Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity (2023) / Chapter Skim
Currently Skimming:
1 Statement of Task and Approach
1 Statement of Task and Approach
Pages 33-76
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THE URGENCY OF ADDRESSING HEALTH INEQUITIES Although COVID-19 laid bare the reality of inequity in the United States, the disproportionate burden of poor health and inadequate access to healthprotective social factors, such as economic stability, quality employment 1 The racial and ethnic categories discussed in this report should not be interpreted as being primarily biological or genetic. Race and ethnicity should be thought of in terms of social and cultural characteristics and ancestry and could be considered proxies that invoke racism (how race impacts how others perceive/treat different populations)
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: • Economic stability • Education access and quality • Health care access and quality • Neighborhood and built environment • Social and community context The committee used this categorization for its report. Chapters 3–7 each focuses on one of the SDOH and describes what each includes and how federal policies in those areas impact health outcomes.
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A key factor driving poor health compared to counterpart nations is the large racial, ethnic, and tribal health inequities and the federal policies and lack of policies driving these inequities. Eliminating inequities will improve the health of not only racial, ethnic, and tribal populations that are minoritized but also the entire population.
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These patterns of inequity transcend most health outcomes. The COVID-19 pandemic brought this crisis into the nation's consciousness as patterns of infection, hospitalization, and mortality took shape, mirroring the racial and ethnic health inequities seen everywhere else (CDC, 2022a; Hill and Artiga, 2022)
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. Income Inequality The economic and other costs individuals, families, and communities face due to racial and ethnic health inequities also perpetuate a cycle of accumulating disadvantage (see Chapter 3)
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. ROOT CAUSES OF HEALTH INEQUITIES IN THE UNITED STATES "The factors that make up the root causes of health inequity are diverse, complex, evolving, and interdependent in nature" (NASEM, 2017)
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contributing to racial and ethnic health inequities and provides solutions for advancing racial, ethnic, and tribal health equity at the federal level. The following four case examples illustrate some of the ways different populations are affected by health inequities via uneven access to the SDOH.
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The Experience of American Indian and Alaska Native People The lived experiences of AIAN people are also shaped by structural disadvantage and a history of extermination, removal, and assimilation in the interest of Euro-American expansion (Moss, 2019)
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. The Experience of Native Hawaiian and Pacific Islander People The lived experience of Native Hawaiian and Pacific Islander (NHPI)
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. Common factors that lead to health inequities in the Native Hawaiian population include poverty, low levels of high school completion, exposure to pollutants, poor physical environments, limited access to care, and discrimination (Liu and Alameda, 2011; Morey, 2014)
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There are groups within the Asian community who suffer greater health inequities than the group as a whole and have unique experiences, histories, cultures, languages, and needs. The Hmong people differ significantly from other Asian American populations in many social factors (such as income and education levels)
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. Given the limited and inaccurate data for specific populations, the committee relied on a variety of data to capture a fuller understanding of the mechanisms that result in health inequities for these different populations and made the intentional decision to center lived experiences and other forms of knowledge as data throughout this study.
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To advance health equity, the role of communities -- particularly those that suffer most from current health inequities -- needs to move further to the right on this spectrum (CDC, 2011; NAM, 2022; NASEM, 2017; South et al., 2015; Wallerstein et al., 2020)
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will provide an evidence-based, independent and objective analysis of federal policies that contribute to racial and ethnic health inequities, including those policies that impact the social determinants of health, as well as potential solutions. The review should focus on all racial and ethnic minority populations in the U.S.
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. While this type of policy does not address racial and ethnic health inequities directly, it does so indirectly.
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society. However, the committee focused on the evidence of how federal policies -- or lack thereof -- have contributed to health inequity and looked to federal policy levers for solutions, as this was its charge, with a focus on policies and programs in the executive and legislative branches of the federal government.
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In this report, as with many other published reports, the comparison group when looking at health inequities is typically non-Hispanic White people. Electing a culturally dominant group as the reference group can subtly imply the notion that dominant groups are the most "normal." However, this report does not do so because Whiteness should be the aspiration or it is centering Whiteness.
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, recognizing the role that the inequitable distribution of SDOH, such as economic stability, health care access and quality, education access and quality, social and community context, and neighborhood and built environment, play in perpetuating racial and ethnic health inequities. Moreover, the SDOH are shaped by structural determinants, including local, state, tribal, territorial, and federal policies and laws, and societallevel aspects of the historical and cultural context, such as structural racism.
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Although not represented in Figures 1-2 and 1-3, the committee also incorporated a life course lens in its analysis and throughout this report. Such approaches to examining health inequities incorporate both structural and developmental perspectives, considering how social and structural determinants of health, particularly exposures "during sensitive life stages" can "shift health trajectories" and "shape health within and across generations" (Jones et al., 2019)
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52 FEDERAL POLICY TO ADVANCE HEALTH EQUITY HISTORICAL + CULTURAL CONTEXT + RACISM TRIBAL POLICY STATE/TERRITORIAL POLICY LOCAL POLICY Economic Stability Education Access and Quality FEDERAL POLICY Health Care Access and Quality Neighborhood and Built Environment Social and Community Context Racial, Ethnic, and Tribal Health Equity FIGURE 1-3 Report conceptual framework illustrating the complex relationships between social determinants, structural determinants, and racial, ethnic, and tribal health equity.
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2. All federal policies have the potential to affect population health.
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Each of these sources of evidence should be valued and evaluated in building the knowledge base, which should be evaluated from a fundamental cause of disease approach,5 focusing on structures and systems versus individual- or community-level actions as the causes of health inequities. This approach requires reviewing other factors that impact health equity, including the intersections of systems of stratification across, but not limited to, race, ethnicity, gender, sexual orientation, class, and ability.
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The committee acknowledges that removing harm, reducing disparities, and/or improving health capacities are necessary first steps; reducing disparities is not the end goal. 6 "Political determinants of health involve the systematic process of structuring relation ships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities" (Dawes, 2020, p.
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Approach to the Report and Recommendations The task provided to the committee was extremely but necessarily broad -- review federal policies that contribute to racial, ethnic, and tribal inequities. The number of factors that contribute to health inequities are large and fall in many domains (see Figure 1-2 and Box 1-1)
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Based on its review, the committee was able to identify aspects of federal policy that cut across domains and contribute to health inequities or could advance health equity. These crosscutting themes formed the foundation of the report recommendations, with the key principles as a guide (see Box 1-5)
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. Per the guiding principles, the committee considered policies that leave populations that have been racially and ethnically minoritized behind, cause harm, undermine civil rights, racial justice, and equal opportunity, omit community voice and evidence, and/or do not consider health equity.
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is 13985,9 Advancing Racial Equity and Support for Underserved Communities Through the Federal Government (January 2021)
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. The EO also highlights the need for "engagement with members of underserved communities" and that the agencies "should consult with members of communities that have been historically underrepresented in the federal government and underserved by or subject to discrimination in federal policies and programs." Another major aspect of the EO was establishing the Equitable Data Working Group (see Chapter 2 for more information)
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, Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals20 Other Federal Government Reports, Initiatives, and Background One example of a federal initiative to advance health equity is Opportunity Zones. EO 13853, signed by President Trump, established the White House Opportunity and Revitalization Council to carry out the administration's 12 This order established regular and meaningful consultation and collaboration with tribal officials to develop federal policies that have tribal implications, strengthen the U.S.
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The vital conditions are the following: • Belonging and Civic Muscle • Thriving Natural World • Basic Needs for Health and Safety • Humane Housing • Meaningful Work and Wealth • Lifelong Learning • Reliable Transportation The vital conditions align with the Healthy People 2030 five SDOH categories that the committee used to guide its work (see Committee Approach section)
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Preventive Services Task Force, Advisory Committee on Immunization Practices– recommended vaccines, Health Resources and Services Administration (HRSA) –recommended preventive care and screening recommendations for children, and HRSA Women's Preventive Services Initiative–recommended services, including contraceptives (Child Welfare Information Gateway, n.d.)
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on a range of topics, including racial and ethnic health inequities; socioeconomic differences in health; housing, transportation, and health policy; federal Indian law and constitutional law; community infrastructure challenges and solutions; policy levers; and interagency collaboration. In addition, the committee held two public comment sessions to solicit feedback on key questions that broadly asked about the impacts, both positive and negative, of health policies and their effects on health equity and the lived experiences of racially and ethnically minoritized groups.
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The request sought input on federal policies that contribute to racial and ethnic health inequities and potential solutions. The committee also requested comments regarding lived experiences navigating federal programs and systems, including barriers and solutions, from community members and organizations.
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66 FEDERAL POLICY TO ADVANCE HEALTH EQUITY BOX 1-7 Continued o Reproductive health and equity o The need for mental health facilities and services, especially for communi ties that experience social and economic marginalization o Universal health care o Bias in medical innovation o Public fund for copays and fees for health care o Incorporation of homeopathic remedies o Mobile health care clinics o Development of a health and allied health workforce that reflects the racial and ethnic diversity of the patients they serve o Access to free clinical trials of promising therapies o Lack of trust in the health care profession o Women's health protections o Overexposure to fluoride o Funding for Black-led HIV service providers o Role of nurse practitioners for advancing health equity o Need for social workers to work in health care and community settings o Medication access o Systemic barriers to the use of naturopathic medicine o Access to care and workforce shortages in rural areas o Prevention and mitigation of tobacco use • Specific health conditions: o Long COVID-19 o Diabetes, prediabetes, and diet-related illnesses o Obesity o Rare neurological conditions o Mental health and substance use disorder crises • Economic stability: o Life insurance policy discrimination o Social security disability programs o Tax reform o Medicaid estate recovery and asset testing rules • Community and built environment: o Housing access and affordability o Transportation access and availability o Trichloroethane groundwater pollution o Environmental justice o Nutrition access • Specific populations: o Inequities for persons with disabilities due to ableism and inaccessibility of facilities and digital information o Sexual discrimination and intersection with race and ethnicity o Barriers for immigrants for access and participation in public programs o Aging and the intersection of race and ethnicity o Native American and Alaska Native/tribal: ■ Underfunding of Indian health services ■ Compliance issues with tribal treaties ■ Returning federal land and reforming the federal tribe recognition process
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CONCLUDING OBSERVATIONS Recent attention given to racial, ethnic, and tribal health inequities across sectors and all levels of government suggests this report is being released during a time of policy interest in the committee's findings,
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2020. Health inequities among Latinos/Hispanics: Documenta tion status as a determinant of health.
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2022. US health care can't afford health inequities.
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https://www.govinfo.gov/app/collection/ statute/2016 (accessed March 7, 2023)
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2023. The economic burden of racial, ethnic, and educational health inequities in the US.
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2022. No equity without data equity: Data reporting gaps for Native Hawaiians and Pacific Islanders as structural racism.
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2023. Profile: Native Hawaiians/Pacific Islanders.
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n.d. Native Hawaiians and Pacific Islanders in higher education: A call to action.
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2020. Incidence of ESKD among native Hawaiians and Pacific Islanders living in the 50 U.S.
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