Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity (2023) / Chapter Skim
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2 Connection Between Health Equity and History, Federal Policy, and Data
2 Connection Between Health Equity and History, Federal Policy, and Data
Pages 77-132
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GOVERNMENTAL STRUCTURES AND POWER This section provides a brief overview of federalism and available policy levers and the unique governing aspects for American Indian and Alaska Native (AIAN) people.
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EOs can advance and contribute to health equity. For example, EO 139851 Advancing Racial Equity and Support for Underserved Communities Through the Federal Government is focused on advancing equity.
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For example, it informed Supreme Court attitudes toward slavery as a state right. In Dred Scott v.
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. Federal civil rights law provides a set of minimum standards on which states can build by enacting further protections (Pepin and Weber, 2019)
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. ACA's Medicaid expansion was also challenged in court, and the Supreme Court found that although the federal government could withhold new funds for that expansion, it could not take away existing Medicaid funds (Cornell Law School, n.d.-a)
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. 10 The Code of Federal Regulations Title 25 contains the codified federal laws and regu lations that are in effect as of the date of the publication pertaining to American Indians (Native Americans)
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This is important to understand as policy makers contemplate the contribution of federal policies to health inequities. "Invasion is a structure not an event" (Wolfe, 1999, p.
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Historical trauma (trauma persisting from previous generations) coupled with some of the highest contemporaneous traumas for AIAN people have resulted in substantial health inequities (see Chapter 7)
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federal law and do not have self-governance rights. Some have engaged in a movement to have their status as Native people revived (though not all Native Hawaiians agree this is the best path -- some argue for complete independence from the United States, federal recognition and Indigenous status, or more control over Native Hawaiian assets, such as crown and ceded lands)
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Not all policies are designed to address health inequities -- a policy or program could be simply neutral. In addition, most policies do not intend to increase inequities; it is an unanticipated outcome.
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. Racism systematically excludes, Black, AIAN, Latino/a, and other targeted people from power, status, and other social, economic, and political resources and opportunities, which contributes to health inequities (Baah et al., 2019; Williams et al., 2019)
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. Theory and empirical research suggest that these historical and contemporary federal and state laws disadvantage people from minoritized groups shape racial and ethnic health inequities through various social, economic, physical, and psychological mechanisms into lowquality neighborhoods, schools, and jobs and other circumstances, including chronic and acute psychosocial stressors (Bailey et al., 2017;
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. STATE OF HEALTH INEQUITIES IN THE UNITED STATES Despite data gaps that prevent accurate and full documentation of health and well-being for many racially and ethnically minoritized populations, data that are available suggest persistent and sometimes growing health inequities.
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Racial, ethnic, and tribal health inequities take on many forms, such as higher rates of chronic disease and premature death. Despite progress to narrow the gaps in some racial, ethnic, and tribal health outcomes, there are still ongoing and persistent inequities tied to the social and structural determinants of health.
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. This heterogeneity applies to other population groups as well (e.g., the AIAN, Black, and Native Hawaiian and Pacific Islander [NHPI]
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examined years of potential life lost by race and ethnicity in Washington State and found that relative to non-Hispanic White people, non-Hispanic Black, AIAN, Asian or other Pacific Islander, multiracial, and Hispanic decedents had significantly higher rates. Disparities were reduced, but not eliminated, when controlling for sociodemographic factors, and controlling for place-based risk factors did not further lessen differences.
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FIGURE 2-2 Pregnancy-related mortality ratio (per 100,000 births) by race and ethnicity 2017–2019.
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. Racially and ethnically minoritized people are more likely to experience certain birth risks and adverse birth outcomes compared to White people.
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NOTES: AIAN = American Indian or Alaska Native. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic.
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. A study found that African American children had the highest prevalence of risk factors, whereas Asian children had the lowest (the sample size for Pacific Islander children was too small, so their data were not included in this study)
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. Several studies and papers find that these inequities are not fully explained by socioeconomic status, and several studies point to structural racism as a contributor (Churchwell et al., 2020; Javed et al., 2022; Mazimba and Peterson, 2021)
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. Black, Hispanic, and AIAN people make up disproportionate shares of SSI enrollees compared to White people (Musumeci and Orgera, 2021)
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. Furthermore, much of the discussion surrounding racial and ethnic health inequities mirrors that on the effect of sex/gender on health outcomes, including the importance of research that distinguishes between females and women from males and men, the historical role and power dynamics between men and women, and the role of policy across the same multiple domains that impact health outcomes.
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Given the co-occurrence and mutual reinforcement of these three factors, racially and ethnically minoritized LGBTQ+ people often experience greater health inequities than their heterosexual and White counterparts (Hatzenbuehler et al., 2013; IOM, 2011; NASEM, 2020b) , which plays out in sexual and reproductive health.
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. Passing, implementing, and enforcing laws and policies that prevent discrimination and advance equity are necessary, but LGBTQ+ racially and ethnically minoritized communities have many strengths that can be leveraged to advance health equity.
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. Rurality is a strong predictor of poor health outcomes and health inequities (James et al., 2017)
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citizenship status, immigration status also plays a powerful role in limiting access to federal programs that can address key SDOH and increasing risks to immigration enforcement actions that may more directly impact health status (NASEM, 2015, 2018b)
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Not all federal agencies collect and report high-quality and accurate data on these minimum racial, ethnic, and tribal population categories, which is a significant barrier to achieving data equity. This lack of data also contributes to health inequities, as policy decisions are not fully informed by the data.
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Update terminology deemed to be inaccurate or archaic, including removing "Negro" from the Black of African American definition; removing "Far East" from the Asian definition -- replacing with "East Asian"; removing the phrase "who maintain tribal affiliation or com munity attachment" in the AIAN definition; and removing "Other" in the Native Hawaiian and Other Pacific Islander definition. The committee provides input on these proposed changes in Chapter 8.
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Accurate data are necessary to inform knowledge and action on racial and ethnic health inequities and their social determinants. The first major barrier is that data on OMB-defined historically underrepresented groups are not disaggregated (Panapasa et al., 2011)
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. In addition, adequate granular/detailed data are not collected on the minimum OMB categories (such as Asian, Native Hawaiian, and Pacific Islander)
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Moreover, health surveys and other federal data collection efforts tend to include only some of the measures needed for an intersectional analysis of racial and ethnic health inequities. For example, although the National Health Interview Survey, the nation's leading source of population health data from CDC, does collect information on sexual orientation identity, it does not include other measures of sexual orientation (e.g., sexual behavior)
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Collecting tribal affiliation is more appropriate, as it does not denote tribal citizenship and is cognizant of the historical context of disenrollment, descendants, and federal initiatives that separated AIAN people from their communities; however, it must be respectful of AIAN data sovereignty (Urban Indian Health Institute, 2020)
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In particular, national health surveys and other federal research efforts (e.g., clinical trials -- see Chapter 5) fail to include measures of historical and contemporary structural, institutional, community, and interpersonal racism and xenophobia, which shape racial and ethnic health inequities (Brown and Homan, 2023)
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. This undermines the ability of policy makers, researchers, and program officials to identify how historical and contemporary structural and social inequities shape racial and ethnic health inequities and, in turn, thwart action on these root causes at the federal, state, territorial, tribal, and local levels (Rodríguez, 2021)
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. To benefit Black, AIAN, NHPI, and other minoritized communities and advance health equity, race and ethnicity data collection efforts have to explicitly inform the equitable allocation of health-promoting resources to underresourced communities through laws, policies, programs, and community efforts.
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In addition, the data can be used for multiple purposes: provider payment (see Chapter 5 discussion on value-based payment) , a primary source for clinical trials and health services research, quality improvement initiatives, and incentives to improve individual behaviors.
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,28 the national organization that promulgates recommendations on clinical preventive services, has launched an initiative to address structural racism that can serve as a model for other regulatory agencies. Given the intrinsic deficiencies in representation of racial and ethnic minorities in clinical trials (see Chapter 5)
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This includes measures to identify and track strategies to demonstrate progress in addressing health inequities regarding clinical preventive services.
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In addition, the Equitable Data Working Group (established under EO 13985) studies and provides recommendations to the Assistant to the President for Domestic Policy to identify inadequacies "in existing Federal data collection programs, policies, and infrastructure across agencies, and strategies for addressing any deficiencies identified" and "support agencies in implementing actions, consistent with applicable law and privacy interests, that expand and refine the data available to the federal government to measure equity and capture the diversity of the American people" (The White House, 2021)
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. Given a delay of more than 2 years in the release of detailed-origin population counts from the 2020 census, community organizations have pushed for timely dissemination as an important aspect of data equity (AAPI Data and National Council of Asian Pacific Americans, 2022)
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However, the chapter also shows the rich information that has been collected that points to the mechanisms for how the social and structural determinants of health have contributed to health inequities and are therefore key areas to focus federal action to advance health equity. Chapters 3–7 take deeper dives into SDOH and how they can positively and negatively impact health equity via federal policies: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and the social and community context.
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2021. Developing a database of structural racism–related state laws for health equity research and practice in the United States.
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2020. Cardiovascular health in American Indians and Alaska Natives: A scientific statement from the American Heart Association.
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2020. Call to action: Structural racism as a fundamental driver of health disparities: A presidential advisory from the American Heart Association.
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2019. Trends in clinical research including Asian American, Native Hawaiian, and Pacific Islander participants funded by the U.S.
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2011. Structural racism and health inequities.
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2014. Systematic review of health disparities for cardiovas cular diseases and associated factors among American Indian and Alaska Native popula tions.
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https://www. governing.com/now/how-american-style-federalism-is-dangerous-to-our-health (accessed March 11, 2023)
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2014. Structural racism and myocardial infarction in the United States.
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2022. Trends in collection of disaggregated Asian American, Native Hawaiian, and Pacific Islander data: Opportunities in federal health surveys.
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2011. Efficacy of federal data: Revised Office of Management and Budget standard for Native Hawaiian and Other Pacific Islanders examined.
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2022. Measuring structural racism and its association with racial disparities in firearm homicide.
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2015. Joint effects of structural racism and income inequality on small-for-gestational-age birth.
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2017. The Native Hawaiian and Pacific Islander national health inter view survey: Data collection in small populations.
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