Oct. 16, 2020: National Advocacy Update

Recent publications detail how the clinical algorithms used to guide treatments may mistakenly substitute and equate racial data for genetic and other information and their use may lead to less-than-optimal care.

"Race is not a reliable proxy for genetic difference" is the phrase used by researchers in "Hidden in Plain Sight—Reconsidering the Use of Race Correction in Clinical Algorithms," an article published in the New England Journal of Medicine (NEJM).

The article prompted Rep. Richard E. Neal, D-Mass., chair of the House Ways and Means Committee, to ask the AMA and other medical societies what they were doing to address health inequities, in general, and to end misuse of race and ethnicity in clinical algorithms in particular.

The AMA responded with a nine-page letter that outlines the multitude of ongoing or previously completed AMA work to address health equity issues, and includes recommendations for federal research that reviews clinical algorithms.

"The AMA has long recognized that racial and ethnic health inequities are an unjust and major public health reality in the United States," AMA Executive Vice President and CEO James L. Madara, MD, wrote in the response.

"Understanding that race is a social and political construct and not a risk factor for disease and death, the AMA has publicly acknowledged that racism impacts public health and is a barrier to effective medical diagnosis and treatment."

The NEJM article looked at how the use of race and ethnicity data in diagnostic algorithms and practice guidelines to adjust outputs altered risk assessment and clinical decision-making in cardiology, nephrology, obstetrics and urology.

"Many of these race-adjusted algorithms guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities," the article says.

"The racial differences found in large data sets most likely often reflect effects of racism—that is, the experience of being Black in America rather than being Black itself—such as toxic stress and its physiological consequences," the article says. "In such cases, race adjustment would do nothing to address the cause of the disparity."

Dr. Madara cited the NEJM article's point—that "race is a poor proxy for genetics"—in his letter to Neal.

The AMA "recognizes that some clinicians and researchers may unknowingly or unintentionally conflate 'race' with 'racism,'" his letter states. "In other words, the AMA is mindful that the myriad effects of racism, rather than race, are responsible for differences in health status and outcomes often attributed to race." Also mentioned, and a focus of considerable AMA attention, are the effects of social determinants of health on a person's risk of poor outcomes from a medical procedure.

Read the full story.

The AMA joined with the American Hospital Association (AHA) and the American Nurses Assocation in calling on the Administration to rescind Executive Order (EO) 13950, Combating Race and Sex Stereotyping, which would effectively reverse decades of progress in combating racial inequality. This EO would stifle attempts to have open, honest discussions of diversity, inclusion and equality in the workplace. To effectively further the goals of health equity, these are factors that must be fully understood and addressed.

As physicians continue to battle the COVID-19 pandemic, they bear witness to the disproportionate effects of this public health crisis on black and brown people. Research conducted at the National Institutes of Health and academic centers to comprehend the effects of structural racism and implicit bias on health care and health outcomes is needed now more than ever. However, this research is threatened by EO 13950's unprecedented attack on scientific freedom. Promoting diversity and inclusion in the federal government would serve to strengthen, not weaken, collaboration among federal workers and contractors who conduct lifesaving research, care for the nation's veterans and administer numerous programs and services to enhance the nation's health and welfare.

On Sept. 22, the AMA joined several other health care organizations in urging the Administration to ensure there would not be a lapse in the provision of medical services for detained migrant children and families seeking to enter the U.S.

In the letter, the AMA expressed deep concern about "a potential lapse in medical services at CBP facilities during the COVID-19 pandemic." The letter went on to state that "[e]nsuring the health and well-being of immigrants protects the health and well-being of us all. This virus does not discriminate, and our response should not either. We must ensure that everyone has access to the health care they need."

As a result of AMA's advocacy efforts, the Administration awarded a medical services contract to Loyal Source Government Services LLC (the current contractee) in the amount of $67.9 million for "medical evaluation/screening" through Feb. 24, 2021, with the possibility of extending this contract to Sept. 29, 2022.

The U.S. Immigration and Customs Enforcement (ICE) has proposed a rule which would eliminate "duration of status" as an authorized period of stay for certain nonimmigrant visas (F, I and J), many of which are used by International Medical Graduates (IMG) to train and practice medicine within the United States.

The AMA has been anticipating the release of this proposed rule since the beginning of 2020. As a result, on March 27, the AMA joined the Educational Commission for Foreign Medical Graduates (ECFMG) and several other organizations, in voicing concern that the prospective change, "if implemented, would significantly and negatively impact patient care at hundreds of teaching hospitals across the United States provided by nearly 12,000 foreign national physicians participating in the U.S. Department of State's (DoS') Exchange Visitor Program on J-1 visas."

Since the formal release of the proposed rule on Sept. 25, the AMA has again partnered with other prominent health care organizations to voice collective concern. The AMA is also advocating on this important issue on Capitol Hill and is drafting formal comments in response to the proposal.

The second issue of this vital webinar series, "COVID-19 vaccine development: What physicians need to know," is now available on the AMA's website. This series addresses the science, evidence and process of vaccine development, regulatory review and what physicians need to know. Hosted by AMA physician leaders, each installment aims to gain fact-based insights from the nation's highest-ranking subject matter experts working to protect the health of the public.

This week's episode, hosted by Susan R. Bailey, MD, AMA President, provides a comprehensive overview of the CDC's role in vaccine review and immunization programs. View a recording and read a transcript here. Nancy Messonnier, MD, Director NCISD at the CDC, and Amanda Cohn, MD, Acting Chief Medical Officer, NCIRD and Executive Secretary for the Advisory Committee on Immunization Practices (ACIP), addressed the prioritization and allocation of vaccines, distribution of vaccines and data systems to monitor distribution and uptake, and the role physicians will play in vaccine distribution and vaccine hesitancy.

• Oct. 16, 2020: Advocacy spotlight on Competition declined in majority of health insurance markets where it is most scarce 
• Oct. 16, 2020: State Advocacy Update