Race, Health Care and the Law 
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U.S. Policy on Health Inequities

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 Vanessa Northington Gamble and Deborah Stone

Excerpted from: Vanessa Northington Gamble and Deborah Stone, U.S. Policy on Health Inequities: the Interplay of Politics and Research, 31 Journal of Health Politics, Policy and Law 93- 122, 93-96 (February, 2006) (17 Footnotes)


W. E. B. DuBois, a towering figure of twentieth-century social and political thought, asserted in his 1903 classic, The Souls of Black Folks, "The problem of the Twentieth Century is the problem of the color line--the relationship of the darker to the lighter races of men" (DuBois 1903: 13). Three years later, in The Health and Physique of the Negro American, DuBois (1906) and his colleagues documented racial inequalities in health. Yet despite a century of activism and research on the problem, inequalities persist.

With the recent resurgence of interest in health inequality among researchers in the United States and other countries, one pressing question is how scientific research can best contribute to reducing health disparities. This article grew out of an international conference on the relationship between scientific research and government action in addressing health inequalities. The conference included participants from six countries who were asked to consider three questions: First, what is or are the major axis/axes of inequality in the distribution of health and health care in each country? Second, what can researchers do to package and disseminate their research so that it is more likely to be translated into action? And third, what structural modifications to government receptor agencies might maximize the likelihood of research uptake by government? The conference participants were asked to select a research report that had had or was likely to have a major impact on policy and to reflect on the characteristics of the report that contributed to its effectiveness.

As participants representing the United States, we chose to focus on racial and ethnic disparities in health. Race and ethnicity are not the only dimensions of health inequality, and indeed, Healthy People 2010, the decennial goal-setting document of the U.S. Department of Health and Human Services, calls for the elimination of all health disparities including differences that occur by race or ethnicity, gender, education or income, disability, geographic location, or sexual orientation (U.S. Department of Health and Human Services 1998). We chose our focus on race and ethnicity for historical, political, and philosophical reasons. Because of the U.S. history of slavery and subsequent de jure and de facto racial segregation and discrimination, race has long been a strong determinant of access to care and health status. Therefore, racial and ethnic disparities as a political and research issue in the United States have a long history. For over one hundred years, minority communities have responded to their poor health status and limited access to health care with research and activism. Racial and ethnic disparities in access to medical care and in those aspects of health that are amenable to human intervention violate the American concept of justice. Finally, racial and ethnic diversity in the United States is growing and issues of race and ethnicity are not going away. With this demographic change, racial and ethnic disparities in health take on a new urgency.

In thinking about the role of research in U.S. policy making, we realized that the conference framework assumed a certain model of the relationship between research and policy change: a research community discovers and documents health inequities and packages and disseminates its findings, and then the research is either successfully taken up by government or not. We question such a model on both theoretical and historical grounds, because it neglects the role of political action as a catalyst for both research and policy.

Theoretically, thirty years of scholarship on agenda setting and issue framing have shown that social problems do not become policy issues just because they exist as problems or even because careful scientific research has documented that they are problems (Elder and Cobb 1983; Gusfield 1981; Kingdon 1999; Gamson 1992; Benford and Snow 2000). Problems such as health disparities must be converted into political issues by leaders (grassroots, community, political, religious, and intellectual). Then they must be defined in a way that government can do something about them with the kinds of tools it has at hand (legislation, regulation, taxation, financing, and public education). Only then does a problem begin to make its way through the political process as something to which government develops a specific policy response. Thus, to be effective, research must not only reveal problems but also frame them in a way that they are perceived as bad situations and moral wrongs that government can and should fix.

Historically, major changes in the access of minority Americans to health care came as a result of political action. Most notably, desegregation of medical institutions (though still not fully accomplished) came about as part of the broader civil rights movement (Smith 2001). But as we will show, in the case of racial disparities in the United States, the mainspring of policy change has always been political action. Some of that activism generated scientific research and government reports. We will show that policy progress on racial disparities in the United States grew from the interplay of scientific research and political activism.

In this article, we first review very briefly the nature of racial and ethnic disparities in health. Second, we present a chronological history of the disparities issue to demonstrate how the continual and persistent interplay between political action and scientific research drives government policy. Third, we compare two recent government-sponsored reports on health disparities: The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination and Ensuring Equality, produced by the U.S. Commission on Civil Rights in 1999, and Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Smedley, Stith, and Nelson 2003), issued by the Institute of Medicine (IOM) in 2002. We chose these two reports because they frame the issue of racial disparities very differently and represent the politics-research dichotomy that we wished to explore. The U.S. Commission on Civil Rights report framed racial inequalities in health primarily as a problem of political action and law enforcement; the Institute of Medicine report framed them primarily as a problem of understanding the causes of disparities through scientific research. We compare the strategic advantages and disadvantages of each framing for mobilizing government action. Last, we draw lessons from our analysis about how disparities research can have a greater impact on public policy. We emphasize that research must go beyond documenting inequalities to developing the political will to redress them.

 


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Professor Vernellia R. Randall
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The University of Dayton School of Law
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Email: randall@udayton.edu

 

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