Recent major events, including the COVID-19 pandemic (with its disproportionate effect on communities of color) and high-profile incidents of racial violence, have drawn renewed attention to persistent racism within the United States and the need for public policy reform. However, there is limited consensus on how to actually assess policy for its impact on racial equity. Below, we highlight the Racial Equity and Policy (REAP) framework—one assessment tool recently proposed by Dr. Jamila Michener at the Cornell Center for Health Equity—and put it to use to examine Pennsylvania policy.
Rather than examining individual policies as discrete outcomes, REAP calls for attention to policy processes. Critical decisions are made at every stage of the policymaking process through design, implementation, evaluation and feedback into larger political processes. By focusing on policy processes, we are encouraged to examine the broader systems that contribute to racist policies, and to reflect on the many pathways through which they can be realized.
Drawing on previous models of policymaking, REAP identifies six features of a policy environment that commonly impact policy choices. These include:
- institutions, such as courts
- actors, ranging from lawmakers to advocates to individual constituents
- networks, or patterns of relationships among actors
- ideas, such as public perception about different populations
- critical events that draw attention to policy issues
- economic, social and political context
REAP then focuses on three themes that directly relate to racial equity within a given policy environment: decentralization, disproportionality and voice. Disproportionality refers to the way policies differentially allocate benefits and burdens to racial groups. Decentralization refers to the level of government through which a given policy benefit or burden is designed or implemented, while voice reflects the ability of communities of color to shape the policy environment. These factors can indicate likely channels through which racism can operate.
Finally, REAP condenses these themes into a practical set of questions for those analyzing or shaping policy. While these questions are intended as a baseline, we believe they can be a valuable starting point to assess racism in public policy and, ultimately, to achieve more equitable policymaking.
Applying the REAP Framework: Care for Substance-Exposed Newborns in Pennsylvania
Substance use has increased among pregnant and postpartum people in Pennsylvania, highlighting the importance of providing wrap-around care for these families, especially given the risk of neonatal abstinence syndrome (NAS). Here, we illustrate how the REAP framework could be applied to assess federal, state and local policy surrounding care for substance-exposed newborns in Pennsylvania. We center our discussion around REAP’s key themes of decentralization, disproportionality and voice.
Policies related to substance use among pregnant and parenting people are highly decentralized. At the federal level, the Child Abuse Prevention and Treatment Act (CAPTA) currently requires that Child Protective Services (CPS) agencies receive a notification anytime an infant is determined to be “affected by” substance use. When infants are deemed to be affected by substance use, families must be offered “plans of safe care” to provide wrap-around services for these babies and their caregivers.
While these policies stem from the federal government, in practice, much of the decision-making falls to lower levels of government. States are left to define the phrase “infants born and identified as being affected by substance abuse or withdrawal symptoms…,” which opens the door for significant differences in interpretation and implementation.
In Pennsylvania, the state legislature passed Act 54 to comply with CAPTA requirements, and the state Departments of Human Services, Health, and Drug and Alcohol Programs released their own guidance document on plans of safe care. However, implementation is still left to individual counties. In practice, individual providers decide whether to report suspected child maltreatment (as opposed to merely the required notification), and individual CPS workers decide whether or not to open an investigation.
In Pennsylvania, prenatal substance use and babies with NAS are more common among White, non-Hispanic people. However, infants born with NAS to mothers who are Hispanic or Black are more likely to have poor outcomes, including low birthweight, prematurity and requiring care in a neonatal intensive care unit (NICU). A lower percentage of Hispanic and Black mothers receive prenatal care, and are less likely to test positive for medications associated with treatment for substance use disorder (such as medication-assisted treatment, or MAT).
Prior research has shown that Black families are more likely to be reported to CPS for prenatal drug or alcohol use, and more likely to have children removed from the home than White families and those with higher incomes. While plans of safe care have the potential to address these disparities through improved care delivery, requiring notifications to the child welfare system risks worsening disparities in CPS reporting. In addition, birth parents who use substances may feel increased mistrust, stigma and lack of autonomy that are already barriers to seeking necessary care. Pennsylvania, at least, is one of the few states that has specifically clarified that a notification alone is distinct from a report of child maltreatment.
REAP encourages us to question the ideas that underlie policies. Pregnant people who use substances have long been stigmatized as “unfit parents,” and punitive policies grounded in these assumptions may dissuade people from receiving treatment and lead to poorer health outcomes for children. Many families may fear any interaction with CPS, and Black families in particular have suffered disproportionately from many child welfare policies. It is thus all the more vital that those with lived experience, and representatives from marginalized communities of color, be invited to share their thoughts and concerns in a safe, nonjudgmental way.
In Pennsylvania, policymakers should probe the state institutions and actors involved in decisions on substance use policies (e.g., Pennsylvania state legislature, governor, agencies including Departments of Human Services, Health, and Drug and Alcohol Programs) to understand who was and is being engaged during decision-making processes. Locally, in order to center the voices of those most impacted, the City of Philadelphia convenes a multidisciplinary Plans of Safe Care Steering Committee that includes advocates with lived experience, in addition to city agencies and community-based organizations. Similar processes should be conducted at the county and health system levels.
Next steps and recommendations
This application of REAP demonstrates how the framework can be used not only to identify problems, but also to drive helpful solutions. For instance, while high levels of decentralization can cause confusion and variation, they can also open the door to many policy interventions. Stakeholders dedicated to helping substance-exposed newborns can readily target a variety of decision-makers (from states and counties to health systems and clinicians) with guidance on how to best implement plans of safe care. Evaluating programs and policies across different jurisdictions may also help determine best practices.
Considering disproportionality can help address disparities (such as by ensuring access to treatment) while also being mindful of potential unintended consequences (such as ensuring that minoritized patients are not disproportionately reported to child welfare agencies). Prioritizing voice in all stages of a policy process can allow communities of color to push back on stigmatizing and erroneous ideas to advance more equitable, effective policies.
By explicitly highlighting actions and decisions being made—processes—rather than intent or policy outputs, and by centering the margins, we can become more cognizant of processes that inadvertently or intentionally exacerbate racial and other inequities.
Caroline La Rochelle, MPH, was a former policy and strategy senior associate at PolicyLab.