Academia and the Profession
3 May 2022

Affirmative Action Bans and Enrollment of Students From Underrepresented Racial and Ethnic Groups in U.S. Public Medical Schools

Publication: Annals of Internal Medicine
Volume 175, Number 6
Visual Abstract. Affirmative Action Bans and Enrollment of Underrepresented Medical Students.
Between 1985 and 2019, 8 U.S. states enacted laws that banned affirmative action during the selection of applicants into 21 public medical schools. The study reported in this article examined whether the bans affected enrollment from racial and ethnic groups that are underrepresented in medicine.

Abstract

Background:

The percentage of U.S. physicians who identify as being from an underrepresented racial or ethnic group remains low relative to their proportion in the U.S. population. How this percentage may have been affected by state bans on affirmative action in public postsecondary institutions has received relatively little attention.

Objective:

To examine the association between state affirmative action bans and percentage of enrollment in U.S. public medical schools from underrepresented racial and ethnic groups.

Design:

Event study comparing public medical schools in states that implemented affirmative action bans with those in states without bans.

Setting:

U.S. public medical schools.

Participants:

21 public medical schools in 8 states with affirmative action bans matched to 32 public medical schools in 24 states without bans from 1985 to 2019.

Measurements:

Percentage of total enrollment from racial and ethnic groups underrepresented in medicine (Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander).

Results:

The percentage of enrollment from underrepresented racial and ethnic groups was 14.8% in U.S. public medical schools in the year before ban implementation in states with bans. The adjusted percentage of underrepresented students in ban schools decreased by 4.8 percentage points (95% CI, −6.3 to −3.2 percentage points) 5 years after ban implementation relative to the year before implementation, whereas the adjusted percentage in control schools increased by 0.7 percentage point (CI, −0.1 to 1.6 percentage points), for a relative difference, or difference-in-differences estimate, of −5.5 percentage points (CI, −7.1 to −3.9 percentage points).

Limitation:

Inability to account for the effect of these bans on undergraduate enrollment.

Conclusion:

State affirmative action bans were associated with significant reductions in the percentage of students in U.S. public medical schools from underrepresented racial and ethnic groups.

Primary Funding Source:

None.

Get full access to this article

View all available purchase options and get full access to this article.

References

1.
Alsan M, Garrick O, Graziani G. Does diversity matter for health? Experimental evidence from Oakland. Am Econ Rev. 2019;109:4071-111.   doi: 10.1257/aer.20181446
2.
Association of American Medical Colleges. 2021 fall applicant, matriculant, and enrollment data tables. December 2021. Accessed at www.aamc.org/media/57761/download?attachment on 18 January 2022.
3.
Garces LM, Mickey-Pabello D. Racial diversity in the medical profession: the impact of affirmative action bans on underrepresented student of color matriculation in medical schools. J Higher Educ. 2015;86:264-294. [PMID: 26052161]
4.
Garces LM. The impact of affirmative action bans in graduate education. UCLA: The Civil Rights Project. 2012. Accessed at https://escholarship.org/uc/item/6np398tm on 18 January 2022.
5.
Long MC, Bateman NA. Long-run changes in underrepresentation after affirmative action bans in public universities. Educ Eval Policy Anal. 2020;42:188-207. doi: 10.3102/0162373720904433
6.
Bleemer Z. Affirmative action, mismatch, and economic mobility after California's Proposition 209. Q J Econ. 2022;137:115-60. doi: 10.1093/qje/qjab027
7.
Venkataramani AS, Cook E, O’Brien RL, et al. College affirmative action bans and smoking and alcohol use among underrepresented minority adolescents in the United States: a difference-in-differences study. PLoS Med. 2019;16:e1002821. [PMID: 31211777] doi: 10.1371/journal.pmed.1002821
8.
Morris DB, Gruppuso PA, McGee HA, et al. Diversity of the national medical student body — four decades of inequities. N Engl J Med. 2021;384:1661-1668. [PMID: 33913645] doi: 10.1056/NEJMsr2028487
9.
Craig SV, Grennan M, Swanson A. Mergers and marginal costs: new evidence on hospital buyer power. Rand J Econ. 2021;52:151-78. doi: 10.1111/1756-2171.12365
10.
Goodman-Bacon A. Difference-in-differences with variation in treatment timing. J Econom. 2021;225:254-77. doi: 10.1016/j.jeconom.2021.03.014
11.
Callaway B, Sant’Anna PHC. Difference-in-differences with multiple time periods. J Econom. 2021;225:200-30. doi: 10.1016/j.jeconom.2020.12.001
12.
Hirschman D, Berrey E. The partial deinstitutionalization of affirmative action in U.S. higher education, 1988 to 2014. Sociol Sci. 2017;4:449-68. doi: 10.15195/v4.a18

Comments

0 Comments
Sign In to Submit A Comment
Michael Zema MD, FACP, CPE 26 June 2022
Unintended Consequences of Well Intentioned Equity

It should not be surprising that the percentage of “underrepresented” students in public medical schools has decreased during the ten year period following implementation of an affirmative action ban in certain states as recently reported by Ly et.al. in the Journal. (1). The authors in their introductory paragraph reference the Association of American Medical Colleges (AAMC) 2021 Fall Applicant, Matriculant and Enrollment data tables (2) in their claim that Blacks and Hispanics remain underrepresented in medical schools relative to their proportion in the overall U.S. population. Indeed, as of the latest available data for 2021-2022 extracted from the AAMCs Table A-9, those students  identifying as solely Black are 13% underrepresented at 11.5% of matriculating students versus 13% of the population. Those identifying solely as Hispanic appear at first blush to be markedly underrepresented by 120% at 8.5% versus 19% of the U.S. population (3). A closer look at the data, however, reveals that many Hispanics also identify as  Black or White, possibly related to the 27% reported incidence of interracial marriage among the Hispanic population (4). If those Hispanics identifying as Black or White are also considered, then Hispanics are 35%, not 120%,  underrepresented at 14% of students versus 19% of U.S. population (3). Examination of the same table, moreover, strongly suggests over the past five years that a gradual shift in student demographics from a white majority to peoples of color has occurred, apparently despite the existence of affirmative action bans on medical student admissions.

Interestingly, two racial groups, one the majority, and the other another minority are conspicuously left out of their discussion. Among those students identifying as a single race only, Whites are themselves now 15% “underrepresented” at 52% of matriculating students versus 60% of the U.S. population (2,3). Has anyone suggested that affirmative action be applied to White applicants? Asians, on the other hand are 360% overrepresented being 28% of matriculating students and only 6% of the population (2,3). Could this  be meritocracy in action? Should Asian applicants, apparently being overwhelmingly qualified, nevertheless as an “overrepresented” group be the target of application discriminatory behavior going forward so as to better achieve parity between student representation and the overall U.S. population? Do you see that in our best efforts to achieve absolute “equity,” we could end up in a very dark place.

REFERENCES

  1. Ly DP, Essien UR, Olenski AR, et al. Affirmative action bans and enrollment of students from underrepresented racial and ethnic groups in U.S. public medical schools. Ann Intern Med. 2022;175:873-878.
  2. Association of American Medical Colleges. 2021 FACTS: Applicants and Matriculants Data. Accessed at https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data on 16 June 2022.
  3. U.S. Census Bureau. Quick Facts. Accessed at https://www.census.gov/quickfacts/fact/table/US/PST045221 on 16 June 2022.
  4. Livingston G, Brown A. for the Pew Research Center. Intermarriage in the U.S. 50 years after Loving v. Virginia. Accessed at https://www.pewresearch.org/social-trends/2017/05/18/intermarriage-in-the-u-s-50-years-after-loving-v-virginia/ on 16 June, 2022.

Disclosures:

Michael Zema MD

Dan P. Ly, MD, PhD, MPP (1,2), Anupam B. Jena, MD, PhD (3,4,5) 8 July 2022
Author Response to Zema

Zema points out that the student body population at U.S. medical schools appears to be diversifying over the past several years.1 We are heartened by this change. However, we note two caveats. One, recent research suggests that changes to the collection of data on race and ethnicity by the Association of American Medical Colleges, which allowed students to choose more than 1 race and/or ethnic group, may make it difficult to interpret absolute trends in diversity.2 It is critical to note that our study examined relative trends—trends in diversity of medical schools in states with affirmative action bans relative to schools in states without such bans—and so controlled for these data collection changes. Therefore, the suggestion by Zema that White individuals are underrepresented in medicine is immaterial to our study approach, which focused on changes in the percentage of students who identify as being from particular minority groups within the same medical school over time. For Zema’s concern to affect our approach, it would need to be the case that the way in which students self-report race and/or ethnicity varies systematically with the timing of affirmative action bans between ban and non-ban states. We think this is unlikely.

Second, although increased matriculation at medical school by students from racial and ethnic groups underrepresented in medicine is an important intermediate step, without support, such students can be lost during medical school and residency on their way to becoming a practicing physician.3 This is one of several reasons why, for example, the proportion of physicians who are Black men has remained unchanged between 1940 and 2018.4

Although not the focus of our study, we also believe that it is important for future work to examine subgroups of Asian American students to examine which subgroups might be underrepresented in medicine. Increasing the number of physicians from these subgroups may improve the care delivered to these populations.5

References

  1. Zema M. Unintended Consequences of Well Intentioned Equity. Ann Intern Med 2022; in press.
  2. Brodt E, Valenzuela S, Empey A, et al. Measurement of American Indian and Alaska Native Racial Identity Among Medical School Applicants, Matriculants, and Graduates, 1996-2017. JAMA Netw Open. 2021;4(1): e2032550.
  3. McFarling UL. ‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents. STAT. 2022. Accessed at: https://www.statnews.com/2022/06/20/black-doctors-forced-out-of-training-programs-at-far-higher-rates-than-white-residents/.
  4. Ly DP. Historical Trends in the Representativeness and Incomes of Black Physicians, 1900-2018. J Gen Intern Med. 2022 Apr;37(5):1310-1312.
  5. Sabado-Liwag MD, Manalo-Pedro E, Taggueg R Jr, Bacong AM, Adia A, Demanarig D, Sumibcay JR, Valderama-Wallace C, Oronce CIA, Bonus R, Ponce NA. Addressing The Interlocking Impact Of Colonialism And Racism On Filipinx/a/o American Health Inequities. Health Aff (Millwood). 2022 Feb;41(2):289-295.

Disclaimer: The views expressed in this manuscript are those of the author and do not necessarily represent the views of the US Department of Veterans Affairs or the US government.

Disclosures:

Dr. Jena reports receiving (in the last 36 months) consulting fees unrelated to this work from Bioverativ, Merck/Sharp/Dohme, Janssen, Edwards Life Sciences, Novartis, Amgen, Eisai, Otsuka Pharmaceuticals, Vertex Pharmaceuticals, Celgene, Sanofi Aventis, Precision Health Economics, and Analysis Group. Dr. Jena also reports receiving (in the last 36 months) income unrelated to this work from hosting the podcast Freakonomics, M.D., from book rights to Doubleday Books, and from speaking fees from AAE.

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 175Number 6June 2022
Pages: 873 - 878

History

Published online: 3 May 2022
Published in issue: June 2022

Keywords

Authors

Affiliations

Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California (D.P.L.)
Utibe R. Essien, MD, MPH https://orcid.org/0000-0002-4494-5028
Division of General Internal Medicine, University of Pittsburgh School of Medicine, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (U.R.E.)
Andrew R. Olenski, MPhil https://orcid.org/0000-0002-7461-0536
Department of Economics, Columbia University, New York, New York (A.R.O.)
Department of Health Care Policy, Harvard Medical School, Boston, Department of Medicine, Massachusetts General Hospital, Boston, and National Bureau of Economic Research, Cambridge, Massachusetts (A.B.J.).
Note: Dr. Ly had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Disclaimer: The views expressed here are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs or the U.S. government.
Acknowledgment: The authors thank Philip A. Gruppuso for answering questions regarding the medical school enrollment data and Atheendar S. Venkataramani for answering questions regarding the state ban data. Neither was compensated.
Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Ly (e-mail, [email protected]). Data set: Publicly available, as described in the Methods section.
Corresponding Author: Anupam B. Jena, MD, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, [email protected].
Author Contributions: Conception and design: A.B. Jena, D.P. Ly, A.R. Olenski.
Analysis and interpretation of the data: A.B. Jena, D.P. Ly, A.R. Olenski.
Drafting of the article: U.R. Essien, A.B. Jena, D.P. Ly.
Critical revision for important intellectual content: U.R. Essien, A.B. Jena, D.P. Ly, A.R. Olenski.
Final approval of the article: U.R. Essien, A.B. Jena, D.P. Ly, A.R. Olenski.
Statistical expertise: A.B. Jena, D.P. Ly, A.R. Olenski.
Administrative, technical, or logistic support: A.B. Jena.
Collection and assembly of data: D.P. Ly.
This article was published at Annals.org on 3 May 2022.

Metrics & Citations

Metrics

Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format





Download article citation data for:
Dan P. Ly, Utibe R. Essien, Andrew R. Olenski, et al. Affirmative Action Bans and Enrollment of Students From Underrepresented Racial and Ethnic Groups in U.S. Public Medical Schools. Ann Intern Med.2022;175:873-878. [Epub 3 May 2022]. doi:10.7326/M21-4312

View More

Login Options:
Purchase

You will be redirected to acponline.org to sign-in to Annals to complete your purchase.

Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.

Create your Free Account

You will be redirected to acponline.org to create an account that will provide access to Annals.

View options

PDF/EPUB

View PDF/EPUB

Related in ACP Journals

Full Text

View Full Text

Figures

Tables

Media

Share

Share

Copy the content Link

Share on social media