By Brietta R. Clark
Health care programs, such as Medicaid, are increasingly using social risk assessments to target certain patients or communities for interventions intended to promote health. This includes partnering with other service sectors to provide nutrition, housing or employment assistance, transportation, parenting education, care coordination, and other behavioral supports.
These social interventions are touted as a way to improve health equity, yet they do not address structural racism, a powerful determinant of health. These interventions tend not to measure racial impact, or account for how racial inequity shapes the very structures and systems upon which social interventions depend. Indeed, this inattention means that such well-meaning interventions may inadvertently reinforce racial inequity, subordination, and stigma in marginalized communities.
To date, the health policy and research literature has paid hardly any attention to these harms. But Critical Race Theory (CRT), considered relatively new to the public health field, provides a valuable framework for attending to race equity in theory and practice.
CRT emphasizes the social construction of race, contemporary mechanisms by which groups are subordinated, and the importance of centering the lived experiences of marginalized communities in discourses typically dominated by the majority. Applying this lens reveals how existing forms of racism or subordination may shape the intervention design and impact of risk targeting in harmful ways.
Policy discussions focused on the design of social risk assessment tools and interventions are overwhelmingly shaped by powerful health actors’ perspectives and interests, especially cost containment goals. Indeed, the expansion of social interventions is a direct result of financing reforms that tie outcomes to reimbursement, leading payors and providers to view addressing social needs as a means of reducing cost.
With cost as a driving factor, it should not be surprising that health actors target risks linked to costly health conditions considered amenable to cost-effective interventions targeting patient behavior. Common examples include nutrition assistance for patients with chronic medical conditions like diabetes and care coordination for patients managing multiple, chronic conditions.
Racism is typically excluded from the risks to be addressed, and interventions promoting structural reforms are rare. One reason for this may be the health sector’s own resistance to structural reform, in particular its failure to address racism in health care. Another may be the fact that targeted patients or communities are not typically involved in identifying or prioritizing the risks assessed.
For example, while intimate partner violence is a common risk screened for, exposure to violent and discriminatory policing is not. This neglect persists despite evidence that police violence is a preventable cause of serious physical and mental health harms to the Black community, growing recognition of this as a public health issue that requires intervention, and the Black community’s own persistent demands for structural reform.
The exclusion of marginalized communities from participation in intervention design, together with the neglect of risks these communities may prioritize, reinforce the existing subordination and invisibility that have allowed structural determinants of health to go unchecked for so long.
Impact of Risk Targeting
A critical race lens also reveals troubling implications of the overlap between groups targeted for social support based on a risk assessment, and those targeted for punitive, violative, and discriminatory interventions because they were viewed as risky to others.
Pregnant women and infants of parents receiving public assistance are deemed high-risk and targeted for well-meaning interventions, such as WIC support, parenting education, and home visits. Newly-eligible adults under the Medicaid expansion are considered prime targets for behavioral and housing support based on data suggesting relatively high rates of substance use disorders, mental illness, criminal justice involvement, and homelessness.
But racial and ethnic minorities, people with mental disabilities, and substance users have also been targeted by states and medical actors for sterilization and other reproductive control measures. Family services agencies have been criticized for improperly separating children from families based on “neglect” instead of providing social supports, and for racial disparities in abuse referrals and offers of support that result in disproportionate numbers of Black and Latino children in the system. And doctors and social workers have worked with police to subject pregnant women to unwanted medical interventions or confinement to prevent behavior they consider risky to the fetus, with Black women being disproportionately targeted.
This context reveals how risk targeting — even if well-intentioned — can trigger fears of continuing discrimination, surveillance, and punitive action by the same systems upon which current social interventions may depend. Well-meaning interventions promoting healthier eating, better parenting, and stricter compliance with physician recommendations may not feel that different from interventions that have treated marginalized groups as inherent risks to be managed or contained.
There may be lingering mistrust, which could explain why some patients do not respond to outreach or share risk-related information. For others, these fears may undermine one’s sense of agency and dignity. Professor Khiara Bridges describes how interventions intended to provide support to low-income families subject parents to intrusive state surveillance. Poor parents may feel they cannot refuse to answer screening questions or refuse “offers” of support, for fear that refusal would be seen as evidence of bad parenting that could be used to justify punitive or unwanted government action later.
The potential harms identified above, largely invisible in the dominant discourse, illustrate the need for an intentional integration of equity in social interventions. Such integration increases the likelihood that health promotion measures will be effective, minimize harm, and be agency-enhancing for marginalized communities. Indeed, a Public Health Critical Race Framework has already been developed to provide a roadmap for this kind of integration. The question is how long it will take a health care industry primarily driven by cost to recognize CRT’s value.
Brietta R. Clark is a Professor of Law and J. Rex Dibble Fellow at Loyola Law School, Loyola Marymount University, Los Angeles.