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