Mixed Race Studies

In First for Sitting President, Obama Publishes a Scholarly Article

Fortune
2016-07-11

Jeff John Roberts

Call him scholar-in-chief

An author named “Barack Obama, JD” published an article on Monday in a scholarly journal. No prizes for guessing the topic: It’s an assessment of the Affordable Care Act as well as policy recommendations for the next president to improve the U.S. health care system.

The article, titled “United States Health Care Reform: Progress to Date and Next Steps,” was published by the Journal of the American Medical Association.

The piece, which contains 68 footnotes to academic journals and government publications, claims to present evidence showing that the number of Americans without health insurance has dropped dramatically, and resulted in lower hospital readmission rates. Obama also used the article to recommend the introduction of a “public option” plan in parts of the U.S. and for the federal government to push down drug prices…

Read the entire article here.

United States Health Care Reform: Progress to Date and Next Steps

The Journal of the American Medical Association
Published online 2016-07-11
DOI: 10.1001/jama.2016.9797

Barack Obama, JD
President of the United States, Washington, DC

Importance The Affordable Care Act is the most important health care legislation enacted in the United States since the creation of Medicare and Medicaid in 1965. The law implemented comprehensive reforms designed to improve the accessibility, affordability, and quality of health care.

Objectives To review the factors influencing the decision to pursue health reform, summarize evidence on the effects of the law to date, recommend actions that could improve the health care system, and identify general lessons for public policy from the Affordable Care Act.

Evidence Analysis of publicly available data, data obtained from government agencies, and published research findings. The period examined extends from 1963 to early 2016.

Findings The Affordable Care Act has made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care. Since the Affordable Care Act became law, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, primarily because of the law’s reforms. Research has documented accompanying improvements in access to care (for example, an estimated reduction in the share of nonelderly adults unable to afford care of 5.5 percentage points), financial security (for example, an estimated reduction in debts sent to collection of $600-$1000 per person gaining Medicaid coverage), and health (for example, an estimated reduction in the share of nonelderly adults reporting fair or poor health of 3.4 percentage points). The law has also begun the process of transforming health care payment systems, with an estimated 30% of traditional Medicare payments now flowing through alternative payment models like bundled payments or accountable care organizations. These and related reforms have contributed to a sustained period of slow growth in per-enrollee health care spending and improvements in health care quality. Despite this progress, major opportunities to improve the health care system remain.

Conclusions and Relevance Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges.

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Genomics and Health Care Disparities: The Role of Statistical Discrimination

The Journal of the American Medical Association
Volume 308, Number 19 (2012-11-21)
pages 1979-1980
DOI: 10.1001/2012.jama.10820

Katrina Armstrong, MD, MSCE, Professor of Medicine
University of Pennsylvania School of Medicine

Ten years ago, 2 events occurred that have transformed biomedical research. In 2001, the draft sequence of the human genome was announced. One year later, the Institute of Medicine released “Unequal Treatment,” the first comprehensive report on racial and ethnic health care disparities in the United States.1 Although the report downplayed the contribution of genetics to disparities, enthusiasm about the human genome spread rapidly to disparities research, creating a new field focused on translating knowledge of human genetic variation into reductions in disparities in health and health care. This Viewpoint examines the potential contribution of 2 pathways in this field—the identification of genetic variation as a cause of disparities and the reduction of clinical uncertainty and statistical discrimination. The terms race and ethnicity are used to mean socially determined, generally self-reported, categories.

A common hypothesis is that advances in human genomics will reduce disparities by identifying genetic causes of disparities. In support of this hypothesis, racial and ethnic differences in genetic variant frequency have been demonstrated for many diseases. However, translating this evidence into reductions in disparities has proven challenging for several reasons. First, many variants identified have a small attributable risk and explain little of the disease burden in any group, either because of a weak association between variant and disease or because the variant is rare in the population. Second, far more genetic variation occurs within racial or ethnic groups than between groups,and disease-associated variation has no apparent predilection for the 4% to 8% of variation that can be linked to race or ethnicity. Thus, if genomic variation explains a minority of most diseases and is unlikely to be linked to a racial or ethnic group, it becomes unlikely that genomic variation between groups will be a substantial cause of disparities in most common diseases. Third, developing interventions based on this information is challenging. Although prenatal or even premarital genetic screening can reduce the burden of severe diseases if screening influences reproductive decision making, lack of acceptance of these approaches has limited their effectiveness. For other diseases, knowledge of genetic risk factors should increase the ability to target preventive interventions to high-risk individuals. However, the limited effect of genomics on risk prediction for many diseases combined with the relative paucity of effective preventive interventions for some diseases has limited the benefit of such an approach.

Another pathway by which genomics may reduce racial disparities that has received considerably less attention is its effect on clinical uncertainty and statistical discrimination. The need to make decisions under conditions of uncertainty is one of the hallmarks of medicine. This uncertainty arises on 2 levels. For many decisions, there is no credible and consistent evidence about risks and benefits of different interventions. Moreover, even when evidence exists, uncertainty arises about the effect of that evidence on the individual patient. The gap between the average effect in a population and the effect in a specific patient can be substantial, in part because of differences between patients in practice and trial participants and in part because the average effect in a trial masks substantial variation among trial participants…

Read or purchase the article here.

A Color Problem in England

The Journal of the American Medical Association
Volume 95, Number 3 (1930-07-19)
Foreign Letters: London Letter
pages 210-211
DOI: 10.1001/jama.1930.02720030040020

From Our Regular Correspondent (1930-06-21)

There is no color line in England such as exists in America. This does not mean that the English do not appreciate differences of race. They are keen on such differences, even between European races, and often contrast the Latin races with themselves. They are by no means without race prejudices but at the same time they have a strong tendency to take a man for what he is, regardless of race or of color. His color may arouse prejudice but this may be overcome when he is known. This absence of a color line has given rise to a color problem. The great seaport of Liverpool is frequented by seamen of many races, including Chinese and many Negroes from West Africa. The cohabitation of these races with the women of the city has given rise to a half-caste population. The number of Anglo-Negroid families is about 450 and the children born of this union amount to about 1,350. On the other hand, the Anglo-Chinese children do not provide any particular problem. The Anglo-Chinese child is declared to be mentally equal if not superior to the white, and since coloring and features are far less distinctive than those of the Anglo-Negroids they are not such a handicap. Further, the family life appears to be stable, the man remaining faithful to one woman though not married to her. The Anglo-Negroid family is far different. A Liverpool association for the welfare of half-caste children has been formed. The chairman, Prof. P. M. Roxby, says that the conditions under which colored seamen from West Africa enter Liverpool are a social menace and detrimental to the best interests of blacks and whites alike.

Miss Muriel E. Fletcher has for nearly two years been occupied with an inquiry for the association into the condition of half-caste children in Liverpool, where they are more numerous than in any other port. Of the Anglo-Negroid unions she says there is little harmony between the parents; the colored man generally despises the woman with whom he consorts, while the majority of the women have little affection for the men. They regret their union but stay for the sake of the children. The mothers are generally good to the children while they are small but later resent the fact that the children cannot get work and grudge having to keep them. The children find their lives full of conflict, and all the circumstances give undue prominence to sex. These families have a low standard of life morally and economically, and there appears to be little future for the children. They attend school in the poor districts and do not show any inferiority of health or proneness to infections compared with white children. The balance of evidence is that their intelligence is below the average. Their relations with the white children are friendly but they begin to feel outcast when they leave school and this feeling develops rapidly. There is no evidence that they have any special delinquent tendencies, but all their circumstances give undue prominence to sex. Owing to their unemployment, fondness of dress and finery, and the persistence of men, it is practically impossible for them to remain chaste, even if they desire to do so. As employers are unwilling to engage colored labor, the association has tried training schemes for colored girls but with limited success. It is thought that a larger and more intensive scheme might have greater success. It has been suggested that the obvious solution of the difficulty is to replace colored firemen by white on all British ships coming to this country, but the shipowners say that white men could not work in the heat of the stokeholds on the West Coast of Africa. However, the National Union of Seamen denies this. Other suggestions are the signing on of men in Africa so that they would be obliged to take the round trip and receive no pay in this country, and greater discrimination in the issue of British passports.

Measuring Race and Ethnicity: Why and How?

The Journal of the American Medical Association
Volume 292, Number 13 (2004)
pages 1612-1614
DOI: 10.1001/jama.292.13.1612

Margaret A. Winker, MD, Deputy Editor and Online Editor
Journal of the American Medical Association

Race and enthnicity are constantly evolving concepts, deceptively easy to measure and used ubiquitously in the biomedical literature, yet slippery to pinpoint as definitive individual characteristics. A current dictionary definition of race is “a family, tribe, people, or nation belonging to the same common stock, or a class or kind of people unified by shared interests, habits, or characteristics.” For 154 years, the US government has defined race for its census takers, and for many years census takers then defined it for US residents. The terms used reflect the nation’s changing demographics and increasing recognition of human diversity. The 1850 enumerators used a form that assumed a default race of white, with a checkmark indicating nonwhites as black or mulatto, with additional indications for free or slave. Indian was added as a category in 1860. Since 1960, individuals have been able to specify their own race and ethnicity, and by 2000 the census enumerated 126 racial and ethnic categories.

Medical definitions of race have lagged behind, although thankfully the former Medical Subject Headings (MeSH) terms such as Caucasoid, Mongoloid, Negroid, and Australoid rarely appear in biomedical literature. Given that the connotations and definitions of race and ethnicity are constantly evolving, the use of the terms and concepts of race and ethnicity in the biomedical literature deserves examination…

…The use of race as a proxy for unmeasured confounders, such as cultural, social, and environmental influences, is commonplace, but race is a poor proxy for these measures. The life experience and cultural milieu of US immigrants may be completely different from those who grew up in the United States, despite being assigned to similar racial or ethnic categories. Socioeconomic status, not race, is likely the greater determinant of health and health-related qualities. Therefore, race is not a substitute for carefully assessed social and cultural characteristics.

On the other hand, race can be an important indicator of health disparities and health care delivery. An American College of Physicians position paper attests to “…ample evidence illustrating that minorities do not always receive the same quality of health care, do not have the same access to health care, are less represented in the health professions, and have poorer overall health status than nonminorities.” While race is just a departure point when evaluating such disparities, the article by Bradley et al in this issue of JAMA illustrates how race can be used along with specifically defined characteristics to begin to explore some of the reasons behind health disparities. In this retrospective, observational study of inpatients from the US-based National Registry of Myocardial Infarction, who were hospitalized during 1999 through 2002 with ST-segment elevation or myocardial infarction or left bundle-branch block and receiving acute reperfusion therapy, Bradley et al assessed time from hospital arrival to acute reperfusion therapy. As previous studies have shown, nonwhites had longer times from hospital entry to reperfusion therapy, as much as 7.3 minutes longer for blacks receiving thrombolytic therapy and 18.9 minutes longer for blacks receiving percutaneous transluminal coronary angioplasty…

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The Morbid Proclivities and Retrogressive Tendencies in the Offspring of Mulattoes

The Journal of the American Medical Association
Volume 20, Number 1 (1893-01-07)
pages 1-2
DOI: 10.1001/jama.1893.02420280009001

W. A. Dixon, M.D.

Read in the Section of Diseases of Children, at the Forty-third Annual Meeting of the American Medical Association, held at Detroit, Mich., June 7, 1892.

Observations extending over a period of more than thirty years have thoroughly impressed the conviction upon my mind that the offspring of mulattoes are the subjects of constitutional diseases to a greater degree than are those of unmixed blood, and that when confined strictly to their own class, they scarcely reach the fourth generation in descent, by reason of disease and sterility.

I have often wondered if others have had occasion to notice this feature in mulatto life, or whether the conclusions at which I have arrived are false and unwarranted from being based upon observations confined to a local district, yet rich in examples that go far to establish the view propounded. I believe that there is not much to be found in current medical writings upon the subject. Our locality is on the border between the free and the slave States of fifty years ago and more. It…

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