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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
00;01;03;24 - 00;01;12;14
Ellen Bayer
Hello and welcome to Health Affairs This Week the podcast where Health Affairs editors go beyond the headlines to talk about the health policy news of the week. I'm Ellen Bayer.
00;01;12;21 - 00;01;15;01
Christopher Fleming
And I'm Christopher Fleming.
00;01;15;04 - 00;01;46;09
Ellen Bayer
We're recording this episode on July 6th 2023. And just last week was the end of the term for the Supreme Court. And it's notable that several of the big decisions will have major implications for health care. This coming Monday, July 10th at 2 p.m. Eastern time, our editor-in-chief Alan Weil will be hosting a virtual Lunch and Learn event for Health Affairs Insiders and he'll be joined by a panel of experts to provide a full Supreme Court wrap up focused on the major health related decisions and their implications.
00;01;46;12 - 00;02;03;27
Ellen Bayer
And we'll put a link in the show notes where you can register for that. And then we're going to talk about one of the rulings that came out last week that might not at first glance seem like a health care decision, but that certainly will have a major impact on health and that is the affirmative action case. Chris, I know you're an avid Supreme Court watcher.
00;02;03;28 - 00;02;06;14
Ellen Bayer
What can you tell us about the case?
00;02;06;16 - 00;02;31;12
Christopher Fleming
Yes, well, this was a case where the plaintiffs challenged the admissions programs of Harvard and the University of North Carolina. Under previous case law the Supreme Court had said that universities and other higher education institutions violated the Constitution if they used strict racial quotas in their admissions process. But that race could be considered as one factor among many, a plus factor,
00;02;31;14 - 00;03;09;15
Christopher Fleming
in the case of affirmative action to maintain a diverse student body. In their decision last week, however, the court said that the use of race at all violated the equal protection clause of the 14th Amendment to the Constitution and that applied directly to the University of North Carolina, because that's a public institution, a governmental institution. It also applied to Harvard because Harvard is governed, like all institutions that take federal funds, by the civil rights, by excuse me, by Title Six of the Civil Rights Act of 1964.
00;03;09;17 - 00;03;29;19
Christopher Fleming
And that's been interpreted by the courts to be co extensive with the equal protection clause. So before we go into the health implications of this case more deeply, I wanted to point out an excellent Forefront article on the decision by Lindsay Wiley and coauthors that was just published on our website. We'll put a link in the show notes and we'll talk a little bit about it today.
00;03;29;19 - 00;03;56;21
Christopher Fleming
But we can't we really can't do justice to it. It's very comprehensive and very nuanced. And I would really encourage readers to to read the full piece. So let's talk about, you know, how this decision, this affirmative action decision, will affect medical schools and other health professional schools. The American Association of Medical Colleges submitted a friend of the court brief, or an amicus brief, as they're called, on behalf of itself and multiple other health care organizations.
00;03;56;23 - 00;04;06;02
Christopher Fleming
They urge the court not to ban consideration of race in admissions because they argued that would hinder efforts to develop a diverse health care workforce.
00;04;06;05 - 00;04;29;05
Ellen Bayer
And we know that we're a long way from having a diverse physician workforce. Data from the American Academy of Family Physicians shows that black and Hispanic populations are extremely underrepresented in the physician workforce, and diversity is critical to population health. The amicus brief you just mentioned, Chris, pointed out that diversity, quote unquote, literally saves lives.
00;04;29;07 - 00;04;59;02
Christopher Fleming
Yeah, that's right. You know, the brief noted that there are these continuing disparities in health and health care that disadvantage blacks and a lot of other people in the U.S. as well. Just to cite some examples, black and Hispanic children with heart conditions are more likely to die than their white counterparts. Black men are twice as likely to die of prostate cancer than white men, and a black mother is up to four times more likely than a white one to die in childbirth of childbirth
00;04;59;02 - 00;05;27;08
Christopher Fleming
related complications. And significant disparities still exist even when you control for factors like socioeconomic status, lifestyle and insurance coverage. You know, and and as you pointed out, a diverse health care workforce matters when it comes to addressing disparities and making sure that all Americans can get quality care. Black physicians, for instance, are more likely than others to accurately assess black patients’ pain tolerance, and to prescribe the correct amount of pain medication as a result.
00;05;28;21 - 00;06;12;02
Christopher Fleming
And for high risk black newborns, this, you know, language really struck me. The AAMC brief likened having a black physician to, quote, a miracle drug, more than doubling the likelihood that the baby will live. Now, of course, you know, not all minority patients are going to be treated by minority health care professionals. But the amicus brief filed by the AAMC also noted research indicating, and its physicians experience indicating as well, that disparities can be minimized when health professionals have learned and work next to colleagues of different racial and ethnic backgrounds reflecting the increasing diversity of the patients they serve.
00;06;12;04 - 00;06;38;25
Christopher Fleming
Thus, diversity in medical education yields better health outcomes, not just because minority professionals are more often willing to serve in and very effective at serving in minority communities. But because all physicians become better practitioners if they work together with people, other practitioners of all backgrounds, and if they learn together with other practitioners of all backgrounds.
00;06;38;28 - 00;06;45;18
Ellen Bayer
So, Chris, given this Supreme Court ruling, what can medical schools and other health professions schools do going forward?
00;06;45;20 - 00;07;13;28
Christopher Fleming
Well, you know, one possibility is to argue in future cases based on the considerations we just talked about, that there are special circumstances in the health professions field that justify race conscious admissions. You know that it's interesting because, you know, Wiley and coauthors of their piece pointed out, for instance, that the court's opinion did carve out a special exemption for military academies to consider race in admissions because there were special circumstances there.
00;07;13;29 - 00;07;47;05
Christopher Fleming
The military branches were worried about having an increasingly diverse military commanded by a homogeneous officer corps. They thought that would be a bad situation, and the court agreed. Justice Jackson, in her dissent, also noted the importance of having a diverse health care workforce and the court itself in the majority in one of the previous seminal cases on race and admission, the Bakke case, which concerned medical schools, the court noted the same thing the importance of diversity in health professional education.
00;07;47;08 - 00;08;14;28
Christopher Fleming
But, you know, when you go back to the opinion last week, justice, the majority opinion included no such recognition. So it's unlikely that the court would extend the military exemption to health care. Doing so as as Professor Wiley and her colleagues pointed out in the Forefront piece I mentioned. You know, that might be seen as opening a door to consideration of race in admissions in lots of other fields where diversity could be seen as important.
00;08;15;01 - 00;08;45;20
Christopher Fleming
You could think of law, education, the importance of having diverse teachers to teach an increasingly diverse student body. And, you know, once the court opened that door, they could be worried that it would be hard to close and that would undermine their decision from last week. So and again, as Wiley and her colleagues suggest, a more promising way for medical schools and health professional schools to proceed based on the decision from last week, might be to pick up on another part of the decision.
00;08;45;20 - 00;09;14;27
Christopher Fleming
The court said schools can consider race as such, but they can consider or they can allow students to talk about in the applications process the impact of race on their life and the experience they've had based on how others see them and the experiences of things like racism and the ability that these experiences to further the mission of the institutions, the educational institutions involved.
00;09;14;29 - 00;09;35;09
Christopher Fleming
Now you want to be careful. The court warned that schools can't use this as a ruse to consider race. As such, you can't use it as a backdoor to get around the court's opinion. But it does provide one way that schools might seek to maintain diversity. Following on the decision from last week.
00;09;35;11 - 00;09;40;06
Ellen Bayer
So, Chris, the potential implications of the court's decision go beyond admissions, right?
00;09;40;08 - 00;10;16;22
Christopher Fleming
Yeah. You know, there was another amicus brief, a group of Republican lawmakers filed in the run up to the decision. They argued that some of the race conscious rules that states used during the COVID pandemic to distribute scarce resources were unconstitutional. And as you know, race is used in multiple ways in public health efforts. For instance, as the Forefront piece mentions, race is often used as part of so-called disadvantage indices that guide resource allocation and reimbursement methodologies in health care and in public health.
00;10;16;24 - 00;10;31;03
Christopher Fleming
You know, so depending on how broadly the Supreme Court's decision is interpreted and how policymakers react, there could be major consequences in health care and public health that go beyond just the admissions process.
00;10;31;05 - 00;10;48;05
Ellen Bayer
Well, clearly, there is a lot more to be said and done following this decision. We'll have to leave it there for today. But the conversation will continue. We encourage our listeners to tune in into Health Affairs’ Lunch and Learn event on Monday, July 10th at 2:00 Eastern time to learn more.
00;10;48;07 - 00;11;07;26
Christopher Fleming
Yeah, and again, I encourage folks to read the Forefront piece by Lindsay Wiley and coauthors. And I also encourage you, if you like this episode, tell a friend, tell lots of friends, tell your enemies even. Be sure to subscribe to Health Affairs This Week wherever you get your podcasts. Thanks, Ellen.
00;11;07;29 - 00;11;08;19
Ellen Bayer
Thanks, Chris.