The Commonwealth Fund outlines framework to assess racial equity in health policy

The Racial Equity and Policy (REAP) framework serves as a tool for researchers, policymakers, and others to identify and examine racial equity implications of health policies.

In an issue brief last week, The Commonwealth Fund provided a framework for systemically assessing racial equity in health policy. As the COVID-19 pandemic continues to disproportionately impact communities of color and bring racial inequities to light, it is critical to examine the role health policies play in racial equity, explained author Jamila Michener, Ph.D., associate professor, Department of Government; codirector, Cornell Center for Health Equity, Cornell University.

“Public policy is among the most enduring and powerful structures shaping racial inequity in health,” she wrote. “Both historically and contemporarily, public policies have been instruments through which government has created, maintained, and exacerbated racial disparities through domains such as housing, healthcare, and welfare. Of course, policy has also been employed to reduce and redress racial disparities. Altogether, the trajectory of U.S. public policy vis-à-vis racism has not been uniform, progressive, or linear.”

The REAP framework aims to provide researchers, policymakers, and others a tool to examine racial equity in health policy, drawing on fundamental elements of the policy process to identify areas of focus within the policy environment that can influence the design, implementation, evaluation, and feedback of policy choices.

Within the REAP framework, these areas of focus include:

• The institutions that create the rules and constraints of policy choices
• The actors, such as state lawmakers, interest groups, and state and local grassroot organizations, that can support or oppose a policy
• The ideas which frame the discourse, logic, and justification for policy
• Critical events that bring policy issues to the forefront
• The networks of policy actors as agents of change
• Political contexts that fundamentally influence efforts to enact, implement, and advance equitable health policy

To further analyze implications of racial equity in policy, the REAP framework analyzes each area of focus under three key considerations that are indicative of racial inequities in policy:

1. Disproportionality: the way policies differentially allocate benefits and burdens to racial groups
2. Decentralization: the level of government designing or implementing a policy benefit or burden, often resulting in barriers to racial equity
3. Voice: the lack of incorporation of equity and voice of communities of color in the shaping of the policy environment

While disproportionality, decentralization, and lack of voice significantly contribute to racial inequities in policy, they are not definitive markers of “racist” policy, according to Michener. “We cannot mechanically characterize a policy as racist simply because it has these characteristics. Instead, these factors indicate likely channels through which racism can operate. The REAP framework alerts us to their importance and points us toward key considerations to guide assessments of public policy and racial inequity.”