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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. Federal policy to advance racial, ethnic, and tribal health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/26834.

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COMMITTEE ON THE REVIEW OF FEDERAL POLICIES THAT CONTRIBUTE TO RACIAL AND ETHNIC HEALTH INEQUITIES

SHEILA P. BURKE (Cochair), Adjunct Lecturer, John F. Kennedy School of Government, Harvard University; Senior Policy Advisor and Chair, Government Relations and Public Policy, Baker Donelson

DANIEL E. POLSKY (Cochair), Bloomberg Distinguished Professor of Health Policy and Economics, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and Carey Business School, Johns Hopkins University

MADINA AGÉNOR, Associate Professor, Department of Behavioral and Social Sciences, Center for Health Promotion and Health Equity, Brown University School of Public Health

CAMILLE M. BUSETTE, Senior Fellow and Director, Race, Prosperity, and Inclusion Initiative, The Brookings Institution

MARIO CARDONA, Professor of Practice and Director of Policy, Children’s Equity Project, Arizona State University¹

JULIET K. CHOI, Chief Executive Officer, Asian & Pacific Islander American Health Forum

JUAN DE LARA, Associate Professor of American Studies and Ethnicity, University of Southern California

THOMAS E. DOBBS, III, Dean and Associate Professor, School of Population Health, University of Mississippi Medical Center

MEGAN D. DOUGLAS, Associate Professor, Department of Community Health and Preventive Medicine; Director, Research and Policy, National Center for Primary Care, Morehouse School of Medicine

ABIGAIL ECHO-HAWK, Director, Urban Indian Health Institute; Executive Vice President, Seattle Indian Health Board

HEDWIG LEE, Codirector, Center for the Study of Race, Ethnicity, and Equity; Professor of Sociology, Courtesy Joint Appointment with the Brown School, Washington University in St. Louis; Scholar in Residence of Sociology, Duke University

MARGARET P. MOSS, Professor, Director of First Nations House of Learning, University of British Columbia

SELA V. PANAPASA, Associate Research Scientist, Research Center for Group Dynamics, Institute for Social Research, University of Michigan

S. KARTHICK RAMAKRISHNAN, Professor of Public Policy, University of California, Riverside

___________________

¹ Resigned from the committee on October 5, 2022.

DIANE WHITMORE SCHANZENBACH, Margaret Walker Alexander Professor of Human Development and Social Policy; Director, Institute for Policy Research, Northwestern University

LISA SERVON, Kevin and Erica Penn Presidential Professor and Chair, Department of City and Regional Planning, University of Pennsylvania

VIVEK SHANDAS, Professor; Founder and Director, Sustaining Urban Places Research Lab, Portland State University

MELISSA A. SIMON, Vice Chair of Research and George H. Gardner Professor of Clinical Gynecology, Department of Obstetrics and Gynecology; Founder and Director, Center for Health Equity Transformation; Associate Director, Community Outreach and Engagement, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University

National Academy of Medicine Greenwall Fellow in Bioethics

KAVITA SHAH ARORA, Division Director, Division of General Obstetrics, Gynecology, and Midwifery; Associate Professor, University of North Carolina at Chapel Hill

Study Staff

AMY GELLER, Study Director

AIMEE MEAD, Associate Program Officer

L. BRIELLE DOJER, Research Associate

MAGGIE ANDERSON, Research Assistant

G. EKENE AGU, Senior Program Assistant

GRACE READING, Senior Program Assistant (through November 2022)

Y. CRYSTI PARK, Program Coordinator

ALINA BACIU, Senior Program Officer

MISRAK DABI, Senior Finance Business Partner

ROSE MARIE MARTINEZ, Senior Board Director

TASHA BIGELOW, Editor, Definitive Editing

Consultants

IGNATIUS BAU, Independent Consultant

AARON KLEIN, The Brookings Institution

BOBBY MILSTEIN, ReThink Health

REBECCA PAYNE, Rippel Foundation

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by JOSE ESCARCE, University of California, Los Angeles and TRACY LIEU, Kaiser Permanente, Northern California. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Contents

PREFACE

ACKNOWLEDGMENTS

ACRONYMS AND ABBREVIATIONS

KEY TERMS

ABSTRACT

SUMMARY

SUMMARY ANNEX

1 STATEMENT OF TASK AND APPROACH

Introduction

The Urgency of Addressing Health Inequities

Root Causes of Health Inequities in the United States

The Committee’s Approach

Current Landscape

Study Process and Report Overview

Concluding Observations

References

2 CONNECTION BETWEEN HEALTH EQUITY AND HISTORY, FEDERAL POLICY, AND DATA

Introduction

Governmental Structures and Power

Historical and Current Structural Racism: Fundamental Contributors to Health Inequity

State of Health Inequities in the United States

Data Gaps and Opportunities

Concluding Observations

References

3 ECONOMIC STABILITY

Introduction

Income and Employment

Poverty

Wealth

Financial Services

Concluding Observations

References

4 EDUCATION ACCESS AND QUALITY

Introduction

Early Childhood Education

K–12 Education

Higher Education

School Opportunities to Directly Promote Health, Insurance Coverage, and Access to Care

Concluding Observations

References

5 HEALTH CARE ACCESS AND QUALITY

Introduction

Federal Health Care Policy Overview

Health Care Access and Health Care Inequity

Medicaid

Health Literacy and Language Access

Health Equity in Value-Based Care and Quality Programs

Representation and Inclusion in Health Care

Health Care Access, Quality, and Inclusion for Specific Populations

Concluding Observations

References

6 NEIGHBORHOOD AND BUILT ENVIRONMENT

Structured Insecurity: Housing Segregation and Displacement

Infrastructure: Investment, Disinvestment, and Community Health

Environmental Exposures: Workplace Vulnerabilities

Food Access and Production

Concluding Observations

References

7 SOCIAL AND COMMUNITY CONTEXT

Introduction

Violence, Public Safety, and the Criminal Legal System

Trauma and Healing

Civic Engagement and Belonging

Concluding Observations

References

8 ROADMAP TO RACIAL, ETHNIC, AND TRIBAL HEALTH EQUITY

Introduction

Recommendations

Call to Action

References

APPENDIXES

A PUBLIC MEETING AGENDAS

B COMMITTEE MEMBER AND STAFF BIOGRAPHIES

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Preface

The United States is a country rich in different cultures, perspectives, languages, and beliefs; that is one of its great strengths. It also is home to a society that values fairness and freedom. But a lack of fairness creates barriers that can keep people from having the opportunities to achieve their highest potential for health, whether they are a small business owner, student, or parent.

The report’s purpose is to conduct a wide-ranging, though not comprehensive, assessment of the relationship between federal policies across multiple domains and health equity along ethnic and racial lines. National Academies studies have closely reviewed the effects of poverty, racism, and discrimination on health outcomes and examined the evidence demonstrating that low-income status and membership in racially or ethnically minoritized communities—both as separate factors and in interaction—result in these populations being more likely to live shorter lives and suffer other health inequities, at a great cost to families, communities, and our nation.²

This work, conducted at the request of the Office of Minority Health in the Department of Health and Human Services (charged with working toward a healthier nation), was intended to look at the effect of past and present federal policies that contribute to racial and ethnic inequities.

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² See, for example, National Academies of Sciences, Engineering, and Medicine (NASEM). 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press; NASEM. 2019. A roadmap to reducing child poverty. Washington, DC: The National Academies Press; and, Institute of Medicine and National Research Council. 2013. U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: The National Academies Press.

Why look at the past? Because it sets in motion processes that continue for decades and generations, operate across multiple domains, and interact in mutually reinforcing ways.

The breadth of the statement of task spanning all federal policies past and present gave this committee the opportunity to identify common crosscutting themes actionable at the federal level for achieving health equity. We arrived at these themes and subsequent recommendations from our analysis of the evidence of the relationship between health equity and historical and current examples of federal policies.

We do call attention to how health inequities result from federal policies, but with a purpose to inform the federal policy change that can effectively address them. Our recommendations provide action steps for federal policy makers to advance the nation’s path toward health equity.

Sheila P. Burke and Daniel E. Polsky, Cochairs
Committee on the Review of Federal Policies that Contribute to Racial and Ethnic Health Inequities

Acknowledgments

The committee wishes to thank and acknowledge the many individuals and organizations that contributed to the study process and development of this report. To begin, the committee would like to thank the Department of Health and Human Services Office of Minority Health, the study sponsor, for its support of this work.

The committee found the perspectives of many individuals and groups immensely helpful in informing its deliberations through presentations and discussions at the public meetings. The following speakers provided their research, expertise, and perspectives: Maggie Blackhawk, Richard Cho, Loretta Christensen, Gail Christopher, RDML Felicia Collins, Janet Currie, J. Nadine Gracia, Cindy Mann, Kamilah Martin-Proctor, Stephanie Martinez-Ruckman, Barbara Masters, Tom Morris, Allison Orris, Liz Osborn, Sue Polis, John A. Rich, Ananya Roy, and Megan Ryerson. The committee also greatly benefited from hearing lived experiences and other input from many individuals and organizations on navigating federal programs and policies that contribute to racial and ethnic health inequities at its public comment sessions and through written comment.

The committee’s work was enhanced by the expertise and writing contributions provided by Ignatius Bau, Aaron Klein, Bobby Milstein, and Rebecca Payne, who served as consultants.

The committee thanks the National Academies of Sciences, Engineering, and Medicine staff who contributed to producing this report, especially the extraordinary, creative, and tireless study staff Amy Geller, Alina Baciu, Aimee Mead, L. Brielle Dojer, Maggie Anderson, G. Ekene Agu, Grace Reading, Y. Crysti Park, and Rose Marie Martinez. The committee thanks

the National Academies and Health and Medicine Division communications staff, including Mimi Koumanelis, Amber McLaughlin, Benjamin Hubbert, and Marguerite Romatelli. This project received valuable assistance from Megan Lowry (Office of News and Public Information); Misrak Dabi (Office of the Chief Financial Officer); and Monica Feit, Samantha Chao, Leslie Sim, Taryn Young, Lori Brenig, Rachael Nance, and Elizabeth Webber (Health and Medicine Division Executive Office). The committee received important research assistance from Anne Marie Houppert and Rebecca Morgan (National Academies Research Center). The committee also thanks Neha Dixit, Donna Doebler, and Kelly McHugh for their additional support.

Finally, the National Academies staff offers thanks to committee members’ executive assistants and support staff, without whom scheduling the multiple meetings and conference calls would have been nearly impossible: Lianne Araki, Duane Haneckow, Lauren Kearns, Caitlin Keller, Jamey Longden, Mischa Makortoff, Kathleen Prutting, Hayley Smart, Liana Watson, and Sarah Wright.

Acronyms and Abbreviations

Key Terms

The committee strived to use language that is respectful, accurate, and maximally inclusive. This relies on attempting to reflect preferences for how individuals and groups wish to be addressed, but there is not always consensus on preferred terms, and these preferences may evolve. The below terms are defined for the purpose of this report and adapted or informed by other several National Academies reports and government agency reports.³

Racial and Ethnic Population Terms

Specific Populations⁴

• American Indian or Alaska Native: For the purpose of this report, “American Indian” and/or “Alaska Native” is used when discussing

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³ NASEM. 2023. Advancing antiracism, diversity, equity, and inclusion in STEMM organizations: Beyond broadening participation. Washington, DC: The National Academies Press; NASEM. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press; NASEM. 2021. Sexually transmitted infections: Adopting a sexual health paradigm. Washington, DC: The National Academies Press; HHS. n.d. Healthy people 2030 social determinants of health. https://health.gov/healthypeople/priority-areas/social-determinants-health (accessed March 7, 2023); Department of the Interior. 2017. Who is an American Indian or Alaska Native? https://www.bia.gov/faqs/who-american-indian-or-alaska-native (accessed March 15, 2023); CDC. 2022. What is health equity? https://www.cdc.gov/healthequity/whatis/index.html (accessed March 15, 2023); Wingrove-Haugland, E., and J. McLeod. 2021. Not “minority” but “minoritized.” Teaching Ethics 21(1):1-11.

⁴ It is important to note that race and ethnicity are not biological categories or otherwise verifiable. In addition, ethnicity is currently treated separately from race in most data collection efforts, but some consider this a flawed approach; for the purpose of this report, the committee treats them as separate categories.

• individuals or the population served by policies or programs that relate to the U.S. federal government’s trust responsibility and its government-to-government relationship with federally recognized Tribal Nations in the United States. Although American Indians and Alaska Natives are also often described along with other racial and ethnic groups, the term “American Indian and/or Alaska Native” is distinct because it is used in the context of legally enforceable obligations and responsibilities of the federal government to provide certain services and benefits to members or citizens (and, in some cases, descendants) of federally recognized Tribal Nations. “Indigenous” and “Native American” are also commonly used but are not specific enough to describe the special political status of American Indian and Alaska Native Tribal Nations.
• Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent; for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. These individuals remain citizens of their home countries.
• Asian American: a resident of the United States who self-identifies as Asian or as one of the ethnic or detailed origin groups classified by the U.S. government as Asian; does not need to be a U.S. citizen or permanent resident.
• African American: U.S.-born people who have African ancestry (typically used for descendants of people from African who were enslaved) and may also refer to those who were not born in the United States but are now U.S. citizens or permanent residents. The committee elected to use “Black” unless the data specifically denote African American.
• Black: a person who was born in or outside of the United States and has origins in any of the Black ethnic groups of Africa. An umbrella term including African American, African, Afro-Caribbean, and other people of African descent.
• Hispanic or Latino/a/x/e: refers to a person of Mexican, Puerto Rican, Salvadoran, Cuban, or other Latin American and Caribbean cultural origin, regardless of race. The committee acknowledges that “Hispanic” is widely used in policy and research discussions when referring to this group. Nonetheless, the committee recognizes that Latin America and the Caribbean are home to many colonial and Indigenous languages and cultures. Therefore, the committee elected to use “Latino/a” unless the data specifically denote Hispanic.
• Native Hawaiian or Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, or other Pacific

• Islands (that is, all sovereign/independent Pacific Island countries, including the Compact of Free Association States).
• White: a person having origins in any of the original peoples of Europe or the Middle East or North Africa (MENA). However, a movement exists to identify MENA people separately in the U.S. Census and elsewhere.

Additional Population Terms

• Ethnicity: In contrast to race, ethnicity has a stronger relationship with place. It is a socially constructed term used to describe people from a similar national or regional background who share common national, cultural, historical, and social experiences. An ethnic group likely contains people who share distinct beliefs, values, and behaviors. Race (even though it is not a valid biological construct) refers to phenotypic features that have been racialized, whereas ethnicity addresses social, cultural, and historical commonalities (see also Race).
• Multiracial: people who identify with more than one race.
• Race: a socially constructed, shorthand concept, dating back to the 15th century, which categorized populations into an arbitrary, hierarchical classification framework, largely based on phenotypic characteristics, such as skin color. Race, although not a valid biological concept, is a real social construction that is linked to racism and gives or denies benefits and privileges to racialized individual people and groups.
• Tribal: describes Tribal Nations in the United States but is also used as an adjective to describe circumstances related to them, such as tribal communities or tribal policies. It is not appropriate to use in the context of Native Hawaiians or Pacific Islanders.

Other Key Report Terms

Community: Any configuration of individuals, families, and groups whose values, characteristics, interests, geography, and/or social relations unite them in some way.

Equality: The treatment of all individuals in the same manner. It is important to emphasize that equity is not interchangeable with equality. Equality assumes a level playing field for everyone without accounting for historical and current inequities. See Health Equity for more details about why “equity” is used in this report.

Health: A state of complete physical, mental, and social well-being; not merely the absence of disease.

Health Equity: The state in which everyone has a fair opportunity to attain full health potential and well-being, and no one is disadvantaged from doing so because of social position or any other socially defined circumstance. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities and historical and contemporary injustices and eliminate health and health care disparities due to past and present causes. It is important to note that equity is not interchangeable with equality (see definition above).

Institutional Racism: policies and practices within institutions that, intentionally or not, produce outcomes that chronically favor White individuals and put individuals from minoritized racial and ethnic groups at a disadvantage.

Policy: For the purpose of this report, a policy is a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions that affects a whole population. Further, it is a course of action or inaction that government selects from among alternatives. Both formal and informal policies exist; formal policy has consequences for not following it when enforced (e.g., fines, withdrawal of funding or eligibility, criminal charges), whereas informal policy (e.g., guidelines, recommendations, funding opportunities for research and community-based initiatives, tax subsidies) does not have such consequences.

Racialized: the extension of racial meaning to resources, cultural objects, emotions, bodies, and organizations that have previously been seen as nonracial.

Racially and Ethnically Minoritized Individuals/Populations: Rather than referring to “racial and ethnic minorities,” “members of minority groups,” or “underrepresented minorities,” this report uses “minoritized,” which refers to people from groups that have been historically and systematically socially and economically marginalized or underserved based on their race or ethnicity as a result of racism (such as American Indian and Alaska Native, Asian, Black, Latino/a/x/e, and Native Hawaiian and Pacific Islander communities). The committee uses this term to make the distinction that being minoritized is not about the number of people in the population but rather about power and equity.

Racism: the combination of policies, practices, attitudes, cultures, and systems that affect individuals, institutions, and structures unequally and confer power and privilege to certain groups over others, defined according to social constructions of race and ethnicity.

Structural Racism: the totality of ways in which a society fosters racial and ethnic inequity and subjugation through mutually reinforcing systems, including housing, education, employment, earnings, benefits, credit, media, health care, and the criminal legal system. These structural factors organize the distribution of power and resources (i.e., the social determinants of health) differentially among racial, ethnic, and socioeconomic groups, perpetuating racial and ethnic health inequities. The key difference between institutional and structural racism is that structural racism happens across institutions, while institutional racism happens within institutions. “Systemic racism” is another term used to describe this.

Social Determinants of Health (SDOH): The conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH can both promote and harm health. For the purposes of this report, SDOH are organized by the Healthy People 2030 domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

Structural Determinants of Health: Macrolevel factors, such as laws, policies, institutional practices, governance processes, and social norms that shape the distribution (or maldistribution) of the social determinants of health (e.g., housing, income, employment, exposure to environmental toxins, interpersonal discrimination) across and within social groups. Structural determinants of health, also referred to as the “determinants of the determinants of health,” include structural racism and other structural inequities and thus influence not only population health but also health equity.

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