Senate Majority Leader Bill Frist has announced that one of his highest priorities this year will be passing legislation designed to eliminate racial disparities in health care. The bill he’s introduced, S. 2217, includes provisions that would target federal money in various programs at “patient populations that are members of racial and ethnic minority groups” and at “increasing minority representation in the health care professions.” Now, moreover, some Democrats are saying that his bill would improve health care for too many whites and not enough minorities, apparently because the bill would also authorize expenditures on “health disparity populations” that might include non-minorities.
Whenever someone promises to attack a racial disparity, I worry. Because, inevitably, the problem turns out to be rooted in something other than race, so that taking a race-oriented approach results in more discrimination than you had to start out with.
For example, a company is hiring whites at a higher rate than blacks, so the company is told by the government to start setting “goals and timetables” for hiring blacks, resulting in them getting a preference. But it turns out that the reason for the initial gap was simply that fewer blacks had the required high-school diploma. So you end up with more discrimination than you started out with.
There is a real danger that the same thing will happen now with health care. The disparities will be addressed by a variety of racially discriminatory means, like giving preferences to “underrepresented minorities” when they want to go to medical or nursing school, or targeting federal programs toward members of those groups. But does this make sense?
Suppose, for example, that Latinos in the United States are more likely than non-Latinos to suffer from untreated diabetes. Is this a problem? Of course suffering from a disease is a problem, but is the fact that there is a disparity a problem that the federal government should address and, in particular, does it need to approach this challenge as a racial/ethnic problem?
Maybe yes, but probably not. It all depends on the reason for the disparity.
Let’s list all the possibilities for the untreated-diabetes disparity and then discuss each one.
(1) Latinos have a disproportionately high percentage of people who are relatively poor and thus cannot afford the best medical care;
(2) Latinos have a disproportionately high percentage of people who, for legal reasons, are afraid to go to the doctor in the first place;
(3) Latinos have a disproportionately high percentage of people who–either for cultural reasons or through lack of education–engage in unhealthy activities, like eating the wrong things, becoming obese, etc., that lead to diabetes;
(4) Latinos have a disproportionately high percentage of people who do not speak English or who don’t speak it well, and who therefore cannot find a doctor with whom they can communicate;
(5) Latinos have a disproportionately high percentage of people who, even when they do speak English well, have a doctor who does not understand their culture and so fails to provide them with good medical care;
(6) Latinos–a decidedly non-biological category, of course–contain a disproportionate percentage of people who are genetically disposed to diabetes (just as, say, blacks are more likely to contract sickle-cell anemia); or
(7) Many doctors don’t like Latinos or don’t take them seriously, and so they tend not to make themselves available to treat them or, if they do, they deliberately or carelessly fail to give them good care.
Reason number one: If this is the problem, then it makes no sense to focus on Latinos per se. We should be trying to improve the medical care for all poor people, not just Latinos. And, conversely, there is no justification for closing the Latino disparity gap by improving the health care given to non-poor Latinos.
Reason number two: Again, you can’t really say this is a problem about Latinos, unless you want to imply that all Latinos are illegal aliens. This, rather, is a problem about encouraging a certain class of lawbreakers to be unafraid of seeking medical care. That is probably a hopeless task, under the circumstances, but if you want to run ads on Spanish-language radio stations that encourage illegals to have annual check-ups, be my guest. Oh, wait though: We taxpayers have to pay for this, right?
Reason number three: This is a real problem, and there is no need to single out Latinos. African Americans, for instance, are prone to high-fat diets; lots of white folks are overweight and don’t get enough exercise; probably there’s something that lots of Asians do that’s unhealthy, too. Again, though, none of this is really about race, per se; in this case, specifically, it’s about behavior. So if there are groups of people who need to be urged to change their behavior, fine, but if there are subsets of non-Latinos who engage in the behavior, they should also be targeted (and if there are subsets of Latinos who don’t engage in the behavior, then they shouldn’t be targeted).
Reason number four: This is a plausible problem, and there are two ways to solve it. The first–and best, for the long term–is for the patients to learn to speak English better. The second is to have more Spanish-speaking doctors. I have no problem with the latter, but bear in mind that non-Latinos can speak Spanish, and many Latinos don’t. So don’t use the language gap as a reason for lowering medical-school admissions for people who simply happen to have a Spanish surname.
Reason number five: “Cultural competency” is all the rage these days–and is endorsed in the pending federal legislation–and perhaps there is something to it. But probably not much. “Take one pill three times a day” ought not to lose much in the cultural translation; neither should “You need to lose some weight.” Of course, the reason cultural competency is all the rage is because it is a useful excuse for lowering admission standards for “underrepresented minorities” to get into medical school. Only black doctors can understand black patients, you see. Yeah, right. And aren’t we all opposed these days to segregated health care? Better to admit and train the best doctors possible, whatever their color, and then teach them the non-rocket-science of cultural competency. And of course the culture gap can be bridged in two ways; perhaps the patients and their cultures need to assimilate better and faster.
Reason number six: If this is the case, then it is very hard to see why there needs to be any kind of ethnic-conscious intervention by the government. So long as the malady exists, we can expect to see an ethnic disparity, and this disparity is a natural, not a social, phenomenon.
Reason number seven: Come on. Of all the possibilities, this seems the least likely. That is not to say that there are no racist doctors, but it is unlikely that the racism is so pervasive to account for a national disparity. And surely if this is the problem, it needs to be addressed head on. We will not make much of a dent in it by leaving these racist doctors in place and hiring a few Latino nurses, too, or creating new programs that simply pump more federal money into this supposedly bigoted system.
The point is that it is very unlikely that the right way to address a racial or ethnic health disparity is through a racial or ethnic approach. These are health issues, not civil-rights issues. There are millions of people who need better health care, and they come in all colors. It is wrong to pass a bill that will encourage the health-care system to focus more on some racial or ethnic groups than others.
–Roger Clegg is general counsel of the Center for Equal Opportunity in Sterling, Virginia.