California’s experience after Proposition 209 offers some clues and lessons
By Robin Buller. Reprinted with permission from the California Health Care Foundation.
The US Supreme Court outlawed the use of affirmative action on June 29, deciding that race and ethnicity can no longer be considered primary factors in university admissions. The ruling of the court’s conservative majority (PDF) favored a plaintiff that sued Harvard University and the University of North Carolina for using race-conscious admissions practices, claiming the universities unfairly give preference to applicants from underrepresented groups. The majority agreed with the plaintiff that affirmative action processes violated the Civil Rights Act and the Equal Protections Clause of the Constitution’s Fourteenth Amendment.
Chief Justice John Roberts wrote in the majority opinion that a student “must be treated based on his or her experiences as an individual — not on the basis of race,” although he did not go so far as to say that universities cannot consider how race has affected a person’s lived experiences. The liberal justices penned strong dissents, stating that the decision “rolls back decades of precedent and momentous progress,” and calling it a “perverse, ahistorical, and counterproductive outcome.”
In their dissents, Justices Ketanji Brown Jackson and Sonia Sotomayor sharply critiqued the ruling as a subversion of the Constitution’s Equal Protections Clause. In reality, wrote Jackson, outlawing affirmative action fails to extend equal opportunity to all Americans by definition and “obstruct[s] our collective progress toward the full realization of the Clause’s promise.” And by ignoring the realities of racial inequality in America, according to Sotomayor, the decision will “entrench racial segregation in higher education” and society writ large.
Health care experts fear that the ruling’s impact could be especially dire for medicine, where Black, Latino/x, and American Indian and Alaska Native communities are severely underrepresented among physicians nationwide. Those concerns are intensified by a widespread consensus that patients coming from underrepresented groups experience better health outcomes when treated by providers who share similar lived experiences due to improved communication, trust, and empathy.
“Health disparities are real, and communities underrepresented in medicine suffer disproportionately,” said Takesha Cooper, MD, chair of the University of California, Riverside, School of Medicine admissions committee. “Without special training and commitment, this will only get worse, and as a result, the whole country will suffer.”
Now, with affirmative action no longer in the higher education admissions toolbox, the nation’s medical schools will need to find other ways to train a diverse future health care workforce in order to meet the needs of the US’s underserved communities.
State Medical Schools Dropped Affirmative Action in 1996
California, where medical schools have already been grappling with this challenge for decades, may offer some lessons to those in other states looking for a viable path forward. In 1996, Californians voted against the use of affirmative action by public institutions, including public universities. In the 27 years since Proposition 209 passed, medical schools in the University of California (UC) system developed new methods to recruit and train diverse and representative cohorts of physicians and saw notable success. Still, according to medical school leaders, developing programs that promote diversity without the use of affirmative action has not been easy, and there is still work to be done.
“California was the laboratory,” said Alicia Fernández, MD, associate dean of population health and health equity at the UCSF School of Medicine. Fernández and Janet Coffman, PhD, co-associate director for policy programs at UCSF’s Institute for Health Policy Studies, have extensively studied Proposition 209’s effects on California’s physician workforce. They found that in the immediate aftermath of its implementation, the number of Black and Latino/x students enrolling in UC medical schools plummeted.
“At first, there were dramatic declines,” said Coffman, noting that not only were medical schools accepting fewer students of color, but the number of applicants from underrepresented minorities also decreased as the most selective undergraduate programs no longer employed affirmative action. Indeed, just one year after Proposition 209 was enacted, the Black and Latino/x undergraduate enrollment at UC Berkeley and UCLA declined by about 40%. “The pipeline shrunk,” Coffman said.
But in the decades that followed, the numbers started to improve, surpassing where they had been before the voters barred affirmative action. While the percentage of Black students in California medical schools hit a low of 5% after Proposition 209, it climbed to 11% by 2019. And the percentage of Latino/x students sunk from 15% to less than 10% after affirmative action was struck down, but grew to 17% by 2019. Coffman and Fernández credit that upswing to more holistic enrollment criteria and funding opportunities for students from underrepresented backgrounds, and, perhaps most importantly, the development of programs that specifically train medical students to practice in underserved communities.
Today, the UC system, led by UC Davis, UC Riverside, and UCSF, boasts some of the nation’s most diverse medical schools, according to data compiled by US News. All the UC institutions emphasize the persistent effort that is required to create and maintain that sort of learning environment.
At UC Davis, where Mark Henderson, MD, is vice chair for education and associate dean for admissions, holistic admissions have become a core practice. That means that not only are an applicant’s grades and test scores considered, but so are their socioeconomic background, history of community engagement, and drive to provide care to those who need it most. To evaluate those factors, Henderson and colleagues developed what they call the “Distance Traveled Score,” a tool that measures the socioeconomic disadvantage that an applicant has had to overcome. The more adversity a person has faced, the higher their score. That number is then placed alongside other elements, such as their undergraduate grade point average and their Medical College Admissions Test score.
Producing Doctors to Serve ‘All of California’
Henderson says that UC Davis School of Medicine does not consider race or ethnicity in the admissions process. However, because socioeconomic distress is so correlated with race in the US, the Distance Traveled Score leads to the acceptance of a high number of students from underrepresented minority groups — and that is something to celebrate. “Our mission is to produce doctors who serve the people of California, and when I say California, I mean all of California,” said Henderson.
Creating a diverse health care workforce isn’t only about medical schools accepting more students from underrepresented groups. It’s also about recruitment and incentivizing more of those individuals to apply in the first place. UC Programs in Medical Education (UC PRIME) is a specialized training program that teaches medical students to meet the needs of California’s underserved populations. Inaugurated at UC Irvine in 2004, PRIME is today offered at all nine UC medical school campuses.
The program offers different focal pathways. At UC Davis School of Medicine, students can choose to focus on caring for rural, tribal, or urban underserved communities; at UC Riverside, PRIME trains physicians to address the needs of Southern California’s “African, Black, and Caribbean communities”; and at UCSF, students can focus on the underserved populations of the San Joaquin Valley.
Melody Le Tran-Reina, MD, executive director of the UC Davis Community Health Scholars Programs, is a graduate of UC Davis PRIME’s urban health pathway, known as Transforming Education and Community Health for Medical Students (TEACH-MS). For her, the opportunity to focus on underserved populations was a big draw, largely because it would enable her to give back to her own community.
Tran-Reina grew up in Los Angeles with parents who were refugees from Vietnam, and in a household that had a low income. As a child, Tran-Reina witnessed the challenges they faced accessing health care, including language barriers, low health literacy, and long wait-times for appointments. “That is why I went into medicine,” she said. “And then I came to Davis, and they had this program, and I was, like, this is everything I wanted.”
Through TEACH-MS, Tran-Reina benefited from being in a small cohort of mission-driven students who brought their own knowledge and experiences to the table. Courses focused not only on diagnosis and treatment, but also on social and structural determinants of health and how best to practice in low-resource settings.
Patients Who ‘Remind Me of My Family’
“Those with the best insights grew up in those communities,” said Tran-Reina, who described the learning process as extremely validating. “It clicked. You realize there’s a reason why things are like this. There’s a reason why it’s so hard for my community to be healthy,” she said. She recounted how meaningful it was for her to care for people with whom she shared a connection. “I’d take care of people who would remind me of my family or remind me of my friends’ families when I was growing up, and that’s really special,” she said.
Matriculation data indicates a high correlation between those who come from underrepresented communities, and those who want to serve them. The UC Davis Class of 2026 had the medical school’s most diverse cohort ever, with students being 3% American Indian and Alaska Native, 36% Asian, 14% Black, 30% Latino/x, and 15% White. Among class members, 42% were first-generation college students, and 84% came from disadvantaged backgrounds.
Getting to this point took years of sustained effort. “California just recently recovered,” said Fernández, noting that some private medical schools in California admit few students from underrepresented communities, despite not having faced the restrictions posed by Proposition 209. There are some exceptions: Stanford University and Loma Linda University Medical Schools have fairly diverse student bodies. However, according to the Integrated Postsecondary Education Data System, between 2012 and 2021 3.1% of University of Southern California medical school graduates were Black and 7.8% Latino/x; for Touro University California, in Vallejo, 0.8% of medical school graduates were Black and 2% were Latino/x.
Fernandéz also underscores that although UC medical schools have seen success in raw numbers, there is still a long way to go to reach full representation, especially as the state becomes increasingly diverse. In 2021, for instance, only 3% of the state’s physicians were Black compared to 6% of the overall population, and only 7% of doctors were Latino/x even though that group accounts for 40% of Californians. “Yes, there are as many Black and Latino medical students or more than [before Proposition 209], but with percentages, representation, especially among Latinos, is way behind,” Fernández said.
‘You’ve Got to Be Willing to Fight That Battle’
To mitigate the impact that the Supreme Court’s decision will have on the diversity of the country’s future health care workforce, medical schools must move swiftly to implement methods like holistic admissions, as well as to create programs that recruit and train providers to work in underserved communities. “It will be hard to ramp up quickly,” said Coffman.
One possibility, she says, is to remodel existing infrastructure, such as the rural-focused programs that many medical schools around the country already offer. “They could be adapted to being more PRIME-like with a focus on the underserved,” Coffman said.
But simply installing a program like PRIME will not be enough. There also needs to be buy-in from leadership, said Henderson. He noted that in advance of the widely anticipated Supreme Court decision that he and colleagues at UC Davis have been receiving countless requests from medical schools outside of California for insights on how to diversify their own student bodies, as well as how to measure Distance Traveled.
His advice is to those schools is to be prepared to support the underrepresented students that they accept beyond their first day of classes, as those individuals may face additional challenges and barriers to success during their years of education and training. Doing so, he says, will require resources and commitment.
“It’s not just taking a different group into the school, it’s what you do with them when they get there,” said Henderson. “I’m optimistic for those institutions who put in the work, but it’s hard work. You’ve got to be willing to fight that battle.”