A Racial Equity Framework for Assessing Health Policy

Abstract

• Issue: Despite enduring racism and the need for greater racial equity, there is limited consensus among analysts, academics, and public officials on how to assess policy for its impact on racial equity. Without instructive conceptual frameworks, our ability to identify, examine, and eradicate racial inequity through health policy will be limited.
• Goal: To establish a conceptually nuanced, empirically informed, and practically useful framework for analyzing the racial equity implications of health policies.
• Key Findings and Conclusions: Analysts, academics, and public officials seeking to evaluate policy through a racial equity lens should consider multiple dimensions of the policy process, including design, implementation, evaluation, feedback, and key aspects of the policy environment. We can gain important insights by systematically probing how racism is structurally produced or reproduced through each of these specific dimensions. In doing so, it is especially crucial to examine the ways that policy: 1) creates or reflects disproportionality in the allocation of benefits and burdens to racial groups, 2) operates through forms of institutional decentralization, and 3) includes or neglects the voices of racially marginalized populations. The Racial Equity and Policy (REAP) framework provides a conceptually sound, empirically grounded basis for systematically assessing racial equity in health policy.

Introduction

Racial equity took center stage in 2020, when COVID-19 and extraordinary uprisings against racial violence converged to expose the depth of racial injustice entrenched in American social, economic, and political life. In the face of a pandemic that devastated Black and Latinx communities and a faltering economy that left many of those same communities in a state of material deprivation, antiracism emerged as a renewed clarion call. The conversation around racial justice has aptly stressed the centrality of structural racism — racial inequity that is “produced and reproduced by laws, rules, and practices, sanctioned and even implemented by various levels of government.”¹

Public policy is among the most enduring and powerful structures shaping racial inequity in health.² Both historically and contemporarily, public policies have been instruments through which government has created, maintained, and exacerbated racial disparities through domains such as housing, healthcare, and welfare.³ Of course, policy has also been employed to reduce and redress racial disparities.⁴ Altogether, the trajectory of U.S. public policy vis-à-vis racism has not been uniform, progressive, or linear.

This issue brief presents a framework for systematically assessing health policy through the lens of racial equity.

Medicaid’s Centrality in Assessing Equity

Given its immense footprint across the U.S. health care system, Medicaid is an obvious choice for applying a framework intended to have broad applicability to public policy. With over 80 million enrollees, Medicaid is the largest public health insurance provider in the United States. It accounts for over 28 percent of all spending by states and more than 9 percent of federal outlays.⁵ The racial composition of people covered by Medicaid further underscores the program’s importance in efforts to address racial equity concerns in health care: nationwide, 30 percent of nonelderly Medicaid beneficiaries are Latinx, 20 percent are Black, and nearly 10 percent comprise additional minoritized racial or ethnic groups, including Asian/Native Hawaiian, American Indian/Alaska Native, and people who identify as multiracial (Exhibit 1).⁶

On a state level, Black, Latinx, Asian, Native, and multiracial Americans compose a majority of Medicaid beneficiaries in 25 states. In many states, people of color account for large majorities, including in Hawaii (87%), California (79%), Texas (79%), Georgia (68%) Florida (65%), and New York (64%).⁷

People of color rely heavily on Medicaid because of existing social and economic inequality. For example, Black and Latinx Americans are more likely to be living in poverty, to work in occupations where employers do not offer health care, and to face a variety of health problems. Medicaid acts a safety net, catching those who would otherwise experience these compounding disadvantages without health insurance and be made even more economically precarious as a result.

Because Medicaid is highly fragmented and decentralized — with the federal government, states, and even localities making ever-evolving decisions about how to fund, design, and administer it —there are numerous touchpoints where inequities rooted in policy can materialize.⁸ For example, state programs vary in terms of:

• Which optional benefits they offer, such as dental, vision, podiatry, or physical therapy.
• The kinds of waivers they pursue for things like work-reporting requirements or home- and community-based services.
• The terms of provider payment as set through contracts and fee schedules.
• How much they invest in outreach to ensure eligible people receive benefits.
• How they oversee program administration.

Each of these Medicaid policy decisions has implications for how benefits (and sometimes burdens) are distributed across racial groups and for how policies interact with the preexisting social and economic disadvantages that are unequally borne across racial groups. Yet policymakers approach many of these decisions without clear consideration of the repercussions their choices have for racial inequity. The framework presented here provides guidance on such matters.

A Policy Process Perspective

Comprehensively evaluating health policy in terms of racial equity necessitates examining policy as a process, not only an output. Just as a focus on structural racism usefully draws attention to systems of laws, rules, and practices that go far beyond individualized instances of discrimination, concentrating on policy processes directs attention away from discrete policies and toward the broader systems that produce them.

As a starting point, this framework draws from popular models of policymaking that reflect fundamental elements of the policy process (Exhibit 2).⁹ At the core of the process are choices. Choices about the contours and characteristics of policies are made at different stages of the policy process: when policy is being designed, implemented, evaluated, and even as the effects of policy feed back into larger political processes to shape future policy trajectories.¹⁰ At any given stage, those choices are embedded within a larger policy environment. Features of that environment — like institutions, actors, networks, contexts, events, and ideas — operate simultaneously to produce and structure policy choices. To identify, assess, and eliminate racial inequity in health policy, it is necessary to understand how it emerges within and through the various dimensions of the policy process specified here.

For example, institutions create the rules and constraints that structure the behavior of policy actors. In the case of Medicaid, although Congress passed the Affordable Care Act (ACA) with the intention that every state would be required to expand eligibility, legal institutions — specifically, the U.S. Supreme Court — prevented the federal government from mandating the expansion.¹¹ The Court’s decision shaped the options available to a variety of actors: state lawmakers can support (or oppose) Medicaid expansion; state and national interest groups can lobby for or against it; state and local grassroots organizations can pressure lawmakers to expand (or not); individual constituents can vote based on their preferences for expansion; and so on.

Corollary institutional processes on the state level have made legal institutions particularly critical for the trajectory of Medicaid expansion. For example, when elected officials in Missouri refused to implement a state ballot initiative that required Medicaid expansion, state courts intervened, ultimately deciding that lawmakers must carry out the will of the state’s voters.

A range of institutions and actors play potentially pivotal roles in the policy process. Exemplifying this are the varied policy solutions proposed for closing the Medicaid coverage gap. Some, like the Medicaid Saves Lives Act,¹² would rely on federal agencies like the Centers for Medicare and Medicaid Services to administer a new program providing Medicaid benefits for uninsured people in nonexpansion states. Other proposals, such as the COVER Now Act,¹³ focus on empowering individual counties and municipalities to expand Medicaid in their jurisdictions. Still other proposals involve amending the ACA to remove the minimum income cutoff for participation in the law’s private health insurance marketplaces, so that Medicaid beneficiaries can get coverage through marketplace plans.¹⁴

Notwithstanding their specifics, each policy reflects the operation of a distinct set of actors and institutions at varying levels of government, taking different pathways in response to the policy environment. Institutions form the boundaries these actors work within (and sometimes against) to determine which policy choices to oppose or support.

Just as policy choices are structured by institutions and actors, they are also simultaneously shaped by other key aspects of the policy environment, including:

• Ideas: Framing the discourse, logic, and justification for policy, ideas are an ever-present part of the policy environment that can sometimes channel racism.¹⁵ For example, ideas about how “deserving” certain populations are, along with racial stereotypes and racial resentment, are correlated with lower levels of public support for programs that are perceived as mainly benefitting people of color (such as Medicaid).¹⁶
• Events: Critical events that bring policy issues into sharp relief also often accentuate existing racial inequities. For instance, the COVID-19 pandemic was a focusing event, bringing racial disparities in infection and mortality to the forefront of health policy agendas.¹⁷
• Networks: Policy actors are not discrete agents of change. Patterns of relationships between policymakers, local residents, interest groups, and other actors are crucial aspects of a given policy environment, with implications for outcomes that matter for racial equity. Medicaid expansion is illustrative of the role of networks: research shows that Republican-leaning states have been most likely to embrace Medicaid expansion when the power of organized business associations outweighs the influence of cross-state networks of ideologically conservative organizations.¹⁸
• Contexts: Policy actors and institutions are embedded within specific economic, social, and political contexts that fundamentally shape efforts to enact, implement, and advance equitable health policy. For example, an approach to achieving health equity taken in Minnesota cannot be applied blithely in Mississippi.¹⁹

Together, institutions, actors, ideas, events, networks, and contexts create a policy environment that structures policy choices. Policy environments shape choices made not only when a law or regulation is first designed but also when it is being implemented, when it is being measured to assess its effect on outcomes, when it interacts with related policies, and when it feeds back into the political system in ways that constrain or enable future policy choices.

Racial Equity and Policy (REAP) Framework

The Racial Equity and Policy framework (REAP) draws on these core insights about policy process and environment to present a set of questions and considerations that policymakers, analysts, academics, and others should attend to when assessing the racial equity implications of policy (Exhibit 3). These questions are meant as starting points, sensitizing us to the kinds of inquiries that are important for analyzing policy through the lens of racial equity. It is both appropriate and ideal to think of the REAP framework as a baseline to build upon as the specifics of policy analysis are elaborated.

Three key considerations that emerge from a process-oriented perspective on racial equity and health policy are disproportionality, decentralization, and voice. These themes pervade the questions embedded within the REAP framework because they are indicative of structural mechanisms through which racial inequities emerge in policy.

• Disproportionality refers to the way policies differentially allocate benefits and burdens to racial groups. Disproportionality can involve disparities in the distribution of beneficiaries of a given policy, such as the proportion of Medicaid beneficiaries who are Black; incongruity in the proportion of a racial group affected by a policy, such as the proportion of Black people who are Medicaid beneficiaries; disparities in benefit size and take-up; and differences in the share of benefits that some racial groups receive relative to others.²⁰
• Decentralization concerns the level of government through which a given policy benefit or burden is designed or implemented. In the U.S. system of federalism, national, state, and local governments have the power to affect a wide variety of policy outcomes — often with striking consequences for racial equity.²¹
• Voice relates to the ability of communities of color to shape the policy environment. Equity and voice are intertwined, because policy processes that incorporate the voices of people of color are better positioned to facilitate racially equitable outcomes.

The REAP framework highlights questions about disproportionality, decentralization, and voice that are crucial to assessing racial equity within a given policy environment (that is, with respect to institutions, actors, networks, events, contexts, and ideas). But to be clear: disproportionality, decentralization, and (lack of) voice are not definitive markers of “racist” policy. We cannot mechanically characterize a policy as racist simply because it has these characteristics. Instead, these factors indicate likely channels through which racism can operate. The REAP framework alerts us to their importance and points us toward key considerations to guide assessments of public policy and racial inequity.

Key Considerations: Ideas

Drawing on Medicaid, let us consider one dimension of the policy environment as an instructive example: ideas. Asking detailed questions about how ideas factor into the policy process sensitizes us to the multifaceted ways that racial inequity can manifest in health care legislation and regulatory action.

Ideas about Medicaid beneficiaries vary from state to state (decentralization).²² Those ideas shape the policy environments in which choices like Medicaid expansion are made. And they can reflect racial meanings and stereotypes about communities of color (disproportionality).

For example, perceptions of Medicaid may be less positive in states with high levels of racial resentment. This larger reality, in combination with other aspects of the policy environment — like the number of legislators opposing Medicaid in response to perceived public sentiment — can make Medicaid expansion less possible or make Medicaid work requirements linked to expansion more popular.²³

Unfavorable racialized ideas about Medicaid can also have repercussions for policy implementation, such as by creating a context where street-level bureaucrats treat Medicaid beneficiaries less respectfully. Furthermore, ideas about Medicaid beneficiaries may inform the ways state actors evaluate Medicaid policy — what metrics they consider and whether they invite beneficiaries to participate in evaluation processes (voice).

Whether in terms of design, implementation, or evaluation, all these propositions suggest a role for interrogating ideas in terms of decentralization, disproportionality, and voice. For each dimension of the REAP framework, similar patterns of questions can reveal insights and perspectives that underline key concerns for racial equity.

Applying the REAP Framework

The REAP framework can complement growing initiatives to systematically track racial data (for example, Boston University’s COVID Racial Data Tracker²⁴) or policies related to racial inequity. Even once such efforts identify key patterns via data or catalog policies vis-à-vis racial outcomes, the task of discerning the reasons for observed racial differences — whether and how they are a function of policy design, implementation, and structures — requires nuance and deep knowledge of policy and political processes. The temptation may be toward simplicity, to look at the effects of policy and designate a policy as racist if it disproportionately affects people of color negatively. This is certainly one important metric by which we can evaluate a policy’s racial inequity (hence the relevance of disproportionality), but it is not the only standard.

Instead, to understand whether and how policies advance or erode racial equity, a comprehensive view of policy processes and environments is necessary. Such a view should attend not only to direct outcomes but also to the other dimensions of the political process outlined in this brief.

Conclusion

REAP is a conceptual tool meant to provide researchers, policymakers, and others with guidance on how to assess the racial equity implications of policy. It can also benefit those who are collecting systematic data on health policies by providing a lens through which to methodically assess what those policies mean for racial equity and why. The REAP framework recognizes that even when researchers and other stakeholders have thorough information about policies, we still need the means to make sense of how those policies affect racial equity.