Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity (2023) / Chapter Skim
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8 Roadmap to Racial, Ethnic, and Tribal Health Equity
8 Roadmap to Racial, Ethnic, and Tribal Health Equity
Pages 407-448
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The committee provided examples in each chapter that highlight aspects of policies, or lack of a policy in a given area, that contribute to health inequities. Many recurring themes stood out in the committee's review of the available evidence; these themes are highlighted and discussed in Chapters 2–7 and include the following: • A lack of prioritization of racial, ethnic, and tribal health equity in policy agenda setting; • A lack of, inconsistent, and incorrect data, which undermines policy makers' and researchers' ability to fully understand the state of health inequities; • Access and eligibility restrictions in federal policy that stifle the ability to further health equity or achieve equitable outcomes; 407
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13985 Advancing Racial Equity and Support for Underserved Communities Through the Federal Government1 (see Chapter 1) , underscores many of these crosscutting needs.
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. To be most effective, federal policies, programs, and services need to focus on the upstream, population-level preventive issues that might impact root causes, using a "whole-of-government," "whole person," and "whole community" approach that increases intentional planning and coordination among departments and agencies and across programs and services to better meet both the short- and long-term whole person/family/community needs in more comprehensive, integrated, and aligned ways.
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are needed to facilitate community participation, especially from underserved communities; 3. offering multiple, accessible avenues (including virtual)
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National Academies reports have made relevant recommendations to improve federal policies to advance racial, ethnic, and tribal health equity that have not yet been implemented and should also be considered (see, for example, Boxes 3-1, 4-2, 5-9, 6-2, 7-5)
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Therefore, achieving racial, ethnic, and tribal health equity requires centering equity in federal policy creation, decision making, implementation, and regulation (including accountability standards) and a sustained effort to ensure equity in agency processes and outcomes.
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Given the central 2 See https://www.whitehouse.gov/wp-content/uploads/2021/10/National-Strategy-on-Gender -Equity-and-Equality.pdf (accessed March 9, 2023) for more information.
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Strong partnerships with OMB in its oversight of agency performance in relationship to racial, ethnic, and tribal equity and with the Domestic Policy Council (DPC) in the crafting and implementation of policies can further solidify this role.
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After final consensus on the plan from agencies involved in its drafting, the committee will be established and provide guidance for implementing recommendations, agency commitment, actionable steps, and milestones. Executive steering committee "decisive leadership is required to compel coordination, within and across federal departments and subordinate agencies, in service of policies and programs that strengthen what works well and re-engineer what no longer serves" (ELTRR Interagency Workgroup, 2022, p.
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. Recommendation 3: The federal government should assess if federal policies address or exacerbate health inequities by implementing an equity audit and developing an equity scorecard.
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The equity audit of existing federal policies in Recommendation 3b would build on the work currently underway by federal agencies under EO 13985, updated by EO 14091,3 that directs each federal agency to develop health equity teams to implement its equity initiatives. Given the numerous federal policies and programs, a mechanism will need to be developed to identify which should be prioritized and reviewed for Recommendations 3a and 3b, but it could include factors such as programs with known barriers to enrollment or access or that have shown inequitable outcomes in the past.
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Although there is no existing or ready to use method for determining or rating equity in this manner, sources are available to inform the development of the equity audit and scorecard (for example, see Ashley et al., 2022; Martin and Lewis, 2019; MITRE, n.d.; OMB, 2021; Urban Institute, n.d.) -- for example, OMB identified several tools in its 2021 review (OMB, 2021)
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. Improved data collection would allow an equity scorecard to better assess the impact of legislative proposals (see Recommendations 5–9)
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Structural changes are needed to move from mitigating to eliminating health inequities. Proposals for an equity scorecard or similar have been introduced by legislators, and CBO occasionally does assess the equity impact of legislative proposals (Ashley et al., 2022)
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. • Develop and implement an equity audit and an equity scorecard to assess federal policies and identify needed changes (Recommenda tion 3)
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. Engaging community voice in federal policies that shape health care (see Chapter 5)
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. A promising strategy to improve policies that do not promote health equity is to elevate and empower community voice and expertise to influence outcomes through the following design principles: 1.
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Below, the committee provides four recommendations to improve federal data sources to advance health equity. These are not the only recommendations on this topic.
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A federal and federal tribal-consulted data system is needed that is intentionally committed to support data equity, particularly for the smallest minimum OMB categories. The statements in this paragraph are also true for detailed-origin categories within OMB 7 OMB requires five minimum reporting categories: American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Black or African American, and White, and an ethnicity category of Hispanic or Latino (OMB, 1997)
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should require the Census Bureau to facilitate and support the design of sampling frames, methods, measurement, collection, and dissemination of equitable data resources on minimum OMB categories -- including for American Indian or Alaska Native, Asian, Black or African Ameri can, Hispanic or Latino/a, and Native Hawaiian or Pacific Islander populations -- across federal statistical agencies. The highest priority should be given to the smallest OMB categories -- American Indian or Alaska Native and Native Hawaiian or Pacific Islander.
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, including populations who self-identify as American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino/a, and Native Hawaiian or Pacific Islander. Implementing this recommendation will increase racial, ethnic, and tribal health equity through the uniform use of detailed-origin and tribal affiliation data to be collected, analyzed, and disseminated for all groups.
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• Expanding sampling frames to generate accurate statistical in formation on detailed-origin groups (such as Chinese, Haitian, Hmong, Chamorro, Native Hawaiian, Nigerian, Samoan, Tongan, and Vietnamese people) where prior evidence -- such as findings on health inequities by race and detailed origin from scientific publications, and on housing and socioeconomic inequities from federal data sources, such as the ACS -- justify producing statisti cally reliable estimates of the population at varying levels of ge ography.
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For example, Chapter 2 points out that national health surveys and other federal administrative and surveillance data sources will have greater potential for informing the development of interventions that address the root causes of racial, ethnic, and tribal health inequities in their proper social, economic, and historical context if such measures are collected. Recommendation 7: The Centers for Disease Control and Preven tion should coordinate the creation and facilitate the use of common measures on multilevel social determinants of racial and ethnic health inequities, including scientific measures of racism and other forms of discrimination, for use in analyses of national health surveys and by 9 Those with community attachment are AIAN people who are not enrolled members of a federally recognized tribe.
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There has been an increasing level of understanding of and attention to the SDOH within public insurance and healthcare programs, including Medicare, Medicaid, the Children's Health Insurance Program, veteran's healthcare, and federally qualified health centers. Measuring and addressing the SDOH in healthcare is important (NASEM, 2019)
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These data will more accurately identify the specific needs of underserved populations and improve overall equity in health and socioeconomic outcomes by identifying where policy change or interventions are needed to inform government investments to advance health equity. In the immediate term, increased funding is especially needed for the following: • The Census Bureau, the Centers for Disease Control and Pre vention, and the National Center for Health Statistics to collect relevant, high-quality, accurate, nationally representative data to monitor the health and nutritional status of the total AIAN and NHPI populations and provide comparable statistics to larger
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to allow for innovation to improve response rates and modernization. However, other funding will also be needed to improve data systems to advance health equity.
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To make this work more enduring, and benefit from the guidance of scientific and community experts, the federal government should make interagency coordination on data equity a permanent feature across statistical agencies. By situating the Office of Data Equity under OMB, the federal government will be able to ensure cross-agency coordination and collaboration on data improvements that advance health equity in all federal agencies and policies.
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. Recommendation 10: Congress and executive agencies should leverage the full extent of federal authority to ensure equitable implementation of federal policies and access to federal programs.
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For example, the Fair Housing Act requires that grantees take steps to affirmatively further fair housing. Equality directives, a civil rights regulation, are used in regulatory frameworks for federal transit funding and function "by placing positive duties on state actors to promote equality and inclusion" (Amri, 2017)
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Implementing this recommendation could also reduce participation churn in federal programs administered by states; in social benefits programs, such as SNAP and Medicaid, this is when otherwise eligible participants fail to recertify and are removed from the program, but subsequently reapply as a new case within a short period, such as in a few months or a year. Churn drives up administrative costs, because new cases are more expensive to process than recertifications, and reduces program effectiveness when families lose benefits due to administrative burdens.
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The Elderly Simplified Application Project is a federal demonstration project that allows streamlined administrative policies for elderly SNAP participants and has been shown to increase participation. Mandating this program or allow ing it without a waiver could advance health equity.
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. Advance American Indian and Alaska Native Health Equity Although the committee was expansive in its attempt to incorporate all racial, ethnic, and tribal communities impacted by federal policies, it paid special attention to AIAN communities who are often overlooked in large national reports.
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However, in the realm of achieving AIAN health equity, further adjustments are necessary to close the inequity chasm. Another appointment is necessary to advance health equity -- the elevation of the Director of IHS to an Assistant Secretary of HHS.
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In 1946, a legislative reorganization act abolished both the House and Senate Committees on Indian Affairs; in 1977, the Senate reestablished its committee.16 It has jurisdiction to study the unique problems of AIAN and Native Hawaiian peoples and propose legislation to alleviate them. These issues include Indian education, economic development, land management, trust responsibilities, health care, and claims against the United States.
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Although these actions will not address all barriers to health equity for the AIAN population, together, they will give more voice and prominence to AIAN people, which will help advance health equity for a population that is inadequately resourced and ignored. Other government agencies support AIAN health and address elements of the SDOH.
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. CALL TO ACTION This report points to both the positive and negative impacts federal policy has had on racial, ethnic, and tribal health equity.
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and their impacts on racial, ethnic, and tribal health inequities, to concerted action to expedite the elimination of inequities. It will also improve the circumstances in which people, families, and communities live, play, work, pray, and age so that all people living in the United States have the opportunity to meet their full health potential.
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https://www.huffpost.com/entry/biden-administration-deb-haaland interior-department-land-costewardship-tribes_n_63b86e01e4b0d6f0b9face1a (accessed March 11, 2023)
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2019. Survey ing strategies for hard-to-survey populations: Lessons from the Native Hawaiian and Pacific Islander national health interview survey.
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https://www.nihb.org/legislative/ advance_appropriations.php (accessed March 11, 2023)
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2017. Health care access and uti lization among Native Hawaiian and Pacific Islander persons in the United States, 2014.
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