On the Eve of the SCOTUS Ruling: Panel on Social Determinants of Health Disparities; Moving the Nation to Care About Social Justice

By: Megan Antonetti-Elford

At the edge of the cliff of good health...
(slide taken from the presentation of Dr. Camara Jones)

I tweeted for everyone to tune in to webcast a few weeks ago to hear discussion about topics that I think are mostly missing from the health care debate. We often hear complaints about constitutionality and the economic pitfalls of controlled markets, but these discussions miss the point with regard to the state of health care in this country. On the eve of the SCOTUS ruling on the Affordable Care Act, we should refocus on the goal of achieving health care equity in America and the impact of social determinants like racism that are at the root of this issue. We have analyze why health disparities arise in the first place.


An archived webcast of the University of North Carolina Minority Health Project's presentation can be viewed here: http://www.minority.unc.edu/institute/2012/. Some points stood out for me particularly and I hope they inspire others to watch the webcast in full and, of course, to tune into the discussion next year, after we have seen the outcomes of the upcoming health care ruling play out.


Dr. Camara Jones, MD, MPH, PhD, Medical Officer for the CDC, opened the program with a electrifying talk setting up a framework for talking about social determinants of health disparities.  She spoke about three levels at which we can approach the problem of health care equity as the "cliff" pictured above -a great metaphor for addressing how health care resources are spent and also how health disparities arise. Dr. Jones argues that disparities arise in quality of care, access to care, and differences in opportunity, exposure, and stress in daily life.  To keep people away from the cliff (getting sick and needing health care), the third level, the differences in opportunity and exposure, must be addressed.


Racism can be difficult to talk about in this context but Dr. Jones pinpointed it quite well, defining it as "a system of structuring opportunity and assigning value based on the social interpretation of how we look." Like all of the other power structures at play, from sexism to capitalism, racism  "unfairly disadvantages some individuals and communities" while providing a reciprocal unfair advantage for others outside those populations.  This may contribute to the fact that knowledge of a persons perceived race and zip code can accurately predict his overall health or BMI. Identifying and correcting the mechanisms of institutionalized racism in decision making in this country may be the most important way to achieve health equity.


What is health equity? According to Dr. Jones, it is "the assurance of the conditions for optimal health for all people." It is a process guided by reason and social morality requiring these three tactics:

• Valuing all individuals and populations equally
• Recognizing and rectifying historical injustices
• Providing resources according to need

How did the U.S. get so behind in looking after the health of its citizens? We have to look at how the system of racism, in its history, in its manifestation outlined by Dr. Jones, and in its limiting of access to health care colors the opposition to the health care law. Racism is a component in this debate we can't be afraid to talk about, especially because it is institutionalized at levels beyond the availability of health care, to public education, protection of reproductive rights and access to accurate sex education, and even the prison system. We have to look at the motivations and actions of the unfairly advantaged because they hurt us all.


*hyperlinked text links to relevant films, viewable online for free

Looking at the Affordable Care Act Through a Pre-Med Lens

Dr. William M. Sage speaks at UT Austin

Dr. Sage holds "the most expensive medical
technology in the world."

Last week the UT Kappa Rho Honor Society hosted an informal talk with MD/JD Professor of Public Health, Dr. William M. Sage about the intersection of law and medicine.  I attended along with about 30 of my peers hoping to hear an expert's perspective on the week's events in the Supreme Court and the future of medical practice in America. Dr. Sage is the vice provost for health affairs at The University of Texas at Austin and carries an impressive resume that includes a joint degree in medicine and Law from Stanford University, membership in the President’s Task Force on Health Care Reform in 1993 under Bill Clinton, numerous publications, awards as well as seats on the leading committees in the field of health care policy and research. Last week he composed lengthy blog entries about the Supreme Court proceedings for Health Affairs online.  

I admit I’m particularly unqualified to write about this subject, having spent the last three years with my head buried in chemistry textbooks and with a generally panicked outlook on my career future.  I have not read the Affordable Care Act, nor have I read the transcript of the Supreme Court proceedings but I have been paying attention.. I have been addicted to NPR’s coverage of the story and, I thought, if anyone could wade through the complexity of health care legislation, Dr. Sage seemed qualified to do it.

At the outset, he asserted “You should expect yourselves to become leaders and society should expect you to be leaders...” He went on to describe the current state of health care in this country as “mediocre” at best.  It is a system whose structure and culture are inhospitable to efficiency and fair commerce; “a huge cottage industry.” Doctors don’t think they are being compensated appropriately and patients think they overpay.  At one point Sage borrowed a pen from an audience member in the front row, holding it up, he called it “the most expensive medical technology in the world.”  He said doctors are responsible for the strain of “a largely discretionary, often unjustified expenditure of a trillion and a half dollars a year... to write prescriptions for drugs, referrals for services, hospitalization, diagnostic imaging etc., etc..”

Title III of the Patient Protection and Affordable Care act of 2010 addresses these concerns.  Last week the Supreme Court did not. So what does an aspiring doctor take away from the discussion? On one hand, the Court makes it seem like the future of health care in America hinges on an individual mandate to buy insurance.  On the other hand, Dr. Sage, says the insurance problem merely scratches the surface of the reform this country needs.  The admissions essay answer is that the discussion doesn’t matter; what matters are the patients.  But what myself and my peers often fail to appreciate is that our job satisfaction and our success at being healers depends a great deal on this discussion and what we have to say.  

If Dr. Sage is right, then the future of healthcare is uncertain. I don’t think any doctor would argue that being allowed to take control of a patient’s treatment requires doing it responsibly and efficiently. And I don’t think any citizen would deny that society would benefit if people did not go bankrupt because they got health care.  Furthermore, by taking responsibility for the delivery of preventative care a reformed system can keep society from having to pay for people who are already sick. It is uncertain how we can reconcile all of these goods without sacrificing the goods in our current system. My hopes echo what Dr. Sage wisely advised; in the future doctors will no longer “merely deliver services,” but will take a leading role in shaping the future structure of American healthcare, not just the way it is paid for.  We can, hopefully, overcome many of its flaws and build a great system.