The AMA's "Advancing Health Equity" plan leaves out everything that matters

The AMA's "Advancing Health Equity" plan leaves out everything that matters

By Matthew Yglesias

Nov. 17, 2021

SlowBoring.com

Changing the way doctors talk isn't nearly as important as the access-broadening policies the AMA has opposed

The American Medical Association is the premier trade group for medical doctors and an influential actor in American healthcare policy. In partnership with the also-influential American Association of Medical Colleges, they’ve released the document “Advancing Health Equity: A Guide to Language, Narrative and Concepts” that asks doctors to reconsider the way they talk about health issues.

They advise, for example, that instead of “marginalized communities,” health professionals should talk about “groups that have been economically / socially marginalized.” They say doctors should refer to “inequities” rather than “disparities.” They also advocate for some linguistic moves that will be broadly familiar to anyone who’s interacted with progressive nonprofit or academic institutions in recent years, including referring to the “formerly incarcerated” rather than “ex-cons” and talking about “enslaved people” rather than “slaves.”

But what’s most striking about the report is that the authors move beyond the idea of swapping in social justice language for more old-fashioned phrases and advise that doctors take up particular ideological perspectives on issues.

This is what attracted criticism from Conor Friedersdorf and Alex Tabarrok, who drew my attention to the document. Tabarrok’s critique is that “politicizing medicine is dangerous,” while Friedersdorf similarly says, “It’s already hard enough to get my conservative grandfather to heed his doctors about how best to care for a bad back worn down from decades in construction” and worries about the impact of medical professionals coming across as alienating leftists.

There’s something to that, but I think the bigger issue here is that the policy perspective the AMA is urging its members to take up is just weirdly distant from the organization’s own work. As a professional association for doctors, the AMA lobbies frequently and effectively on a host of policy issues, often in really harmful ways.

If the AMA is truly worried about medical equity, we could use less amateur-hour commentary on issues outside of its scope and expertise and more focus on the organization’s real lever for change: addressing the policy barriers to adequate medical care.

It’s helpful to know what you’re talking about

Table 5 of the document urges medical professionals to replace conventional narratives with “equity-focused language that acknowledges root causes of inequities.”

That’s fine, and I actually think that in a lot of ways American public policy would benefit from more people with expertise in medicine and biology trying to help us understand the root causes of various social problems.

But the quality of the policy analysis on display here is simply very poor.

I do not know much about Native American public health, and the proposed equity narrative here seems plausible. Still, a pretty casual Google search suggests that present-day material conditions probably deserve more foregrounding. The Indian Health Service budget spends less than half the national average per capita on patient care, the basic logistics of getting to a medical facility are not great for many people who live on reservations, and the whole IHS appears to be a long-running disaster zone. Much of this is obviously far beyond the scope of the medical profession, but when your country has an unusually small number of doctors per capita, it’s of course people who live in poor and remote areas who suffer. And that shortage is directly related to the AMA’s work.

This discussion of poverty, meanwhile, is just embarrassingly bad. It is not real estate developers but NIMBY neighborhood defenders who are responsible for housing scarcity, and in the international context, it’s pretty clear that America’s stingy welfare state (something that is hopefully changing!) more so than a paucity of labor unions is responsible for its unusually high poverty rate.

(Jeffrey Greenberg/Universal Images Group via Getty Images)

And racism and class exploitation are obviously bad. But this is also an area where it would be helpful to hear from more medical experts about specific medical issues. In the U.S., for example, people of Latin American origin live longer than the U.S. population average despite being poorer, less-educated, and having less access to health insurance than the American average. It would be perverse to stop caring about the relative socioeconomic deprivation of Hispanic Americans just because they live longer, but it would also be good to know more about what’s actually happening here. The relationship between health outcomes and socioeconomic variables is somewhat nuanced, and we could all learn useful things about population health.

America’s shortage of doctors is a big problem

I’ve shown this chart from Robert Orr before. You see here that one way the United States stands out compared to other rich countries is that despite us being richer and having worse population health outcomes, we have fewer doctors — and radically fewer GPs.

This is a huge issue for health equity in both big and small ways. The obvious one is that by making doctors scarce, you inflate the unit price of a doctor’s visit, making it more expensive to expand access.

The more subtle problem, per the problems with the Indian Health Service, is that because doctors are perennially in such short supply in the United States, they can afford to be extremely choosy about their assignments. You never have a down-on-his-luck doctor looking for work and realizing that there’s demand for medical care in poor neighborhoods or rural communities.

Even more subtly, because doctors are scarce, they can afford to treat their patients relatively poorly. Doctors’ offices normally keep business hours that are convenient for the doctor, rather than convenient for patients. And while you’ll lose your appointment if you’re running late, the doctor runs late all the time — it’s more cost-effective for him to run a schedule with zero padding, so you just need to wait if things go wrong. As a person who is persnickety about schedules and punctuality, this has frequently annoyed me, but I’ve always had very flexible jobs. For people with jobs that require them to be in specific places at specific times, scheduling hassles are a big deal. More medical abundance would mean not just lower costs, but potentially much greater convenience.

There are lots of ways to increase medical abundance, but unfortunately, the AMA is normally standing in the way — blocking increased scope of practice for nurses, making it hard for foreign-trained doctors to practice in the United States, and historically pushing to train too few doctors here at home.

It’s a trade association and, unfortunately, this is what trade associations do. The AMA is also involved in stuff like bilking Medicare out of money by overestimating how long it takes to do various procedures. Doctors don’t like Medicare because it’s so large that it uses its purchasing power to drive down unit costs — hence not only the bilking, but opposition to Medicare for All and strong versions of health care public options. It’s ancient history at this point, but AMA opposition was critical to killing Harry Truman’s universal health care proposal, and they opposed early versions of the proposals to create Medicare and Medicaid. Martin Luther King believed the AMA was complicit in upholding segregated medical facilities in the south and discriminatory treatment in the north.

Some of this was a long time ago, but some of it is very present day. And at all points in time, the key issue is what the doctors’ trade association actually does — in this case, fighting to make medical care scarce and against cost-effective forms of provision — rather than what they advise people to say.

Language isn’t what matters most

The priority that some progressives place on getting everyone to use the right words seems so obviously misguided that few people actually explicitly argue for it.

One noteworthy exception to this is Robin DiAngelo, the best-selling author, who in her most recent book writes:

Or trace the trajectory of changes over my lifetime of this set of terms; “bum,” “tramp,” “wino, “hobo,” “vagrant,” “homeless,” “persons without housing.” There are significant differences between the images and associations at the start of that list and the end. Those differences impact our perceptions and have real consequences for how people are treated and the resources they receive. Language is political and thus a continual site of struggle over who is deemed worthy of respect and access.

The problem with this is that the actual housing situation in the United States has been getting worse during this period of linguistic ferment. How is it that we have managed to house a smaller share of the population in 2020 than the much poorer America of 1960? Well, it’s because American localities moved aggressively with land-use rules to ban low-end housing that served the most economically marginal members of society. Then having done that, they swept in with minimum lot rules and height limits and apartment bans and started making housing less affordable — especially in the big coastal metro areas.

The conditions of the homeless are not the worst in the places where they are most likely to be referred to as “bums;” it’s the worst in the places where they are most likely to be referred to as “unhoused” or “people experiencing homelessness.”

Big liberal cities combine a lack of affordable housing with a robust complex of nonprofits and social service workers who try to deal with the catastrophic results. The members of that service complex devise these linguistic theories about how to be nicer to people. But the underlying issue remains.

In the health space, the AMA report claims:

By health inequities, we mean gaps that are “unjust, avoidable, unnecessary and unfair. They are neither natural nor inevitable. Rather, they are produced and sustained by deeply entrenched social systems that intentionally and unintentionally prevent people from reaching their full potential. Inequities cannot be understood or adequately addressed if we focus only on individuals, their behavior or their biology. We have the opportunity— and the obligation—to do better, and to achieve more equitable outcomes. We believe that a critical component of that effort involves a deep analysis of the language, narrative and concepts that we use in our work.

I just don’t actually think it’s true that whether or not we talk about “people who do not seek healthcare” or “workers under-resourced with (specific service/resource)” is an important determinant of if those underlying structural issues get addressed. By contrast, the AMA’s lobbying on issues specific to health care is very important.

Last but not least, it strikes me that there is an element of blame-shifting here. Many disparities in health outcomes are the products of larger social forces. But there is longstanding research (it’s become a hot topic recently, but here’s a study on it from as far back as 2003) that medical doctors exhibit racial bias in pain assessment and under-treat Black patients’ pain. Other studies find evidence of biased treatment in other areas, and Tina Sacks’ book “Invisible Visits: Black Middle-Class Women in the American Healthcare System” found fairly widespread mistreatment of relatively well-off Black patients.

I don’t know that a PDF saying “hey, doctors, try to be less racist!” would do a ton of good, but I do think this is another example where focusing on structural conceptions of racism can sometimes elide the enduring relevance of old-fashioned bias and discrimination.

But almost everything about inequities in the medical system comes back to scarcity of supply and very limited consumer power, and that comes back — in a very direct way — to the American Medical Association and its decades-long status as a bad actor.

Open, accessible language matters

I think it’s mostly uncontroversial to say that this kind of linguistic fussing matters less than whether or not we tackle the material roots of deprivation and inequality.

But people who agree with that tend to get a little soft and lax when it comes to following through. Because at the end of the day, the most important sense in which language matters to politics is that it marks in-groups and out-groups. More than anything else, using lots of social justice jargon marks you out as a member of one sort of community and marks people who find it confusing or alienating as non-members of the community.

Yet the core policy goals that would advance health equity — increase the supply of providers, tax the rich, expand Medicaid, create a strong public option — are all broadly popular ideas. They just also happen to be ideas that are fiercely opposed by influential (and highly focused) interest groups. Talking about how “narratives that uncritically center meritocracy and individualism render invisible the very real constraints generated and reinforced by poverty, discrimination and ultimately exclusion” often confuses people.

If you actually care about addressing these issues, you need to speak to people in language they understand and in terms of values they are sympathetic to. You also need to tackle the American Medical Association as a lobbying group. If you don’t really care about outcomes and just want to signal that you are the right kind of person, then this document’s approach is great.