Achieving Health Equity: The Role of Law and Policy offers a groundbreaking exploration of how legal and policy frameworks shape health outcomes for marginalized populations, with a particular focus on racial minorities in the United States. This comprehensive guide dissects the complex interplay of factors determining health: 20% healthcare, 30% health behaviors, 40% social and economic factors, and 10% physical environment.
Amid the backdrop of the COVID-19 pandemic and a national reckoning on racism, this timely work provides an urgent call to action and a practical roadmap for transformative change. It examines how laws and policies across sectors intersect to perpetuate or dismantle health inequities, offering concrete strategies for reform.
Key features include: - An ecosystem approach exploring four critical domains: healthcare access and quality, health behaviors, social and economic factors, and physical environment - Analysis of emerging issues such as addressing the impact of climate change on health disparities, strategies for mitigating algorithmic bias in healthcare AI, and promoting equity in organ transplantation and clinical trials - Examination of cross-cutting themes like community engagement, civil rights protections, and data disaggregation to guide targeted interventions - Case studies and policy tools for dismantling structural drivers of health inequity
Written in accessible language without sacrificing depth, this book illuminates complex concepts through relatable examples. It serves as an invaluable resource for a diverse audience including health system administrators implementing diversity, equity, and inclusion initiatives, public health officials and policymakers, legal professionals and advocates, researchers and students in health-related fields, community organizers and racial justice activists.
Achieving Health Equity provides a comprehensive blueprint for leveraging law and policy to build a more just, equitable, and healthy future for all.
Table of Contents
Foreword xv
Acknowledgment xvii
1 Empowering Marginalized Communities: Legal and Policy Levers for Health Equity 1
1.1 Navigating Law, Policy, and Health Inequities 1
1.2 The Purpose and Importance of Examining Health Equity Through Law and Policy 2
1.3 Key Concepts and Definitions 3
1.4 An Ecosystem Approach to Health Equity Law and Policy 4
1.5 An Urgent Imperative 5
1.6 Conclusion: A Roadmap for Equitable Policy Change 5
References 6
Part I Health Care: Examining Access and Quality 9
2 Narrowing Health Access Disparities: The Affordable Care Act and Medicaid Expansion 11
2.1 Health Disparities and Insurance Coverage in America: A Century of Change 12
2.2 The ACA’s Mechanics and Effectiveness 13
2.2.1 How Did the ACA Increase Health Insurance Coverage? 13
2.2.2 The ACA’s Effectiveness 14
2.3 Ramifications of an ACA Repeal 14
2.4 Conclusion: The ACA’s Impact on Health Equity Amid Ongoing Challenges 15
References 17
3 Tackling Insulin Affordability: Addressing Systemic Failures and Policy Solutions 19
3.1 Insulin Affordability: Progress, Disparities, and the Need for Systemic Change 20
3.2 State Initiatives on Insulin Affordability: An Overview 21
3.2.1 State-Mandated Diabetes Coverage: Benefits and Limitations 22
3.2.2 State Copay Caps: Limited Impact and Scope 22
3.2.3 State Insulin Safety Net Program: A Limited Solution 22
3.2.4 Biosimilar Insulin: Interchangeability, State Initiatives, and Challenges 23
3.3 Federal Efforts and the Inflation Reduction Act for Insulin Affordability 23
3.4 Policy Recommendations 24
3.5 Conclusion: Addressing Systematic Failures for Equitable Insulin Access 26
References 26
4 Ensuring Equitable Healthcare: Overcoming Language Barriers Through Policies 29
4.1 Challenges and Implications of Language Barriers in Healthcare 30
4.2 Federal Laws Addressing Language Needs in Healthcare 31
4.2.1 Federal Authority and Related Standards and Guidance 31
4.2.2 The Affordable Care Act 32
4.2.3 Additional Federal Laws and Funding 33
4.3 State Initiatives 33
4.4 Recent Developments and Practical Challenges 34
4.5 Conclusion: Charting a Path to Linguistically Inclusive Healthcare 35
References 36
5 Confronting the US Maternal Mortality Crisis: Addressing Racial Disparities 39
5.1 Racial Disparities Fuel US Maternal Mortality Crisis 40
5.2 Preventable Deaths: Addressing Systemic Barriers via Policy 41
5.2.1 Federal Initiatives: Driving Change in Maternal Health 41
5.2.2 State-Level Initiatives: Medicaid Expansion and Targeted Interventions 42
5.3 Overcoming Fragmentation: Collaboration and Bias Training 44
5.4 Conclusion: Strengthening Legislation: Equity-Focused Interventions 45
References 45
6 Mitigating Algorithmic Bias in Healthcare AI for Equitable Care 47
6.1 Addressing Algorithmic Bias in AI to Ensure Fair Healthcare 48
6.2 Legal Landscape and Challenges in Regulating Algorithmic Bias in Healthcare AI 48
6.3 Collaborative Efforts to Address Algorithmic Bias in Healthcare AI 49
6.3.1 Enhancing Data Quality and Diversity to Address Algorithmic Bias 50
6.3.2 Regulatory Oversight and Transparency in Medical AI Development and Implementation 50
6.3.3 Diverse Teams and Inclusive Datasets: Strategies for Mitigating Algorithmic Bias 51
6.4 Conclusion: Overcoming Challenges in Addressing Racial Bias in Medical AI 52
References 53
7 Confronting Inequities in the US Organ Transplant System 55
7.1 Inequities in Organ Transplantation Disproportionately Affect Communities of Color 56
7.2 Barriers to Specialist Referrals and Data Gaps Perpetuate Inequities 57
7.3 Race-Based Clinical Policies Hinder Equitable Waitlist Placement 57
7.4 Waitlist Policies Favor Socioeconomically Advantaged Patients 57
7.5 Communication Barriers and Resource Limitations Hinder Diverse Organ Donation 58
7.6 Provider Bias and Insurance Disparities Impede Black Patients’ Transplant Access 58
7.7 OPTN Mandates Race-Neutral Transplant Eligibility Calculations 58
7.8 Recommendations for Improving Equity at Each Stage of the Transplant Process 59
7.9 Discrimination Based on Disability in Organ Transplantation Persists 60
7.10 A Comprehensive, Multistage Approach for Equitable Organ Allocation 60
References 61
8 Transforming Blood Donation: Path to Inclusivity and Science-Based Guidelines 65
8.1 Updated FDA Blood Donation Guidelines Promote Inclusivity and Safety 66
8.2 The Evolution of FDA Blood Donation Policies for Men Who Have Sex with Men 67
8.3 Challenging the Constitutionality of FDA’s MSM Blood Donation Policies 68
8.4 FDA’s New Guidelines Combat Stigma and Promote Inclusivity 70
8.5 Conclusion: Rebuilding Trust and Encouraging Inclusive Blood Donation 70
References 71
9 Addressing Barriers and Disparities in Clinical Trials: FDA’s Diversity Plan 73
9.1 Enhancing Diversity in Clinical Trials: Addressing Barriers and Disparities 74
9.2 Legislative and Regulatory Efforts to Enhance Clinical Trial Diversity 75
9.3 Potential Impact of Diversity in Clinical Trials on Medical Outcomes 76
9.4 Limitations and Challenges in Enforcing Diversity Requirements 77
9.5 Strategies to Increase Access and Participation in Clinical Trials 77
9.6 Incentives and Post-Approval Requirements to Promote Diversity 78
9.7 Conclusion: Future Steps and Expanding Diversity Efforts 78
References 79
10 Strengthening the Safety Net to Mitigate Reproductive Health Inequity After Dobbs 83
10.1 Reproductive Health Inequities Post-Dobbs 84
10.2 Maternal Health Inequities Deepen Post-Dobbs 85
10.3 The Critical Role of Safety-Net Providers 86
10.4 Advancing Equity Through Research 88
10.5 Conclusion: Advancing Equity Amid Reproductive Crisis 89
References 89
11 Advancing Mental Health Equity Through Policies 93
11.1 Disparities in Mental Health Care 94
11.2 Major Shifts Needed 95
11.3 Addressing Root Causes 96
11.4 States as Laboratories for Innovation 97
11.5 Conclusion: Urgency for Mental Health Reform 98
References 99
Part II Health Behaviors: Exploring the Influences of Exercise, Diet, and Drug Use 103
12 Promoting Physical Activity: Policy Strategies for Equity and Engagement 105
12.1 Tackling the Global Inactivity Crisis: WHO’s Action Plan for a Healthier World 106
12.2 Addressing Inequities in Physical Activity: Inclusive Strategies and Community Engagement 106
12.3 Implementing Inclusive Health Equity Strategies: CDC Guidelines and Community Examples 107
12.4 Leveraging Legal Strategies and Policy Domains to Promote Physical Activity and Address Inequities 108
12.5 Conclusion: Overcoming Challenges in Promoting Physical Activity for Youth of Color 110
References 110
13 Reducing Sugary Beverage Consumption: Regulatory Measures 113
13.1 Consequences of Sugary Drink Consumption 114
13.2 Factors Driving Sugary Drink Consumption Disparities in Communities of Color 114
13.2.1 Sugary Drink Consumption Disparities Among Racial and Ethnic Groups 114
13.2.2 Targeted Marketing of Sugary Drinks to Minority Youth 115
13.2.3 Limited Access to Healthy Options in Minority Neighborhoods 115
13.3 Limitations of Current Policies Addressing Sugary Drink Consumption 116
13.4 Policy Strategies for Reducing Sugary Drink Consumption 117
13.4.1 A National Sugary Drink Tax: Recommendations and Considerations 117
13.4.2 Promoting Healthier School Meals and Reallocating Agricultural Subsidies 118
13.5 Conclusion: A Comprehensive Approach to Reducing Sugary Drink Consumption 118
References 119
14 Promoting Health Equity via Tobacco Control 123
14.1 Tobacco-Related Disparities 124
14.2 Strategies for Policy Interventions to Foster Health Equity 125
14.2.1 Implementation of Smoke-Free Laws 126
14.2.2 Investment in Anti-tobacco Education and Ad Campaigns 126
14.2.3 Investment in Tobacco Cessation Programs 126
14.2.4 Increase in the Cost of Tobacco Products 127
14.2.5 Regulation of Tobacco Product Sales 127
14.2.6 Raising the Minimum Age for Tobacco Purchases 127
14.2.7 Strengthening Enforcement 127
14.3 Strategizing Policy Implementation to Enhance Health Equity 127
14.3.1 The Comprehensive Approach 128
14.3.2 Minimizing Unintended Consequences 128
14.3.3 Promoting Investment in Tobacco Control 128
14.4 Conclusion: Achieving Equity in Tobacco Control 129
References 130
15 Tackling the Overdose Crisis Through Equitable Harm Reduction Policies 133
15.1 The Need for an Equity-Centered, Harm Reduction Approach 134
15.2 Expanding Access to Naloxone 135
15.3 Providing Safer Use Supplies and Services 135
15.4 Expanding Access to Evidence-Based Treatment 136
15.5 Addressing Structural Determinants and Promoting Health Equity 136
15.6 Investing in Community Development 137
15.7 Reforming the Criminal Justice System 137
15.8 Addressing Stigma and Misconceptions 137
15.9 Enhancing Data Collection and Oversight 138
15.10 Conclusion: Leveraging Resources and Centering Equity in the Fight Against the Opioid Crisis 138
References 140
16 Confronting the HIV/AIDS Epidemic: Progress, Challenges, and the Path Forward 143
16.1 Ending the HIV Epidemic: Addressing Social Disparities and Ensuring Access 144
16.2 Addressing Social Determinants: Key to Ending HIV Inequities 144
16.3 Effective HIV Prevention: Education, Access, and Comprehensive Strategies 145
16.4 Government Response: Progress and Persistent Challenges in HIV Policy 146
16.5 Dismantling HIV Discrimination: Reforming Laws and Addressing Stigma 147
16.6 Conclusion: Addressing HIV/AIDS Inequities, Ensuring Care for All 148
References 149
Part III Social and Economic Factors: Education, Income, Rurality, and Structural Racism 153
17 Addressing Food Insecurity: Strengthening Assistance Programs and Promoting Equity 155
17.1 Food Insecurity, Health Risks, and COVID-19: Exposing Systemic Inequities 156
17.2 Federal Food Assistance 156
17.2.1 SNAP and Temporary Relief Efforts 157
17.2.2 Food Assistance Programs for Children and the Elderly 157
17.3 Strategies for Enhancing Food Assistance Programs Amidst Challenges 158
17.3.1 Evaluating Food Assistance Programs for Equity and Efficiency 159
17.3.2 Improving SNAP: Tackling Barriers and Benefit Adequacy 160
17.3.3 Strengthening Food Assistance: Expert Recommendations 160
17.4 Conclusion: Transforming Food Assistance for a Resilient Future 161
References 161
18 Promoting Access to Early Care and Education: Anti-Racist Policies 165
18.1 Early Care and Education 166
18.2 Head Start and Early Head Start 167
18.3 Child Care Development Fund 167
18.4 Additional Federal Programs 168
18.5 Addressing Structural Issues in Childcare Provision 169
18.6 Conclusion: Enhancing Childcare Policies for Better Outcomes 169
References 171
19 Enacting Paid Family Leave for Health Equity 175
19.1 Barriers to Equitable Paid Family Leave in the United States 176
19.2 The Impact of Paid Leave Policies on Vulnerable Workers and the Far-Reaching Benefits for Health and Equity 176
19.3 Designing Effective and Equitable Paid Family Leave Policies: Key Strategies for Inclusivity and Uptake 177
19.4 Conclusion: Paid Leave: A Crucial Step Toward Health and Economic Equity 179
References 179
20 Enhancing Rural, Remote, and Tribal Health Equity Through Policies 181
20.1 Challenges Facing Rural, Remote, and Tribal Health 182
20.2 Advancing Rural and Tribal Health Equity Through Federal Policies 183
20.3 State-Level Policy Trends 184
20.4 Remaining Gaps and Recommendations 186
20.5 Conclusion: Seizing Opportunities, Achieving Equity 187
References 188
21 Addressing Medical Debt on Marginalized Communities: Potential Reforms 191
21.1 The Burden and Disproportionate Impact of Medical Debt 192
21.2 Government’s Role in Addressing Medical Debt Disparities 192
21.2.1 The No Surprises Act: Protections, Limitations, and Enforcement 193
21.2.2 Medicaid Expansion and Enrollment Adjustments Reduce Medical Debt 193
21.2.3 Expanding Appeal Rights and Funding Consumer Assistance Programs 194
21.2.4 State Laws Surpassing Federal Protections and Ensuring Affordable Care 194
21.3 Legislative and Policy Initiatives to Mitigate Medical Debt 194
21.3.1 Arizona Ballot Initiative: Reforming Medical Debt Collection Practices 195
21.3.2 Challenges of Medical Debt Cancellation Proposal 195
21.3.3 Provider Interactions, Cost Controls, and Insurance Reforms 195
21.3.4 Remove Medical Debt from Credit Reports 195
21.4 Conclusion: Key Considerations for Policymakers 197
References 197
22 Preserving Diversity: Impact of Affirmative Action Ruling on Healthcare 201
22.1 Supreme Court Ruling Threatens Diversity in Healthcare Education 202
22.2 The Importance of Diversity in Healthcare 202
22.3 Impact of Overturning Affirmative Action 203
22.4 Maintaining and Improving Diversity Post-ruling 204
22.4.1 Rethinking Merit and Applicant Evaluation 204
22.4.2 Proxies and Race-Neutral Alternatives 204
22.4.3 Invest in Pipeline Programs and Partnerships 205
22.4.4 Revamp Recruitment and Yield Activities 205
22.4.5 Reimagine Curriculum, Climate, and Inclusion 206
22.4.6 Leadership, Accountability, and Collaboration 207
22.5 Conclusion: Urgent Strategies Needed to Protect Diversity in Healthcare Education 207
References 208
23 Reforming the Public Charge Rule for Immigrant Health Equity 211
23.1 Barriers to Immigrant Healthcare Access: The Public Charge Rule’s Impact 212
23.2 Comparing Trump and Biden Public Charge Rules 213
23.2.1 Defining Public Charge 213
23.2.2 Difference in Application 213
23.3 The Chilling Effect: Immigrant Hesitancy to Access Public Benefits Despite Policy Changes 214
23.4 Limited Policy Solutions to Address Immigrant Distrust and Expand Access to Benefits 215
23.5 Strategies to Rebuild Trust and Increase Immigrant Access to Public Benefits 216
23.6 The Need for Legislative Action to Provide Certainty and Stability for Immigrants 216
References 216
24 Promoting Health in All Policies (HiAP) Approach 219
24.1 Integrating HiAP: A Strategic Approach to Achieving Health Equity 220
24.2 Legal Frameworks Facilitating Multi-sector Collaboration for HiAP 221
24.3 Establishment and Impact of California’s HiAP Task Force 221
24.4 Strategies for Enhancing and Sustaining HiAP Initiatives 222
24.5 Challenges and Strategic Insights for Implementing HiAP Amidst a Pandemic 224
24.6 Conclusion: Lessons and Challenges in Implementing HiAP 224
References 225
25 Rethinking Preemption for Health Equity 227
25.1 The Double-Edged Sword of Preemption in Public Health Regulation 228
25.2 Preemption During the COVID-19 Pandemic: Challenges and Consequences 229
25.3 Preemption’s Disproportionate Impact on Vulnerable Populations and Inequities 229
25.4 Conclusion: Toward an Equity-First Preemption Framework 231
References 233
26 Achieving Health and Economic Equity Through Broadband Access and Policy 235
26.1 Broadband: A Crucial Determinant of Health Equity 236
26.2 The Digital Divide: Perpetuating Systemic Inequities 237
26.3 Lawmakers’ Role in Achieving Equitable Broadband Access 237
26.3.1 Federal Efforts to Support Broadband Access and Digital Equity 238
26.3.2 State-Level Strategies for Promoting Digital Equity 238
26.3.3 Local Initiatives Addressing Community-Specific Digital Needs 240
26.4 Conclusion: A Public Value Essential for Health and Economic Equity 240
References 241
27 Expanding Vaccine Equity: Policy Strategies 245
27.1 Vaccine Inequity: Disparities in Access and Health Outcomes 246
27.2 Government Efforts to Address Vaccine Inequity: Successes and Challenges 247
27.3 Addressing Persistent Vaccine Inequities: Proposed Solutions and Global Efforts 249
27.4 Federalism and Vaccine Inequity: Challenges, Criticisms, and Federal Efforts 250
27.5 Data Gaps: Hindering Efforts to Address Vaccine Inequities 251
27.6 Conclusion: Addressing Vaccine Inequity: Lessons, Strategies, and a Call to Action 252
References 253
28 Disaggregating Data: Unveiling the Diversity and Disparities Within the AAPI Population 255
28.1 Diversity and Disparity: The Complexity of AAPI Data Aggregation 256
28.2 Model Minority Myth: Masking AAPI Health Disparities Through Aggregation 257
28.3 State-Led Initiatives: Advancing AAPI Data Disaggregation Amid Federal Inconsistency 258
28.4 Barriers to Disaggregation: Sample Sizes and Community Opposition 259
28.5 Conclusion: Disaggregation Imperative 259
References 261
Part IV Physical Environment: The Role of Housing, Transit, Water, and Climate Change 265
29 Achieving Health Equity Through Housing Laws and Policies 267
29.1 Housing and Health: The Impact of Segregation 268
29.2 How Laws and Policies Post-fair Housing Act Have Furthered Residential Segregation 268
29.2.1 The Low-Income Housing Tax Credit 268
29.2.2 Nuisance Ordinances 269
29.2.3 Rent Control 269
29.2.4 Housing Choice Voucher Program 270
29.2.5 Zoning Laws 270
29.3 Positive Legal Interventions 271
29.3.1 Land Banks 271
29.3.2 Inclusionary Zoning 272
29.3.3 Earned Income Tax Credit 272
29.3.4 Other Policy and Legal Interventions 272
29.4 Conclusion: Addressing Residential Segregation for Better Health 273
References 275
30 Advancing Transportation for Health Equity Through Policies 277
30.1 The State of Transportation Inequity 278
30.2 An Agenda for Transportation Justice Policy 279
30.2.1 Participatory Community Planning 279
30.2.2 Equitable Transportation Funding 280
30.2.3 Antiracist Mobility Policies 280
30.2.4 Accessible and Resilient Mobility Ecosystems 280
30.2.5 Data-Driven and Community-Defined Metrics 281
30.2.6 Capacity Building and Narrative Shift 282
30.2.7 Cross-Sector Collaboration 283
30.3 Conclusion: Transportation Justice Drives Health Equity 283
References 284
31 Providing Access to Clean Water for Health Equity Through Policies 287
31.1 Water Insecurity in America 288
31.2 Causes of Water Insecurity and Access Inequities 288
31.2.1 Aging and Inadequate Infrastructure 289
31.2.2 Inequitable Water Policies and Underinvestment 289
31.2.3 Climate-Related Threats 290
31.3 Health Disparities of Water Insecurity 290
31.4 Comprehensive Policy Solutions 291
31.5 Conclusion: Achieving Water Equity Through Policy 293
References 293
32 Addressing Climate Change-Induced Health Disparities Through Policy and Planning 297
32.1 Climate Change: A Threat Multiplier Exacerbating Health Inequities 298
32.2 Frontline Communities: Disproportionate Climate Impacts and Inadequate Support 298
32.3 Addressing Climate Inequity: Challenges and Progress in Policy and Legislation 299
32.4 Equitable Climate Policies: Engaging Communities, Strengthening Health Responses, and Prioritizing Research 301
32.5 Conclusion: Embracing Health Equity as a Cornerstone of Climate Policy 303
References 303
Index 305
