Evaluating Bias within State Laws and an Association with Premature Mortality Rate

Introduction

This study seeks to evaluate whether policies and laws that were classified as either protective or harmful are associated with premature mortality rates. In essence, the analysis is a new method for measuring structural racism and estimating the joint effects of multiple laws on racial health equity.

In the study, laws are deemed as protective or harmful depending on whether the law possessed anti-Black sentiments and/or discriminated against ethnically minoritized peoples. The study found that there are associations between  laws that were deemed discriminatory or  structurally racist and premature mortality rates for minority groups. Overall, the study also found that premature mortality rates were lowest in states that had more protective laws and highest in states which had harmful laws. The authors included [1] Jaquelyn L. Jahn, Ph.D., MPH, Assistant Professor at the University of Drexel; Dougie Zubizarreta, MS, PhD student at the FXB Center for Human Rights at Harvard University; Jarvis T. Chen, Associate Director for the Population Health Sciences Ph.D. Program at the Harvard T.H. Chan School of Public Health; Belinda Needham, PhD, MA, social epidemiologist and the Chair of Epidemiology at the University of Michigan’s School of Public Health; Goleen Samari, Ph.D, population health demographer at Columbia University’s Mailman School of Public Health; Alecia J. McGregor, PhD, an Assistant Professor of Health Policy and Politics at the Harvard T.H. Chan School of Public Health; Megan Daugherty Douglas, J.D.,      Assistant Professor at the Department of Community Health and Preventive Medicine at the Morehouse School of Medicine; S. Bryn Austin, ScD, Professor of Social and Behavioral Health Sciences at Harvard T.H. Chan’s School of Public Health and Professor of Pediatrics at Harvard Medical School; Madina Agénor, ScD, MPH, Associate Professor in the Departments of Behavioral and Social Sciences and Epidemiology and Center for Health Promotion and Health Equity at Brown University School of Public Health.

Methods and Findings

The study utilizes a latent class analysis to group states statistically based on laws present within a respective state; the analysis aims to provide an understanding on how states group based on protective or harmful laws, which were categorized based on if they carried anti-Black sentiment. This analysis facilitates the evaluation of states, particularly states with a history of utilizing Jim Crow Laws and/or laws that promote restriction, or to better understand the association between premature mortality and state laws (protective and harmful). The study uses the CDC Wonder’s Database for premature mortality and couples this data with state-level and age-adjusted data that comes from the 2013 National Center for Health Statistics (NCHS) dataset. The premature mortality cutoff was indicated to be before age seventy-five in this study. To estimate the premature mortality, the authors utilized a “three-step” estimating method which centered on:

• a weighted linear regression model;
• an association with the latent class analyses for the states; and
• a regression for the non-Hispanic Black and White adults and the ratios for Black and White premature mortality.

Because the study aims to address socioeconomic factors, the research team did not adjust for socioeconomic factors and political contexts, such as the political party in place at the time. However, to ensure that the latent class analyses are effective and that the findings still stand true, socioeconomic factors and political contexts were controlled for after the initial regression.

The findings of the study showcase three different state classes,

• Class 1 is the class of states with strictly harmful laws. All southern states were a part of class 1.
•  Class 2 is the class most prone to have states with protective laws. Many West Coast, mid-Atlantic, and southwestern states were class 2
• Class 3 states possess  protective laws but are also most likely to have harmful laws that related to welfare, state Earned Income Tax Credit, tuition, and renter protections. Class 3 states were scattered but had some clustering in the Northeast.

For associations between premature mortality and the aforementioned classes, the study shows that the more protective a state was classified, it was also more likely to have less premature mortality rates.

A limitation to this study is the research team’s inability to empirically evaluate much of the informal racist practices that may permeate the state as laws are not the only way to perpetuate structural racism. In addition, the study only analyzes laws in their written context and does not evaluate or assess if a law was implemented in a discriminatory fashion. Other confounding factors for the study include no controls for residential mobility and individual-level factors, such as behavior. In addition, state laws that are implemented at local levels also cannot be analyzed because of the state-level approximation used in the study.

Conclusions

This study shows how differences in racist and discriminatory laws are associated with an increase in premature mortality rates. The historical context and racism behind these laws also signifies that health systems and structures have been shaped by discriminatory ideologies that result in lower health outcomes. The authors conclude, “Dismantling structural racism to address racialized health inequities will require macro-level interventions in the form of sets of laws and policies across social systems and institutions, as well as a deep understanding of the historical underpinnings of structural racism and how it has shaped and continues to shape social norms, institutional practices, ideology, and politics.”

Tenant Organizing: The Power of Collective Action at the Intersection of Racial, Health, and Housing Equity

Introduction

Despite the significant role that power asymmetries play in driving health inequities, there is a dearth of research on the intersection of power, racism, and health equity. In this article, Michener argues that housing is a driver of racial health inequity and that tenants play a significant and overlooked role in combating health-threatening housing conditions. The author highlights two primary channels through which tenants nationwide have organized to improve housing and health equity: 1) direct action that places pressure on key stakeholders who have the power to improve housing conditions, and 2) local policy change to address housing conditions. In examining these channels, the author discusses the importance of understanding the role of power in health equity research and argues that centering tenants and their power as solutions to health equity challenges is necessary for institutional change.

Jamila Michener is an Assistant Professor of Government at Cornell University. Her work focuses on unpacking the political causes and impacts of racial inequities, and her most recent book, Fragmented Democracy: Medicaid, Federalism and Unequal Politics, explores how having Medicaid affects political participation.

Methods and Findings

The author conducted 79 semi-structured interviews with tenants nationwide over four years. Interviewees were asked to share their housing experiences, and the majority discussed the negative consequences of inequitable housing policies on their health. The interviews with tenant organization members, which comprised the majority of those interviewed, shed light on how these organizations have built and wielded power to fight against the political, economic, and racial systems that produce health-threatening housing conditions.

On the intersection of race, housing, and health equity

Michener discusses how health-threatening housing conditions disproportionately affect racially marginalized communities and argues that collective power is needed to address these conditions. Firstly, the author establishes the link between race and housing inequality. Michener references decades of research to highlight how substandard housing conditions can result in respiratory illnesses and other severe health risks. The author argues that these conditions disproportionately affect racially marginalized communities due to the role of structural racism, which manifests as policies and practices that normalize decayed housing and limit the supply of affordable housing for racially marginalized communities. Key mechanisms of structural racism in this case include discriminatory financial lending practices and underfunded public housing programs.

Michener posits that racially marginalized communities require collective power to confront these systemic barriers. Collective power can enable tenants “to identify the systemic failures underlying their individual problems and to strategically channel their collective energies through concerted social and political action.” The interviewed tenants wielded their collective power through two main mechanisms: 1) organizing to pressure key stakeholders such as landlords, property management companies, and government officials, and 2) driving local policy change to improve housing conditions.

Organizing to pressure critical stakeholders

In interviews, tenants shared examples of how they pressured landlords, government officials, and other stakeholders through protests, rallies, and rent strikes. For instance, in Texas, rent strikes were used to pressure the management company of an apartment complex without running water.

Lessons learned when organizers apply pressure:

• Many tenants viewed the ability to pressure institutions through collective power as particularly important in the context of racism.  Tenants convey how they see their own struggles with housing conditions connected to historically racist laws and policies. 
• Effectively applying pressure requires understanding the political context. In the example of the water shortage in an apartment complex in Texas, an interviewee highlights how the tenant organization deprioritized putting pressure on elected officials, given that management companies had more immediate ability to address the water shortage.
• Events like protests and rallies can create opportunities to negotiate with elected officials for more direct policy change.  For example, one tenant organization in the Deep South successfully changed eviction policies through sustained protests and negotiations with elected officials at City Hall.

Organizing to drive local policy change

Michener focuses on the example of two tenant organizers, Joe and Jocelyn, from a Southern city to highlight the potential for organizing to drive local policy change. 80-90% of the members of this tenant union were Black, and the primary objective of this organizing effort was to remove an extractive property management company that contractually oversaw the city’s public housing properties.

Lessons learned when organizers drive policy change:

• The tenant organizers were particularly successful in this example because they sought to understand the role of race in the city’s power structures. The organizers identified that the elected official was unlikely to take action to break the contract with the management company because these city officials were largely insulated from the harm that was disproportionately affecting Black women in the city. Recognizing this power structure enabled the tenant organization to develop an effective negotiation strategy that brought together tenants, union members, the city council, and the management company and focused on public testimonies.
• The tenant organizers engaged in strategic institutional negotiations centered around tenant testimonies and highlighted the imbalanced power dynamic between the management company and tenants. After organizing hundreds of the city’s tenants, the union met with the city council through a committee hearing. Tenants shared their experiences with housing related health risks, and the management company’s egregious public dismissal of their responses led to the cancellation of their contract.

Conclusions

The author argues that organizing and driving local policy change can potentially improve the health equity of racially marginalized populations. Through examples from tenant organizers, Michener highlights how collective action requires understanding the racial and political contexts of the most affected. Furthermore, driving local policy change requires understanding the city’s power structure and corresponding power dynamics. 

The author suggests that further research should focus on better understanding the ways in which power operates at the intersection of race, health, and housing equity. This study argues that health equity researchers should move towards a theory of change that highlights the political agency of racially marginalized communities. These organizing efforts underscore the potential for tenant and other forms of organizing to drive sustained institutional change in health.

A Framework to Assess Equity in Policymaking

Introduction

This article introduces a framework called the Policy Equity Assessment that was designed for policy analysts and researchers to assess a policy’s or program’s ability to reduce inequities. This framework couples policy analysis approaches with rigorous equity-focused research methods. This combination allows for a more comprehensive equity analysis compared to other research methods. This article demonstrates how to apply the assessment, highlights new findings, and provides recommendations for future analyses to fill evidence gaps.

The article focuses on use of this assessment in the context of child health equity. Despite increases in racial and ethnic diversity in the United States, wide inequities persist in social determinants of child health and health care access, which lead to harmful and costly racial/ethnic gaps in child health and developmental outcomes. The authors encourage the use of their framework to develop policies that reduce this disparity. 

Pamela K. Joshi is a Senior Research Scientist and the Associate Director of the Institute on Children, Youth and Families at Brandeis University. Joshi’s work focuses on conducting research and evaluating public policies relating to family and children’s health in diverse populations.

Methods and Findings

The Policy Analysis Framework encompasses three stages and focuses on general policy assessment questions. Each stage addresses a core equity question:

1. “What is the policy designed to do?” 

The Logic Stage evaluates whether the goals of a particular policy recognize and acknowledge unfair differences between different racial and ethnic groups. The main goal of this stage is to determine if services are specifically designed to tackle these differences, and if that equity goal is mentioned directly or indirectly. This requires a detailed examination of legislation and rule changes over time.

2. “Is the policy implementing services and distributing benefits as intended?”

The Capacity Stage examines a policy’s ability to provide sufficient quality and intensity of services to all those who are eligible for and could benefit from the policy. This stage focuses on equitable distribution, determining if a policy can reduce disparities in distribution of benefits among different racial and ethnic groups. For example, by looking at the policy capacity in this stage, the early childhood program Head Start assessed that while its eligibility criteria primarily targets low-income children, it has finite capacity to serve that population because limited funding restricts the number of available program slots.

3. “Is the policy effective for the defined target population?”

The Research Evidence Stage looks at research evidence “to determine what works, for whom, and under what conditions, as well as whether policies reduce racial/ethnic inequities in outcomes.” It can be broken down into three crucial inquiries determining: 1) whether a policy is effective in improving outcomes for specific racial or ethnic groups, 2) whether any analyses have been done to measure the differences in health outcomes between different racial and ethnic groups, and 3) how the delivery of services, the resources available for the program, and the quality of a program might differ depending on the race or ethnicity of the participants. 

The authors demonstrate how the Policy Equity Assessment can be applied by working through key examples in early childhood education, parental employment, and housing—specifically Head Start, the Family and Medical Leave Act, and the Section 8 housing program. Through these examples, the authors illustrate the importance of collecting and reporting information by race and ethnicity, socioeconomic status, and other relevant characteristics.

Conclusions

The Policy Equity Assessment offers practical benefits for policymakers interested in improving racial and ethnic equity. By assessing equity at all stages of a policy, interested stakeholders can  identify areas for equity-focused analysis and advocate for the collection of new data to inform policymaking. Additionally, the framework provides a comprehensive understanding of how program effectiveness and resources can differ by race and ethnicity. By doing so, the framework also helps highlight the unmet needs of specific marginalized subgroups.

Recommendations from the authors to address equity disparities in policymaking include:

• Social programs should systematically collect and report information by race/ethnicity, socioeconomic status, disability, nativity, and other characteristics.
• Organizations should create capacity indicators, such as population eligibility, enrollment, funding, services, and quality by race/ethnicity; the authors advocate that these indicators should be included as measures in program evaluation and impact analyses.
• Federal and state agencies should establish funding streams for programs that demonstrate evidence of reducing inequities in outcomes or services for marginalized  groups.

Overall, the Policy Equity Assessment serves as a valuable tool for enhancing the evaluation and monitoring of policies, aiming to improve outcomes for all children and families, especially those from historically marginalized groups.

Organizational Strategies for Addressing Racial and Ethnic Disparities in Health Care

Introduction

This study seeks to understand the best ways to address racial and ethnic disparities within healthcare institutions, with a particular focus on organization management. The study draws upon learnings from the Disparities Solution Center at Massachusetts General Hospital and specifically references data produced from the Disparities Leadership Program (DLP) that began in 2007. The DLP helped illuminate patterns in leadership in healthcare institutions and how leaders view eliminating disparities in healthcare. Ultimately, the study identifies common barriers and potential solutions to helping healthcare institutions begin the work of achieving health equity within their respective organizations. This study is noteworthy because while there is a wealth of research on health equity, there needs to be more research on how organizational change management can spearhead or hinder the progress of addressing those inequities.

Joseph Betancourt, MD, MPH, is the Senior Vice President of Equity and Community Health at Massachusetts GeneralHospital (MGH) and the founder, senior advisor, and faculty Director of the Disparities Solutions Center (DSC) at MGH Betancourt. He also served on the leadership team of the MGHCenter for Diversity and Inclusion. Aswita Tan-McGrory, Karey S. Kenst, and Thuy Hoai Phan all serve in various roles on the Disparities Solutions Center team at Massachusetts General Hospital. Lenny Lopez is the Chief of Hospital Medicine and an Associate Professor of Medicine at the University of California, San Francisco. 

Methods and Findings

The study uses survey data from nine cohorts of participants in the DLP. Each cohort consists of multiple health organizations. Each organization sends teams of 1-9 people to participate in the program, which includes a trip to Boston, Massachusetts, Santa Monica, California, and various remote activities throughout the year. Teams can be made up of a variety of different members within an organization and are not necessarily consistent in size or makeup throughout each cohort. The unit of analysis for this study is the survey completed by each organization’s team at the end of the program. Responses from organizations that were not hospitals or health-focused centers were excluded from this study. In the end, 97 organizations, which equates to roughly 119 surveys and 269 individual participants, were used for the qualitative analysis. A sequential grounded theory approach was used to analyze the data; three authors read the survey responses separately and identified the main patterns. Then, the authors discussed the main patterns or ‘domains’ they found in the data collectively. This process was repeated on small samples of the data until all domains were identified. Using the agreed-upon domains, two authors manually coded all survey responses. After completing the analysis, five major domains were identified: 

1. Know Who to Involve. This domain focused on engaging the correct leadership members in any process involving equity or changing organizational processes. 
2. Shape Organizational Culture. How an organization decides to prioritize addressing disparities, their cultural awareness that disparities exist in their workplace, and their knowledge about how to reduce disparities were all included in this domain. 
3. Create Urgency and a Vision and Make the Rational and Emotional Case. This domain focused on communications strategies and message framing that could add urgency to the case for implementing equity-related efforts. 
4. Engage your organization and your audience. An organization’s ability to identify all relevant internal and external stakeholders was an important domain for organizations participating in the DLP. There was a particular focus on engaging with Black, Indigenous, People of Color (BIPOC) patient communities for those healthcare organizations that serve those patient populations.   
5. Harness the power of a collaborative network:  It is essential that the process by which equity-focused solutions are developed and implemented is collaborative and draws upon the collective knowledge of the entire organization. Sharing ideas, resources, and strategies was crucial for organizations participating in the DLP.

Conclusions

The authors highlight two important observations across all of their findings regarding addressing racial disparities in healthcare institutions. First, there was strong evidence to suggest that healthcare organizations already understand what racial and ethnic disparities are present in their organizations and what needs to be done to eliminate them. Second, the real barriers lie in getting leadership buy-in and organizational prioritization toward fixing these disparities. The authors offer some specific strategies and advice to best tackle these issues within the framing of the five domains listed above:

1. Many survey respondents mentioned both Executive “Champions,” who lead the effort for broader leadership buy-in, and midlevel and frontline staff members, who implement the strategy to address inequities, were critical components in creating a strategy that can help develop momentum among organizational leadership. 
2. Survey respondents proclaimed that they successfully addressed disparities once they linked disparities work with other initiatives or priorities that were already occurring. 
3. Benchmarking or numerically quantifying disparities work was crucial for creating organizational urgency and vision. It is helpful to do this in conjunction with communication strategies that are developed clearly and concisely. 
4. Engaging organizations by sharing your vision early in the strategic process was beneficial in terms of developing internal and external partnerships. Furthermore, leveraging awards or recognition achieved for disparities work helped to continue momentum. 
5. Lastly, organizations that were successful in reducing racial and ethnic disparities by the end of the program highlighted their use of diverse and collaborative coalitions that were able to anticipate changing environments, provide general networking and peer support, and encourage divergent points of view to address health disparities more effectively.

These recommendations are crucial for the future of the healthcare field, especially as the sector continues to lack clarity regarding the future of nationwide healthcare efforts like the Affordable Care Act. In the wake of governmental uncertainty, healthcare institutions themselves must work towards transforming their institutional responses to racial and ethnic disparities. Organizational change management strategies should be a core part of that discussion, and this study illustrates how effective they can be in conversations around disparities reduction specifically. The DLP and the specific recommendations in this study serve as a springboard to further the discussion around disparity reduction within healthcare institutions.