The Health Equity Agenda is a Bad Prescription

An essay by Sally Satel

My friend Sally Satel, AEI senior fellow, lecturer at the Yale School of Medicine, and author of several books, has written an essay for the Sensible Medicine newsletter that I found incisive and enlightening. It underlines the way that an undue emphasis on racial disparities in medicine can undercut evidence-based approaches to treatment and diagnosis.

I often write about the inadequacy of “disparity” as an analytic category. Too often, “overrepresentation,” “underrepresentation,” or “disparity” are pointed to as concrete proof that systemic racism exists, with no further effort to discover the cause of the disproportionality. Racial disparities are treated as ipso facto evidence of racial discrimination. Medicine is a field in which that fallacy can have major, even deadly consequences. Many African Americans have “poorer health and lower access to care” for a number of historical, legal, and political reasons. But systemic racism does not necessarily explain the underlying causes of the disparities. When researchers see “disparity” and automatically name “systemic racism” as the cause, they prematurely negate other possible causes of those disparities, especially those that ought to be addressed medically rather than politically.

I’m presenting the first chunk of Sally’s essay here for your perusal. You can find the rest (without a paywall) at Sensible Medicine.

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The Health Equity Agenda is a Bad Prescription

by Sally Satel

Methadone has been used for decades as treatment for heroin addiction. The long-acting synthetic opioid is given daily to block withdrawal symptoms and drug craving. Patients attend a methadone clinic every day to get their dose and, as they demonstrate reliability and growing commitment to the treatment program can earn increasing numbers of “take home” doses, up to a full month. The staff balance the earned freedom with the risk that a patient might sell their methadone or combine it with other drugs.

During COVID-19, federal government issued a new guidance for methadone clinics, in an effort to decrease infection risk. Whereas before the pandemic, even patients in good standing had to wait months before they could get a single “take-home” bottle per week, the new rule allowed “stable” patients, as the guidance called them, an entire month of take-home doses within a matter of weeks.

A research team decided to examine the distribution of take-home privileges by race. As they reported recently in JAMA Network Open, Black methadone patients on Medicare were less likely to receive take homes than white and Hispanic patients. The authors speculated upon possible reasons why this might have been the case: not all clinics necessarily adopted the new, more lenient policy, some patients may have preferred to attend daily, perhaps there was racial and ethnic bias on the part of the staff, and, critically, it was unlikely that all patients were deemed stable enough for take-homes.

Yet absent any clues about the relative contribution of these potential variables to the outcome—the racial distribution of take-homes—the authors concluded that, “Our findings highlight the imperative to reduce inequities in [Opioid Use Disorder] treatment.”

This is a problem. It is one thing to generate hypotheses about why disparities in health practices or outcomes exist, but wholly another to infer bad faith—“inequity”—as their cause without adequate information.

This paper is certainly not an isolated example. A 2023 meta-analysis targeting six studies found that Black patients were physically restrained in the emergency room more often than patients of other racial groups. However, the authors could not link use of restraint to agitated psychosis—a common reason for restraint—because the studies included in the analysis reported their data in aggregate form. Despite this formidable limitation, the authors concluded that, “methods to address racism at all levels (individual, institutional, and systemic) should be considered.”

Attributing disparities to racism is routine. The CDC deems racism “a public health threat” because it leads to disparities. The University of Michigan’s Center for Antiracism Research for Health Equity identifies "structural racism as a fundamental cause of health inequities." The Senior Vice President of the American Medical Association says that “[R]acism — as a system of power and oppression embedded into policies and culture — is at the root of [health] inequities.”

There is no question that the poorer health and lower access to care suffered, in the aggregate, by Black Americans is partly due to the legal, political, and social institutions that have historically discriminated against them. At times, inferior treatment has been explicit and at other times passively inflicted through disregard of the differential brunt of policies.

But systemic racism is neither an actionable diagnosis nor a valid explanation of every disparity. After all, factors that initiate problems are not necessarily the ones sustaining them.

Only when researchers bring causal dynamics into sharp focus can health professionals know which points of entry into the healthcare system can help them minimize inter-group discrepancies in health care and health outcomes.

Readiness to invoke racism as the cause of health disparities is accompanied by a tendency to propose dubious, and potentially unconstitutional, policies to address the disparities.

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