Position Papers12 January 2021

A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care: A Policy Paper From the American College of Physicians

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    Abstract

    Racial and ethnic minority populations in the United States experience disparities in their health and health care that arise from a combination of interacting factors, including racism and discrimination, social drivers of health, health care access and quality, individual behavior, and biology. To ameliorate these disparities, the American College of Physicians (ACP) proposes a comprehensive policy framework that recognizes and confronts the many elements of U.S. society, some of which are intertwined and compounding, that contribute to poorer health outcomes. In addition to this framework, which includes high-level principles and discusses how disparities are interconnected, ACP offers specific policy recommendations on disparities and discrimination in education and the workforce, those affecting specific populations, and those in criminal justice practices and policies in its 3 companion policy papers. ACP believes that a cross-cutting approach that identifies and offers solutions to the various aspects of society contributing to poor health is essential to achieving its goal of good health care for all, poor health care for none.

    Research has shown that Black, Indigenous, Latinx, Asian American, Native Hawaiian, Pacific Islander, and other persons in the United States experience disparities in health and health care associated with their race, ethnicity, religion, and cultural characteristics and identities. Although the reasons for such disparities are multifaceted, discrimination and biases, both explicit and implicit, are major contributors to lower rates of health care access and coverage (1, 2), higher rates of mortality and morbidity (3, 4), and poorer health outcomes and health care quality (3). Many interacting factors, including social determinants of health, racism and discrimination, economic and educational disadvantages, health care access and quality, individual behavior, and biology, affect a person's health (5). Living in communities with poor social drivers of health substantially contributes to health and health care disparities, and such factors need to be addressed and ameliorated for all persons. However, certain populations experience disparities in health and health care associated with their race, ethnicity, religion, and cultural characteristics and identities that are independent of or in addition to those caused by their socioeconomic status and where they live; this may reflect current and historical discrimination, bias, and racism. With population trends diversifying, there is an urgent need for policymakers and clinicians to adapt and reenvision the way health care is structured to reduce racial and ethnic health care gaps and meet the needs of persons affected by discrimination because of their race, ethnicity, and cultural characteristics and identities.

    The American College of Physicians (ACP) believes that although public policy must focus on ensuring that everyone has access to high-quality health care and the best possible health outcomes—good health care for all, poor health care for none—this cannot be achieved without understanding and addressing the unique circumstances of persons who are discriminated against because of their race, ethnicity, religion, and cultural characteristics and identities, including the effect of discrimination and racism on health. In this paper, ACP proposes a comprehensive, interconnected, and evidence-based policy framework to understand, address, and end such disparities. As the United States struggles to understand and address the effect of racism on society and health, ACP believes that it is imperative to speak up and promote an evidence-based understanding and propose evidence-based solutions according to its mission “to enhance the quality and effectiveness of health care.” In the pursuit of fostering excellence, ACP strives to achieve its goals to “promote and respect diversity, inclusion, and equity in all aspects of the profession” and “advocate responsible positions on individual health and on public policy related to health care for the benefit of the public, patients, the medical profession, and our members” (6).

    Research can only imperfectly capture the lived realities of the many Americans who experience discrimination and injustice. What is clear is that overt and covert discrimination exist on both an interpersonal and a societal level throughout various facets of life and directly and indirectly affect persons' health and well-being. Hence, to effectively understand, address, and end disparities, one must recognize and confront the fact that many elements of U.S. society, some of which are intertwined and compounding, contribute to poorer health outcomes. If we accept that no one element of society is solely responsible for creating disparities, then any strategy to eliminate disparities that addresses any element independently of the others will fail to accomplish its goal. Rather, ACP believes that a comprehensive and interconnected framework is best suited to achieve its goal of a society in which no one is discriminated against or receives poorer care because of their race, ethnicity, religion, or cultural characteristics and identities. Such a framework would identify, prioritize, and offer solutions to the various elements contributing to poorer health outcomes for persons and populations most at risk—including disparities in health care and health care delivery, education, and criminal justice and law enforcement. In this paper and 3 companion papers, ACP outlines a framework and principles for addressing disparities and discrimination in health and health care and offers policy recommendations on coverage, criminal justice, the workforce, and general and medical education and on the unique and shared issues facing racial and ethnic minorities. Background information (Appendix 1) and a glossary (Appendix 2) provide a rationale for the development of these recommendations and our choice of specific language.

    In 2010, ACP published the paper “Racial and Ethnic Disparities in Health Care, Updated 2010” (7), which provided recommendations addressing the ongoing challenges faced by racial and ethnic minorities in achieving health equity and the need for a more diverse and inclusive health care system. Although some progress has been made since then, large inequities persist. There is now a greater understanding that to reduce health disparities, management of a patient's health can no longer end at the office door. Social drivers of health, such as education, environment, employment, housing, and access to healthful foods and safe places to exercise, all directly and indirectly contribute to a person's health status. There is a growing public consciousness about—and a national reckoning over—the presence of structural racism and its effect on health, which is discussed in “Racism and Health in the United States: A Policy Statement From the American College of Physicians” (8). This paper and 3 companion policy papers that examine particular contributors to disparities in health build on previous ACP policies.

    Methods

    This policy paper was drafted by ACP's Health and Public Policy Committee, which is charged with addressing issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties. The authors reviewed available studies, reports, and surveys related to health, education, and criminal justice disparities from PubMed and Google Scholar between 1990 and 2020 and relevant news articles, policy documents, websites, and other sources. Recommendations were based on reviewed literature and input from ACP's Board of Regents; Diversity, Equity and Inclusion Committee; Education Committee; and Ethics, Professionalism and Human Rights Committee and other external experts. The policy paper and related recommendations were reviewed and approved by ACP's Board of Regents on 7 November 2020. Financial support for the development of this position paper came exclusively from the ACP operating budget.

    Recommendations

    1. ACP recommends that U.S. policymakers commit to understanding and addressing disparities in health and health care related to a person's race, ethnicity, religion, and cultural identity [their personal characteristics], as aligned with ACP's mission “to enhance the quality and effectiveness of health care for all.”

    2. ACP recommends that policymakers comprehensively address the interconnected contributors to health and health care disparities, including the role of racism, discrimination, lack of coverage and access to care, poverty, and other social drivers of health.

    3. ACP believes that public policy must support efforts to acknowledge, address, and manage preconceived perceptions and implicit biases by physicians and other clinicians.

    4. ACP believes that health care facilities and medical schools and their clinicians and students should be incentivized to use patient-centered and culturally appropriate approaches to create a trusted health care system free of unjust and discriminatory practices.

    5. ACP believes that a diverse, equitable, and inclusive physician workforce is crucial to promote equity and understanding among clinicians and patients and to facilitate quality care, and it supports actions to achieve such diversity, equity, and inclusion.

    6. ACP believes that policymakers must strengthen U.S. education at all levels to improve health, health literacy, and diversity in medical education and in the physician workforce and must prioritize policies to address the disproportionate adverse effect of discrimination and inequitable financing in education on specific communities based on their personal characteristics.

    7. ACP recommends that policymakers consider discrimination and hate against any person on the basis of personal characteristics as a public health crisis.

    8. ACP recommends that policymakers address the effect of social drivers of health, like poverty, on the health and health care of those affected, while addressing disparities associated with personal characteristics independent of, or in addition to, socioeconomic status.

    9. ACP believes that public policy must strive to make improvements to coverage, quality, and access to care for everyone, while addressing the disproportionate effect on those at greatest risk because of their personal characteristics.

    10. ACP believes that public policy must acknowledge the long history of racism, discrimination, abuse, forced relocation, and other injustices experienced by Indigenous persons and commit to focused and culturally appropriate policies to address their present reality of injustice, disparities, and inequities.

    11. ACP believes that physicians and other clinicians must make it a priority to meet the cultural, informational, and linguistic needs of their patients, with support from policymakers and payers.

    12. ACP believes that public policies should reflect the unique effects that country of origin, language, immigration status, workplace, and culture have on health disparities among various distinct communities associated with their personal identities.

    13. ACP believes that health care delivery and payment systems should support physician-led, team-based, and patient- and family-centered care that is easily accessible to those affected by discrimination and social drivers of health.

    14. ACP believes that policymakers should recognize and address how increases in the frequency and severity of public health crises, including large-scale infectious disease outbreaks, poor environmental health, and climate change, disproportionately contribute to health disparities for Black, Indigenous, Latinx, Asian American, Native Hawaiian, Pacific Islander, and other vulnerable persons.

    15. ACP believes that policies must be implemented to address and eliminate disparities in maternal mortality rates among Black, Indigenous, and other women who are at greatest risk.

    16. ACP believes that more research and data collection related to racial and ethnic health disparities are needed to empower policymakers and stakeholders to better understand and address the problem of disparities. Collected data must be granular and inclusive of all personal identities to more accurately identify socioeconomic trends and patterns.

    17. ACP recommends that policymakers understand, address, and implement evidence-based solutions to systemic racism, discrimination, and violence in criminal justice and law enforcement policies and practices because they affect the physical health, mental health, and well-being of those disproportionately affected because of their personal identities.

    Along with this paper, the ACP Board of Regents approved 3 related policy papers (9–11), which are available on ACP's website.

    In “Understanding and Addressing Disparities and Discrimination in Education and in the Physician Workforce: A Policy Paper From the American College of Physicians” (www.acponline.org/acp_policy/policies/understanding_discrimination_in_education_physician_workforce_2021.pdf), ACP offers recommendations to create safe, inclusive, and supportive educational and workplace environments; to promote diverse medical school bodies and workforces; and to support, fund, and strengthen education at all levels. Achievement of these goals is essential to enhancing the physician pathway, ensuring a diverse health care workforce that is representative of the patients it serves, building trust and understanding between patients and health care professionals of different backgrounds, and equipping persons with the knowledge and skills needed to live healthy lives.

    In “Understanding and Addressing Disparities and Discrimination Affecting the Health and Health Care of Persons and Populations at Highest Risk: A Policy Paper From the American College of Physicians” (www.acponline.org/acp_policy/policies/understanding_discrimination_affecting_health_and_health_care_persons_populations_highest_risk_2021.pdf), ACP makes recommendations to address disparities in coverage, access, and quality of care for racial and ethnic minorities, including expanding Medicaid and insurance marketplace subsidies, funding translation and patient navigator services, and supporting programs that place physicians in underserved communities. Specific recommendations are offered to address issues that disproportionately affect racial and ethnic minorities, such as maternal mortality rates and coronavirus disease 2019.

    In “Understanding and Addressing Disparities and Discrimination in Law Enforcement and Criminal Justice Affecting the Health of At-Risk Persons and Populations: A Policy Paper From the American College of Physicians” (www.acponline.org/acp_policy/policies/understanding_discrimination_law_enforcement_criminal_justice_affecting_health_at-risk_persons_populations_2021.pdf), ACP calls for changes to criminal justice and law enforcement policies and practices that result in racial and ethnic disparities in interactions, sentencing, and incarceration as well as disproportionate harm to these communities. ACP's review of the evidence finds that these policies can negatively affect the physical health, mental health, and well-being of racial and ethnic minorities. Further, ACP affirms that injury and loss of life at the hand of the state, whether in law enforcement encounters or through inequities in capital punishment sentencing, is a health issue. It supports further exploration of evidence-based best practices to address episodes of mental health and homelessness by specialized and trained professionals, with the goal of reducing interactions that can lead to injuries and deaths for those involved. ACP also calls for a more proactive approach to understanding and addressing the socioeconomic factors associated with crime.

    In conclusion, this framework is the basis of the more detailed policy recommendations included in the 3 related papers. We believe that, taken together, these 4 papers provide a comprehensive and interconnected set of policies to address some of the most pressing issues throughout society that contribute to health disparities based on race, ethnicity, religion, and cultural characteristics and identities. We implore readers to read the 3 papers, along with this framework, to better understand the policy recommendations that make up ACP's holistic vision to eliminate health disparities.

    Appendix 1: Background and Rationale

    The Healthy People 2020 program of the U.S. Department of Health and Human Services defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities” (12). Despite efforts to close gaps, progress in mitigating disparities in some areas has begun to reverse. Recent data show that racial and ethnic group mortality disparities are widening for some age groups, particularly the youngest and oldest. For example, the infant and child mortality rate is twice as high for Black children as for White children (13).

    Preventable and Chronic Disease

    Certain chronic health conditions disproportionately affect racial and ethnic minorities. Between 2011 and 2014, 21.9% of Hispanic children and adolescents were obese—the highest prevalence of obesity in the United States (14). Black men are twice as likely as White men to die prematurely of stroke (15), and Black, American Indian, and Alaska Native women have higher rates of stroke-related death than Hispanic or White women (16). Black women are much more likely than White women to die of breast cancer, and the mortality gap is widening as the incidence rate in Black women has caught up to that in White women (4). Racial and ethnic minority children are more likely to develop type 2 than type 1 diabetes, and racial and ethnic minorities in the United States are more likely to develop complications of diabetes and lower limb amputations, which can contribute to disability (17).

    Addressing Historical and Systemic Factors Fueling Disparities

    To meaningfully reduce disparities in health care, stakeholders must acknowledge how such issues as implicit bias and structural racism have affected the lives, environments, communities, and health care quality of Black, Indigenous, Latinx, Asian American, Native Hawaiian, Pacific Islander, and other persons affected by discrimination because of their race or ethnicity (18). The Institute of Medicine's report Unequal Treatment argued that physician bias could contribute to racial disparities in health (19). Further evidence shows that health care professionals exhibit levels of implicit bias toward personal characteristics, such as race, ethnicity, sex, socioeconomic status, age, mental illness, or disability, that are similar to levels in the wider population (20, 21). The body of evidence indicating that racism is a social determinant of health has grown over the years; however, additional research is needed to identify best practices for education on and mitigation of structural racism in the health care setting. The Institute for Healthcare Improvement developed a framework for health care organizations on how to achieve health equity, which includes guidance for decreasing institutional racism within an organization and measuring health equity outcomes (22).

    Conclusion

    Too many Americans face discrimination and disparities in health and access to health care related to how society treats their race, ethnicity, religion, and cultural identities and characteristics. Black, Indigenous, Latinx, Asian American, Native Hawaiian, Pacific Islander, and other persons in particular face discrimination and disparities in health. Increasing cases of hate crimes and violence directed at Black, Indigenous, Latinx, Asian American, Jewish, Muslim, and Sikh communities are a public health crisis. Further disparities in other socioeconomic factors exacerbate health disparities and result in lower rates of health care access and coverage, higher rates of mortality and morbidity, and poorer health outcomes and health care quality. These challenges are complex and require greater understanding and a commitment to proposing and advocating evidence-based solutions. As an organization representing internal medicine physician specialists on the front line treating patients of diverse backgrounds, ACP asserts that there is a moral imperative to focus resources toward developing solutions to addressing the health disparity gap. The College believes that achieving the goals of expanding coverage, improving cultural humility, diversifying medical schools and the workforce, eliminating racism and discrimination throughout society, and reforming the criminal justice and education systems, as proposed in this policy framework and as addressed in more detail in the 3 companion policy papers, would have a meaningful effect on improving health outcomes and access to high-quality health care.

    Appendix 2: Glossary

    Black: The term Black is used rather than African American to capture the shared and distinct experiences of both those who are descended from enslaved Africans brought to North America who have a long history in the United States as well as others who have more recently immigrated from African, Caribbean, and other countries and who may not as strongly identify with the American identity.

    Latinx: Gender-neutral term to refer to those living in the United States who are of Latin American descent, rather than Hispanic, which refers to those who share Spanish as a common language. While respecting the views of those who do not prefer to be called Latinx, we conclude that Latinx captures power and privilege dynamics in the United States better than Hispanic, which would include those of Spanish descent who would identify as White but would exclude those of Brazilian descent and other non–Spanish-speaking Latin American countries. When referencing other sources, we use the descriptors the authors used. We recognize the controversy over the use of Latinx: Some argue that the term imposes American and Anglocentric ideals, encompasses a broad and diverse group, is incomprehensible to native Spanish speakers without any fluency in English—some of the very people the term is meant to serve—and is not a term that most persons of Latin American descent identify with. Although an imperfect solution, we choose to use the gender-neutral Latinx over Latino (in Spanish, many nouns and adjectives are gendered, with nouns ending in -o typically using masculine pronouns) in an effort to be as inclusive as possible.

    Social drivers of health: The terms social drivers of health and social determinants of health are used interchangeably. When discussing the social and economic factors that contribute to health, we prefer to use the term social drivers of health to emphasize that these factors are changeable drivers that can be influenced rather than fixed determinants that are immutable. However, given the predominant use of the term social determinants of health in the literature, we use that term in this article when referencing other sources that used the term.

    Cultural humility: Self-reflection and self-critique of one's own beliefs, values, biases, and cultures in an effort to increase awareness for others, with an emphasis on openness and readiness to learn.

    Racism: Prejudice, discrimination, hate, or bias toward a person or group on the basis of their actual or perceived race/ethnicity. Racism can exist at various levels, from the individual, to the interpersonal, to the institutional, to the structural. It can also manifest in both overt/explicit and covert/implicit manners.

    Individual racism: Privately held biases, beliefs, and actions that perpetuate racism and are often informed by culture.

    Interpersonal racism: Public expressions of racism that arise when interacting with others.

    Institutional racism: Policies and practices within institutions (for example, education or criminal justice system) that, regardless of intent, result in different outcomes for different racial or ethnic groups.

    Structural racism: “Macrolevel systems, social forces, institutions, ideologies, and processes … [that] interact with one another to generate and reinforce inequities among racial and ethnic groups” that can persist even in the absence of interpersonal discrimination and without regard to individual action or intent (23, 24). In this article, structural racism and systemic racism are used interchangeably.

    Antiracism: The intentional and conscious effort to take action to oppose racism and racial inequities in all realms of society.

    References

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    Jeffrey T. Berger M.D., Dana Ribeiro Miller M.Div. L.C.S.W., Sandy Dorcelus D.O.26 April 2021
    The Anchoring of Fallacious Race-Based Beliefs in Medicine

    The April 13 2021 issue of the Annals of Internal Medicine illustrates the entrenchment of structural racism in the medical literature and in organized medicine. The ACP position paper A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Policy states that “…it is imperative to speak up and promote an evidence based understanding” of racism on health. Yet in the very same issue, the Annals published Cases in Precision Medicine: Genetic Testing to Predict Future Risk for Disease in a Healthy Patient in which race and ethnicity (see figure 1) are endorsed as scientifically valid constructs despite substantial and compelling evidence to the contrary.(1,2,3) In its Comprehensive Policy Framework, the ACP largely externalizes structural racism and does little to acknowledge its manifestations from within the health system and this Annals’ issue provides an example of the anchoring of fallacious race-based beliefs. Speaking up about misuse of race in health care must include an examination of the systems and structures in organized medicine that perpetuate such beliefs.

     

    1. Witzig, R. 1996. The medicalization of race: Scientific legitimization of a flawed social construct. Ann Intern Med. 1996;125:675-679 https://doi.org/10.7326/0003-4819-125-8-199610150-00008
    2. Race Is a Social Construct? Scientists Argue. Megan GannonLiveScience. Scientific American 2016. https://www.scientificamerican.com/article/race-is-a-social-construct-scientists-argue/ Accessed April 17, 2021
    3. Bonham, VL, Green ED, Perez-Stable E. Examining How Race, Ethnicity, and Ancestry Data Are Used in Biomedical Research. JAMA 2018;320(15):1533-4.