April 3, 2023
In April 2023, Eric Patashnik edited the volume Entrenchment and Health Equity as well as authoring the introduction and a wrap-up essay summarizing the volume’s lessons for researchers, advocates, and policymakers. The articles in the volume were originally presented at a virtual conference held by the Watson Institute with the financial support of the Robert Wood Johnson Foundation.
This volume focuses on ways that law and politics can “entrench” power, with significant consequences for health equity and other social outcomes. Most of the time, actors who participate in the policy-making process take existing rules, institutions, and norms as given. They pursue incremental goals, knowing that victories and defeats are usually temporary and that the battle will have to be joined again tomorrow. At other times, however, actors seek to alter basic features of the political and social world itself. As Paul Starr explains in his important book Entrenchment: Wealth, Power, and the Constitution of Democratic Societies: “Entrenchment, like the closely related terms ‘lock-in’ and ‘consolidation’ can refer to any process whereby an institution, a technology, a group, or a cultural form—any kind of social formation—becomes resistant to pressures for change.”
Though entrenchment is found in many policy domains, it is particularly pervasive in the field of health. As is well known, the United States spends dramatically more on health care as a share of its economy than other wealthy nations, yet it produces worse outcomes than many of its international peers. The inefficiencies and inequities in American health care persist not because most policy makers believe the current system is ideal, but rather because there are high barriers to change. Venturing further afield, entrenchment can affect upstream determinants of health such as housing and education. Redlining in the postwar years, for example, made it difficult for Black families to purchase homes in many affluent areas, constraining their ability to accumulate wealth and fencing them out of high-quality public school systems. Once the doors of opportunity begin to close on marginalized populations, it becomes harder and harder to open them. Even major investments in the downstream determinants of health—such as the Affordable Care Act's investment in insurance coverage—may be insufficient to make up for entrenched patterns of health inequities.
The articles in this volume examine laws, policies, and norms that are entrenched (or may become entrenched), with an eye to the implications for health equity. Contributors include Paul Starr (Princeton) on strategic options for overcoming entrenchment; Jamila Michener (Cornell) on state preemption of local housing policy; Jessica Tounstine (UC Merced) and Sidra Goldman-Mellor (UC Merced) on racial disparities in Covid-19 outcomes; Amy Kapczynski (Yale Law School) on the political economy of market power in pharmaceuticals; Jing Liu (East China University of Political Science and Law) and David Hyman (Georgetown Law School) on licensure in allied health professions; and Carolyn Hughes Tuohy (University of Toronto) on institutional entrenchment in the health care state.