On May 11, 2021, the American Medical Association (AMA) released an 86-page “Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.” The document, produced by the organization’s Health Equity Task Force, is described by the US’s largest physician member association as a roadmap “to embed racial justice and advance health equity for years to come.” The report has received public attention for its systematic assessment of the causes and impacts of structural racism in medicine. Yet, one year after George Floyd’s murder sparked a national reckoning around racial justice, it is far from clear that documents such as this will actually guide medicine toward racial justice.
The AMA’s strategic plan is released at a time when more and more US physicians are speaking up about racism and racial injustice and pushing against the fiction of a post-racial apolitical approach to medicine and science. Some of these physicians have focused their efforts on pressuring their professional associations to be more aggressive about confronting systemic racism. These cries for association leadership on anti-racism come most strongly from medical students, residents, and racial minority constituencies. Their efforts have resulted in a range of race-based programming, public statements, and, more recently, strategic plans. These are promising developments, particularly given the troubling history of racism in many of these associations. However, members must contend with whether physician associations are the correct venue for this activism.
We express hesitancy not because—as has been argued elsewhere—physician associations should avoid controversial positions or “political” advocacy. Instead, our concern, as social scientists who research the exercise of physicians’ power in policy arenas, is about the relationship of this burgeoning anti-racism advocacy to other association advocacy. What happens when associations make public statements in support of antiracism while continuing to advance physician interests that subjugate systemically oppressed groups?
Acknowledging The Paradoxes Of Organized Medicine
Physician associations—the professional membership associations representing physician interests—face significant challenges articulating their priorities because of their multiple purposes. These organizations lobby for physicians’ financial interests and control of medicine at the same time that they issue guidance on ethics and public health. These overlapping tasks reflect the diverse priorities of membership and often make it difficult for associations to take decisive action. This is indicated by physician associations’ responses to pressure to take action on racism—while many, many public statements have been produced, few associations have committed to substantive advocacy to change the health system. In the weeks following the murder of George Floyd and the subsequent protests, physician associations pumped out statements opposing racism in quick succession. Of the 183 associations that make up the AMA House of Medicine—54 geographic member associations, 123 specialty associations, and 6 affinity-based societies—more than 60 percent have issued statements decrying racism and vowing to work as champions for racial equity. Many associations also signed on to joint statements, such as the one produced by the Council of Medical Specialty Societies, on behalf of its 45 member associations representing 800,000 physicians. Most of these statements refer to “structural” or “systemic” racism, and several pledge to invest in diversity, equity, and inclusion initiatives, but few (with some notable exceptions) explicitly connect racism to their own specialties or member populations. Of these, only a small number of associations have gone so far as to make anti-racism a part of their federal or state legislative advocacy.
These anti-racism proclamations are poorly connected to the traditional policymaking and lobbying activities of these associations. Take, for instance, the AMA’s Health Equity Plan. The document is an initiative of the association’s Center for Health Equity—made up primarily of non-physician association staff. Although the Center engaged association stakeholders to develop its plan, it is imperative to keep in mind that the AMA creates policy and sets its lobbying agenda through its House of Delegates, a parliamentary democracy made up of physician members. Any actual shift in associational priorities will have to take place within the membership, rather than through a document created by staff. And, while there is evidence that members of the AMA are attempting to build on the Health Equity Plan through association policy, the process is inherently slow, and proposed initiatives for racial equity will have to compete against members’ other concerns. Given that physicians fall across a wide political spectrum, it is likely that among the broader membership there is a greater divergence in perspectives about engaging with racial justice movements than is reflected in association statements.
Of perhaps greater concern is the fact that these statements serve to distract attention from associations’ less publicly visible work of using their lobbying power to secure physicians’ financial interests and power in state and federal legislatures at the expense of minority populations’ access to health care. At the same time that physician associations are decrying police brutality and the racialized impacts of COVID-19, they are simultaneously blocking a pathway to securing universal health care coverage, pushing back against surprise billing legislation meant to protect vulnerable patients, and exacerbating the provider shortage in low-income communities by restricting the “scope of practice” of non-physician clinicians. These actions have far greater impacts on the perpetuation of systemic racism in health care than the release of statements opposing racism because they exacerbate existing inequalities in health care access. There is certainly room to debate the relationship between any of these individual policies and racial inequality, but physician associations are ill-equipped to weigh this concern against the financial interests of members.
Physician associations’ leadership on racial inequities will always be compromised by their directive to protect the financial interests and power of physicians. Take, for instance, the recent leadership offered by the California Medical Association (CMA) on issues of racial justice. The association has been vocal about its anti-racism initiatives, including supporting legislative efforts to ban the use of chokeholds by police officers. However, the CMA continues to use its lobbying power to resist legislation with the potential to increase health care access for marginalized communities because it would not guarantee physicians oversight of other clinical professionals. The conflicting priorities animating physician associations indicate that they are ill-suited to be the standard bearers of the physician movement to address systemic racism. Indeed, other organizations such as Physicians for a National Health Program and the American Medical Student Association and viral movements such as #WhiteCoats4BlackLives have been able to speak more decisively on these issues.
Activism Within Bounds
In pointing out the compromises inherent to physician associations, we do not argue that members should not pressure associations to act on behalf of racial equity; rather, we do so to convince them to do so strategically. Physician associations have long held a seat at the table in driving health care policy—particularly around financing. This makes them a natural venue for advocacy within medicine. However, activists should never lose sight of the reality that physician associations are structured to protect the financial interests and authority of physicians, and that the interests of physicians do not always align with those of patients—particularly minority and disenfranchised patients. Any efforts to reorient these organizations toward racial equity and social justice must be clear-eyed about their limits.
This means that physicians looking to advocate for racial justice must consider the incentives shaping the advocacy of their particular association. For instance, there are important differences between state and specialty associations that may impact the types of race-based advocacy they might take on. State associations often prioritize the preferences of small physician practices—and, as a result, they may be less likely to take on advocacy that diminishes the role of private insurance or pits health equity against reimbursement rates. Physicians within specialty associations should consider how employment arrangements and revenue structure particular to the specialty might impact what types of race-based inequality their associations take on. This may mean, for example, that specialties where most physicians work as employees (rather than in solo or small group practice) or those that already have a higher proportion of patients who rely on public insurance may be better positioned to advocate for expanding coverage to marginalized populations. Specialty associations may also be best equipped to mobilize around substantive racial equity issues that are particular to their patient populations (see, for instance, the American Society for Hematology’s work on behalf of patients with sickle cell disease).
In expressing measured enthusiasm for the role of physician associations in addressing systemic racism, we direct members to lessons provided by US politics over the past few years. The 2020 election season brought disappointment for many progressives hoping to advance a more left-leaning Democratic presidential candidate. Many were shocked that the most “establishment” candidate, Joe Biden, emerged as the party nominee, even as there was support for a sea change in Democratic politics. However, even as many progressive-identifying voters were left disappointed by the election results, the impact of progressive grassroots actors in US politics is apparent. Progressive grassroots groups have successfully used strategic advocacy, public engagement, and coalition building to pressure the “establishment” to champion some progressive priorities, such as universal health care access, expansion of civil rights, and climate action. Physicians hoping to use associations as venues to advance racial equity might take note.
Physician associations are not—on their own—the strongest vehicle for transformational action on racial health equity. However, physicians seeking racial equity have an opportunity to use physician associations as one tool among many, as part of a multi-dimensional coalition. As the release of the AMA strategic plan and increased public engagement on race over the past year demonstrate, associations are listening to the demands of physicians to explicitly target racism. However, without strategic engagement, declarative statements may be both the beginning and end of physician association action on behalf of racial justice.
Brophy and Sriram have recently co-edited a special section of the Journal of Health Politics, Policy, and Law on global politics of physician associations and are conducting ongoing research on health worker protests.
Originally Appeared Here