Perspective: Health Care and the Politics of Race

Abstract

Straw men are large players in the debate over racial disparity in American medicine. Most have been deployed by the disparities-denying right, but progressives intent on “outing” racism have sent forth their share. In this chapter, I devote some effort to flushing them out. But my larger aim is to understand the competing moral premises that drive the politics of healthcare disparity. At the end of the chapter, I contend that arguments about the scope of disparity and discrimination in medical care are disputes about the appropriate scope of personal responsibility for life circumstances. Further research into the factors that correlate with racial differences in health care can shed light on the circumstances that bring about these differences. But whether these circumstances, once understood, should be deemed acceptable is a moral and political matter. Sharp disagreements over the scope of personal and public responsibility for these circumstances are inevitable. These disagreements make it harder to pursue common ground solutions to racial and other inequities in health care. The Institute of Medicine’s (IOM) report on racial disparity in health care (IOM 2003) has become the subject of much sound and fury. Critics on the right have attacked the authors’ motives, condemned them for being too quick to diagnosis discrimination, and insisted that racial disparity in health care remains unproven. Prominent conservative scholar Richard Epstein has characterized the report as both a “genteel-guilt trip” and “a determined effort to make things appear worse than they really are”. Some on the left, meanwhile, have criticized the IOM for papering over pervasive racism in American medicine. Since the politics of race is hardly genteel (and since I was a coconspirator in the IOM report¹), I shall take Epstein’s remark as a compliment. But rather than bemoaning the ideological fuss, I shall try in this chapter to glimpse what lies behind it, with an eye toward possibilities for common ground in the pursuit of healthcare equity. That the politics of healthcare disparities has at times been testy is clear. Allegations of racism attract attention, and the charge that America’s physicians are biased against blacks and Latinos has drawn considerable press coverage. Disparities-denying conservatives, on the other hand, have found welcoming audiences in high places. In 2003, top officials at the Department of Health and Human Services ordered HHS researchers to strike the term disparity from a congressionally mandated annual report on “healthcare disparities”. Officials told the researchers to delete their conclusion that racial disparities are “pervasive in our healthcare system” and to remove findings of disparity in care for cancer, cardiac disease, AIDS, asthma, and other ­illnesses. The researchers complied. Two days before Christmas of 2003, HHS secretary Tommy Thompson released a neutered rewrite, one that rejected the IOM’s findings of racial disparity and dismissed the “implication” that racial “differences” in care “result in adverse health outcomes” or “imply moral error … in any way.” Unhappy HHS officials then leaked earlier versions of the report. Irate House and Senate Democrats insisted that Thompson retract the rewrite and issue the researchers’ suppressed version in its stead. In February 2004, Thompson did so, telling a Congressional hearing that the rewrite had been a “mistake.” This, in turn, disappointed disparities-deniers, who chided Thompson for failing to maintain a stand against political correctness. All sides in this debate have deployed straw men, though the disparities-denying right has assembled them in greater numbers. I devote some effort in this chapter to flushing them out. But my larger aim is to understand the ire. To this end, I search for the competing moral premises that inspire conflict over whether racial disparities in health care are a problem and what the state should do about them. Further research into the factors that correlate with group differences in health care can shed light on the circumstances that bring about these differences. But whether these circumstances, once understood, should be treated as unjust or inevitable (or even as a matter of just dessert) is a moral and political matter. Those wedded to an ethic of individual responsibility and self-reliance, unleavened by sensitivity to unlucky life circumstances differ sharply from those more concerned with fair distribution of life’s possibilities and misfortunes.

M.G. Bloche

Professor of Law, Georgetown University, Senior Fellow, The Brookings Institution, Adjunct Professor, Bloomberg School of Public Health, Johns Hopkins University, Washington, DC, USA

I was a member of the IOM committee responsible for the report and was one of the principal drafters of the chapters that assessed the mechanisms by which racial disparities arise.