biases directly impact the care provided (van Ryn & Burke, 2000). van Ryn and Burke (2000)
found that physician perceptions of Black patients were more negative than White patients
regarding substance abuse, medical advice compliance, and intelligence. Implicit biases
demonstrated by medical providers have contributed to healthcare disparities (Burgess et al.,
2019). Burgess et al. conducted a survey experiment with providers in the most extensive
integrated healthcare system in the United States. Results suggest clinicians across various
specialties and delivery settings hold stereotypes that impact patient interactions and clinical
decisions, evidenced by over 70% of providers’ inability to acknowledge the role of the provider
as a contributor to disparate health outcomes. Although there is a considerable acknowledgment
of the intersectionality between implicit bias and health disparities, a limited number of studies
have addressed workable solutions.
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Multiple studies have explored the best way to measure and reduce implicit bias in
healthcare providers, which leads to negative health outcomes. Paradies et al. (2012) explored
racism among healthcare providers and introduced the term “internalized racism” to the
literature, suggesting that the racism in healthcare providers and experienced by patients is
systemic. A meta-analysis of 37 studies confirms that racism exists yet fails to measure its scope
in individual providers conclusively. Due to its systemic nature, medical students detect implicit
racial bias among providers (van Ryn et al., 2014). An observational study of medical students
by van Ryn et al. (2014) used various assessments and instructional formats to determine the best
type of training to reduce racial bias. However, this research indicates that curricula as a stand-
alone approach are inadequate to improve overall bias. Negative experiences from daily
exposure to racism outside the medical setting also contribute to bias (Shariff-Marco, 2011). Past
perceived racism experienced by the patient also harms the patient-provider relationship.
According to Hausmann et al. (2011) in their findings, negative racial experiences in society
hinder patient-provider communication. These lifelong experiences of systemic racism contribute
to African American patients’ skepticism of medical care and decreasing guideline concordance
(Hausmann et al., 2011). Implicit bias, ingrained in patient and provider behavior, lends to the
complexity of reversing health disparities in the United States.
As previously stated, the literature has explored implicit bias and its impact on healthcare
delivery and disparate healthcare. Research, however, has not discovered practical solutions. As
a result, policymakers have funded programs and task forces to reduce disparities and inequities
in healthcare (Jacobson, 2013). Increasing diversity in healthcare providers, increased
accessibility to medical care, acknowledging SDOH, and educating African American patients
on chronic disease are all needed approaches to a complicated problem (Jacobson, 2013).
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Current Health Equity Solutions
Today, there is greater accountability in the clinical industry toward accepting health
inequities as a problem and action toward positive solutions. Although research and evidence to
support the case for health equity solutions have been around for many decades, potential
solutions from different healthcare accrediting bodies are currently emerging. The social justice
awakening, coupled with the health inequities highlighted by the COVID-19 pandemic, created a
cataclysm of racism and healthcare issues in the mainstream. A simple Boolean search in Google
Scholar on “systemic racism” and “health” shows, since 2020, over 1,000 peer-reviewed articles
and white papers released on systemic racism and healthcare. In late 2021 and early 2022, some
organizations started to act toward realizing change.
In 2021, the CMS accepted comments for proposals on how to reduce inequities in
healthcare through quality data outcome measures in the prospective payment system for
inpatient and long-term care hospital facilities (CMS, 2022). These comments will inform the
2023 proposed and final rules released later this year and will impact the payment model. Other
professional organizations like the National Committee for Quality Assurance (NCQA), The
Joint Commission (JC), Agency for Healthcare Research and Quality (AHRQ), and American
Hospital Association-Institute for Diversity and Health Equity (AHA-IFDHE) have also released
solutions or potential solutions to decreased health disparities. Also, at the beginning of his term
in January 2021, one of the first executive orders signed by President Biden urged government
agencies to actively research and create viable solutions for decreasing inequities in healthcare
(The White House, Office of the Press Secretary, 2021). Since then, several states have passed
legislation requiring healthcare workers to receive training on implicit bias as part of their license
recertification (LegiScan, 2021, 2022; Illinois General Assembly, 2021; Kentucky General
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Assembly, 2022; Maryland Department of Health, 2021; MI Department of Health and Human
Services, 2019). Some states have extended the training requirement to long-term care facility
works and mandated reports for youth (Illinois General Assembly, 2021; Maryland Department
of Health, 2022; MI Department of Health and Human Services, 2019).
Created in the 1990s, the NCQA aimed to increase accountability and transparency in
healthcare. The NCQA is best known for the Healthcare Effectiveness Data and Information Set
program, a performance improvement tool used by health plans and CMS to improve the quality
of care (NCQA, 2022). In addition, the NCQA (2022) is currently providing an accreditation
distinction in health equity for healthcare organizations that shows an organization’s
commitment to excel in health equity, reducing disparate outcomes, and delivering CLAS. In
2021, nine health systems and health plans piloted this program, and it is now available to all
organizations (NCQA, 2022).
For more than 70 years, the JC has been a healthcare quality and patient safety
accreditation and accountability organization working to improve healthcare across the
continuum (JC, 2022). The JC has provided accreditation to over 22,000 healthcare organizations
across the United States (JC, 2022). In November 2021, the JC released a list of actions
healthcare organizations should take to address health disparities by improving the quality and
safety of care (JC, 2021). In addition, as of March 2022, the JC was taking open comments on
new and revised requirements to reduce disparities in healthcare for behavioral health,
ambulatory care, critical access, and hospitals (JC, 2022). These requirements will inform and
change the current accreditation programs for the lines of care previously mentioned. Effective
July 2023, National Patient Safety Goal 16 will apply to all hospital, ambulatory, behavioral
health, and critical access hospitals and is a directive to demonstrate improvements in health
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equity (JC, 2023). The updated standard in seven areas relate to health equity and are as follows
(JC, 2023):
1. Organization designates an individual to lead activities to reduce healthcare
disparities for the patients they serve.
2. Organization assesses patient health-related social needs and provide information
about community resources and support services.
3. Organization identifies healthcare disparities in its patient population by stratifying
quality and safety data using the sociodemographic characteristics of the
organization’s patients (age, gender, language, race, and ethnicity).
4. Organization develops a written action plan that describes how it will address at least
one of the healthcare disparities identified in its patient population.
5. Organization acts when it does not achieve or sustain the goal(s) in its action plan to
reduce healthcare disparities.
6. At least annually, the organization informs key stakeholders, including leaders,
licensed practitioners, and staff, about its progress to reduce identified healthcare
disparities.
7. The medical record contains the patient’s race and ethnicity.
Accrediting bodies such as the JC are essential in creating accountability and ensuring the quality
of care (Jha, 2018). In addition, because payments often link to accreditation (Jha, 2018)., this is
a significant step toward change in advancing health equity initiatives.
The AHA-IFDHE is an organization within the American Hospital Association dedicated
to helping promote equitable outcomes in the U.S. healthcare system (AHA-IFDHE, 2022).
IFDHE provides resources to AHA member organizations and individual certifications in
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diversity, webinars, and conferences (AHA-IFDHE, 2022). In the second quarter of 2022, the
IFDHE launched an organizational change framework called the Health Equity Roadmap (AHA-
IFDHE, 2022). The Health Equity Roadmap is a framework that helps organizations understand
their entry point to implement health equity initiatives (American Hospital Association, 2021).
Along this roadmap are stages: exploring, committing, immersing, affirming, and transforming
(American Hospital Association, 2021). The roadmap begins with an organizational assessment
that provides an outlook of where an organization is on its journey toward health equity across
six domains: culturally appropriate care, equitable and inclusive organizational policies,
collection, and use of data to drive actions, diverse representation in leadership and governance,
community collaboration for solutions, and systemic and shared accountability (American
Hospital Association, 2021).
Culturally appropriate care ensures that patient care providers are sensitive to all patients’
cultural and linguistic needs (American Hospital Association, 2021). Equitable and inclusive
organizational policies aid in the organizational application of diversity, equity, and inclusion to
all policies that govern the care of patients and the management of staff (American Hospital
Association, 2021). The collection and use of data to drive actions describe qualitative and
quantitative data-driven decision-making (American Hospital Association, 2021). Diverse
representation in leadership and governance holds healthcare organizations accountable for
leadership that mirrors the racial and ethnic diversity of the populations they serve (American
Hospital Association, 2021). Community collaboration for solutions includes the voice of the
organization’s surrounding community in advancing health equity and inclusive solutions
(American Hospital Association, 2021). Systemic and shared accountability involves
establishing a foundation for systemic anti-racism that is sustainable and perpetuated across the
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ecosystem (American Hospital Association, 2021). This program aims to eliminate structural
barriers to healthcare organizations’ health equity and belonging initiatives (AHA-IFDHE,
2022).
As of today, Michigan, Illinois, Maryland, California, Kentucky, and New York, require
healthcare workers, like nurses, doctors, long-term health caregivers, and allied health
professionals, to take implicit bias training as part of their stated licensure requirements (CA
Assembly, 2021; IL General Assembly, 2021; KY General Assembly, 2022; MI Department of
Health and Human Services, 2019; MD State, 2021; NY General Assembly, 2022). Most of these
state training initiatives originated from the awareness of inequities during the COVID-19
pandemic and after the murder of George Floyd. Twelve years prior, Rush University Medical
Center received a grant to start the Rush University Medical Center for Health Equity (RCHE) in
Chicago (NewsRX, 2010). Since then, the RCHE has become a model in strategic organizational
efforts to address the root causes of systemic racism, economic deprivation, and SDOH (Ansell
et al., 2021).
As Ansell et al. (2021) discussed, RCHE started the foundational efforts for this strategy
prior to the COVID-19 pandemic and social uprisings of 2020, therefore allowing them to
quickly mitigate disparities. In addition, the RCHE worked with city officials to respond with
additional resources to areas of the local community hardest hit by the effects of COVID by
providing access to food, masks, testing, and immunization (Ansell et al., 2021). Their
established strategy allowed them to buffer the impact that COVID-19 may have had on their
local communities by providing resources to combat the SDOH (Ansell et al., 2021). The federal,
state, local and professional efforts either in place or underway provide models of success for
other organizations to implement as they look to reduce health inequities. In addition, the federal,
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state, and professional efforts provide organizations with the greatest amount of accountability
and thus should see the greatest participation in health equity initiatives in the future.
Conceptual Framework
Critical race theory (CRT) and SCT are the theoretical frameworks used to guide this
study. These two separate theoretical frameworks arose from two separate industries and two
separate originators. However, both theories describe why people behave. This section of the
paper describes CRT and SCT and introduces the conceptual framework used for this study.
Critical Race Theory and Interest Convergence
Critical race theory is a framework first used in legal studies developed to assist in
applying social justice in legislation (Demaske, 2009). The CRT framework suggests that
systemic racism, so deeply ingrained in the day-to-day aspect of American society, requires
consideration in legal interpretation when proceedings involve African Americans (Demaske,
2009). Bell (1980, 2005) explored the range of CRT in his evaluation of the decision in Brown v.
Board of Education (1954), from which he deduced that interest convergence explains the
rationale for the ruling in favor of African Americans. The CRT of interest convergence
supposes that the interests of the majority race will always be primary to those of the minority
race, and the minority race will only receive favoritism as it seeks to elevate the interests of the
majority race (Bell, 1980, 2005; Demaske, 2009). According to Delgado and Stefancic (2017),
CRT progressed beyond its legal origins to include radical feminism, education scholars, and
political scholars, along with the critical voices of other races, including Asian, Latino, Native
American, and White. The basic tenets of CRT propose that racism is a societal norm, and
systemic racism promotes the interests of Whites, leaving the dominant group with little to no
motive to change the status quo (Delgado & Stefancic, 2017).
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Interest convergence describes the phenomena of issues that promote the well-being of
African Americans addressed to the extent that it is to the benefit of Whites (Bell, 1980). Derrick
Bell (1980) derived the theory of interest convergence in his groundbreaking thesis describing
the Brown v. Board of Education (1954) decision. The matter was not that Whites felt moved
with compassion to elevate the cause of the African Americans in the matter of Brown v Board
of Education (1954), but that the outcome of this landmark case provided an opportunity to
realize global economic and political advantages (Bell, 1980). Delgado and Stefancic (2017)
posited a correlation between global relations, labor supply, and demand, along with the interests
of White elites, to that of the wealth trends for African Americans and other minorities, which
will provide a record of interest convergence throughout U.S. history.
Moral Disengagement
Bandura’s (1986) SCT grounds in the influence of the social environment on individual
and collective behavior. Social cognitive theory explains the motivations behind self-efficacy or
what drives a person to produce an intended result (Osofsky et al., 2005). Moral disengagement
is a further exploration of SCT that suggests an individual, society, or organization will
disengage from what is morally right to achieve an intended goal if deemed socially acceptable
(Bandura, 1986, 2005). Social cognitive theory addresses the alignment of behaviors and
environmental factors influencing a person (Bandura, 1986). Moral disengagement speaks to
how an individual enacts moral agency and their thoughts about those actions (Bandura, 2016).
The theory confronts the dichotomy of magnanimity in perspective and debility in action
(Bandura, 2016).
Bandura (2016, 2018) formally defined moral disengagement as the act of disassociating
from the obligation of morality without remorse for any detriment that may come to others from
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the action. Four loci of moral agency and eight forms of moral disengagement derive its
mechanisms or actions (Bandura, 2016). The loci of moral agency are the behavioral locus,
agency locus, victim locus, and effects loci, and each locus represents different forms of moral
disengagement. A visual representation of the eight forms of moral disengagement across the
four loci is in Table 1.

Table 1
Bandura’s Eight Forms of Moral Disengagement Across the Four Loci of Moral Agency
Behavior Agency Victim Effects
Advantageous
comparison
Diffusion of
responsibility
Attribution of blame Minimization of
effects
Euphemistic
language
Displacement of
responsibility
Dehumanization
Moral, social, and
economic
justification

Note. This table depicts the mechanisms of moral disengagement across the loci from which they
originate.

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Mechanisms and Forms of Moral Disengagement
Bandura (2016) used the four loci to describe what occurs when someone or something
employs moral disengagement. The eight forms or mechanisms fall under each loci category to
describe how the actions unfold (Bandura, 2016). The behavioral locus is where one justifies
harmful actions (Bandura, 2016). The behavioral locus mechanizes the forms of advantageous
comparison, euphemistic language, and moral justification in moral disengagement (Bandura,
2016). Bandura (2016) explained advantageous comparison as a phenomenon where one may
consider one’s actions moral in comparison to another action that is deemed to be worse. When a
country justifies casualties of war by stating that not taking military action would result in
casualties at home, it is an example of an advantageous comparison.
Euphemistic language is the word choice or semantics one uses to minimize or
disassociate from harmful actions (Bandura, 2016). An example of euphemistic language is the
term “Jim Crow.” Jim Crow was a minstrel show performer whose name is synonymous with the
segregationist apartheid period in the United States (Hannah-Jones, 2019). Moral justification is
when one deems another as morally good. (Bandura, 2016). According to Bandura (2016), this
behavior can cause harm on a moral, social, or economic level. The greatest example of moral
justification is religion. The Crusades, colonialism, and jihad were all enacted in the name of
religious, moral good, yet have done great harm in the world (Huff, 2004; Polk, 2018).
The agency locus is where one will disassociate from the responsibility or harmful action.
In the agency locus, one may also move the responsibility to another or spread the responsibility
across a greater population. The forms of moral disengagement in the agency locus are the
diffusion of responsibility and the displacement of responsibility. The names of these two
mechanisms are self-defining. An example of displacement of responsibility is hiring a hitman to
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perform a murder; the person ordering the job may not feel as guilty because they did not
personally murder another human.
An example of diffusion of responsibility is the act of capital punishment. It is hard to
determine who is responsible for the inmate's death; blame can fall on the state, the judge, the
warden, the execution team, the inmate, or all of them. The victim locus includes those who
perpetuate harm, placing the onus of the action onto the victim. This locus mechanizes through
the dehumanization of the victim and by blaming the victim altogether for what has occurred.
Examples of this locus occurred in slavery, where the Whites did not view enslaved Africans as
fully human, justifying the institution of slavery. Blaming the victim also played out in slavery,
as Whites beat, maimed, and brutally killed slaves for not following the directions of their
masters; it was their fault for not being obedient (Hannah-Jones, 2019; Wilkerson, 2020).
The last locus is the locus of the effects, also referred to as the outcomes locus and occurs
when one minimizes or negates the impact of the actions (Bandura, 2018). Limiting the
television broadcast of war efforts is one example of minimizing the effects of the aggressions
afflicted upon the casualties of the war. These loci and mechanisms of moral disengagement are
not mutually exclusive; more than one loci and mechanism can be enacted simultaneously.
This study explored the moral disengagement of healthcare organization operations and
their inaction toward demolishing systemic racism to promote equitable health outcomes. The
study also explored the interests that will need to converge to reverse the mechanism of moral
disengagement in which healthcare organizations participate. The next section describes how the
theories of interest convergence and moral disengagement comprise the conceptual framework
used to explore the problem presented in this study.

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Moral Disengagement and Interest Convergence Conceptual Framework
A conceptual framework exhibits the point of view and approach to research. According
to Varpio et al. (2020), a conceptual framework seeks to define the purpose of a study and to add
to what is currently known about a subject to eliminate the currently unknown areas. The
conceptual framework in this study sought to explore the influence of moral disengagement and
interest convergence on the engagement of healthcare organizations in the promotion of health
equity. Significant harm has occurred in a field that seeks not to harm, as evidenced in statistics
highlighting disparities in access to care and disparate healthcare outcomes. As depicted in
Figure 4., the healthcare organization’s ability to morally disengage in care delivery will always
increase as the interest convergence decreases. The converse is also true, as the healthcare
organization’s willingness to engage in morally inequitable care will increase when the interest
converges with its bottom line. This research posits that there is a display of moral
disengagement on behalf of healthcare organizations in their pursuit of profits and the
perpetuation of systems of race in the delivery of care. Additionally, I suggest that this moral
disengagement will only lessen when the interests of society are served in the implementation of
solutions to provide equitable healthcare solutions that benefit the bottom line of healthcare
corporations and the U.S. government.

50

Figure 4
Moral Disengagement and Interest Convergence Conceptual Framework Depiction

Summary
The literature demonstrates the reach of racism in the day-to-day life of African
Americans and other ethnic minorities in the United States. Annually, racism costs 800 million
dollars (Payne, 2021). The National Institutes of Health estimated a savings of $1.23 trillion in
direct and indirect medical costs by eliminating health disparities (LaVeist et al., 2011). Research
by Norton and Sommers (2011) is the impetus for ethnographic research by Heather McGhee
(2021), which discovered that White Americans perceive the promotion of equity as an anti-
White effort. McGhee (2021) posited that Whites primarily perceive the elevation of African
Americans and other minority groups to result in the demise of the White race, evidenced by
socio-political constructs that cause both sides to lose. This narrative shows the actions
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continually taken by the United States from the inception of slavery, the actions taken or avoided
during the reconstruction period that led to the establishment of Jim Crow laws, and the effects
of systemic racism that persist to the present day. These examples throughout U.S. history
remigrate to the rationale behind the perpetuation of racism over such an extended period and at
the detriment of not only those who descend from enslaved Africans but also those considered
White.

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Chapter Three: Methodology
The purpose of this research was to assist U.S. healthcare organizations in understanding
how they contribute to systemic racism and the disparate health outcomes of African American
patients. The study employed a qualitative survey of stakeholders in the healthcare industry to
explore the different perspectives on systemic racism in large U.S. healthcare organizations. This
chapter describes the study’s methodology, including an overview of its design, information
about me and my positionality, data collection methods, ethical considerations, and potential
limitations and delimitations.
Research Questions
The research questions guiding the study are as follows:
1. What are the perceptions of systemic racism in healthcare among the stakeholders of
large healthcare organizations (i.e., patient vs. provider vs. administrator)?
2. What role does the healthcare organization play in promoting health equity across
minoritized patient populations?
Overview of Design
This study employed qualitative research methods to understand how healthcare
organizations perpetuate unequal treatment of African Americans. Creswell (2018) described the
qualitative approach to research as one that seeks to understand the why behind complex societal
problems through open-ended questions and responses. I conducted the interviews using an
online survey consisting of seven demographic questions and nine base questions. The seven
base questions had Likert and open-end response options. The open-ended questions assessed
perceptions, expectations, and experiences of equal treatment in healthcare delivery from
healthcare organizations’ stakeholders. According to Braun et al. (2020), an online survey is a
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qualitative, affordable, flexible, inclusive, and confidential approach that provides rich deep data.
The qualitative online survey format is also attractive for students facing time limits in their
research (Braun et al., 2021). The research aimed to determine the impact racism has on health
outcomes, the healthcare organization’s role in promoting health equity, and how moral
disengagement and interest convergence impact organizational decisions in developing health
equity strategies.
Research Setting
I used an online survey to interview the stakeholders of major healthcare organizations.
The questionnaire was created in Qualtrics, survey software that hosts the collection and
reporting of data. The survey was available through a unique link. I promoted the survey using
LinkedIn, Instagram, and Facebook networks daily from January 12, 2023, through January 25,
2023. I sought participants through direct message requests as well as references from
individuals outside of my immediate network. Finally, I asked participants to share the link to the
online survey with someone in their network who fits the participation requirements.
The Researcher
As the researcher, I have a background in healthcare and have worked for several of the
largest healthcare corporations in the United States. I am an African American female and have
personally experienced systemic racism in healthcare organizations as a healthcare worker,
employee, caregiver, and patient. Therefore, I am aware of my positionality, which might have
influenced this study. I acknowledge how SDOH dictate disparate healthcare delivery and
outcomes for marginalized patients (AHRQ, 2020). I also recognize that the U.S. health system
is a business that supports capitalism over health, regardless of large organizations’ stated
mission and visions (South et al., 2020). I also sought to comprehend why there has not been a
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centralized effort to dismantle the systems that perpetuate harm to health (Lavizzo-Mourey et al.,
2021).
I view the problem of this study and viable solutions through two lenses: a critical
philosophical worldview and a post-positivism worldview. The critical or transformative inquiry
paradigm seeks to center the experience of the minoritized and uproot unjust systems of power
(Hinga, 2019). From an ontological perspective, the critical belief system assumes that there are
known systems of power in place, and these systems cause disparities (Hinga, 2019). According
to Merriam and Tisdell (2016), critical research assumes the presence of socially constructed
positions of power and that critical inquiry seeks to confront the injustice those positions of
power have injected into society. I applied the critical worldview to assess the urgency of the
need for standardized solutions to inequitable healthcare. I also acknowledge the reality of the
gray areas in this world, as emphasized by a post-positivism philosophy (Grigoriev & Hoboken,
2019). From an epistemological perspective, this inquiry paradigm understands that it is difficult
to determine if what is known as a personal truth is entirely fact (Hinga, 2019). I recognize that
systemic racism is as challenging to identify as the man behind the curtain (Jones, 2000). Racism
exists through the accounts of those it has impacted (Shariff-Marco, 2011), and history proves
the existence of racism in various systems and structures of society (Hannah-Jones & The New
York Times Magazine, 2022; Wilkerson, 2020), yet the entity or entities responsible for the
undoing of systemic racism remains undefined (Jones, 2000). My individual implicit bias based
upon individual experiences with the healthcare system may insert ambiguity in the quest for a
solution (Blair et al., 2013).

55

Data Sources
This study used a qualitative online survey approach during the interview. I promoted the
online survey using social media, relying primarily on my personal network. The survey
remained open from January 12 to January 25. The following sections will provide details about
the study participants and survey instrumentation, along with a description of the data collection
and analysis.
Online Qualitative Questionnaire Study Protocol
This study employed the qualitative questionnaire as an inquiry protocol. I collected
qualitative data via a survey with open-ended fixed questions in which participants could provide
self-guided written responses. I sought the perspective of stakeholders of healthcare
organizations, which is a population representative of the entire United States. The methodology
for the survey was qualitative as the questions were primarily open-ended, and I analyzed textual
data even if the instruments included commonly quantitative demographic questions (Braun et
al., 2021; Terry & Braun, 2016; Toerien & Wilkinson, 2004). According to Toerien and
Wilkinson (2004), the qualitative questionnaire is a different and practical approach to collecting
qualitative data across many participants.
Additionally, the qualitative approach to inquiry using open-ended questions provided
insight into data themes that may not appear through a quantitative approach. According to
Robinson and Firth Leonard (2019), open-ended questions provide an opportunity to gain insight
from rich data that can reflect a variance in responses that cannot be captured in a quantitative
survey. Qualitative questionnaire studies are also helpful when inquiry is sensitive, which can
apply to this study as it sought to understand how organizations may have participated in acts of
moral disengagement and interest convergence. According to Terry and Braun (2016), the
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qualitative survey conducted using an online tool such as Qualtrics provides participants with a
significant level of confidentiality due to the anonymity provided. Toerien and Wilkinson (2004)
have leveraged the qualitative questionnaire approach in studies that seek opinions of a personal
nature that may be in opposition to societal norms. Lastly, I chose an online questionnaire study
for cost-effectiveness and to accommodate the short timeline for data collection (Braun et al.,
2021). Several scholars have opined on the use of the qualitative questionnaire as beneficial to
their study for rapid implementation of research and integration to coding software for data
analysis (Braun et al., 2021; Terry & Braun, 2016).
Participants
The survey targeted participants over 18 years of age who were stakeholders of a large
healthcare corporation or an affiliated facility. Stakeholders represent the patients, employees,
leadership, board members, and shareholders of large corporations and their affiliated facilities.
In this study, I defined large healthcare corporations as companies that provide or deliver
medical services with 3000 or more employees and more than five service locations. An
affiliated facility is a healthcare delivery point owned or corporately operated by a large
healthcare organization. I listed the participant stratification of age, gender, organization size,
organization type, and stakeholder title on the survey promotional information and included it in
the demographic questions. I chose this latitude of survey respondents to develop a panoramic
perspective of the U.S. healthcare organization from the stakeholders that benefit from or
contribute to the organizations. I used non-probability, purposeful, convenience, and snowball
sampling to recruit participants for this dissertation study. Non-probability, purposeful sampling
allows the qualitative researcher to intentionally include responses to ensure the inclusion of the
voices of certain groups (Creswell, 2018; Merriam & Tisdell, 2018). Convenience sampling uses
57

the most readily available participants (Merriam & Tisdell, 2018). Finally, snowball sampling
allows participants to refer the study to other potential participants who may fit the research
requirements (Merriam & Tisdell, 2018). I implemented convenience and snowball sampling for
ease of use and to widen the pool of participants to ensure saturation.
Researchers present a variety of thoughts in the literature regarding sample size and the
qualitative study in general (Creswell, 2018; Merriam & Tisdell, 2018) and online qualitative
studies (Braun et al., 2021; Braun & Clarke, 2013; Toerien & Wilkinson, 2004;). A commonality
in the thought about sample size in the qualitative method points to saturation as the determining
factor (Creswell, 2018; Merriam & Tisdell, 2018). Saturation is the point in data collection
where the data are adequate to satisfy the studies across all categories and yield no new insights
(Creswell, 2018). According to Merriam and Tisdell (2016), this is not a number that can be
determined before conducting the research. Instead, saturation will be determined a posteriori,
which will occur after the initiation of data collection and analysis (Sim et al., 2018).
According to Morse et al. (2021), the determination of saturation in all aspects of the
study is challenging, especially for novice researchers. A minimum of 15 participants were
sought as the sample size for this study. Braun et al. (2021) cited a benefit of the qualitative
questionnaire as the ability to obtain a larger sample size than traditional qualitative interviews. I
aimed to obtain an equal number of responses from each stakeholder category as well as an even
distribution of responses by race and organizational size (Merriam & Tisdell, 2018).
Instrumentation
I built and distributed the online survey using the Qualtrics online survey platform. The
survey consisted of nine demographic and 15 open-ended questions and required approximately
25 minutes to complete. The survey was only available in English. Free access to the Qualtrics
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online tool is a tuition benefit to the organizational change and leadership program at the
University of Southern California. The survey items represented four sections: demographics,
perception, expectation, and experience. The demographics section contained nine multiple-
choice questions to assist with the stratification of the online survey responses. I posed the 15
open-ended questions in a static method for all participants across three categories. The survey
items related to the research questions as they measured how one perceives systemic racism in
healthcare organizations, how the participant expects the healthcare organization to approach
systemic racism, and an account of the participant’s personal experience with systemic racism
and the healthcare organization.
Braun et al. (2021) proposed using a follow-up online survey for additional data
collection where participants can opt-in to provide additional questions to help the researcher
gain insight if necessary. This survey provided participants an opportunity to opt-in to answer
additional questions with the provision of an email address. Due to the asynchronous nature of
this study, creating an opportunity to follow up with targeted participants proved to be
resourceful in the initial data analysis phase (Merriam & Tisdell, 2018). If follow-up with a
particular participant was necessary, I conducted a qualitative live interview as an opportunity to
gain deeper insight into the data.
Data Collection
I collected data from January 12 to January 25 using the Qualtrics online survey software.
I promoted access to the survey through social media networks and referrals. For those
participants opting to provide an email address, I entered them into a drawing for an Amazon gift
card. The Qualtrics online link was the sole access to the study. The promotional material
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included target participant criteria and stratification. I conducted a pilot test of the survey
questions with persons representing the stakeholder groups in the study.
The survey questionnaire included 16 questions comprised of seven demographic
questions and nine base questions (Appendix A). The base questions addressed the research
questions by determining the relationship between systemic racism and adverse health outcomes
and healthcare organizations' role in perpetuating the outcomes. In addition, the questions in the
demographics section aided in the stratification of the participants and the answers provided. The
patient and community member stakeholder group received a different set of questions in the last
section of the survey from the healthcare employee, clinician, and leadership stakeholder groups
(Appendix A).
I structured the online questionnaire to present questions in a fixed, predetermined order
(Merriam & Tisdell, 2018). Merriam and Tisdell (2016) cited the disadvantages of using the
highly structured asynchronous online survey as a qualitative interview, with the main objection
being the inability of the researcher to influence the interview in any manner, primarily to ensure
the interview is on track. Braun et al. (2021) offer options to provide clarity and guidance during
the online survey by including the definition of terms. This study employed the terms defined in
Chapter One to clarify the meaning of specific questions. I conducted the study pilot prior to the
launch of the study to ensure the stated questions and assumptions in the survey were clear. The
study provided participants the option to provide an email address to participate in follow-up
interviews, but I did not organize follow-up interviews for this study.
Data Analysis
According to Merriam and Tisdell (2016), qualitative analysis involves the classification
and organization of data conducted simultaneously with data collection. I considered data
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analysis while designing the survey instrument, as I organized the online questionnaire into four
sections. The first section collects participant demographics. The demographic data inform the
categorization of the qualitative analysis. Creswell (2018) categorized qualitative data as
winnowing, where the aggregated data filter down to fit into several themes. According to Terry
and Braun (2016), thematic analysis of structured qualitative surveys is direct while also noting
the need for the researcher to become acquainted with the data. This study relied on computer
software to assist with coding. For further organization and classification, I coded the data to
identify patterns and themes until the main ideas emerged (Creswell, 2018). According to
Merriam and Tisdell (2016), using computerized qualitative data analysis software to assist with
coding can allow the researcher to gain greater insight into the data. For this study, I used the
Text iQ feature in Qualtrics for primary and secondary coding.
Validity and Reliability
This section addresses the strategies used to ensure data obtained are dependable and
valid. Reliability in research refers to the ability with which a measurement tool provides
consistent results (Salkind, 2014). The validity of research assesses the ability of the
measurement tool to provide the intended results (Salkind, 2014). Qualitative and quantitative
research uses several types of reliability and validity approaches (Salkind, 2014). To promote
reliability and validity in the qualitative inquiry methodology, Creswell (2018) suggests that
researchers align the interview items and approach to the lens through which one views the
problem. It is important to note that the qualitative questionnaire approach can impact the
response rate of participants due to the greater time commitment required for completion.
Krosnik (1999) suggests that this phenomenon is not always true and that response rates for
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open-ended questions can outperform closed-ended surveys with respect to reliability and
validity.
Creswell (2018) noted that the reliability and validity of a qualitative study are relative
because the answers and the way the participants provide them are unique to the individual. I
performed a mock field study as part of the pilot to evaluate the questions in the online survey.
Krosnick (1999) noted that the pretesting of the questionnaire is an important step in identifying
potential interpretation issues that may impact a study’s reliability. This research also ensured
that my method of investigation and inquiry was highly ethical. The next section describes the
steps taken to ensure ethics in the study.
Ethics
Transparency of the research purpose and positionality of the researcher is important to
maintain ethical standards in a study. Therefore, I reminded all potential participants of the
voluntary nature of the study and the confidentiality of the data in the consent questionnaire
preceding the study. I prioritized privacy and confidentiality in this study’s design and data
collection phases to provide anonymity for participants employed by well-known healthcare
organizations. I established trustworthiness by leveraging detailed, thick descriptions and
reflexivity during data analysis. Merriam and Tisdell (2016) defined reflexivity as a way of
reflecting on the researcher’s positionality. I limited personal biases that may interfere with the
inquiry and the subsequent interpretation of the results by providing participant anonymity. The
online qualitative survey provided anonymity in data collection for participant confidentiality. I
removed all selections and interpretation bias (Smith & Noble, 2014). I do not provide
participant or organization names. I redacted any identifying information provided in the
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responses of this study to emphasize confidentiality. I created a separate study link for
participants opting to provide an email address to strengthen confidentiality.

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Chapter Four: Results or Findings
This chapter reviews the study’s findings through the lens of the moral disengagement of
Bandura’s (2106) SCT and Bell’s (1980) interest convergence concept of CRT. The purpose of
the study was to understand healthcare organization stakeholders’ perceptions of the extent to
which healthcare organizations have allowed racism and greed to influence healthcare outcomes
in the United States. The goal was to use the data to contribute to policy and practice changes in
healthcare organizations. Two research questions supported the inquiry:
1. What are the differences in the perceptions of systemic racism in healthcare between
the stakeholders of large healthcare organizations (i.e., patient vs. provider vs.
administrator)?
2. What role does the healthcare organization play in promoting health equity across
minoritized patient populations?
Participants
The participants were over the age of 18 and identified as stakeholders of a hospital or
healthcare organization as patients, community advocates, administrators, employees, payors,
executives, or clinicians. I collected demographics regarding race, age, education level, income
level, type of stakeholder, type of organization, and size of the organization. Table 2 shows
participants’ races and ethnicities. Table 3 displays their gender distribution. Their ages at the
time of the survey are in Table 4. Table 5 shows the states in which they live. Table 6 lists each
participant’s role in relation to the healthcare organization. Table 7 shows the size of the
healthcare organization with which they are affiliated. Table 8 displays the participants’
organization type. Table 9 presents their salary ranges, and Table 10 provides their education
levels. This section continues with greater details about the participants and their demographics.
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Table 2
Demographics Data: Race and Ethnicity
Race and ethnicity n = 190
African American 32
Asian American 27
Native American 27
American Indian or Alaskan Native 21
Native Hawaiian 15
Pacific Islander 19
White 48
Other (please specify) 1
Are you of Hispanic or Latino descent? n = 115
Yes 56
No 59

Note. The count value represents the number of participants who provided a qualifying answer to
each question. Participants were allowed to skip questions. These data were not analyzed
quantitatively; therefore, standard deviation and/or p-values are unavailable.

Table 3
Demographics Data: Gender
Gender Count
(n = 118)
Male 55
Female 61
Non-binary/third gender/ agender 1
Prefer not to say 1
Other (please specify) 0

Note. The count value represents the number of participants who provided a qualifying answer to
each question. Participants were allowed to skip questions. These data were not analyzed
quantitatively; therefore, standard deviation and/or p-values are unavailable.
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Table 4
Demographic Data: Age
Age range Count
(n = 115)
18–24 5
25–34 50
35–44 31
45–54 23
55–64 4
65–74 1
75–84 0
85 or older 1

Note. The count value represents the number of participants who provided a qualifying answer to
each question. Participants were allowed to skip questions. These data were not analyzed
quantitatively; therefore, standard deviation and/or p-values are unavailable.

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Table 5
Demographic Data: State of Residency
State Count
(n = 108)
Alabama 3
Alaska 11
California 20
Colorado 1
Connecticut 1
Delaware 1
Georgia 23
Hawaii 1
Kansas 1
Kentucky 1
Louisiana 1
Maryland 1
Massachusetts 1
Missouri 2
New York 10
North Carolina 2
Ohio 5
Tennessee 9

Note. The count value represents the number of participants who provided a qualifying answer to
each question. Participants were allowed to skip questions. These data were not analyzed
quantitatively; therefore, standard deviation and/or p-values are unavailable.

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Table 6
Demographic Data: Stakeholder Role
Stakeholder role
Count
(n = 115)
Patient 29
Community member 24
Patient advocate 16
Employee (under director level) 16
Leader (director level and above) 15
Clinician (RN, MD, DO, NP, PA, APRN, RNMW,
PharmD, etc.) 11
C-suite leader 1
Organization board member 0
Other 3

Note. Conditional actions were placed in the survey based on the answer to this question. Patient,
community member, and advocate roles had different question paths than those who identified as
employees or leaders.

Table 7
Demographic Data: Organization Size
Size of organization Count
(n = 43)
Under 3,000 employees 7
3,000 to 5,000 employees 5
5,000 to 10,000 employees 24
10,000 to 50,000 employees 5
50,000 to 100,000 employees 1
Greater than 100,000 employees 1

Note. Only participants who selected the role of employee, leader, clinician, C-suite leader, or
organization board member were provided with this question.
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Table 8
Demographic Data: Organization Type
Type of organization Count
(n = 42)
For-profit healthcare organization 11
For-profit hospital 3
Not-for-profit healthcare organization 21
Not-for-profit hospital 2
Government 4
Payor 1
Other (please specify) 0

Note. Participants who selected the role of employee, leader, clinician, C-suite leader, or
organization board member were provided with this question. The participants self-defined the
organization type. The definition of a healthcare organization was also left to the participants’
interpretation.

Table 9
Demographic Data: Salary
Salary range Count
(n = 67)
Under $50,000 12
$50,000-$150,000 30
$150,000-$250,000 17
Above $250,000 7
I prefer not to respond 1

Note. The count value represents the number of participants who provided a qualifying answer to
each question. Participants were allowed to skip questions. These data were not analyzed
quantitatively; therefore, standard deviation and/or p-values are unavailable.

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Table 10
Demographic Data: Education
Education level Count
(n = 115)
Did not complete HS/GED 4
High school/GED diploma 20
Associate 5
Bachelor’s 58
Master’s 16
Terminal degree (MD, DO, PhD,
EdD, JD, etc.)
9
I prefer not to respond 3

Note. The count value represents the number of participants who provided a qualifying answer to
each question. Participants were allowed to skip questions. These data were not analyzed
quantitatively; therefore, standard deviation and/or p-values are unavailable.

Socioeconomic Demographics
The participants’ gender and race distribution mirrors that of the healthcare industry (U.S.
Census Bureau, 2019), as most of the participants (n = 69) represented the patient or community
stakeholders and identified as White (n = 48) of non-Hispanic origin (n = 59) and female (n =
61). A comparison of participant gender demographics to the U.S. Census gender demographics
of healthcare workers is shown in Table 11. Over 50% of the respondents were from the
following three states: Georgia (n = 23), California (n = 20), and Texas (n = 13). Sixty percent of
the participants reported an annual household income under $150,000 (n = 42). Over 75% of the
respondents had a bachelor’s degree or higher (n = 83).
According to the Bureau of Labor Statistics (2022), these results are analogous to the
entry-level education level required for occupations in the healthcare industry. An interesting
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finding is that three participants responded in a language other than English, while the remaining
participants responded in English. The questionnaire did not ask if participants spoke English as
a second language, nor was the questionnaire offered in any second language. I used Google
Translate to transcribe the written responses captured from participants using other languages.
Since one in five Americans speaks a language other than English at home (U.S. Census Bureau,
2019), future questionnaires should consider providing participants the opportunity to self-
identify their preferred spoken language and offer the questionnaire in languages other than
English.

Table 11
Comparison of Participants to U.S. Healthcare Workers Demographics: Gender
Participant male %
n = 55
Healthcare workers
male %
Participant female%
N = 61
Healthcare workers
female %
n = 2,679,879 N = 8,212,440
46.6% 24.6% 51.69 75.4%

Note. This table depicts a comparison of participant gender by count and percentage. Data from
the 2020 U.S. Census were used and did not include gender identification other than male and
female.

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Organizational Affiliation
Almost 70% of the respondents represented healthcare organizations with over 5,000
employees (n = 31). Although the study initially targeted respondents from large organizations
only, the information provided by those affiliated with smaller-sized organizations employing
fewer than 5,000 people was beneficial, and those data are included in the final findings.
Participants acknowledged affiliation with not-for-profit healthcare (n = 27)
organizations more than for-profit (n = 14). One respondent self-identified as a board member (n
= 1), and none identified as C-suite leaders (n = 0). However, two clinician respondents
acknowledged they served as C-suite and board members; both participants revealed their
identities in the final comments section and were personal contacts. Additionally, one participant
designated an affiliation with a medical payor organization. It was impossible to determine if
other participants felt reluctant to reveal their affiliation with a medical payor or a corporate
board.
Out of the total participants who completed the questionnaire in its entirety (n = 136),
33% of the participants provided a response to the open-ended questions (X
̄ = 45), and less than
half of the respondents provided a response to the Likert scale questions (X
̄ = 67). The values are
expressed as a mean, indicating the average number of participants who responded to the
questions. Table 12 depicts the responses received for the Likert style and open-ended questions.
The targeted sample size of 15 participants was well achieved, and saturation was met for the
data from the open-ended questions.
Data Validation
I analyzed data using the constant comparative method, supported with a priori,
descriptive, and theoretical coding (Fram, 2013). I analyzed the responses to the open-ended
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questions using qualitative methods, and I used the Likert question responses to provide
supporting information during data analysis. I organized the qualitative questionnaire survey into
three sections. The sections served as the a priori coding themes for response analysis. The
questions in each section assessed stakeholders’ perceptions, experiences, and expectations of
healthcare organizations in relation to equitable care practices (Appendix A). The survey
questions will be referred to by the section and the order in which they appeared, as shown in
Appendix A. During coding, I organized the initial open-ended responses using topics to denote
the descriptions expressed in the responses. I assessed topic descriptions for patterns using the
word cloud and Text iQ topic coding features in Qualtrics. Then, I compared the topic
description patterns to the loci and mechanisms of moral disengagement shown in Table 1.
Lastly, I assessed the quotations for language that suggests interest convergence as an
impediment or solution for equitable healthcare.

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Table 12
Likert and Open-Ended Response Count
Question Likert count (n) Open-ended count (n)
Perception 1 89 55
Perception 2 75 55
Perception 3 136 62
Expectation 1 79 44
Expectation 2 79 36
Expectation 3 79 48
Experience 1 72 44
Experience 2 – 51
Experience 3 – 30
Experience 3a – 15
Experience 3b 26 –
Experience 3c – 14
Final question – 42
Mean response count (X
̄ ) X
̄ = 67 X
̄ = 45

Note. This table provides an overview of the count variation by survey question. The empty cells
represented by a dash indicate that type of question (Likert or open-ended) was not provided. A
mean (X
̄ ) is provided to show the average number of responses received per type of question.

Results or Findings for Research Question 1
The first research question pertained to differences in the perceptions of systemic racism
in healthcare among the participants. I created Research Question 1 to assess the various
stakeholders’ perspectives as they relate to their perceptions, expectations, and experiences of
healthcare organizations in the United States. This first question sought to understand if all
stakeholders share similar perspectives about systemic racism in the healthcare setting and if
their experiences and expectations are similar. As discussed in Chapter Two, the healthcare
industry has known of the inequity in healthcare delivery and the disparate outcomes for at least
20 years (Smedley et al., 2002). It is not currently known why these disparities continue to
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perpetuate with the available information. Researchers suggest that moral disengagement and
interest convergence theories are applicable explanations as to why these disparities continued
(Bandura, 2016; Bell, 1980).
Moral disengagement theory is a part of SCT from Bandura, which suggests that
individuals and corporations alike are willing to disengage or detach from what society considers
moral if the action is deemed a societal norm and will achieve an assumed greater intention
(Bandura, 2016). The interest convergence theory derived by Bell (1980) and expounded upon
by Delgado and Stefancic (2017) suggested a coincidence of the interests of White in America
correlating with their willingness to promote equality for African Americans and other
minoritized populations. This portion of the paper discusses themes extracted through qualitative
data analysis. I discuss the themes of Research Questions 1 and 2 as they relate to awareness,
justification, and accountability avoidance loci and mechanisms of moral disengagement as well
as the concepts of interest convergence.
Awareness
The first question in this survey sought to understand if participants recognized the
existence of inequities in the healthcare setting. I intentionally chose this specific question first to
elicit an authentic response by allowing the participant the opportunity to embrace or refute the
basis of this research. This approach aligns with the discussion by Charmaz (2014), supporting
the use of the questionnaire as a valid approach to obtaining rich qualitative data while providing
the respondents with anonymity. The first question of the questionnaire:
Perception 1: Please indicate the level of agreement with the following statement:
Inequitable healthcare exists in the United States.
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I presented this question with a Likert scale option of responses and followed with an
open-ended question for participants to expound upon their responses. For analysis purposes, I
categorized agree and somewhat agree responses into the top box, and the ‘neutral’ and
‘disagree’ choices were in the bottom box, as depicted in Table 13. The distribution of
participant responses across stakeholder groups is shown in Table 14. These data showed a
distribution of 55.1% (n = 49) in the top box to 44.9% (n = 40) in the bottom box. In the open-
ended question that followed, there were 58 (n = 58) recorded responses, 18 of which I
disregarded due to minimal, incomplete, or incoherent responses. However, the 40 responses I
analyzed all recognized the existence of systemic racism and disparate treatment of African
Americans and other marginalized populations in the United States. There were accounts of
firsthand experiences and witnesses to racism in general society with top and bottom box
responses to the previous statement. One response from a patient stakeholder disagreed with the
existence of inequalities in the healthcare system: “This [healthcare inequity] is normal.” This
statement represents the behavior locus of moral disengagement using the social justification
mechanism (Bandura, 2016).

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Table 13
Perception 1 Likert Results
Please indicate the level of agreement with the
following statement: 1. Inequitable healthcare exist
Count
(n = 89)
Percent%
Top box 49 55.1%
Bottom box 49 44.9%

Note. The top box represents responses that indicate any level of agreement with the statement.
The bottom box represents responses with any level of disagreement or ambiguity. The count
and percentage represent all qualifying responses to this individual question. Likert responses
were not analyzed quantitatively. The results were used to support comparative qualitative
analysis.

Table 14
Perception 1 Likert Participants by Stakeholder
Total Patient
Community
member
Patient
advocate Employee Leader Clinician C-suite
Board
member Other
Total count 89 24 18 11 14 10 11 0 0 1

Agree 40% 63% 33% 27% 21% 30% 45% 0% 0% 100%
Somewhat agree 15% 8% 33% 18% 14% 10% 0% 0% 0% 0%
Neutral 19% 13% 11% 18% 50% 10% 18% 0% 0% 0%
Somewhat disagree 15% 8% 6% 27% 14% 40% 9% 0% 0% 0%
Disagree 9% 8% 11% 0% 0% 10% 27% 0% 0% 0%
Unsure 2% 0% 6% 9% 0% 0% 0% 0% 0% 0%

Note. The count and percentage represent all qualifying responses to this individual question. Likert responses were not analyzed
quantitatively. The results were used to support comparative qualitative analysis.
77
78

The question on how often participants think African American patients receive unequal
treatment based on race in U.S. hospitals and healthcare systems signified a greater awareness of
the disparate treatment of African Americans in healthcare. Of the 72 responses to the Likert
scale portion of the question, 79.2% (n = 57) selected often or sometimes, 12.5% (n = 9) chose
unsure, and 8.3% (n = 6) chose never. I aggregated the results into a top and bottom box for
display purposes, as shown in Table 15. The distribution of participant responses across
stakeholder groups is shown in Table 16. Participants who selected the stakeholder role of
clinician (n = 4) and community member (n = 5) represented the majority of the never and
unsure responses (n = 15). It is important to note that none of the participants who selected never
chose to provide an open-ended response with the rationale behind their answer.
The participants largely acknowledge firsthand evidence of inequitable treatment in the
healthcare organization, with 27 of the 48 comments received noting firsthand accounts. Phrases
such as “I’ve seen it,” “the data show,” “pattern,” and “distrust” are reoccurring statements noted
in the open-ended responses collected from participants acknowledging the existence of unequal
treatment for African American patients. These statements signify the moral disengagement
mechanism of moral justification, which lies in the behavior locus. The intent to examine the
awareness of healthcare inequalities specifically uncovered an awareness of systemic racism and
unequal treatment as part of the societal culture in the United States.

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Table 15
Experience 1 Likert Results
Q. Experience 1 Count
(n = 72)
Percent
Top box 57 79.2%
Bottom box 15 20.8%

Note. The top box represents responses that indicate any level of agreement with the statement.
The bottom box represents responses with any level of disagreement or ambiguity. The count (n)
and percentage represent all qualifying responses to this question. Likert responses were not
analyzed quantitatively. The results were used to support comparative qualitative analysis.

Table 16
Experience 1 Likert Participants by Stakeholder

Total Patient Community
member
Patient
advocate
Employee Leader Clinician C-suite Board
member
Other
Total count (n) 72 20 15 10 9 7 10 0 0 1
Often 40% 55% 33% 40% 22% 14% 50% 0% 0% 100%
Sometimes 39% 35% 33% 40% 67% 71% 10% 0% 0% 0%
Never 8% 5% 13% 0% 0% 14% 20% 0% 0% 0%
Unsure 13% 5% 20% 20% 11% 0% 20% 0% 0% 0%

Note. The count and percentage represent all qualifying responses to this individual question. Likert responses were not analyzed
quantitatively. The results were used to support comparative qualitative analysis.

80
81

Justification
The second section of questions in the survey sought to assess the various stakeholders’
expectations of the healthcare system concerning unequal treatment. The main question in the
section determined participant sentiments about the ethical nature of the corporatization of the
U.S. healthcare system. As established in the literature review, capitalism and corporatization
rely upon a class or caste system that exploits a lower class’s labor for the upper class’s support
and wealth (Eichenlaub et al., 2010; Tolnay, 2003; Wilkerson, 2010). The majority of
participants responded positively to Expectation 2: Is it ethical for healthcare organizations to
operate as for-profit corporations?.” There were 79 responses to the Likert form of this question
and 40 responses to the open-ended form of the question. I aggregated the agree and somewhat
agree responses into the top box and all others into the bottom box for display purposes, as
shown in Table 17. The distribution of participant responses across stakeholder groups is shown
in Table 18. Of those in agreement with the statement, clinician stakeholders are the largest in
representation (54%).

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Table 17
Expectation 2 Likert Results
Q. Expectation 2 Count (n = 79) Percent
Top Box 51 64.6%
Bottom Box 28 35.4%

Note. The top box represents responses that indicate any level of agreement with the statement.
The bottom box represents responses with any level of disagreement or ambiguity. The count
and percentage represent all qualifying responses to this individual question. Likert responses
were not analyzed quantitatively. The results were used to support comparative qualitative
analysis.

Table 18
Expectation 2 Likert Participants by Stakeholder

Total Patient Community
member
Patient
advocate
Employee Leader Clinician C-suite Board
member
Other
Total count 79 21 16 10 12 8 11 0 0 1

Agree 25% 33% 13% 30% 25% 13% 36% 0% 0% 0%
Somewhat agree 39% 43% 31% 20% 58% 75% 18% 0% 0% 0%
Neutral 18% 5% 25% 30% 17% 0% 27% 0% 0% 100%
Somewhat
disagree
1% 0% 0% 10% 0% 0% 0% 0% 0% 0%
Disagree 11% 14% 25% 0% 0% 13% 9% 0% 0% 0%
Unsure 5% 5% 6% 10% 0% 0% 9% 0% 0% 0%

Note. The count and percentage represent all qualifying responses to this individual question. Likert responses were not analyzed
quantitatively. The results were used to support comparative qualitative analysis.
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In the open-ended response portion of this questionnaire, only one clinician chose to
provide a rationale for their response:
Here’s the problem with that question: what do you mean by ethical? I can promise you
that I can run a healthcare system and make a profit and have that system located in the
most underserved areas in any big city. So, … is that system unethical? … I can name
numerous “non-profit” healthcare systems that are loaded with unethical and racist
policies and procedures, and outcomes. Poor question.
The intent of this question was to determine if participants agreed that hospitals make a
profit from healthcare services. While the clinician respondent has a point about the question
being ill-worded, it is important to note that this respondent drew attention to the fact that profits
occur even in areas where there are underserved patients, whether the profit model is for-profit or
not-for-profit, which provides insight into the corporatization of the healthcare system being an
acceptable practice. This statement represents the behavior locus of moral disengagement
through the advantageous comparison and moral justification mechanisms.
Additional responses also representing the moral justification mechanism of the behavior
locus of moral disengagement from those in the agreement were “Hospitals are about making
money” and “healthcare organizations need money.” These sentiments suggest that healthcare
organizations’ stakeholder sentiment compares corporate healthcare organizations to for-profit
businesses from other industries. For the statement: “Hospitals are about making money,” it is of
note that the statement could mean that the sole or primary goal of healthcare is to make a profit;
however, it was derived that the respondent felt that it was acceptable for hospitals to be for
profit since they also agreed with the statement that it is ethical for healthcare organizations to
operate as for-profit organizations. Other sentiments expressed by those in favor of the for-profit
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healthcare model did signify that government policy change to create regulations in healthcare
could provide needed oversight for “equitable care delivery, patient experience, and healthcare
outcomes.” Another respondent representing the community member stakeholder group
expressed, “heavier regulation and … [have a] fixed profit it is allowed to earn like a utility
company.” Of the few participants who disagreed with the ethics of healthcare, none provided a
rationale for their response.
Accountability Avoidance
In each section of the survey, I posed a question to understand the stakeholder’s opinion
on who or what entities are responsible for solving health inequities and how they envision
workable solutions. As previously discussed, JC (2022), a hospital quality and patient safety
regulation agency, elevates the healthcare equity standard to its National Patient Safety Goal,
which will go into effect on July 1, 2023. In a JC publication, they propose the Implicit
Association Test as a tool for healthcare organizations to help bring awareness to physicians’
implicit biases against race and other physical attributes (JC, 2018). The survey prompted
participants to provide their perspective about the IAT in question Expectation 3: Please indicate
the level of agreement with the following statement: Patient-facing employees (nurses, providers,
allied health, nursing support, etc.) should take the implicit association test as a condition of
licensing, certification, and employment as an effort to promote anti-racism in healthcare
delivery.
I aggregated the agree and somewhat agree responses into the top box, and all others
were aggregated into the bottom box for display purposes, as shown in Table 19. The distribution
of participant responses across stakeholder groups is shown in Table 20. Of the 79 participants
who responded to this question, 69.6% agreed with this statement. Most of the participants in
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agreement were patients and community members, while 63.6% of clinician respondents favored
implementing the IAT as a condition of licensing, with over half of those clinicians identifying
as White.
Emerging themes demonstrated a desire to be aware of implicit biases. One clinician
provided the following statement:
See, there are only three things in the universe: Things I know. Things I don’t know. And
things I don’t know that I don’t know. And my implicit biases and pre-conceived notions
are often hidden to me-but perhaps I could be enlightened.
In a similar sentiment, another clinician suggested that physicians should take the IAT for
biases to physical attributes in addition to the one for race, citing that the test should be a starting
point for education but not to “preclude certification or employment.” These results show
clinicians’ willingness to take some responsibility for steps toward change but not to the extent
that it would threaten their livelihood. These sentiments represent the effects locus of moral
disengagement using the minimization of effects mechanism, which seeks to make light of the
harm caused by implicit behavior.
Expressions of those against the IAT also cite the need for awareness and education and
some skepticism of retaliation, further demonstrating moral disengagement. Awareness would be
inadequate if used independently of education. One participant against an IAT requirement
stated, “I would suggest education versus a required test. Those who are interested in improving
will respond based on education. A test doesn’t guarantee a changed attitude.” In the case of the
respondents against IAT, moral disengagement is mechanized through the displacement of
responsibility and the agency locus. These participants expressed an unwillingness to take
responsibility for personal biases by ignoring their existence.
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Table 19
Expectation 3 Likert Results
Q. Expectation 3 Count
(n = 79)
Percent
Top Box 55 69.6%
Bottom Box 24 30.4%

Note. The top box represents responses that indicate any level of agreement with the statement.
The bottom box represents responses with any level of disagreement or ambiguity. The count
and percentage represent all qualifying responses to this individual question. Likert responses
were not analyzed quantitatively. The results were used to support comparative qualitative
analysis.

Table 20
Expectation 3 Likert Participants by Stakeholder

Total Patient Community
member
Patient
advocate
Employee Leader Clinician C-suite Board
member
Other
Total count 79 21 16 10 12 8 11 0 0 1

Agree 42% 33% 56% 20% 33% 38% 64% 0% 0% 100%
Somewhat agree 28% 38% 25% 50% 17% 13% 18% 0% 0% 0%
Neutral 18% 14% 6% 10% 33% 50% 9% 0% 0% 0%
Somewhat disagree 6% 10% 0% 10% 17% 0% 0% 0% 0% 0%
Disagree 4% 5% 6% 0% 0% 0% 9% 0% 0% 0%
Unsure 3% 0% 6% 10% 0% 0% 0% 0% 0% 0%

Note. The count and percentage represent all qualifying responses to this individual question. Likert responses were not analyzed
quantitatively. The results were used to support comparative qualitative analysis.
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Discussion Research Question 1
There was awareness and ability to provide personal and empirical evidence about
societal inequities in general and those impacting healthcare outcomes. However, these same
participants believed that healthcare organizations that profit from healthcare have an ethical
right to do so and that it is commonplace for healthcare organizations to earn profit for their
enterprise. The sentiments expressed by the participants suggest that despite a blanket awareness
of health inequities, there is a consensus that society expects inequities in healthcare to occur.
While there was an expressed normalcy with the way the healthcare system operates,
stakeholders do feel there is room for improvement and offered suggestions for change while
expressing little optimism that change will come. The behavior, agency, and effects loci of moral
disengagement were prominently represented by participants throughout the responses relevant
to Research Question 1.
Results or Findings Research Question 2
The second research question asked about the role of healthcare organizations in
promoting health equity across minoritized patient populations. I posed the second research
question to uncover the various sentiments about how healthcare organizations promote health
equity in the day-to-day operations across the care continuum. While this question also sought
the different perspectives of stakeholders, the aim was to determine the health organizations’
opinions of culpability, if any, toward the issue of health inequities. The literature review section
on the overview of the U.S. health system revealed a time in this country’s history when
healthcare establishments provided for free to the most vulnerable people. During and
immediately following the Civil War, the poor and formerly enslaved alike received the medical
care needed when stricken by illness (Bradley et al., 2013). Since then, healthcare organizations
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have become one of the largest commodities of the U.S. economy (Bradley et al., 2013;
Schneider et al., 2021). Through the analysis of the data pertaining to Research Question 2, this
study aimed to explore why the current corporatization of healthcare is commonly acceptable
and what measures healthcare organizations are taking to mitigate the harm caused by its current
practices. The analysis of the responses revealed themes that implicate the role of government,
incentives to change, and overall frustration, which include additional mechanisms of moral
disengagement and concepts of interest convergence.
Role of Government
In coding responses to questions posed to address Research Question 2, a reoccurring
theme emerged about expectations of the role of government in creating and solving health
inequities. Question Perception 2 asked participants to rank the causes of health inequities in the
U.S. healthcare system. Twenty-five percent of participants answering the question ranked
healthcare organizations as the top contributor to health inequities, as shown in Table 21. The
word cloud shown in Figure 5 depicts the text provided in response to question Perception 2; it
shows government as the most widely used response.
Yet, the data obtained from open-ended responses provided additional insight into these
rankings. The distribution of participant responses across stakeholder groups is shown in Table
22. Of the comments received (n = 58), three mentioned the practices of healthcare
organizations. One participant mentioned, “People have choices, but I believe organizations can
do more to help.” This same participant chose individual choices as the top contributor to health
inequities and represents the leader stakeholder role. This singular response represents the
attribution of blame mechanism in the victim locus of moral disengagement. The other 55
responses implicated the government either directly or indirectly. Participants frequently used
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terms such as “systemic racism in the United States,” “government policies,” and “the society,”
implying a larger issue that contributes to inequalities. A respondent from the patient stakeholder
category commented,
Systematic racism is held up by government policy, [healthcare] practices and
procedures, and clinician bias. Social determinations are equal to systematic racism in my
opinion. I ranked it lower because of how systematic [sic] racism greatly inhibits certain
communities from improving social determinations.
The sentiments about systemic racism and SDOH circle back to government and
legislation as the root cause for its perpetuation. In the responses to this question, attributes of
interest convergence emerge. One patient stakeholder shared, “In the absence of rational
government policy, a healthcare system that moves from treatment-focused to prevention-focus;
operates at times to be accessible to people; and strives to pay its bills without turning its CEOs
into billionaires, could move closer to a model that focuses on the patient and not the money.”
Another respondent from the employee stakeholder group provided the following commentary as
a rationale for selecting the government as the top contributor to health inequities:
[Healthcare] providers cherry-pick patients based on my factors and “dump” (it’s a crude
term, but that’s what is said, please this isn’t a reflection of me) patients who are deemed
to cause a problem or not be as profitable. Another is fear of bad reviews or bad press
Gary [sic] scores.
These comments suggest that an absence of accountability in healthcare organizations
leads to inequities. Furthermore, these responses suggest that if there were a reason to improve
disparities in care, healthcare organizations would have the motivation to do so.

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Figure 5
Perception 2 Results

Table 21
Perception 2 Results
Rank
#
Question 1 2 3 4 5 6 Total

% n % n % n % n % n % n n
1 Healthcare
organizational
policies and
practices
33.33% 25 18.67% 14 20.00% 15 13.33% 10 8.00% 6 6.67% 5 75
2 Systemic racism 26.67% 20 24.00% 18 22.67% 17 10.67% 8 10.67% 8 5.33% 4 75
3 Government
policies
14.67% 11 24.00% 18 24.00% 18 16.00% 12 13.33% 10 8.00% 6 75
4 Individual
lifestyle
choices
9.33% 7 10.67% 8 13.33% 10 20.00% 15 24.00% 18 22.67% 17 75
5 Social
determinants
of health
12.00% 9 12.00% 9 8.00% 6 21.33% 16 30.67% 23 16.00% 12 75
6 Clinician
implicit bias
4.00% 3 10.67% 8 12.00% 9 18.67% 14 13.33% 10 41.33% 31 75

Note. This table shows the count and percentage of ranked responses for this question. The number column and row (#) represent the
ranking selected by the participant for that response. The count represents the number of participants who provided a qualifying
answer for that response. The total is the number of participants who provided a qualifying answer to the question. The percentage is
calculated using the response count and the total count. Data were not analyzed quantitatively and were used in comparative
qualitative analysis only.
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Table 22
Perception 2 Likert Participants by Stakeholder

Rank Total Patient
Community
member
Patient
advocate Employee Leader Clinician C-Suite
Board
member Other
Total count 75 24 17 10 9 4 10 0 0 1
Healthcare
organiza
tional
policies
and
practices
1 33% 46% 24% 30% 56% 25% 10% 0% 0% 0%
2 19% 21% 24% 10% 22% 0% 20% 0% 0% 0%
3 20% 17% 18% 20% 11% 25% 40% 0% 0% 0%
4 13% 8% 6% 20% 11% 25% 20% 0% 0% 100%
5 8% 4% 18% 10% 0% 25% 0% 0% 0% 0%
6 7% 4% 12% 10% 0% 0% 10% 0% 0% 0%
Systemic
racism
1 27% 21% 18% 40% 11% 25% 50% 0% 0% 100%
2 24% 33% 29% 10% 33% 25% 0% 0% 0% 0%
3 23% 38% 24% 10% 22% 0% 10% 0% 0% 0%
4 11% 8% 12% 10% 11% 25% 10% 0% 0% 0%
5 11% 0% 6% 30% 0% 25% 30% 0% 0% 0%
6 5% 0% 12% 0% 22% 0% 0% 0% 0% 0%
Governme
nt
policies
1 15% 17% 12% 20% 11% 0% 20% 0% 0% 0%
2 24% 25% 24% 30% 0% 25% 30% 0% 0% 100%
3 24% 29% 18% 10% 44% 50% 10% 0% 0% 0%
4 16% 8% 24% 10% 22% 25% 20% 0% 0% 0%
5 13% 17% 12% 10% 22% 0% 10% 0% 0% 0%
6 8% 4% 12% 20% 0% 0% 10% 0% 0% 0%
Individual
lifestyle
choices
1 9% 4% 18% 10% 11% 25% 0% 0% 0% 0%
2 11% 8% 18% 10% 22% 0% 0% 0% 0% 0%
3 13% 4% 12% 40% 22% 0% 10% 0% 0% 0%
4 20% 33% 12% 10% 22% 0% 20% 0% 0% 0%
5 24% 21% 29% 20% 11% 50% 30% 0% 0% 0%
6 23% 29% 12% 10% 11% 25% 40% 0% 0% 100%
Social
determin
1 12% 8% 18% 0% 11% 25% 20% 0% 0% 0%
2 12% 8% 6% 0% 11% 50% 30% 0% 0% 0%
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Rank Total Patient
Community
member
Patient
advocate Employee Leader Clinician C-Suite
Board
member Other
ants of
health
3 8% 8% 12% 0% 0% 0% 10% 0% 0% 100%
4 21% 13% 29% 50% 0% 0% 30% 0% 0% 0%
5 31% 42% 18% 30% 67% 0% 10% 0% 0% 0%
6 16% 21% 18% 20% 11% 25% 0% 0% 0% 0%
Clinician
implicit
bias
1 4% 4% 12% 0% 0% 0% 0% 0% 0% 0%
2 11% 4% 0% 40% 11% 0% 20% 0% 0% 0%
3 12% 4% 18% 20% 0% 25% 20% 0% 0% 0%
4 19% 29% 18% 0% 33% 25% 0% 0% 0% 0%
5 13% 17% 18% 0% 0% 0% 20% 0% 0% 100%
6 41% 42% 35% 40% 56% 50% 40% 0% 0% 0%

Note. This table displays a breakdown of the participant-ranked responses by participant role. The rank indicates the level of
responsibility the participant assigned to the response. Data were not analyzed quantitatively and were used in comparative qualitative
analysis only.
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Incentives to Change
The Likert version of question Experience 2 asked how often participants believed
African American patients received unequal treatment based on race in U.S. hospitals and
healthcare systems. I aggregated the often and sometimes responses into the top box and all
others into the bottom box for display purposes, as shown in Table 23. The distribution of
participant responses across stakeholder groups is shown in Table 24. Seventy-nine percent
(n = 72) of respondents acknowledge their awareness of unfair treatment in the healthcare
setting. The open-ended version of question Experience 2 asked participants to expound upon
why they feel African American patients receive unequal treatment in U.S. hospitals. Forty
participants (n = 55) provided rich data reflecting their opinions. Only one person stated they did
not feel that African American or other minority groups receive unequal treatment in the
healthcare setting.
Of those who did agree, there were various rationales provided. In these responses,
participants shared that those who impart unfair treatment have an incentive to continue the
behavior, signified by comments such as: “I think it occurs because some of us (and usually the
people on top making decisions) benefit from racism and keeping others down,” and “It may
occur because many people don’t think discriminating them is a big deal to them.” One person
representing the patient stakeholder group penned, “African Americans are not pure blood and
are not real citizens of the United States.” All aforementioned statements are examples of moral
disengagement touching on all four loci of moral agency, as they leverage behavior and agency,
dehumanize the victims, and disregard negative effects. These statements also signify interest
convergence as it suggests that there is greater interest in continuing unfair treatment than
changing it, as people initiating it have a direct benefit from it.

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Table 23
Experience 2 Likert Results
Experience 2 Count
(n = 72)
Percent
Top box 58 79.2%
Bottom box 15 20.8%

Note. The top box represents responses that indicate any level of agreement with the statement.
The bottom box represents responses with any level of disagreement or ambiguity. The count
and percentage represent all qualifying responses to this individual question. Likert responses
were not analyzed quantitatively. The results were used to support comparative qualitative
analysis.

Table 24
Experience 2 Likert Participants by Stakeholder

Total Patient
Community
member
Patient
advocate Employee Leader Clinician C-suite
Board
member Other
Total count 72 20 15 10 9 7 10 0 0 1
Often 40% 55% 33% 40% 22% 14% 50% 0% 0% 100%
Sometimes 39% 35% 33% 40% 67% 71% 10% 0% 0% 0%
Never 8% 5% 13% 0% 0% 14% 20% 0% 0% 0%
Unsure 13% 5% 20% 20% 11% 0% 20% 0% 0% 0%

Note. The count (n = ) and percentage represent all qualifying responses to this question. Likert responses were not analyzed
quantitatively. The results were used to support comparative qualitative analysis.
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In the experience section of the questionnaire, there was a different pathway of questions
posed to stakeholders representing employees, leaders, clinicians, or healthcare organizations.
This question series sought direct information about what healthcare organizations have done
and are doing to promote health equity and/or diversity, equity, and inclusion, as well as when
organizations implemented the initiatives and an opportunity to share success stories. The
purpose behind these questions was to determine if the social climate from the public health
crises exposed by COVID-19 and the death of George Floyd influenced healthcare organizations
to promote health equity actively. Of the 42 participants who identified as employees, leaders,
clinicians, or C-suite leaders, 26 shared information about initiatives. In a Likert scale question,
participant responses designated when they believed the initiative’s implementation occurred,
prior to 2020, 2020, 2021, 2022, and or if no initiative existed. I categorized answers into a top
and bottom box. Prior to 2020 was the top box selection, and all others were the bottom box, as
shown in Table 25.

Table 25
Experience 3a Likert Results
Experience 3a Count (n = 26) Percent
Bottom box 16 61.5%
Top box 10 38.5%

Note. The top box responses represent the “Prior to 2020” responses. The bottom box represents
all other responses.

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The distribution of participant responses across stakeholder groups is shown in Table 26.
Approximately 62% (n = 16) of responses were in the bottom box, with seven of those having
implemented initiatives after 2020 or not at all. Comments about the types of initiatives
implemented revealed examples reflecting the image of the healthcare organization or the
opinion of the healthcare workers, as opposed to underserved patients. Participants noted,
“Success today is about awareness and alignment to our values as a company” and “Most people
were very nice and humane about our decision.” These are examples of comments that centered
on the organizational culture. It bears stating that this may be an inference on the meaning as
there was not an opportunity to gain details about the company values and specific decisions
referenced in these comments.
Descriptions of the types of initiatives implemented involved the creation of senior-level
diversity, equity, and inclusion leaders (n = 2), the establishment of employee resource groups
(n = 2), and training for patient-facing and non-patient-facing staff (n = 2). Of the 15 responses
received prompting participants to share success stories of the implemented initiatives, none of
the comments provided a clear story of success other than the fact that an initiative was
implemented. Nine of these responses were disregarded due to limited and incohesive
information. While there were limited data obtained from these questions, the overall theme
suggests that the organizations represented in this study implemented performative initiatives
with no clear descriptions of success.

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Table 26
Experience 3a Likert Participant by Stakeholder

Total Employee Leader Clinician
C-
suite
Board
member Other
Total count (answering) 26 9 6 10 0 0 1
Prior to 2020 38% 11% 50% 50% 0% 0% 100%
2020 35% 56% 50% 10% 0% 0% 0%
2021 8% 11% 0% 10% 0% 0% 0%
2022 8% 22% 0% 0% 0% 0% 0%
This organization has not
implemented a health
equity and/or diversity,
equity, and inclusion
initiative. 12% 0% 0% 30% 0% 0% 0%

Note. The count and percentage represent all qualifying responses to this individual question.
Likert responses were not analyzed quantitatively. The results were used to support comparative
qualitative analysis.

Overall Frustration With the Current State of Healthcare
To close out the questionnaire, I provided all stakeholders an opportunity to share
suggestions and open comments about potential solutions to promote safe and equitable care.
When reviewing participant responses, I identified an emerging theme of frustration. Across
stakeholder groups, I posed two versions of questions for Experience 3: “Please share any
thoughts or suggestions you would like to see Healthcare organizations implement to promote
equitable and safe care” was the open-ended question posed to the patient group. In the previous
section, I discussed the question series posed to the healthcare worker and clinician group. This
question received 30 responses, eight of which I disregarded for incomplete or incohesive
comments. Participants shared thoughts about hindrances and potential solutions to the health
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equity issue. There is a trend among responses from the patient stakeholder group expressing a
need for relief from the effects of health inequities. One White female patient commented,
Since our healthcare organizations are profit-driven, any real change toward safe and
equitable care that they take the lead in would have to come with a dent in profits. One
thing they could do now is one bill. Not a bill from the hospital, a bill from the pharmacy,
a bill from the provider, etc. Remove barriers to care. With many people working
multiple jobs, access to care at varying hours and on weekends. Aid in transportation.
And enough of the ridiculous policy that you can’t bring kids. Childcare should not be an
additional financial burden to receiving medical care.
In this comment, the participant expresses an awareness of the need for interest
convergence to move healthcare organizations to provide better treatment of patients. There is an
underlying tone of exasperation with the healthcare system through their offering of solutions,
which are currently barriers to equal care. Another respondent also references access to care as a
strategy to ensure equitable care:
One of the feasible strategies to ensure equitable healthcare in the [U.S.] is establishing a
universal healthcare which would provide full healthcare coverage to all citizens financed
through taxation. Such a strategy would avoid implicit [bias] resulting from one’s social
and economic class. Moreover, the government should establish policies which would
discourage all forms of racism, which should be categorized as a punishable crime in a
court of law.
This statement implies an awareness or acknowledgment that the current practices are conducted
through a social justification mechanism and that what is currently considered a societal normal
would need to change through the legislature, with consequences for infractions.
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In the final survey question, I provided all participants an opportunity to share general
thoughts about the survey and the topics shared with the following prompt: “Please feel free to
provide any additional thoughts that you think would be helpful for this research study.” There
were 42 responses received from participants, and 33 (78.38%) were disregarded for incomplete
or incohesive answers. This may be due to cognitive overload experienced by participants at the
close of this study (Sweller et al., 2011). Of the responses I included in the analysis of this
answer, there was an overarching sentiment of frustration for actionable change. Comments such
as “good luck with that,” “above my pay grade,” and “fight” expressed a sentiment of distancing
from active participation toward a solution. One sentiment expressed by a C-suite level clinician
was the strongest expression of disdain for current practices: “I have been a fierce defender of
patients since my early days at XXX Hospital, and care that is not safe, timely, equitable,
efficacious, efficient, and patient-centered frankly pisses me off.” Another participant shared:
“Pay attention to racial discrimination in the medical care environment.” These sentiments imply
the engagement of the agency and victim loci where the respondents expressed exasperation with
the issue of health inequity but a disassociation with the solution and even a confounding sense
of what the healthcare industry can actually do to change the current trajectory.
Discussion Research Question 2
The data show that the healthcare organization is just one player, albeit a major player, in
promoting health equity and dismantling health inequities. Regarding Research Question 2,
government policy allows for the corporatization of healthcare delivery, which is the underlying
root cause of this matter. The U.S. government has created an opportunistic environment for a
capitalistic approach to medical care that healthcare organizations have leveraged for profit. The
corporatization of health and medical care leverages all loci of moral disengagement, the
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mechanism of moral, social, and economic justification being the most prominent. It is also
evident to healthcare employees, clinicians, leaders, and laypersons that an interest convergence
of benefit or penalty would be necessary to change current practices.
Summary
This study conducted an evaluation of stakeholder perspectives on the role of the
healthcare organization in the United States and analyzed data using moral disengagement and
interest convergence conceptual frameworks. The initial aim of the study was to uncover
practical steps that the healthcare organization can take to eliminate racial disparities in
healthcare and promote equal treatment. Interestingly, I discovered that organizations and the
larger public are aware of systemic racism and its adverse impact on healthcare. Furthermore,
stakeholders demonstrate awareness of potential solutions to eliminate health disparities and
promote equal medical care as well as feelings of exasperation with how to affect change. The
data concludes that healthcare organizations perpetuate systemic racism through healthcare
delivery because government and policy allow it to continue. As long as policies remain in their
current state, so will the practices of the healthcare organization in the United States. Plausible
solutions will need to involve federal-level regulation of healthcare organizations.

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Chapter Five: Recommendations
The purpose of this research was to understand the perpetuation of systemic racism in
healthcare. It simultaneously acknowledges that systemic racism and capitalism are synonymous
in the sense that both seek to exploit people for the benefit of others. The following
recommendations extend beyond the reach of the healthcare organization, and as a result, they
will continue to perpetuate inequities if the current level of accountability remains. Competing
priorities and market fluctuations create opportunities and excuses to perpetuate systemic racism
and greed. Valid solutions must come from the federal level. I recommend the following
solutions to eliminate the perpetuation of systemic racism in the healthcare system: medical
education curriculum standardization, patient safety regulation, and healthcare policy reform.
The literature and study findings reinforce the recommendations of this study. I found
limited empirical evidence of systemic racism; however, the historical accounts of the origins of
racism in the United States discussed in chapter two provide validation that it exists and
information on how it impacts healthcare. White supremacists established the systems of racism
in this country's founding years to exploit African Americans through enslavement and apartheid
conditions (Hannah-Jones, 2019; Wilkerson, 2020). The tentacles of the systems of race still
adversely impact social drivers of health, such as education, living conditions, economics,
nutrition, and access to care (Hacker et al., 2020; Hill-Briggs et al., 2021; McGhee, 2021).
For the first research question: RQ1. What are the differences in the perceptions of
systemic racism in healthcare between the stakeholders of large healthcare organizations (i.e.,
patient vs. provider vs. administrator)? One of the first findings to appear in the data of this study
was the general awareness of racism in healthcare. The data show that stakeholders of healthcare
organizations are aware that racism exists in the healthcare continuum. I expected data to reflect
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a general awareness of the impact of racism on health conditions in the United States because
literature about health inequities has been available for over 4 decades (Heckler, 1985; Smedley
et al., 2002). This awareness correlates to the moral disengagement conceptual framework
through the behavior loci and mechanism of moral justification (Bandura, 2016, 2018).
The next finding was that the stakeholders justified current practices that prioritize
revenue over equitable care. Healthcare organizations’ corporatization stems from the
exploitative culture established in the founding years of the United States (Hannah-Jones, 2019).
Data imply that mechanisms of moral disengagement across all four loci are employed to justify
this corporatization to the point of normalization (Bandura, 2016, 2018). The literature shows
that despite legislative attempts to provide equal care for all Americans regardless of ability to
pay, 12 states refused federal funding slated for Medicaid expansion (Frist & Churchwell, 2020;
Young, 2020).
The last finding is accountability avoidance. A review of the data suggests that
participants do not feel accountable for their personal contributions to the perpetuation of
unequal care. Members of the majority racial caste in the United States have historically rejected
advancements for African Americans and other minorities (Feagin, 2006; Gates, 2019; McGhee,
2021). The accountability avoidance seen in the data primarily engages the agency locus of
moral disengagement through the mechanisms of diffusion and displacement of responsibility
(Bandura, 2016, 2018).
The second research question asked about the role of healthcare organizations in
promoting health equity across minoritized patient populations and addressed the second part of
the conceptual framework of interest convergence. The data analysis revealed perceptions about
the role of government and incentives to change current practices. Government has always
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played a large part in minorities’ healthcare. The systems of race and racism began in the
founding years of this country and continue to impact every aspect of life, including healthcare
(Hannah-Jones, 2019; McGhee, 2021; Wilkerson, 2020). The participants expressed that the U.S.
government is responsible for promoting equitable care, suggesting that corporations remain
unchecked by the government in healthcare delivery practices. This aligns with the conceptual
framework of interest convergence, as the undoing of systemic racism will only occur when the
interests of those in power converge with the interests of those who are not.
The U.S. government originally established hospitals for the formerly enslaved through
the Freedman’s Bureau, and when that became economically overwhelming at a federal level,
the responsibility shifted to local agencies leaving many without proper care (Gamble, 1995; Shi
& Singh, 2017). A similar occurrence happened again in the United States when those in power
attempted to provide universal access to medical care. Local governments in mostly former
slave-holding states opposed the program and refused federal funds to ensure all have access to
equitable healthcare (ACA, 2010; Bradley et al., 2013; KFF, 2022; Medicare Access and CHIP
Reauthorization Act of 2015; Social Security Act, 1935). The literature and findings of this study
suggest that a greater interest would need to converge in U.S. society for the government to take
a stronger stance on health equity.
The next finding from Research Question 2 is incentive to change. The data show that
without an incentive to change, healthcare systems will continue to perpetuate inequitable
healthcare delivery. This finding correlates to the conceptual framework by proving that interest
convergence is the motivating factor for changes to the racial structure of the United States (Bell,
1980). The U.S. culture has shown that without interest convergence, White supremacist ideals
will perpetuate even when these penalize other Whites (McGhee, 2021). Researchers have noted
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this historically and present day in healthcare reform, as shown with attempts at universal
healthcare (ACA, 2010; Bradley et al., 2013; KFF, 2022; Medicare Access and CHIP
Reauthorization Act of 2015; Social Security Act, 1935). The interest will need to create an
incentive to change at the federal level for change to happen in the healthcare industry.
The last finding is the perception of frustration. When asked for suggestions for potential
solutions to promote equitable care, there was a general sentiment of frustration expressed by all
stakeholders on the feasibility of change. Participants expressed concern with the current state of
healthcare in the United States and disappointment directed toward the federal government. This
finding correlated to the behavior locus of the moral disengagement conceptual framework, as it
shows awareness and frustration without action (Bandura, 2018). This finding does not tie back
to historical literature because it suggests a readiness for change. The disparities seen in the
COVID-19 pandemic, paired with the social injustices displayed during the summer of 2020,
may have an impact on readiness (Watson et al., 2020; Wright et al., 2020). What remains
unknown is if the readiness expressed in this study is sustainable.
The findings provide insight into the perceptions, expectations, and experiences of
various stakeholders regarding healthcare organizations. Because moral disengagement toward
systemic racism and its perpetuation in the healthcare industry has continued to the point of
normalization, solutions must come from beyond the organization’s reach. Therefore, I offer the
following recommendations in the closing section of this paper: standardization of medical
education curriculum, heightened patient safety standards, and healthcare policy reform. The
remainder of this paper details the recommendations and suggestions for future research on
health equity promotion.

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Recommendation 1: Education Curriculum Standardization
The first recommendation is to reform the education curriculum for healthcare
professionals to include implicit bias and health equity subject matter. The changes should
involve educating all professionals involved in the patient care continuum. Pre-medicine and
healthcare administration programs should include an introduction to health equity and implicit
bias in the program curricula. This section will discuss the entry point for health equity in
physician education programs and the importance of its incorporation into healthcare leadership
and administration programs.
Physician Education
As previously established studies have shown, physicians’ implicit negative perceptions
of Black patients lead to disparate health outcomes (Burgess et al., 2019; van Ryn & Burke,
2000). Physicians should receive foundational training on eliminating disparities early in the
medical education journey to understand the impact of health disparities as well as their
underlying causes. Physicians should also be aware of implicit biases early on and understand
how to mitigate known biases from influencing care. The Liaison Committee on Medical
Education (LCME) governs accreditation of the medical school component of medical education,
and the American College of Graduate Medical Education (ACGME) governs the accreditation
of medical education residency and fellowship components in the United States. The LCME
requires medical schools to train physicians “to recognize and appropriately address biases in
themselves, in others, and in the health care delivery process” (LCME, 2023, p.11). The
ACGME’s common program competency requirements refer to the physician’s need to respect
and respond to diverse patient populations (ACGME, 2023). Yet, neither organization provides
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details on how they assess these competencies, nor is there a standardization of how to
implement this curriculum.
Figure 6 shows the timeline of medical education across the physician’s career. The
highlighted areas represent when medical students are introduced to touch points such as health
equity, implicit bias, and the concept of cultural competencies. However, the current curricula
guidelines are vague and up to the interpretation of the individual programs. Standardization of
implicit bias and health equity curriculum is important to provide clear guidance for medical
education organizations and a method to assess the success of the curriculum. Additionally, there
is no requirement for pre-medical students to receive education on health inequities or their root
causes. An introduction to foundational education about SDOH, health disparities, and implicit
biases should begin in the undergraduate setting with increasing complexity and context as
students matriculate through their medical education program. Nursing and allied health
programs that train other patient care professionals should also consider a similar structure.

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Figure 6
Health Equity Curriculum Across the Physician Education Timeline

Healthcare Leadership and Administrative Education
The role of the healthcare administrator has a significant influence on the patient care
continuum. In the current atmosphere of the healthcare system in the United States, the
healthcare administrator’s role has a larger sphere of influence on healthcare delivery than any
patient care professional because administrators set the policies, processes, and governance in
which medical professionals can provide care. At present, specific training is not required for
healthcare administrators. Various degree pathways can provide healthcare administrators and
leaders with information unique to the industry, but these are not a requirement. It is important
for current and future healthcare leaders to understand how their decisions impact the patient and
how they can promote equitable care. Organizations such as the American College of Healthcare
Executives, the Commission on Accreditation of Healthcare Management Education, and the
Association of University Programs in Health Administration provide options for healthcare
Pre-Med
Medical Student
- LCME
Residency
Program -ACGME
Fellowship
Program -ACGME
Continuing
Professional
Development -
Specialty & State
Licensure Boards
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administration program accreditation and professional prestige among executives. However,
there is no standard curriculum for healthcare leaders provided. One sure way to eliminate the
perpetuation of systemic racism in healthcare is to inform future leaders of healthcare
organizations on SDOH, health disparities, and their root causes early on in the educational path.
Additionally, entry-level education and continuing education for healthcare leaders on health
equity should be a requirement in the same manner as patient care professionals. The
standardization and continuing education approach should dimmish healthcare leaders’ profit-
first mentality and reinforce a patient-first mindset.
Recommendation 2: Heighten Patient Safety Standards
The goal of the second recommendation is to improve accountability for healthcare
organizations in the area of patient safety reporting and data analysis. As shared in Chapter Two,
African Americans report instances of discrimination in the healthcare setting (Nguyen et al.,
2017). In the current practice, when a patient safety reporting system documents an incident, the
event’s details are considered protected work products through the Patient Safety Organization
(U.S. Department of Health and Human Services, 2008). Protected work product means that
once a healthcare employee documents an event in the event reporting system, the event
investigation and response details do not have to be shared, even in a court of law (U. S.
Department of Health and Human Services, 2008). Even sentinel events reporting, which are
events of the greatest severity, including death and permanent harm, are only suggested by the
JC for accredited facilities (The JC, 2023). In most cases, sentinel events are reportable to state
agencies, but there are no standard guidelines. I recommend elevating reports of discrimination
to a sentinel event and having mandatory reporting requirements as part of the JC patient safety
guidelines as a metric of how well an organization is improving health equity. There should also
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be standard requirements for state health agencies in reporting and investigating reports of
discrimination in the healthcare setting. Additionally, patients should have access to the tools and
resources to advocate for themselves in the healthcare setting. Healthcare organizations should
explicitly communicate contact information to report adverse events, including discriminatory
ones. Contact information for patient advocates and navigators should be available to
marginalized patients for in-the-moment assistance when facing an issue or for any reason to
help create an atmosphere of trust in the care setting.
Those on the federal level should mandate funding for groups providing patient advocacy
and navigation services to patients impacted by SDOH. This differs from a social worker in the
sense that this person has specific training with regard to advocacy techniques and walks
alongside the patient. Lastly, hospitals and ambulatory settings currently implement the AHRQ
Surveys on Patient Safety Culture (SOPS). The submission of the completed surveys is optional.
In 2022, only 400 of the 6093 active hospitals in the United States participated and submitted
information (AHA, 2022; AHRQ, 2023). This number represents only 6.56% of the total
hospitals in this country. The SOPS report is currently one of the optional performance
improvement activities for the merit-based incentive payment system, assessed at the hospital
level and not the system level (CMS, 2023).
I recommend that the survey and submission of the data is a Medicare reimbursement
requirement for all hospitals and ambulatory care centers. The survey assesses the level of
patient safety from the view of the healthcare employee, and if a larger data set were available,
there would be a more accurate picture of the status of safe and equitable care in the United
States. Also, the survey should consider the diversity of the patient populations served and the
diversity of the employees in assessing equitable care. Medical establishments should implement
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the SOPS reporting mandates, the use of health equity advocates and navigators, and
transparency in adverse event reporting with minimal government intervention. However, it is
worth noting that it will require federal-level enforcement to ensure accountability and follow-
through.
Recommendation 3: Overall Policy Reform
The issue of health disparities has been known for decades (Smedley et al., 2002) and is
not a new phenomenon. As demonstrated in this study's findings, mechanisms of moral
disengagement have allowed the federal government to approach health disparities with fits and
starts over the years. At present, the fervor for health equity is waning as competing priorities
such as staffing, revenue, and physician burnout take precedence. However, health equity cannot
be a trend addressed only when made popular because of racial tensions in our greater society.
An equity lens must always be at the forefront of healthcare to keep the most vulnerable people
safe from the capitalism that drives the healthcare industry. Therefore, the first and most
important recommendation is healthcare industry regulation. This academic program gears itself
toward understanding how to lead and manage change in organizations. The greatest and most
impactful change needed in healthcare is policy reform. Current policies in healthcare have
created an atmosphere that allowed for the corporatization of health, which is at the root of the
perpetuation of disparate health outcomes in the United States. I am well aware that this is a lofty
recommendation that those at the federal level must enact. I also understand that the social and
political will of the United States would need to change before policy changes in healthcare
occur. However, this section will provide recommendations for implementing regulatory options
over time.
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One recommended approach for policy change came from a response to the
questionnaire: “Maybe the government should limit earnings from healthcare organizations
similar to how utility companies are regulated.” No agency currently regulates healthcare
organizations’ earnings, and a curb on how healthcare organizations earn money may bring
patient care back into focus. Future policy research should consider examining the feasibility of
enacting healthcare industry regulations similar to those in the energy sector. These regulations
should impact the earnings of healthcare organizations and ensure that all Americans, regardless
of race, economic status, and location, have access to safe and equitable care.
In addition, unionizing healthcare workers is an additional approach that would create
greater accountability. The voices of the healthcare workers and patient community will need to
lobby for the desired improvements and regulations. A report from the Service Employees
International Union (SEIU, 2022) found the conglomerate healthcare organization HCA
responsible for poor business behavior in low staffing. The report details how the organization
reduced staffing levels to increase profits in hospitals across the country, jeopardizing patient and
employee safety (SEIU, 2022). Broadscale unionization of patient-facing healthcare workers,
including physicians, would give this group a greater voice to lobby for what is necessary to
provide safe and equitable care. Increasing union participation and representation could also
accelerate policy reform efforts, adding a voice that speaks to patients’ interests and not those of
the corporation.
Limitations and Delimitations
During the inquiry phase of this study, the largest constraint was due to the methodology.
The qualitative questionnaire allowed for participant confidentiality and fit within this program’s
time and resource constraints. However, the methodological approach I chose was a compromise
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with my previous dissertation chair. I may have obtained greater quality data using a true mixed-
methods approach. I would have maintained confidentiality for the quantitative data and targeted
rich data through qualitative interviews, thereby increasing the validity and reliability of the data
analysis.
The incentive of a $100 Amazon gift card may have contributed to the lack of quality
responses received. It was evident during the clean-up portion of the study that some participants
may have responded only to receive a chance to enter the drawing for the gift card. Additionally,
the senior leadership stakeholder groups should have been the sole focus of this study. The
organizational leadership stakeholder group is where moral disengagement and interest
convergence play out and where I should have focused my exploration. The data analysis phase
revealed the need to focus on a singular stakeholder group. Lastly, I only offered the survey in
English, which may have excluded participants who do not read and write in English. Providing
the survey in different languages like Spanish and French may have attracted additional
participants from the patient and healthcare employee stakeholder groups.
The delimitations of this study also involve the methodology choice. The initial plan was
to employ a mixed methodology to include a quantitative field study and targeted qualitative
interviews of key leaders in the healthcare industry. That approach would have broadened the
audience of respondents and the quality of responses received for this study. I appreciate this
study’s responses and contributions toward recommended health equity promotion policy reform
solutions. Yet, healthcare organizations still need specific guidance on practice changes to
implement at the organizational level while the people of the United States await policy reform.
Additionally, the research questions chosen for this study excluded the perspectives of
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lawmakers. I include potential solutions to overcome the limitations and delimitations of this
study in the following section.
Recommendations for Future Research
Future research should repeat a similar version of this study, incorporating a different
methodology and a wider target audience. A researcher could repeat this study as three separate
studies: one focused solely on the patient’s perspective, another on the healthcare workers and
providers, and a third on the senior leaders and board members of healthcare organizations. As
expressed in the previous section on limitations, time and resource constraints related to the
doctorate dissertation research may have impacted the depth and quality of data collection.
Research on understanding the causes and impact of health disparities has been saturated.
Also, future research should use qualitative and quantitative data on potential solutions
from the aforementioned stakeholder groups. These solutions should include greater
accountability regarding quality and patient safety while restricting healthcare organizations’
earning capabilities. Future research should also explore standardizing health equity education
and introduce curricula early and consistently along educational paths for patient-facing
caregivers and healthcare administrators. Future participants should include policymakers,
lobbyist groups, and legislators to understand how to advance safer and equitable care. All
explored solutions should involve changes to policies and agencies that govern healthcare
organizations and should come from the federal level, not independent corporations.
Conclusion
In conclusion, systems of race and racism, including capitalism, are woven into the fabric
of U.S. society. Previous approaches have sought to change the hearts and minds of individual
contributors from discrimination to equality. However, I believe this is the wrong approach. This
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study’s findings and subsequent recommendations are important, as they highlight what may
already be known but not admitted: this system cannot change by simply addressing the
symptoms. Like taking cough medicine for the flu, it will stop the coughing temporarily, but the
virus will continue to manifest throughout the body. In the same sense, the disease of systemic
racism has been perpetuated for far too long in this country, and exploiting people for another’s
gain must stop.
The post-Civil War Southerners knew this well and took extenuating steps to ensure the
order of the pre-Civil War era remained intact, even after it unraveled. The government should
take a similar approach by creating accountability measures for organizations that perpetuate
injustices. Unfortunately, political will waned on this subject from the start of this research, and
change will rely heavily on the people’s will to do it. The decades of data demonstrating the
harms caused by racism in healthcare are inadequate to propel society toward change. Right now,
we are at an inflection point where the country has an opportunity to do the right thing in
promoting health equity. The current presidential administration has charged government
organizations (The White House, Office of the Press Secretary, 2021) with the duty of
researching potential solutions. Those solutions must move past presenting the case for health
equity and create standards for change across the continuum that restore faith, hope, and trust in
the patient populations that have been harmed.

119

References
Agency for Healthcare Research and Quality. (2020). Social determinants of health database.
https://www.ahrq.gov/sdoh/data-analytics/sdoh-data.html
Agency for Healthcare Research and Quality. (2022). What is cultural and linguistic
competence? https://www.ahrq.gov/ncepcr/tools/cultural-competence/definition.htm
Ahnquist, J., Wamala, S. P., & Lindstrom, M. (2012). Social determinants of health – A question
of social or economic capital? Interaction effects of socioeconomic factors on health
outcomes. Social Science & Medicine 74(6), 930–939.
https://doi.og/10.1016/j.socscimed.2011.11.026
Alexander, M. (2020). The New Jim Crow: Mass incarceration in the age of colorblindness. The
New Press.
American College of Graduate Medical Education Common Program. (2023). Competency
manual for residents.
https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.
pdf
American Hospital Association. (2021). American Hospital Association: History.
https://www.aha.org/about/history
American Hospital Association. (2022). Fast facts on hospitals in US.
https://www.aha.org/system/files/media/file/2022/01/fast-facts-on-US-hospitals-2022.pdf
American Hospital Association Institute for Diversity and Health Equity. (2021). Equity
roadmap. https://equity.aha.org/
Anderson, O. W. (1990). Health services as a growth enterprise in the United States since 1875.
Health Administration Press.
120

Andrasfay, T., & Goldman, N. (2022). Reductions in US life expectancy from COVID-19 by
race and ethnicity: Is 2021 a repetition of 2020? PLoS One, 17(8), Article e0272973.
https//doi.org/10.1371/journal.pone.0272973
Andrews, K. (2021). Racism is the public health crisis. Lancet, 397(10282), 1342–1343.
https://doi.org/10.1016/S0140-6736(21)00775-3
Ansell, D. A., Oliver-Hightower, D., Goodman, L. J., Lateef, O. B., & Johnson, T. J. (2021).
Health equity as a system strategy: The Rush University Medical Center framework.
NEJM Catalyst Innovations in Care Delivery, 2(5), Advance online publication.
https://doi.org/10.1056/CAT.20.0674
Artiga, S., & Hinton, E. (2018). Beyond health care: The role of social determinants in
promoting health and health equity. Kaiser Family Foundation.
https://files.kff.org/attachment/issue-brief-beyond-health-care
Baciu, A., Negussie, Y., Geller, A., & Weinstein, J. N. (2017). Communities in action: Pathways
to health equity. National Academies Press.
https://www.ncbi.nlm.nih.gov/books/NBK425845/
Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural
racism and health inequities in the USA: Evidence and interventions. The
Lancet, 389(10077), 1453–1463. https://doi.org/10.1016/S0140-6736(17)30569-X
Baker, R. B. (2014). The American Medical Association and race. The Virtual Mentor, 16(6),
479–488. https://doi.org/10.1001/virtualmentor.2014.16.06.mhst1-1406
Baker, R. B. (2022). The historical racial regime and racial inequality in poverty in the American
south. American Journal of Sociology, 127(6). https://doi.org/10.1086/719653
121

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Prentice-Hall.
Bandura, A. (2016). Moral disengagement: How people do harm and live with themselves.
Worth Publishers, Macmillan Learning.
Bandura, A. (2018). A commentary on moral disengagement: The rhetoric and the reality.
American Journal of Psychology, 131(2), 246–251.
https://doi.org/10.5406/amerjpsyc.131.2.0246
Bell, D. (2005). Silent covenants: Brown V. Board of Education and the unfulfilled hopes for
racial reform. Oxford University Press USA - OSO.
Bell, D., Jr. (1980). Brown v. Board of Education and the interest-convergence dilemma.
Harvard Law Review, 93, 518–533. https://doi.org/10.2307/1340546
Blair, I., Steiner, J. F., Fairclough, D. L., Hanratty, R., Price, D. W., Hirsh, H. K., Wright, L. A.,
Bronsert, M., Karimkhani, E., Magid, D. J., & Havranek, E. P. (2013). Clinicians’
implicit ethnic/racial bias and perceptions of care among Black and Latino patients.
Annals of Family Medicine, 11(1), 43–52. https://doi.org/10.1370/afm.1442
Boilard, S. (2020). Redlining. In Civil Rights Movements: Past and Present: L-Z (pp. 542–543).
Salem Press.
Bonds, A., & Inwood, J. (2016). Beyond white privilege: Geographies of white supremacy and
settler colonialism. Progress in Human Geography, 40(6), 715–733.
https://doi.org/10.1177/0309132515613166
Bonilla-Silva, E. (1997). Rethinking racism: Toward a structural interpretation. American
Sociological Review, 62(3), 465–480. https://doi.org/10.2307/2657316
122

Bonilla-Silva, E. (2015). The structure of racism in color-blind, “post-racial” America. The
American Behavioral Scientist, 59(11), 1358–1376.
https://doi.org/10.1177/0002764215586826
Bradley, E. H., Taylor, L. A., & Fineberg, H. V. (2013). The American health care paradox:
Why spending more is getting us less. Public Affairs.
Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners.
Sage Publications.
Braun, V., Clarke, V., Boulton, E., Davey, L., & McEvoy, C. (2021). The online survey as a
qualitative research tool. International Journal of Social Research Methodology, 24(6),
641–654. https://doi.org/10.1080/13645579.2020.1805550
Braveman, P. A., Arkin, E., Proctor, D., Kauh, T., & Holm, N. (2022). Systemic and structural
racism: Definitions, examples, health damages, and approaches to dismantling. Health
Affairs, 41(2), 171–178. https://doi.org/10.1377/hlthaff.2021.01394
Braveman, P. A., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider
the causes of the causes. Public Health Reports, 129(Suppl 2), 19–31.
https://doi.org/10.1177/00333549141291S206
Bretz, B. (2010). The poor people’s campaign: An evolution of the Civil Rights Movement.
Sociological Viewpoints, Spring, 19–25.
Brown Henderson, C., & Brown, S. M. (2016). The Southern Manifesto: A Doctrine of
Resistance 60 Years Later. Journal of School Choice, 10(4), 412–419.
https://doi.org/10.1080/15582159.2016.1238732
Brown v. Board of Education of Topeka, 347 U.S. 483 (1954)
Brownstein, M. (2019). Implicit bias. https://plato.stanford.edu/entries/implicit-bias/
123

Brückmann, R. (2019). Citizens’ councils, conservatism and White supremacy in Louisiana,
1964–1972. European Journal of American Studies, 14(1). Advance online publication.
https://doi.org/10.4000/ejas.14437
Brückmann, R., Hartmann, D., Ogbar, J. O, Rolland-Diamond, C., Street, J., van den Berk, J.,
Visser-Maessen, L., & Zwiers, M. (2019). Special issue: Race matters: 1968 as living
history in the Black freedom struggle. European Journal of American Studies, 14(1).
https://doi.org/10.4000/ejas.14226
Burgess, D., Bokhour, B. G., Cunningham, B. A., Do, T., Eliacin, J., Gordon, H. S., Gravely, A.,
Jones, D. M., Partin, M. R., Pope, C., Saha, S., Taylor, B. C., & Gollust, S. E. (2019).
Communicating with providers about racial healthcare disparities: The role of providers’
prior beliefs on their receptivity to different narrative frames. Patient Education and
Counseling, 102(1), 139–147. https://doi.org/10.1016/j.pec.2018.08.030
Castro, F. G., Kellison, J. G., Boyd, S. J., & Kopak, A. (2010). Methodology for conducting
integrative mixed methods research and data analyses. Journal of Mixed Methods
Research, 4(4), 342–360. https://doi.org/10.1177/1558689810382916
Centers for Disease Control and Prevention. (2017). African American health: Creating equal
opportunities for health. Vital Signs. https://www.cdc.gov/vitalsigns/pdf/2017-05-
vitalsigns.pdf
Centers for Disease Control and Prevention. (2022a). Chronic diseases. National Center for
Chronic Disease and Health Promotion.
https://www.cdc.gov/chronicdisease/about/index.htm
Centers for Disease Control and Prevention. (2022b). Health disparities. Healthy youth.
https://www.cdc.gov/healthyyouth/disparities/index.htm
124

Centers for Disease Control and Prevention. (2022c). Health equity.
https://www.cdc.gov/chronicdisease/healthequity/index.htm
Centers for Medicare and Medicaid Services. (2022a). CMS program history.
https://www.cms.gov/About-CMS/Agency-Information/History
Centers for Medicare and Medicaid Services. (2022b). CMS proposes policies to advance health
equity and maternal health, support hospitals [Press Release].
Centers for Medicare and Medicaid Services. (2023). Quality payment program improvement
activities. https://qpp.cms.gov/mips/explore-
measures?tab=improvementActivities&py=2023
Centers on Budget and Policy Priorities. (2022). Tracking the COVID-19 economy’s effects on
food, housing, and employment hardships. COVID hardship watch. Special report.
https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-
effects-on-food-housing-and
Charmaz, K. (2014). Constructing grounded theory (2nd ed.). SAGE Publications.
Cheeseman-Day, J., & Christnacht, C. (2019). Women hold 76% of all health care jobs, gaining
in higher-paying occupations: America counts: Stories behind the numbers; Your
healthcare is in women’s hands. U.S. Census Bureau.
The Civil Rights Act of 1964 is Public Law 88-352 (78 Stat. 241)
Clayton, D. (2018). Black Lives Matter and the Civil Rights Movement: A comparative analysis
of two social movements in the United States. Journal of Black Studies, 49(5), 448–480.
https://doi.org/10.1177/0021934718764099
Clotfelter, C. T. (2004). After Brown: The rise and retreat of school desegregation. Princeton
University Press.
125

Coe, E. H., Cordina, J., Feffer, D., & Parmar, S. (2020). Understanding the impact of unmet
social needs on consumer health and healthcare. McKinsey & Company.
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-
insights/understanding-the-impact-of-unmet-social-needs-on-consumer-health-and-
healthcare
Collins, W. J., & Wannamaker, M. H. (2014). Selection and economic gains in the Great
Migration of African Americans: New evidence from linked census data. The American
Economic Journal, 6(1), 220–252.
Columbia Public Schools. (2022). Map: Slave states v. free states.
https://www.cpsk12.org/cms/lib/MO01909752/Centricity/Domain/3513/Civil%20War%2
0Essay%20Charts.pdf
Conrad, C. A., Whitehead, J., Mason, P. L., & Stewart, J. (2005). African Americans in the U.S.
economy. Rowman & Littlefield.
Cooper, L., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A., Greenwald, A. G., & Inui, T.
S. (2012). The associations of clinicians’ implicit attitudes about race with medical visit
communication and patient ratings of interpersonal care. American Journal of Public
Health, 102(5), 979–987. https://doi.org/10.2105/AJPH.2011.300558
Cordina, J., Greenfield, M., Purcell, L., & Stueland, J. (2021). How employers can help advance
health equity in the workplace. McKinsey & Company.
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-
insights/income-alone-may-be-insufficient-how-employers-can-help-advance-health-
equity-in-the-workplace
126

Coronavirus Aid, Relief, and Economic Security Act 15 U.S. Code Chapter 116
https://www.congress.gov/bill/116th-congress/senate-bill/3548
Crenshaw, K., Gotanda, N., Peller, G., & Thomas, K. (Eds.). (1995). Critical race theory: The
key writings that formed the movement. The New Press.
Creswell, J. (2018). Research design: qualitative, quantitative, and mixed methods approaches
(5th ed.). SAGE Publications.
Cummins, S. (2012). Review of Black & White: The Confrontation of Reverend Fred L.
Shuttlesworth and Eugene “Bull” Connor, by L. D. Brimner. Journal of Adolescent &
Adult Literacy, 55(6), 569–570. http://www.jstor.org/stable/41827867
Cutting, C. C., & Collen, M. F. (1992). A historical review of the Kaiser Permanente Medical
Care Program. Journal of the Society for Health Systems, 3(4), 25–30.
Delgado, R., & Stefancic, J. (2017). Critical race theory: An introduction (3rd ed.). NYU Press.
Dellinger, D. (2018, April 4). The last march of Martin Luther King. The Atlantic.
Demaske, C. (2009). The First Amendment encyclopedia. Free Speech Center at Middle
Tennessee State University. https://www.mtsu.edu/first-amendment/article/1254/critical-
race-theory
Devine, P. (1989). Stereotypes and prejudice: Their automatic and controlled components.
Journal of Personality and Social Psychology, 56(1), 5–18. https://doi.org/10.1037/0022-
3514.56.1.5
Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017). Inequality and the health-care
system in the USA. The Lancet, 389.
127

Dovidio, J. F., Eggly, S., Albrecht, T., Hagiwara, N., & Penner, L. (2016). Racial biases in
medicine and healthcare disparities. Testing, Psychometrics, Methodology in Applied
Psychology, 23(4), 489–510.
Downs, J. (2012). Sick from Freedom: African American Illness and Suffering during the Civil
War and Reconstruction. Oxford University Press.
https://doi.org/10.1093/acprof:osobl/9780199758722.001.0001
Du Bois, W. E. B. (1901). The Freedman’s Bureau. The Atlantic, March.
https://www.theatlantic.com/magazine/archive/1901/03/the-freedmens-bureau/308772/
Du Bois, W. E. B. (2017). Black Reconstruction in America: Toward a history of the part which
black folk played in the attempt to reconstruct democracy in America, 1860–1880. Taylor
and Francis. (Original work published in 1935). https://doi.org/10.4324/9781315147413
Du Bois, W. E. B., & Anderson, E. (1996). The Philadelphia Negro: A social study. University
of Pennsylvania Press. (Original work published 1899).
https://doi.org/10.9783/9780812201802
Dunning, W. A. (1907). Reconstruction, political and economic, 1865–1877. Harper & Brothers.
Eichenlaub, S. C., Tolnay, S. E., & Trent Alexander, J. (2010). Moving Out but Not Up:
Economic Outcomes in the Great Migration. American Sociological Review, 75(1), 101–
125. https://doi.org/10.1177/0003122409357047
Elfil, M., & Negida, A. (2017). Sampling methods in clinical research: An educational review.
Emergency, 5(1), e52.
Entress, R., & Anderson, K. (2020). The politics of health care: Health disparities, the
Affordable Care Act, and solutions for success. Social Work in Public Health, 35(4),
152–162. https://doi.org/10.1080/19371918.2020.1767750
128

Equal Justice Initiative. (2022). Reconstruction in America: Racial violence after the Civil War,
1865–1876. https://eji.org/report/reconstruction-in-america/
Falk, G. (1999). Hippocrates assailed: The American health delivery system. University Press of
America.
Feagin, J. R. (2000). Racist America roots, current realities, and future reparations. Routledge.
Feagin, J. R. (2006). Systemic racism: A theory of oppression. Routledge.
https://doi.org/10.4324/9781315880938
Feagin, J. R. (2012). White party, White government: Race, class, and U.S. politics. Routledge.
https://doi.org/10.4324/9780203122433
Feagin, J. R., & Ducey, K. (2019). Racist America: Roots, current realities, and future
reparations (4th ed.). Routledge.
Feagin, J. R., & McKinney, K. D. (2003). The many costs of racism. Rowman & Littlefield.
FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic
review. BMC Medical Ethics, 18, Article 19. https://doi.org/10.1186/s12910-017-0179-8
Flexner, A. (1910). Medical education in the United States and Canada: A report to the
Carnegie Foundation for the Advancement of Teaching (Bulletin No. 4). The Carnegie
Foundation for the Advancement of Teaching,
Ford, C. & Airhihenbuwa, C, (2010). Critical race theory, race equity, and public health: Toward
antiracism praxis. American Journal of Public Health, 100(S1), S30–S35.
https://doi.org/10.2105/AJPH.2009.171058
Fram, S. M. (2013). The constant comparative analysis method outside of grounded theory.
Qualitative Report, 18(1), 1–25.
129

Framingham Source. (2021). Mass Nurses Association calls for investigation into patient
dumping by Tenet Healthcare.
https://framinghamsource.com/index.php/2021/10/26/mass-nurses-association-calls-for-
investigation-into-patient-dumping-by-tenet-healthcare/
Fredrickson, G. M. (2008). Big enough to be inconsistent: Abraham Lincoln confronts slavery
and race. Harvard University Press. https://doi.org/10.4159/9780674033733
The Freedmen’s Bureau. (1871). The Anti-Slavery Reporter. British and Foreign Anti-Slavery
Society.
Frist, B. (2021, April 12). Nashville is the health services capital – Here's why this explosively
growing region is more than music city USA. Forbes.
https://www.forbes.com/sites/billfrist/2021/04/12/nashville-is-the-health-services-capital-
-heres-why-this-explosively-growing-region-is-more-than-music-city-usa/
Frist, B., & Chruchwell, A. (2020, July 31). Discrimination and disparities in health:
Examinations of racial inequities in Nashville. The Tennessean.
https://www.tennessean.com/story/opinion/2020/07/31/examination-racial-inequality-
nashvilles-healthcare/5540680002/
Fu, J., Reid, S. A., French, B., Hennessy, C., Hwang, C., Gatson, N. T., Duma, N., Mishra, S.,
Nguyen, R., Hawley, J. E., Singh, S. R. K., Chism, D. D., Venepalli, N. K., Warner, J. L.,
Choueiri, T. K., Schmidt, A. L., Fecher, L. A., Girard, J. E., Bilen, M. A., . . . Peters, S.
(2022). Racial Disparities in COVID-19 Outcomes Among Black and White Patients
With Cancer. JAMA Network Open, 5(3), Article e224304.
https://doi.org/10.1001/jamanetworkopen.2022.4304
130

Gamble, V. N. (1995). Making a place for ourselves the Black hospital movement, 1920–1945.
Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195078893.001.0001
Gamble, V. N. (1997). Black Autonomy versus White Control: Black Hospitals and the
Dilemmas of White Philanthropy, 1920–1940. Minerva, 35(3), 247–267.
https://doi.org/10.1023/A:1004234101887
Gamble, V. N. (2019). Edith Irby: A hidden figure in the history of medical education. Academic
Medicine, 94(11), 1670–1674. https://doi.org/10.1097/ACM.0000000000002772
Gates, H. L., Jr. (2019). Stony the road: Reconstruction, White supremacy, and the rise of Jim
Crow. Penguin Publishing Group.
Gay, T., Hammer, S., & Ruel, E. (2020). Examining the relationship between institutionalized
racism and COVID–19. City & Community, 19(3), 523–530. https://10.1111/cico.12520
Gravlee, C. (2020). Systemic racism, chronic health inequities, and COVID‐19: A syndemic in
the making? American Journal of Human Biology, 32(5), e23482–n/a.
https://doi.org/10.1002/ajhb.23482
Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., & Banaji,
M. R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions
for black and white patients. Journal of General Internal Medicine: JGIM, 22(9), 1231–
1238. https://doi.org/10.1007/s11606-007-0258-5
Grigoriev, S., & Hoboken, W. (2019). Post positivism and the logic of the avant-garde. History
and Theory, 58(1), 89–111. https://doi.org/10.1111/hith.12101
Hacker, K., Auerbach, J., Ikeda, R., Philip, & Houry, D., (2022). Social determinants of health—
An approach taken at CDC. Journal of Public Health Management and Practice 28(6),
589–594. https://doi.org/10.1097/PHH.0000000000001626
131

Hannah-Jones, N. (2019, August 14). The 1619 Project. The New York Times.
https://www.nytimes.com/interactive/2019/08/14/magazine/1619-america-
slavery.html?searchResultPosition=2
Hannah-Jones, N., & The New York Times Magazine. (2022). The 1619 Project: A new origin
story. Penguin Random House.
Hausmann, H., Hannon, M. J., Kresevic, D. M., Hanusa, B. H., Kwoh, C. K., & Ibrahim, S. A.
(2011). Impact of Perceived Discrimination in Healthcare on Patient-Provider
Communication. Medical Care, 49(7), 626–633.
https://doi.org/10.1097/MLR.0b013e318215d93c
Health Maintenance Organization Act 42 U.S.C. §300e. https://www.congress.gov/bill/93rd-
congress/house-bill/7974
Health Resources & Services Administration. (2022). 2021 health center data. Health center
program uniform data system data. https://data.hrsa.gov/tools/data-reporting
Heckler, M. (1985). Report of the Secretary’s Task Force on Black & Minority Health. U.S.
Dept. of Health and Human Services.
Hill, H. (1959). Labor unions and the Negro: The record of discrimination. Commentary,
December. https://www.commentary.org/articles/herbert-hill/labor-unions-and-the-
negrothe-record-of-discrimination/
Hill-Briggs, A., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien,
A., Thornton, P. L., & Haire-Joshu, D. (2021). Social determinants of health and
diabetes: A scientific review. Diabetes Care, 44(1), 258–279.
https://doi.org/10.2337/dci20-0053
132

Hinga, B. (2019). Paradigms of inquiry for practice [Lecture notes on paradigms of inquiry]
USC Rossier School of Education.
History House. (2022). The Civil Rights Movement and The Second Reconstruction, 1945–1968.
https://history.house.gov/Exhibitions-and-Publications/BAIC/Historical-Essays/Keeping-
the-Faith/Civil-Rights-Movement/
Huff, L. M. (2004). The Crusades and Colonial Imperialism: Some Historical Considerations
concerning Christian-Muslim Interaction and Dialogue. Missiology, 32(2), 141–148.
https://doi.org/10.1177/009182960403200202
Hunt, M. (2007). American Ascendancy: How the United States Gained and Wielded Global
Dominance. The University of North Carolina Press.
Illinois General Assembly. (2021). Illinois House Bill 0309.
https://www.ilga.gov/legislation/102/HB/10200HB0309.htm
Institute for Diversity and Health Equity. (2022). Crosswalk of AHA health equity roadmap with
selected national health equity quality measures and standards for hospitals and Health
systems. https://ifdhe.aha.org/crosswalk-aha-health-equity-roadmap-selected-national-
health-equity-quality-measures-and-standards-hospitals-and-health-systems
Institute for Healthcare Improvement. (2019). Improving health equity: Build infrastructure to
support health equity. Guidance for health care organizations.
Institute for Healthcare Improvement. (2021). Health equity: Prioritization, perception, and
progress. https://www.ihi.org/Topics/Health-Equity/Documents/IHI-2021-Pulse-
Report_Health-Equity-Prioritization-Perception-Progress.pdf
Iton, A., & Ross, R. (2016). Understanding how health happens: Yor zip code is more important
than your genetic code. In Callahan, R., & Bhattacharya, D. (Eds.), Public health
133

leadership: Strategies for innovation in population health and social determinants (1st
ed. pp. 66–83). Routledge.
Jacobson, J. (2013). AJN reports: From Disparity to Equity. The American Journal of Nursing,
113(4), 21–23. https://www.jstor.org/stable/23461292
Jahan, S., & Mahmud, A. S. (2015). What Is Capitalism? Finance & Development, 52(2), 45.
Jha, A. K. (2018). Accreditation, quality, and making hospital care better. Journal of the
American Medical Association, 320(23), 2410–2411.
https://doi.org/10.1001/jama.2018.18810
Johnson, B. D., Boon-Dooley, A. S., DeCleene, N. K., Henny, K. F., Blacker, B. F., Anderson, J.
A., Afshin, A., Aravkin, A., Cunningham, M. W., Dieleman, J. L., Feldman, R. G.,
Gakidou, E., Mokdad, A. H., Naghavi, M., Spencer, C. N., Whisnant, J. L., York, H. W.,
Zende, R. R., Zheng, P., . . . Roth, G. A. (2022). Life expectancy for White, Black, and
Hispanic race/ethnicity in U.S. States: Trends and disparities, 1990 to 2019. Annals of
Internal Medicine, 175(8), 1057–1064. https://doi.org/10.7326/M21-3956
Johnson, L. B. J. (1964). Radio and television remarks upon signing the Civil Rights Bill. July
02, 1964. The American Presidency Project
https://www.presidency.ucsb.edu/node/239092
The Joint Commission. (2018). Quick Safety 23: Implicit Bias in health care.
The Joint Commission. (2023). National patient safety goals® effective July 2023 for the
hospital program. https://www.jointcommission.org/-
/media/tjc/documents/standards/national-patient-safety-
goals/2023/npsg_chapter_hap_jul2023.pdf
134

Jones, C. (2000). Levels of racism: a theoretic framework and a gardener’s tale. American
Journal of Public Health (1971), 90(8), 1212–1215.
https://doi.org/10.2105/AJPH.90.8.1212
Just Capital. (2022). Advancing racial equity. https://justcapital.com/about/
Kaiser Family Foundation. (2020). Health disparities are a symptom of broader social and
economic inequities. https://www.kff.org/policy-watch/health-disparities-symptom-
broader-social-economic-inequities/
Kaiser Family Foundation. (2022). Status of state Medicaid expansion decisions: Interactive
map. Medicare. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-
expansion-decisions-interactive-map/
Kaye, S. (2019). Disability-related disparities in access to health care before (2008–2010) and
After (2015–2017) the Affordable Care Act. American Journal of Public Health, 109,
1015–1021. https://doi.org/10.2105/AJPH.2019.305056
Kelman, B. (2018, August 17). HCA: 50 Years ago, A chicken-fried idea launched Nashville’s
most important company. The Tennessean.
https://www.tennessean.com/story/money/industries/health-care/2018/08/16/hca-50-
thomas-frist-jack-massey-launched-nashville-healthcare-industry/763946002/
Kendi, I. X. (2019). How to Be an Antiracist. One World.
Kendi, I. X. (2021, June 22). Our new postracial myth. The Atlantic.
https://www.theatlantic.com/ideas/archive/2021/06/our-new-postracial-myth/619261/
Kenneally, C. (2020, July 23). Large DNA study traces violent history of American slavery. The
New York Times. https://www.nytimes.com/2020/07/23/science/23andme-african-
ancestry.html
135

Kentucky General Assembly. (2022). House Bill 37.
https://apps.legislature.ky.gov/record/22RS/hb37.html
King, M. L. K., Jr. (1967). Southern Christian Leadership Conference presidential address 1967.
http://www.hartford-hwp.com/archives/45a/628.html
Kizer, B. H. (2017). The impact of Brown vs. Board of Education. Gonzaga Law Review, 53(2),
375.
Klaber, W. (Host). (2022). The MLK Tapes [Audio Podcast]. iHeart Radio. TenderfootTV.
https://themlktapes.com/
Klarman, M. J. (2006). From Jim Crow to Civil Rights: The Supreme Court and the Struggle for
Racial Equality. Oxford University Press, Incorporated.
Klonoff, E., & Klonoff, E. (2009). Disparities in the provision of medical care: An outcome in
search of an explanation. Journal of Behavioral Medicine, 32(1), 48–63.
https://doi.org/10.1007/s10865-008-9192-1
Krosnick, J. (1999). Survey research. Annual Review of Psychology, 50(1), 537–567.
https://doi.org/10.1146/annurev.psych.50.1.537
LaVeist, T. A., Gaskin, D., & Richard, P. (2011). Estimating the economic burden of racial
health inequalities in the United States. International Journal of Health Services, 41(2),
231–238. https://doi.org/10.2190/HS.41.2.c
Lavizzo-Mourey, R. J., Besser, R. E., & Williams, D. R. (2021). Understanding and Mitigating
Health Inequities — Past, current, and future directions. The New England Journal of
Medicine, 384(18), 1681–1684. https://doi.org/10.1056/NEJMp2008628
136

Laws, T. (2021). How should we respond to racist legacies in health professions education
originating in the flexner report? AMA Journal of Ethics, 23(3), 271–275.
https://doi.org/10.1001/AMAJETHICS.2021.271
LegiScan. (2021). Bill Text: CA AB1407. https://legiscan.com/CA/text/AB1407/2021
LegiScan. (2022). New York Assembly Bill 5426. https://legiscan.com/NY/text/A05426/2021
Levingston, S. (2020, May 30). Like Trump, JFK faced riots. Here’s what he did to stop the
violence in Birmingham in 1963. The Washington Post.
https://www.washingtonpost.com/history/2020/05/30/john-kennedy-mlk-birmingham-
riots-trump/
Liaison Committee on Medical Education. (2023). Rules of procedure.
https://lcme.org/publications/#Guidelines--amp--Procedures
Livingston, S. (2018). Racism Is Still a Problem in Healthcare’s C-Suite: Efforts Aimed at
Boosting Diversity in Healthcare Leadership Fail to Make Progress. Journal of Best
Practices in Health Professions Diversity: Research, Education and Policy, 11(1), 60–65.
Logan, T. D. (2020). Do Black politicians matter? Evidence from Reconstruction. The Journal of
Economic History, 80(1), 1–37. https://doi.org/10.1017/S0022050719000755
Love, T. (2001). Resolving problems with the Foundations of PhD Education: Theoretical
Perspectives in Long Thesis PhD Submissions [Paper presentation]. The Teaching and
Learning Forum 2001, Curtin University, Perth.
https://www.love.com.au/docs/2001/mod-5-ch-thesis.pdf
Loyd, J. M. (2012). The fire next time: Rodney King, Trayvon Martin and law-and-order
urbanism. City, 16(4), 431–438. https://doi.org/10.1080/13604813.2012.696941
137

Lucas, L., Lumley, M. A., Flack, J. M., Wegner, R., Pierce, J., & Goetz, S. (2016). A preliminary
experimental examination of worldview verification, perceived racism, and stress
reactivity in African Americans. Health Psychology, 35(4), 366–375.
https://doi.org/10.1037/hea0000284
Lynch, M. J., & Cass, E. S. (2021). Slavery, economics, race and convict leasing: A general and
materialist history of punishment and prisons in Florida, 1840–1923. International
Journal of Comparative and Applied Criminal Justice, ahead-of-print(ahead-of-print), 1–
24. https://doi.org/10.1080/01924036.2021.1875252
Mallory, C. (2022). Measures of central tendency [asynchronous lecture on central tendency].
USC Rossier School of Education.
Manikandan, S. (2011). Measures of central tendency: Median and mode. Journal of
Pharmacology & Pharmacotherapeutics, 2(3), 214–215. https://doi.org/10.4103/0976-
500X.83300
Marler, S. P. (2004). Fables of the Reconstruction: Reconstruction of the fables. The Journal of
the Historical Society, 4(1), 113–137. https://doi.org/10.1111/j.1529-921X.2004.00088.x
Medicare Access and CHIP Reauthorization Act of 2015, 42 USC 1305
Maryland Department of Health. (2021). Implicit bias training required for 2022 license
renewal. https://health.maryland.gov/boardsahs/Documents/implicitb.pdf
Massey, D. S. (1990). American Apartheid: Segregation and the Making of the Underclass.
American Journal of Sociology, 96(2), 329–357. https://doi.org/10.1086/229532
Matthew, D. B. (2015). Just medicine: A cure for racial inequality in American healthcare. New
York University Press.
Maxwell, J. A. (2013). Qualitative research design: An interactive approach (3rd ed.). SAGE.
138

McGhee, H. (2021). The sum of us: What racism costs everyone and how we can prosper
together. One World.
McMillen, N. R. (2007). The White Citizens’ Council and resistance to school desegregation in
Arkansas. The Arkansas Historical Quarterly, 66(2), 125–144.
http://www.jstor.org/stable/40018695
Medicare Access and CHIP Reauthorization Act of 2015 42 USC 1305.
https://www.congress.gov/bill/114th-congress/house-bill/2/text
Merriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and
implementation (4th ed.). Jossey-Bass.
Messent, P. (2020). Covid‐19, race, and family therapy. Journal of Family Therapy, 42(4), 453–
456. https://doi.org/10.1111/1467-6427.12315
Mohamed, A. N. (2021). Influence of the Supreme Court’s Plessy v. Ferguson decision on
Southern editorial arguments during the “Massive Resistance” to integration: Perspective
from Alabama. The Howard Journal of Communications, 3, 1–16.
https://doi.org/10.1080/10646175.2021.1985660
Morone, J. A. (2010). Presidents and health reform: From Franklin D. Roosevelt to Barack
Obama. Health Affairs, 29(6), 1096–1100. https://doi.org/10.1377/hlthaff.2010.0420
Morse, J. M., Bowers, B. J., Charmaz, K., Clarke, A. E., Corbin, J., Porr, C. J., & Stern, P. N.
(2021). Developing grounded theory: The second generation revisited (2nd ed.).
Routledge. https://doi.org/10.4324/9781315169170
Muller, C. (2018). Freedom and convict leasing in the Postbellum South. American Journal of
Sociology, 124(2), 367–405. https://doi.org/10.1086/698481
139

Muoio, D. (2022). Here’s what CEOs at the US’ top for-profit health systems earned in 2021.
Health System CEO Compensation. Special Report. Fierce Healthcare.
National Committee for Quality Assurance. (2021). NCQA launches pilot program for health
equity accreditation plus. https://www.ncqa.org/news/ncqa-launches-pilot-program-for-
health-equity-accreditation-plus/
National Committee for Quality Assurance. (2022). Health equity. https://www.ncqa.org/about-
ncqa/health-equity/
National Medical Association. (2022). National Medical Association: History.
https://www.nmanet.org/page/History
News RX Health and Science. (2010). NIH awards $10 million to Rush University Medical
Center to address health disparities. (2010, June 6). NewsRx Health & Science, 55.
https://link.gale.com/apps/doc/A227574108/HWRC?u = usocal_main&sid = bookmark-
HWRC&xid = 65fa8900
Noguera, P. A. (2016). Race, education, and the pursuit of equity in the twenty-first century. In
P. Noguera, J. Pierce, & R. Ahram (Eds.), Race, equity, and education (pp. 3–23).
Springer. https://doi.org/10.1007/978-3-319-23772-5_1
Office of Disease Prevention and Health Promotion. (2022). Healthy People 2030. U.S.
Department of Health and Human Services. https://health.gov/healthypeople/objectives-
and-data/social-determinants-health
Office of Minority Health. (1999). Assuring cultural competence in health care:
Recommendations for national standards and an outcomes-focused research agenda.
Department of Health and Human Services.
140

Onwuachi-Willig, A. (2018). From Emmett Till to Trayvon Martin: The persistence of white
womanhood and the preservation of white manhood. Du Bois Review, 15(2), 257–294.
https://doi.org/10.1017/S1742058X18000292
Osofsky, M. J., Bandura, A., & Zimbardo, P. G. (2005). The role of moral disengagement in the
execution process. Law and Human Behavior, 29(4), 371–393.
https://doi.org/10.1007/s10979-005-4930-1
Paavola, A. (2022). 7 health systems reported profits over $1B in 2021. Becker’s Healthcare.
https://www.beckershospitalreview.com/finance/7-health-systems-reported-profits-over-
1b-in-2021.html
Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., &
Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-
analysis. PLoS One, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511
Paradies, Y., Truong, M., & Priest, N. (2013). A systematic review of the extent and
measurement of healthcare provider racism. Journal of General Internal Medicine, 29(2),
364–387. https://doi.org/10.1007/s11606-013-2583-1
Pascoe, R., & Richman, L. S. (2009). Perceived discrimination and health: A meta-analytic
review. Psychological Bulletin, 135(4), 531–554. https://doi.org/10.1037/a0016059
Patient Protection and Affordable Care Act, 42 USC Ch. 157.
Payne, A. (2021). The high cost of racism: Inequality, the economy, and public health [Webinar].
The Emancipator. https://www.hsph.harvard.edu/event/the-high-cost-of-racism-
inequality-the-economy-and-public-health/
Peeples, L. (2020). What the data say about police brutality and racial bias - and which reforms
might work. Nature, 583(7814), 22–24. https://doi.org/10.1038/d41586-020-01846-z
141

Perry, C. (1995). A structured approach to presenting theses: Notes for students and their
supervisors. SAGE Publications.
Philpott, D., Hughes, C. M., Alroy, K. A., Kerins, J. L., Pavlick, J., Asbel, L., Crawley, A.,
Newman, A. P., Spencer, H., Feldpausch, A., Cogswell, K., Davis, K. R., Chen, J.,
Henderson, T., Murphy, K., Barnes, M., Hopkins, B., Fill, M.-M. A., Mangla, A. T., . . .
Johnson, S. (2022). Epidemiologic and clinical characteristics of monkeypox cases —
United States, May 17–July 22, 2022. Morbidity and Mortality Weekly Report, 71(32),
1018–1022. https://doi.org/10.15585/mmwr.mm7132e3
Polk, W. (2018). Crusade and Jihad: The thousand-year war between the Muslim world and the
Global North. The Henry L. Stimson Lectures Series. Yale University Press.
https://doi.org/10.2307/j.ctv1bvnfdq
Raup, R. M., & Williams, E. A. (1964). Negro students in medical schools in the United States.
Journal of Medical Education, 39(5), 444–450.
Robinson, S. B., & Firth Leonard, K. (2019). Designing quality survey questions. SAGE
Publications, Inc.
Rogelberg, S. (Ed.). (2017). The SAGE encyclopedia of industrial and organizational psychology
(2nd ed., Vols. 1–4). SAGE Publications, Inc. https://doi.org/10.4135/9781483386874
Rouse, C. E. (2006). Prefatory note. American Law and Economics Review, 8(2), 181–182.
https://doi.org/10.1093/aler/ahl010
Salkind, N. J. (2014). Statistics for people who (think they) hate statistics. Sage.
Santry, H., & Wren, S. (2012). The role of unconscious bias in surgical safety and outcomes. The
Surgical Clinics of North America, 92(1), 137–151.
https://doi.org/10.1016/j.suc.2011.11.006
142

Schneider, E. C., Shah, A., Doty, M. M., Tikkanen, R., Fields, K., & Williams, R. D., II. (2021).
Mirror, Mirror 2021. Reflecting poorly: Health care in the U.S. compared to other high-
income countries. The Commonwealth Fund.
https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-
2021-reflecting-poorly
Schoonenboom, J., & Johnson, R. B. (2017). How to construct a mixed methods research design.
Kölner Zeitschrift für Soziologie und Sozialpsychologie, 69(Suppl 2), 107–131.
https://doi.org/10.1007/s11577-017-0454-1
Scott, T. (2021, April 28). Republican response to the presidential economic address. C-SPAN.
https://www.c-span.org/video/?511326-1/senator-tim-scott-delivers-republican-response
Seals, D. (2003). The Wiley-Bishop student movement: A case study in the 1960 civil rights sit-
ins. Southwestern Historical Quarterly, 106(3), 418–440.
Serchen, J., Doherty, R., Atiq, O., & Hilden, D. (2020). Racism and health in the United States:
A policy statement from the American College of Physicians. Annals of Internal
Medicine, 173(7), 556–557. https://doi.org/10.7326/M20-4195
Setia, M. S. (2016). Methodology Series Module 3: Cross-sectional studies. Indian Journal of
Dermatology, 61(3), 261–264. https://doi.org/10.4103/0019-5154.182410
Shi, L., & Singh, D. A. (2017). Delivering health care in America: A systems approach (7th ed.).
Jones & Bartlett Learning, LLC.
Sim, J., Saunders, B., Waterfield, J., & Kingstone, T. (2018). Can sample size in qualitative
research be determined a priori? International Journal of Social Research Methodology,
21(5), 619–634. https://doi.org/10.1080/13645579.2018.1454643
143

Smedley, S., Stith, A. Y., & Nelson, A. R. (Eds.). (2002). Unequal treatment: Confronting racial
and ethnic disparities in health care. Journal of the National Medical Association, 94(8),
666–668. National Academies Press. https://doi.org/10.17226/12875
Smith, J., & Noble, H. (2014). Bias in research. Evidence-Based Nursing, 17, 100–101.
https://doi.org/10.1136/eb-2014-101946
Social Security Act 42 U.S.C. Chapter 7
Stabler, A. (2020). The contractual aesthetics of sharecropping in Black conceptualism. Critical
Arts, 34(6), 41–55. https://doi.org/10.1080/02560046.2020.1829668
Starr, P. (1982). The social transformation of American medicine: The rise of a sovereign
profession and the making of a vast industry. Basic Publishers, Inc.
Stelzner, M., & Beckert, S. (2021). The contribution of enslaved workers to output and growth in
the Antebellum United States (Working Paper 62421). Washington Center for Economic
Growth.
Stevens, R. (1989). In sickness and in wealth: American hospitals in the twentieth century. Basic
Books.
Sue, C., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., &
Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical
practice. The American Psychologist, 62(4), 271–286. https://doi.org/10.1037/0003-
066X.62.4.271
Sweller, J., Ayres, P., & Kalyuga, S. (2011). Cognitive load theory: Explorations in the learning
sciences, instructional systems, and performance technologies (Vol. 1). Springer.
https://doi.org/10.1007/978-1-4419-8126-4_6
144

Tenet Healthcare. (2022). Investor relations. Financial & ESG summary.
https://investor.tenethealth.com/press-releases/press-release-details/2022/Tenet-Reports-
Strong-Fourth-Quarter-and-FY-2021-Results-Announces-Plan-to-Retire-700-Million-of-
Debt-Provides-Detailed-2022-Financial-Outlook/default.aspx
Terry, G., & Braun, V. (2016). Short but often sweet. In V. Braun, V. Clarke, & Gray, D. (Eds.),
Collecting qualitative data: A practical guide to textual, media and virtual techniques
(pp. 13–14). Cambridge University Press
Toerien, M., & Wilkinson, S. (2004). Exploring the depilation norm: A qualitative questionnaire
study of women’s body hair removal. Qualitative Research in Psychology, 1(1), 69–92.
Tolnay, S. E. (2003). The African American “Great Migration” and Beyond. Annual Review of
Sociology, 29(1), 209–232. https://doi.org/10.1146/annurev.soc.29.010202.100009
Tonti, J. (2022). Corporate racial equity tracker: Methodology. JUST Capital.
https://justcapital.com/reports/2022-corporate-racial-equity-tracker/#methodology
Trent, M., Dooley, D. G., Dougé, J., Trent, M. E., Cavanaugh, R. M., Lacroix, A. E., Fanburg, J.,
Rahmandar, M. H., Hornberger, L. L., Schneider, M. B., Yen, S., Chilton, L. A., Green,
A. E., Dilley, K. J., Gutierrez, J. R., Duffee, J. H., Keane, V. A., Krugman, S. D.,
McKelvey, C. D., … Wallace, S. B. (2019). The impact of racism on child and adolescent
health. Pediatrics, 144(2), Article e20191765. https://doi.org/10.1542/peds.2019-1765
Tucker, R. B., Sr. (2017). The color of mass incarceration. Ethnic Studies Report, 37-38(1), 135–
149. https://doi.org/10.1525/esr.2017.37_38.1.135
Tyson, T. B. (2017). The blood of Emmett Till (First Simon & Schuster hardcover edition.).
Simon & Schuster.
145

Upchurch, T. A. (2004). Senator John Tyler Morgan and the genesis of Jim Crow Ideology,
1889-1891. The Alabama Review, 57(2), 110.
U.S. Bureau of Labor Statistics. (2022). Healthcare occupations: Occupational outlook
handbook. https://doi.org/10.4135/9781446263372
U.S. Census Bureau. (2014). Projecting majority-minority: Non-Hispanic Whites may no longer
comprise over 50 percent of the U.S. population by 2044. U.S. Department of Commerce
Economics ad Statistics Administration.
https://www.census.gov/content/dam/Census/newsroom/releases/2015/cb15-
tps16_graphic.pdf
U.S. Department of Health and Human Services. (2015). HHS action plan to reduce racial and
ethnic health disparities: Implementation progress report 2011-2014. Office of the
Assistant Secretary for Planning and Evaluation.
U. S. Department of Health and Human Services. (2008). Patient safety and quality improvement
final rule. https://pso.ahrq.gov/sites/default/files/wysiwyg/Patient-Safety-Rule-2008.pdf
U.S. Senate. (1956). Declaration of constitutional principles.
Van Delinder, J. (2008). Struggles before Brown: Early civil rights protests and their significance
today. Paradigm Publishers.
van Evrie, J. H., & Smith, J. D. (1993). Van Evrie’s White supremacy and Negro subordination.
Garland Pub.
van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on
physicians’ perceptions of patients. Social Science & Medicine, 50(6), 813–828.
https://doi.org/10.1016/S0277-9536(99)00338-X
146

van Ryn, M., Hardeman, R., Phelan, S. M., PhD, D. J. B., Dovidio, J. F., Herrin, J., Burke, S. E.,
Nelson, D. B., Perry, S., Yeazel, M., & Przedworski, J. M. (2015). Medical school
experiences associated with change in implicit racial bias among 3547 students: A
medical student CHANGES study report. Journal of General Internal Medicine, 30(12),
1748–1756. https://doi.org/10.1007/s11606-015-3447-7
Varpio, L., Paradis, E., Uijtdehaage, S., & Young, M. (2020). The distinctions between theory,
theoretical framework, and conceptual framework. Academic Medicine, 95(7), 989–994.
Advance online publication. https://doi.org/10.1097/ACM.0000000000003075
Walensky, R. (2021). Director’s commentary. Centers for Disease Control and Prevention.
https://www.cdc.gov/healthequity/racism-disparities/index.html
Washington, H. A. (2006). Medical apartheid: The dark medical history of medical
experimentation on Black Americans from colonial times to the present. Anchor Books.
Watson, B., Bacigalupe, G., Daneshpour, M., Han, W.-J., & Parra-Cardona, R. (2020). COVID‐
19 Interconnectedness: Health inequity, the climate crisis, and collective trauma. Family
Process, 59(3), 832–846. https://doi.org/10.1111/famp.12572
Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., & Sommers, B. D. (2022).
Addressing social determinants of health: Examples of successful evidence-based
strategies and current federal efforts. U.S. Department of Health and Human Services.
https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/S
DOH-Evidence-Review.pdf
The White House, Office of the Press Secretary. (2021, January 20). Executive order on
advancing racial equity and support for underserved communities through the federal
government. https://www.whitehouse.gov/briefing-room/presidential-
147

actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-
underserved-communities-through-the-federal-government/
The White House, Office of the Press Secretary. (2022). Executive order on advancing racial
equity and support for underserved communities through the federal government.
https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-
order-advancing-racial-equity-and-support-for-underserved-communities-through-the-
federal-government/
Wilkerson, I. (2010). The warmth of other suns: The epic story of America’s great migration.
Vintage.
Wilkerson, I. (2020). Caste: The origins of our discontent. Random House.
Williams, D., & Mohammed, S. (2008). Discrimination and racial disparities in health: Evidence
and needed research. Journal of Behavioral Medicine,32(1), 20–47.
https://doi.org/10.1007/s10865-008-9185-0
Williams, D., & Wyatt, R. (2015). Racial bias in health care and health: Challenges and
opportunities. Journal of the American Medical Association, 314(6), 555–556.
https://doi.org/10.1001/jama.2015.9260
Wilson, C. A. (1996). Racism: From slavery to advanced capitalism. SAGE Publications, Inc.
https://doi.org/10.4135/9781483327761
World Health Organization. (2022). Health topics. Social determinants of health.
https://www.who.int/health-topics/social-determinants-of-health#tab = tab_1
Wright, J., Jarvis, J. N., Pachter, L. M., & Walker-Harding, L. R. (2020). “Racism as a public
health issue” APS racism series: At the intersection of equity, science, and social justice.
Pediatric Research, 88(5), 696–698. https://doi.org/10.1038/s41390-020-01141-7
148

Wright, J. W. (2020). The New York Times Almanac. Penguin Putnam.
Wyatt, R., Laderman, M., Botwinick, L., Mate, K., & Whittington, J. (2016). Achieving health
equity: A guide for healthcare organizations. Institute for Healthcare Improvement.
Yeung, W. J., & Conley, D. (2008). Black-White achievement gap and family wealth. Child
Development, 79(2), 303–324. https://doi.org/10.1111/j.1467-8624.2007.01127.x
Young, K. (2020). Rooted In racism: An analysis of health disparities in Tennessee. Tennessee
Justice Center.

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Appendix A: Survey Questions
Survey and research title: Is Healthcare for All? A qualitative questionnaire study
of systemic racism in healthcare and the perception among stakeholders of large U.S.
Healthcare corporations; an exploration of moral disengagement and interest convergence
in healthcare delivery.
Introduction
Thank you for your interest in this study. This survey is about large U.S.
healthcare companies, also known as corporations. By “large companies,” we mean those
that employ at least 3000 thousand people and provide medical services at more than five
locations. Therefore, your responses to these questions are essential, no matter how much
you currently know or do not know about large healthcare companies. Participants will be
entered in a drawing for a $100 Amazon gift card. Participation is voluntary, and your
identification will be kept strictly confidential.
Research Questions
1. What are the differences in the perceptions of systemic racism in healthcare
between the stakeholders of large healthcare organizations (i.e., patient vs.
provider vs. administrator)?
2. What role does the healthcare organization play in promoting health equity
across minoritized patient populations?
Consent
Completing all survey questions will help us obtain the best possible results.
There are four sections to this survey. First, read the questions entirely, as some may not
150

apply to you based on previous responses. Then, please select the answer that most
closely represents your answer and use the space to provide a detailed response.
Consent Checklist
Participants must select all to proceed with the questionnaire.

Table A1
Consent Checklist
Please check here Before we begin, please read the following and confirm the
statements listed below.
I am over the age of 18.
I have read and understand the information describing this
survey and the goal of the research study.
I understand that my electronic completion of this survey
grants my consent to participate in the research under the
indicated terms.

151

Demographics Section
1. Please select your race/ethnicity (RQ2):
• African American or Black
• American Indian or Alaska Native
• Asian; Native Hawaiian or Other Pacific Islander
• White
• Other (Please Specify) _________
2. Are you of Hispanic or Latino descent (RQ2)
• Yes
• No
3. Please select your gender (RQ2)
• Male
• Female
• Non-binary
• A different gender (Please specify: __________________)]
4. Please select your age group (RQ1; RQ2)
• 18–29
• 30–44
• 45–54
• 55–64
• 65–74
• 75–84
• 85 or older
152

5. Please select your state of primary residence (RQ1; RQ2). Drop down of 50
states.
For the purposes of this survey, large healthcare corporations are defined as
organizations that provide medical care and have approximately 5,000 or more
employees and/or five or more locations.
6. Please select your primary association with large healthcare organizations
(RQ1)
• patient
• employee
• leader (director or above)
• c-suite
• board member
• payor (employee or leader)
• community member/patient advocate
• If employee, leader, c-suite, board member, or community member is
selected (RQ1):
• (Please specify your current title:
_________________________)
• Please select the size of your organization (RQ1; RQ2):
• under 5,000 employees
• 5000-10,000 employees
• 10,000-50,00 employees
• 50,000-100,000 employees
153

• 100,000+ employees
• If Patient is selected (RQ1; RQ2):
• Please select your current healthcare coverage:
• private insurance (self-pay)
• private insurance (employer paid)
• Medicare, Medicaid
• no Insurance Coverage
• Do you suffer from a chronic health condition (RQ1; RQ2)?
• Yes
• No
7. All: Please select your current household income (RQ2):
• Less than $25,000
• $25,000 but less than $50,00
• $50,000 but less than $75,000
• $75,000 but less than $150,000
• $150,000 and over)
Perception
1. Do you acknowledge the existence of inequitable healthcare in the United
States (RQ1)
2. What do you feel is the root cause of health inequities in the United States
(RQ1, RQ2)?
3. In your opinion, who should be primarily responsible for driving the
advancement of equitable healthcare (RQ1; RQ2)? (e.g., healthcare
154

corporations, the government; community and patient advocacy groups, etc.)
Please explain.
Expectation
Social determinants of health are socioeconomic conditions that impact
individuals’ and populations’ overall health, wellness, and quality of life.
Healthcare quality outcomes represent how well an organization or provider cares
for a patient with specific diseases (heart disease, diabetes, cancer, etc.)
The implicit association test measures unconscious attitudes and beliefs about
race, gender, sexuality, weight, and religion.
1. Do you believe federal regulators and payors should tie health equity
initiatives to healthcare quality outcomes* that impact federal payment and
reimbursement programs (RQ1)?
2. What are your thoughts about the ethics of healthcare organizations operating
as for-profit corporations (RQ1)??
3. Please share your thoughts about patient-facing employees (nurses, providers,
allied health, nursing support, etc.) taking the implicit association test* as a
condition of licensing, certification, and employment (RQ1):
Experience
1. How often do you think African American patients receive unfair treatment
based on race in hospitals and healthcare systems (RQ1, RQ2)?
2. To the extent that the health care system mistreats people based on their race
or ethnic background, Please share why you feel this may occur (RQ1, RQ2).
155

3. Please describe any initiatives the healthcare organization you are affiliated
with has taken to promote health equity and diversity, equity, and inclusion, if
any (RQ1; RQ2).
4. If yes, when was/were this/these initiative(s) implemented (RQ1)?
Please feel free to provide any additional thoughts that you think would be helpful
for this research study (RQ1; RQ2):
If you are open to providing additional information about this topic for this study,
please provide your email address to be contacted at a later time.
Thank you for your participation!
Please enter your email address to be included in the drawing.
Appendix B: Survey Questions With Response Count
The following sections present the survey questions used in this study.
Research Questions
1. What are the differences in the perceptions of systemic racism in healthcare between
the stakeholders of large healthcare organizations (i.e., patient vs. provider vs.
administrator)?
2. What are the differences in the perceptions of stakeholders in the role that the U.S.
healthcare organization plays in promoting health equity across minoritized patient
populations?
Perception
1. Inequitable healthcare exists in the United States (RQ1): Please indicate the level of
agreement with the following statement (n = 89):
• Agree
156

• Somewhat Agree
• Neutral
• Somewhat Disagree
• Disagree
• Unsure
• Please explain your response: ____________ (n = 55)

2. Please rank the following choices based on how much you feel they contribute to
health inequities in the United States (RQ1, RQ2)?
• Healthcare organizational policies and practices
• Systemic Racism
• Government policies
• Individual lifestyle choices
• Social determinants of health (n = 75)
• Please explain your response: _________________ (n = 55)

3. In your opinion, who should be primarily responsible for driving the advancement of
equitable healthcare (RQ1; RQ2)? Please select from the following choices:
• Healthcare corporations
• Government agencies
• Community and patient advocacy groups. (n = 136)
• Please explain your response: _________________ (n = 62)
Expectation
Healthcare quality outcomes represent how well an organization or provider cares for a
patient with specific diseases (heart disease, diabetes, cancer, etc.)
157

Implicit association test (IAT) measures unconscious attitudes and beliefs about race,
gender, sexuality, weight, and religion.
1. Federal regulators and payors should tie health equity initiatives to healthcare quality
outcomes* that impact federal payment and reimbursement programs (RQ1): Please
indicate the level of agreement with the following statement:
• Agree
• Somewhat agree
• Neutral
• Somewhat disagree
• Disagree
• Unsure (n = 79)
• Please explain your response: ____________ (n = 44)
2. It is ethical for healthcare organizations to operate as for-profit corporations (RQ1):
Please indicate the level of agreement with the following statement:
• Agree
• Somewhat agree
• Neutral
• Somewhat disagree
• Disagree
• Unsure (n = 79)
• Please explain your response: ____________ (n = 36)
3. Patient-facing employees (Nurses, Providers, Allied health, Nursing support, etc.)
should take the implicit association Test* as a condition of licensing, certification,
158

and employment as an effort to promote anti-racism in healthcare delivery (RQ1):
Please indicate the level of agreement with the following statement
• Agree
• Somewhat agree
• Neutral
• Somewhat disagree
• Disagree
• Unsure (n = 79)
• Please explain your response: ____________ (n = 48)

159

Experience
If Patient Is Selected
1. How often do you think African American patients receive unfair treatment based on
race in U.S. hospitals and healthcare systems (RQ1, RQ2):
• Often
• Sometimes
• Never
• Unsure (n = 72)
• Please explain your response: _____________ (n = 44)
2. To the extent that the U.S. healthcare system unfairly treats people based on race or
ethnic background, please share why you feel this may occur (RQ1, RQ2). (n = 51)
3. Please share any thoughts or suggestions you would like to see Healthcare
organizations implement to promote equitable and safe care: (n = 30)
If Clinician, Administrator, or Payor is Selected
Please describe any initiatives the healthcare organization you are affiliated with has taken to
promote health equity and diversity, equity, and inclusion, if any (RQ1, RQ2). (n = 15)
• If yes, when was/were this/these initiative(s) implemented (RQ1, RQ2)? 2022, 2021,
2020, before 2020 (n = 26)
• Please share any success stories from these initiatives and how you define the success. (n
= 14)

Please feel free to provide any additional thoughts that you think would be helpful for this
research study (RQ1, RQ2): (n = 42).

Abstract (if available)

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Asset Metadata

Creator Flowers, Maria D. (author)

Core Title Is healthcare for all? A qualitative questionnaire study of systemic racism in healthcare and the perception among stakeholders of U.S. healthcare corporations: an exploration of moral disengagement..

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-08

Publication Date 07/25/2023

Defense Date 04/28/2023

Publisher University of Southern California. Libraries (digital)

Tag critical race theory,health equity,healthcare,healthcare organizations,interest convergence,moral disengagement,OAI-PMH Harvest,social cognitive theory,social determinants of health,systemic racism

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hinga, Brianna (committee chair), Green, Alan (committee member), Wyatt, Ronald (committee member)

Creator Email flowersm@usc.edu,info@mariadflowers.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113289513

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