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Ban the Box: Confronting Discrimination in Hospital Hiring

Much has been said about the growing crisis of mass incarceration in our country, especially how it disproportionately affects people of color. And it’s true, the United States currently houses 2.2 million people behind bars, a greater percentage of the population than that of any other nation in the world. Sixty percent of those incarcerated today are people of color. Nonviolent drug offenses make up the majority of convictions, and people of color are three times more likely to go to jail for these offenses — not because of greater prevalence of drug sales or use, but rather due to more severe policing and sentencing.

But, the consequences of racism do not disappear when an individual is released from prison. They are carried into the reentry process and pervade the community. When the time comes to re-enter society, the prospect of meeting basic needs like food, housing and employment becomes more difficult, and desperation leads to what’s known as “recidivism,” or relapse into imprisonment.

Regrettably, many health care institutions marginalize formerly incarcerated job applicants, oppose legislation in favor of fair hiring practices, and have not partnered with workforce intermediaries, thus perpetuating institutionalized discrimination and systemic racism.

In medicine, we hope our interventions will both diminish symptoms and target the source of a problem. For a moment, consider mass incarceration as a disease. Providing employment is an intervention that would accomplish both aims. Statistics show that formerly incarcerated people who were consistently employed throughout the year had a 16 percent recidivism rate, compared to a 52 percent recidivism rate for all other Department of Correction releases. Employment allows individuals to provide for themselves and also reduces the symptom of recidivism.

But something stands between the formerly incarcerated and gainful employment: the box.

It’s a small square that asks a big question: have you ever been convicted of a crime? All potential employees with criminal histories must check the box. And too often, regardless of the crime and its relevance to the position applied for, it is enough to remove a qualified applicant from consideration.

Though it was designed to notify employers of specific criminal records that could compromise the needs of the position, employers often see a checked box and throw out the application without further investigation. This type of hiring discrimination is illegal, but is so hidden that it is impossible to enforce by any legal authority. Ultimately, the box turns any criminal record into a life sentence by preventing gainful employment and creating the circumstances for recidivism.

The box also reinforces pre-existing racial discrimination. Research shows that 17 percent of white applicants with a criminal record were later contacted about a callback interview. In comparison, 14 percent of black applicants without, and only 4 percent of those with a criminal record received a callback. Indeed, the percentage of black applicants without criminal records who received a callback interview was lower than the percentage of white applicants with criminal records that received a callback interview.

Statistics like these demonstrate two intertwined types of discrimination: one against formerly incarcerated individuals, and another of systemic racism against African-Americans. An employer’s interpretation of a checked box varies with the applicant’s race, disproportionately penalizing people of color. Beyond the obvious discrimination against all formerly incarcerated individuals, the box creates another avenue for racist hiring practices in our country.

New York City Council is currently considering legislation called The Fair Chance Act that proposes to remove questions about criminal history from the initial job application. This follows the pattern of many cities and states across the country that have already enacted similar “ban-the-box” legislation. Banning the box prevents employers from asking about an applicant’s criminal history before the applicant’s qualifications have been considered. After a conditional offer of employment has been extended, the employer can run a background check and ask the applicant for information about convictions relevant to the position.

Basically, banning the box allows people with criminal records to have their qualifications assessed just like everyone else. It allows formerly incarcerated individuals to earn a livelihood, fills positions with qualified employees, and begins to eliminate the institutionalized racism that permeates our society. Unfortunately, few hospital systems have taken strides to remove the box from their applications. Hospitals often raise these concerns:

  1. Hospitals worry patient safety will be affected by hiring the formerly incarcerated. However, pre-existing laws already require background checks and prevent people with compromising convictions from working in patient care. The Fair Chance Act does not change these requirements. Still, many positions in a hospital don’t involve direct patient care and can be responsibly filled by a formerly incarcerated applicant. For example, a person convicted of identity theft would not be permitted to work in a position with access to secure patient information, but can easily be employed in a field like hospital catering.
  2. Hospitals do not want to be held liable for the potentially compromising actions of formerly incarcerated employees. But, a past criminal record does not make an employee inherently dangerous. Furthermore, background checks, conducted after a conditional job offer, would screen out applicants who pose such liabilities. Thus, in the rare event of a lawsuit, employers would not be found negligent.
  3. Some hospitals are concerned that formerly incarcerated employees are bad workers, which hurts the bottom line. But employers who do hire people with criminal records find that they work harder and stay at a job longer. For example, the Johns Hopkins Health System reviewed the employment files of nearly 500 of their formerly incarcerated employees and found that these individuals had significantly higher retention rates as compared to employees without a criminal record.

Ultimately, the concerns of hospitals come from hypersensitivity towards their own economic interests instead of the interests of communities they were built to serve.

It’s clear that efforts to ban the box are critically necessary. But even if we were to hypothetically remove discrimination from the hiring process, many formerly incarcerated applicants would still face an array of barriers including inadequate job skills, lack of familiarity with the application process, and reluctance to apply for fear of discrimination or lack of job experience. These complex needs have led to the development of ‘workforce intermediaries’ — nonprofits that provide job skills training, job placement assistance and career development counseling to link formerly incarcerated individuals with employers. These intermediaries also respond to the needs of employers, assisting them by pre-screening applicants and guiding them in claiming government tax credits.

Only a few hospitals, including the Montefiore Medical Center and Johns Hopkins Health System, have built partnerships with workforce intermediaries. Despite the more widespread success of workforce intermediaries in reducing recidivism and facilitating employment in other sectors, the vast majority of hospitals have not taken advantage of their services. This needs to change.

As doctors-in-training, we frequently limit ourselves to effecting change within the narrow confines of the clinic. While we learn that albuterol can treat asthma and intubation can open airways, we lack the education to heal the social and political diseases of a nation that cries out “I can’t breathe.”

We would like to propose a new standard of care: we as students within a medical community must collectively leverage the institutions we comprise — hospitals — to roll back discrimination and institutionalized racism. To do this, students should become educated about the hiring practices of their local institutions, and start talking to other students, care providers and administrators about how to better support fair-hiring practices at their hospitals and medical schools. As students, we can push hospitals and medical schools to institute a policy of intentional hiring that includes:

  • Pledging to respond to the needs of formerly incarcerated applicants by working with workforce intermediaries specific to their respective neighborhoods, and;
  • Releasing a public statement explaining the policy change and support for non-discrimination.

Moreover, students, especially those in New York City, can play a key role in advocating for hiring reform in the health sector by contacting their city councilperson. Students can speak to legislators, and encourage the participation of hospitals and medical schools in The Fair Chance Act and ban-the-box reform by:

  • Removing the box from hospital job applications, and;
  • Inserting a statement informing applicants of their right to not be discriminated against based on a past criminal record.

As community institutions and centers of healing, hospitals should lead efforts against discrimination based on both race and history of incarceration. It’s time that we as medical students claim our role as stakeholders in our hospitals and assume responsibility for discrimination in our communities. In recent public discourse, the non-indictments following the deaths of Eric Garner and Michael Brown have tragically demonstrated the persistence of institutionalized racism in the criminal justice system. Much of the discussion has focused on police officers and prosecutors, but disregard for the lives and health of people of color extends well beyond the patrol car and prison cell. Many of the methods of discrimination remain locked and hidden, not behind bars, but within our hospitals. As students, we must first form networks of advocacy and take action within our hospitals and home institutions. In doing so, we will begin to eradicate the disease of discrimination that continues to plague our country.

Author’s note: This article is written on behalf of Mount Sinai Organized for Action, a group of students that is committed to opposing systems of injustice that produce gross inequities present in our society. We recognize that the health care system is complicit in perpetuating health inequalities. As students in the medical field, we believe that we are in a unique position to work against actors who perpetuate inequality in the health care system. Please subscribe to our listserv to get involved.

John Power (1 Posts)

Contributing Writer

Mount Sinai School of Medicine

My name is John Power, a 2012 graduate of Johns Hopkins University in Baltimore, Maryland and a member of the Class of 2018 at Mount Sinai School of Medicine. Before medical school, I spent one year working with a community health program in rural Haiti and one year working on health policy issues with an HIV advocacy group. Let's be good doctors together.

  • Eric

    A powerful article. Linking the idea of disease and social disparity as a conundrum for the physician, not just the politician or hospital management. It is a challenge that may be willful ignored. However, it is a reality that physicians must be confronted with if we ever expect to to see positive change in both our society and our faltering health care system. The question remains, what will it take for these organizations, nay this entire country, to hear the message they would so rather write off as staticky white noise?