THE TREATMENT OCTOBER 12, 2009
The U.S. Commission on Civil Rights (USCCR) has released a public letter concerning HR3200, the main House health reform bill.
Many people have framed health reform as a civil rights concern. More than one-fifth of African-Americans, and more than one-third of Hispanic Americans, are uninsured. Race/ethnic disparities in access to high-quality medical care are profound. Disparities in health status and lifespan are even larger, and must be counted among the most serious structural inequalities in American society. On many levels, these issues warrant the attention of USCCR.
Oh wait--these are conservative civil rights people. As first reported by Jennifer Haberkorn in the Washington Times (yes, that Washington Times), USCCR objects to provisions in the House bill, which it regards as racially discriminatory. By a 4-2 vote, Bush-era holdovers sent a letter to President Obama and Congressional leaders “expressing deep reservations about racially discriminatory provisions included in H.R. 3200.”*
USCCR has a problem--a constitutional problem--with the bill’s language that favors institutions with “a high rate of placing graduates in practice settings having the principal focus of serving in underserved areas or populations experiencing health disparities (p. 882).” As USCCR phrases it,
[W]e have two concerns. First, racial preference policies that assume racial health disparities are caused by a shortage of medical professionals of particular races misdiagnose the problem and may well exacerbate it. Second, Congressionally-mandated affirmative action of this type is likely to be held unconstitutional.
The letter goes on to say:
Over the years, some observers have argued that racial disparities in health are the result of disparities--whether caused by conscious or unconscious discrimination--in the provision of health care, and that expanding the number of minority physicians (even if that means lowering academic standards in medical school) and ensuring that all health care professionals receive “cultural competency” training would help remedy the problem. But as Dr. Amitabh Chandra of Harvard University testified at a recent briefing before the Commission, this view is “grounded in hope more than science.”
A growing body of evidence shows that health care disparities are not the result of individual physicians treating their white patients differently from their black patients or of nonblack physicians’ lack of familiarity with African-American culture. Rather, the problem lies with the fact that, as a population, black patients use different doctors, clinics and hospitals than white patients. On the whole, the doctors who treat black patients with frequency are less likely to be highly credentialed and more likely to report obstacles in gaining access to high-quality service for their patients. As one might expect, these circumstances can lead to poorer health outcomes.
Here the Commission runs together two points, one quite valuable, the other quite silly.
First the good point. Explicit provider discrimination is a smaller factor in generating health disparities than many people suppose. Thousands of minority patients--many others, too--experience avoidably bad outcomes because of where they receive their care. Being more likely to be poor or to lack good insurance, many are treated in under-funded or low-quality facilities that provide measurably poorer treatment.
As Chandra puts it: "Forty years after the passage of the Civil Rights Act, minority health care is de facto separate and unequal." Hospitals that mainly serve African-Americans have markedly higher adjusted mortality rates than are found in hospitals that mainly serve non-Hispanic whites. Hospitals that predominantly serve African-Americans are also less likely to provide key evidence-supported interventions.
USCCR conflates this valid point with a very different argument against “racial preferences” that mainly knocks down caricatured arguments no sensible affirmative action supporter actually accepts. Thus, USCCR criticizes the “notion that simply increasing the numbers of black doctors is the solution to the problem of inferior treatment for minorities.”
Rather than undercutting the case for affirmative action or for cultural competence, Chandra’s work and others actually underscore the need for universal coverage and for delivery system reforms that improve clinical care in underserved communities. Hundreds of pages in HR3200 seek to accomplish precisely this.
For the record, I believe USCCR is wrong about the narrow issues, too. Virtually everyone in American medical care agrees that the dearth of African-American, Native American, and Latino medical providers is a serious concern. Minority under-representation--and the correlated insensitivity of providers to cultural factors that really do matter in patient care--reinforce the mutual estrangement between patients and their health care providers.
One does not have to be a liberal Democrat to appreciate these points, Informed by such experiences, and by evidence that minority physicians are especially likely to serve underserved patients, generally-staunch affirmative action critic John McWhorter has wisely supported race-sensitive medical school admission policies to promote a more diverse medical workforce.
In the dog days of August, rumors persisted that conservatives would make a concerted effort to decry supposed “health care racism” in Democratic health reform bills. This hasn’t happened, though the USCCR letter is of a piece with this campaign.
That letter highlights the debasement of civil rights discourse as a rhetorical trope in health care debate. The central debate over HR3200 concerns the basic rights and dignity of American citizenship, the right of each person to decent and affordable health care. Denial of this right hits most sharply in minority communities, which endure staggering rates of avoidable mortality, disability, injury, and illness that kill or maim hundreds of thousands of people every year. (For more, see Adam Serwer’s recent piece over at Prospect.org.)
HR3200, for all its imperfections, seeks to rectify these injustices. There is something oddly irrelevant--a throwback to the culture wars--in focusing on some mild affirmative action passages given what else is at stake.
To deny this reality is more than colorblind. It is willfully obtuse.
*I originally wrote that every Republican on the Commission supported the majority.
I received an email today from Abigail Thernstrom, which noted: I am a Bush holdover, and indeed the vice-chair of the USCCR and did not sign the letter…. I joined the two Democrats in not adding my signature.
She adds: “My beef with the USCCR letter is that it distorts what's in the bill.”
My apologies to Dr. Thernstrom for not pointing this out. Given her long record as an emphatic critic of affirmative action and like-minded policies, her decision not to sign this one-sided letter is especially noteworthy.