In 2021, let us all resolve to continue our efforts begun in the wake of the turmoil caused by the pandemic, the unprecedented political upheaval and the consequences of the Black Lives Matter movement to ensure greater access and equity in healthcare for all citizens. Let us vow that when the public focus moves away from inequality, as it inevitably will, that we maintain our personal and professional commitment to reducing bias in healthcare education, training and service provision. Institutionalized racism in healthcare education is real and its effects on healthcare delivery are equally so. Physician David Paul observed in a recent compelling editorial in the New England Journal of Medicine, “When 13% of our population but only 2% of psychiatrists and 3% of health service psychologists identify as Black or African American, there is a bigger problem.” Then ask yourself how many of your colleagues are first nation or Native American—and even greater disparities emerge. Institutionalized racism in healthcare delivery is real, driven not only by systemic exclusion of minority groups from the learned professions but by long-accepted clinical practices that subtly pathologize behaviors of minority group members.
Our profession has long advocated for equality, and we have made many gains. But our intellectual history is darker than we generally care to acknowledge, stained as it is by the influence of racism and eugenics on many prominent leaders of the field in the 20th century and later misapplication of the results of standardized testing. This history is, sadly, still alive and we continue to deal with the consequences of our previous mistaken overreliance on the predictability of standardized assessment. The misapplication and misinterpretation of intelligence testing continue to have life and death consequences. As this column is being written, Corey Johnson is scheduled for execution in the Federal Correctional Institute in Terre Haute, IN, in part because he was found to be mentally competent on the basis of an estimated IQ score of 77, a few points above the accepted standards for mental incompetence. Elizabeth Bruenig noted that this is admittedly a nuanced case—his defense attorneys did not argue that he was ineligible for the death penalty on the basis of incompetence—but it illustrates the power of standardized IQ testing, often demonstrated to be inaccurate for members of disadvantaged groups. As the Register’s legal writer Steve Smith pointed out in his excellent review of the 2018 Supreme Court term, the Court has recognized that competence cannot be reduced to a single score on a standardized IQ test but it is clear that this standard is not consistently applied.
By focusing our research initiatives on problems of systemic bias and adopting a willingness to re-examine our clinical practices we can amend the failings of our collective past. This does not, as some aver, result in a diversion of resources away from other pressing areas to focus only on ethnically based inequities, although a persuasive moral argument for doing this can easily be constructed. But ethnically mediated inequities are, while uniquely derived from a history of racism and exclusion, fundamentally the same inequities that are faced by a growing number of economically disadvantaged citizens of any ethnicity. Lack of financial wherewithal to secure adequate housing, education, and decent health care choices results in far more than an inability to fully access our treatment systems, it results in an inability to be full participants in a democratic society. The social determinants of health have never mattered more than they do now, given that pandemic-related unemployment has disproportionately affected those in lower-income jobs. In the US, post-reconstruction racism and Jim Crow created a stratum of disenfranchised African American citizens whose struggles continue today in manifestly apparent ways. Increasing income inequality threatens to not only erase those gains but to spread them more widely among citizens of any ethnicity. Rochelle Walensky, the nominated chief of the Centers for Disease Control in the Biden administration commented “A frail, poorly tended public health infrastructure can bring a great country to its knees”. I agree with Walensky that we must address inequities that make Native Americans, African Americans, and those of Hispanic descent more vulnerable to COVID-19, but I reiterate that addressing these inequities will improve the health of all Americans, not just those in targeted groups.
The conservative columnist David Brooks wrote in his end-of-2020 column “This is the year that broke the truth. This is the year when millions of Americans—and not just your political opponents—seemed impervious to evidence, willing to believe the most outlandish things if it suited their biases, and eager to develop fervid animosities based on crude stereotypes”. This is not a political column and psychologists have no magic wand to calm misled zealots or heal political divisions. But we must, as individuals, professionals and members of society speak the truth. The truth is that on 6 January 2021 we saw the frightening reality that was the direct consequence of the President of the United States fomenting violence based on lies. These lies were amplified by elected representatives to the US Congress who encouraged insurrectionists in their destructive rampage through our capitol. Psychologists are intimately familiar with bias, as current APA President Jennifer Kelly and APA CEO Arthur Evans recently wrote. To amplify, we strive to identify and correct investigational bias in our research and reporting. Social psychologists study attribution theory to identify the origins of prejudice. Clinicians strive to help patients whose cognitive biases warp their views of self and others and lead to dysfunction and misery. There are no easy cures for bigotry and prejudice, their roots are deep and they are by no means an American problem. Nor is their invocation by leadership as a means to achieve craven political ends. The solutions to bigotry and prejudice aren’t psychological, they are societal and, sadly, multigenerational. They require sustained, systemic commitments that no group by itself can hope to adhere to or implement. But there are systems under our direct control that we can influence to ameliorate the effects of systemic bias. Psychology is of the academy, and the academy has and should continue to forcefully argue that preparation for entry into STEM professions be expanded. Enrollment into graduate programs for members of underrepresented groups should continue to be incentivized. These initiatives are not new, but efforts to date have not been as successful as we would like. In the graduate curriculum a wholesale re-examination of the role of standardized testing should be urgently undertaken, incorporating the many analyses of bias inherent in standardized testing. We must also teach effective interventions for combatting racism and bias. We should pay heed to David Brooks’ observation that diversity awareness training as commonly construed does not result in a more representational workplace. It is up to us to develop effective interventions that result in greater workplace equity. In training curricula, we need to not only question the role of standardized testing in clinical decision making but we must also re-examine procedures that reflect institutional racism. When teaching the psychological intake, for example, why do we continue to mandate that the patient’s ‘race’ be identified? As I’ve written elsewhere, identification of characteristics such as ‘race’ or sexual orientation does not contribute to clinical decision making, but likely introduces an element of hidden bias in the opening sentences of an evaluation. While it is likely that members of non-dominant groups have suffered the effects of bias, this is not axiomatic. If discrimination has contributed to the clinical presentation then this should be addressed in the clinical history, not as an identifying characteristic of the patient.
The Register is a member of the Mental Health Liaison Group, an organization of over 60 not-for-profit mental health entities in Washington. We have already had the opportunity to meet with members of the transition team for the Department of Health and Human Services, where we emphasized a number of priorities. Among these was an expansion of telepsychology. Although the COVID relief bill passed in the waning days of the 116th Congress as a component of the consolidated appropriations act did address telehealth expansion, some essential elements were missing. The Register, along with other MHLG entities, has advocated for an end to the requirement of an in-person interview in the six months before telepsychology services begin. We have also advocated that the Center for Medicare and Medicaid Services (CMS) reimburse for audio-only (i.e., telephone) services, especially important since our two recent surveys on pandemic practice discovered a significant minority of providers were providing audio-only therapeutic services. The COVID relief bill contains some funding to extend internet access to economically disadvantaged and rural citizens—a step in making them full-fledged participants in an increasingly electronic healthcare system. But the individual amounts allocated are relatively small, and much more needs to be done to ensure access to all. The bill also contains some important language regarding parity enforcement and provides a fund for states to survey billing practices of for-profit insurers to determine if they are complying with extant parity laws. Our advocacy initiatives in the latter part of 2020 were unsuccessful in convincing CMS to abandon reimbursement cuts in the 2021 Physician’s Fee Schedule that resulted in net negative reimbursements for psychologists. We are hopeful that new leadership in CMS and among our allies in Congress will finally see fit to put a legislative end to budgetary requirements that result in often futile and time-consuming negotiations with CMS. With much of outpatient healthcare practice, including psychological practice, suffering badly during the pandemic, now is not the time for the government to cut reimbursement – cuts that are often mimicked by for-profit insurers. The failings of a system that still ties employment to adequate access to healthcare have become starkly apparent during the pandemic, when job losses disproportionally affected the economically disadvantaged. Fixing this will not be easy but it is possible. We should not be distracted by arguments that these fixes are too expensive. These are false economies, since it is well-established that systems denying access to health care are in the long run more costly to society. This is a perfect example of how creating a system that benefits members of traditionally disadvantaged groups creates more equitable healthcare for all. It should be an immediate priority for the new Congress and administration.
Copyright © 2021 National Register of Health Service Psychologists. All Rights Reserved.