Summary Annex

Report Conclusions by Chapter

This Annex contains all of the report conclusions, organized by chapter. The discussions and evidence to support these conclusions are available in the corresponding chapter. There are conclusions on data gaps, the connection of the social determinants of health to health and health inequities, and the policy topics the committee reviewed.

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

• Conclusion 2-1: The lack of oversampling of underrepresented racial, ethnic, and tribal populations in national health surveys and other relevant federal data collection efforts—for example, the Office of Management and Budget categories of American Indian or Alaska Native and Native Hawaiian or Pacific Islander—limits the availability of reliable data, and therefore meaningful action, by federal programs, researchers, and advocates to advance health equity for these communities.
• Conclusion 2-2: Disaggregated data on social, economic, health care, and health indicators that reflect the heterogeneity of racial and ethnic groups, including in relation to country of origin, are needed to inform targeted actions that promote health equity across and within groups.

CHAPTER 3: ECONOMIC STABILITY

• Conclusion 3-1: Evidence demonstrates that pretrial detention substantially reduces lifetime income, and strongly links incarceration with lower lifetime earnings and family income for incarcerated individuals. Given racial and ethnic inequities in incarceration and pretrial detention, there are opportunities in these areas to address racial and ethnic inequities in income and, thereby, health and well-being.
• Conclusion 3-2: Stagnation in the federal minimum wage, coupled with inflation, has left the real value of the minimum wage at a level not seen since the 1950s. Increases to the federal minimum wage raise incomes among low- and moderate-income families and lift families out of poverty. Since racially and ethnically minoritized populations and tribal communities are disproportionately represented in the groups that would be impacted by an increased federal minimum wage, such an increase is one method to address racial and ethnic inequities in economic stability and, therefore, health and well-being.
• Conclusion 3-3: Federal social benefit programs, such as the Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants, and Children, and the Earned Income Tax Credit, significantly alleviate poverty and reduce the negative health consequences of poverty; however, there are barriers that prevent participation among many people who would otherwise qualify for these programs. Some racial, ethnic, and tribal populations have lower participation rates in these programs, contributing to racial and ethnic health inequity. Therefore, policies that address administrative barriers, hold programs accountable for participation rates, and improve administrative capacity can improve participation rates and reduce racial and ethnic health inequity.
• Conclusion 3-4: Federal social benefit programs, such as the Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants, and Children, and the Earned Income Tax Credit, significantly alleviate poverty and reduce the negative health consequences of poverty. In some cases, eligibility for these and similar programs has been restricted for some groups, including childless adults, formerly incarcerated individuals, and immigrants. Because these groups disproportionately represent racially and ethnically minoritized populations, these restrictive policies contribute to racial and ethnic health inequity.

• Conclusion 3-5: Nonprofit sector partnerships play an important role in poverty alleviation and emergency food assistance that can influence racial and ethnic health inequities. Federal programs, such as the Emergency Food Assistance Program, help the nonprofit sector more effectively serve those in need by providing food for distribution and grants for infrastructure and capacity building.
• Conclusion 3-6: Gaps in wealth for many racially and ethnically minoritized populations are linked to past and current federal policies, including redlining, disparate access to benefits of the 1944 GI Bill, and the financialization of the criminal legal system. Furthermore, policies that reward existing wealth, like the mortgage tax deduction, can exacerbate these gaps. Since wealth operates in tandem with income to enable access to healthier living conditions, quality health care, and amelioration of stress, these racial and ethnic inequities in wealth produce racial and ethnic inequities in health and well-being.
• Conclusion 3-7: Policies to support savings and wealth accumulation, for example, government subsidies of savings accounts for children, can increase wealth and narrow racial and ethnic differences in savings rates and wealth holding.
• Conclusion 3-8: Unequal access to safe and affordable financial services, including bank accounts and low-cost credit, is a driver of inequities. Enabling the provision of financial services that allow all Americans to spend, save, borrow, and plan will enable greater economic stability and increase health equity for low-income and racially and ethnically minoritized populations.

CHAPTER 4: EDUCATION ACCESS AND QUALITY

• Conclusion 4-1: There remain large differences in educational achievement and attainment between White and Asian students, on one hand, and Black, Latino/a, and American Indian and Alaska Native students, on the other. The empirical evidence that education is associated with health is strong. The causal evidence that more education can improve health is compelling given the many pathways through which education can affect health.
• Conclusion 4-2: There is strong evidence some federal policy changes and investments can improve educational outcomes and narrow differences in educational attainment and quality across racial and ethnic groups. However, the best mix of changes to policy and practice to improve student outcomes will vary across states, districts, schools, or groups of students. Thus, evidence-based policy, accountability, and community engagement play a critical role in improving federal policy for education as it relates to equity.

• Conclusion 4-3: Increases in per-pupil school spending have been shown to improve a range of student outcomes in the short and long run, including test scores, educational attainment, and earnings—all of which in turn are correlated with better health outcomes. Decreases in school spending lead to worse student outcomes, especially for children living in low-income neighborhoods and Black students. Federal policy could play a role to offset differences in cross-state spending and close spending gaps across racial and ethnic groups.
• Conclusion 4-4: In 1994, the federal government disqualified incarcerated people from Pell Grant eligibility, and in 2020, lawmakers reinstated Pell Grant access for incarcerated people enrolled in qualifying prison education programs. This is a promising example of how removing erected barriers to access for specific populations, such as incarcerated people, can address unequal access to federal programs that are linked to social determinants of health and health inequities.
• Conclusion 4-5: Minority serving institutions have demonstrated value on investment in economic outcomes for their students, and their effects on the racially and ethnically minoritized communities they serve merit research and measurement.
• Conclusion 4-6: Schools have unique opportunities to advance health, ranging from assisting in outreach and enrollment of eligible children in public health insurance programs and income support programs, to offering direct care through school-based health centers, to reducing food insecurity and improving dietary quality through school meals programs. Evidence shows that when schools adopt or improve these opportunities, both health and educational outcomes can be improved.

CHAPTER 5: HEALTH CARE ACCESS AND QUALITY

• Conclusion 5-1: Medicaid and the Children’s Health Insurance Program are the most important federal policies that address the racial and ethnic inequities in access to affordable health care. The Medicaid expansions in eligibility incentivized in the 2010 Affordable Care Act have increased insurance coverage, improved health outcomes, and reduced racial and ethnic health inequities in access to preventive services, delayed care, and unmet health care needs.
• Conclusion 5-2: Among those eligible for Medicaid under the current federal eligibility criteria, racial and ethnic inequities in enrollment and participation remain. While acknowledging the important role of states, the federal government can play a role in addressing these issues, such as by reducing administrative burden

• and examining the racial and ethnic health equity implications of policies that exclude specific populations, such as immigrants and people involved with the criminal legal system.
• Conclusion 5-3: State variation in implementation of the federal Medicaid law, most notably the state variation in the implementation of ACA Medicaid expansions, creates barriers to enrollment and differences in program eligibility and accessibility that have widened the gap in insurance coverage and access to care. The barriers disproportionately affect racially and ethnically minoritized populations, thus contributing to place-based racial and ethnic health inequities. While federal policies can address these barriers by limiting restrictive use of Medicaid flexibilities and effectively incentivize increasing access, these policy changes will require overcoming political and philosophical barriers related to Medicaid, federalism, and the role of government to ensure universal access to health care.
• Conclusion 5-4: Value-based payment and other programs intended to improve quality have, to date, not prioritized health equity. For example, such programs do not measure and incentivize reduction of racial and ethnic health inequities.
• Conclusion 5-5: A lack of inclusion and representation in clinical research may perpetuate health inequities because it limits the ability to identify issues of safety or effectiveness that might be specific to the populations that are not well represented. A lack of inclusion and representation in the health care workforce may perpetuate health inequities given the evidence that suggests better health outcomes when there is identity concordance between patients and providers.
• Conclusion 5-6: The Indian Health Service is the primary source of health care for many American Indian and Alaska Native people. The current structure and inadequate funding level of the Indian Health Service contributes to health inequities for American Indian and Alaska Native people.
• Conclusion 5-7: A lack of coordination, measurement, and prioritization of equity activities across the Department of Health and Human Services contributes to racial, ethnic, and tribal health inequities.
• Conclusion 5-8: Increasing access to high-quality, comprehensive, affordable, accessible, timely, respectful, and culturally appropriate health care would advance racial and ethnic health equity. Progress toward universal health care access can be achieved through many federal policy avenues, including but not limited to increasing access to public and private insurance coverage.

CHAPTER 6: NEIGHBORHOOD AND BUILT ENVIRONMENT

• Conclusion 6-1: Redlining and associated policies and structures resulted in residential segregation and neighborhood disinvestment, which have led to measurable health inequities present today. Safe, quality housing is necessary for maintaining an adequate standard of living, and there is a compelling link between housing and health equity. Increased federal investment in housing interventions for low-income people, such as the housing voucher program, could improve housing security and health outcomes for children and adults, especially among Black, Latino/a, American Indian and Alaska Native, and Native Hawaiian and Pacific Islander populations, and advance racial and ethnic health equity. Federal investment in housing would benefit from evidence-based guidelines to ensure that such investments do not contribute to future health inequities.
• Conclusion 6-2: The federal infrastructure policies governed by the Department of Housing and Urban Development, the Environmental Protection Agency, the Department of Transportation, and other agencies play critical roles to ensure health equity. Essential in these policies is the protection for those most vulnerable to the health effects of infrastructure investments, since, in many cases, federal funding propels infrastructure spending from state and local governments. While the role of federal funding may be limited in terms of the types of state and local infrastructure projects, there are missed opportunities for the federal government to monitor and address the health inequities tied to infrastructure. Coordination, monitoring, and guidance on infrastructure spending are lacking across federal agencies.
• Conclusion 6-3: There is a lack of coordination among relevant federal agencies to address workplace protection from pesticides, such as among the Occupational Safety and Health Administration, the Environmental Protection Agency, and the Centers for Disease Control and Prevention. Inadequate workplace protections from pesticides for agricultural workers disproportionately impact Latino/a workers, their children, and surrounding communities.
• Conclusion 6-4: Community voice through advocacy has played a positive role in shaping iterations of the Agriculture Improvement Act. However, given the bill’s size and scope, an audit of the equity implications of the bill could identify additional areas of improvement, such as areas to expand further tribal self-determination and self-governance in relevant programs and other mechanisms to advance racial and ethnic health equity.

CHAPTER 7: SOCIAL AND COMMUNITY CONTEXT

• Conclusion 7-1: Community safety is critical for health and wellbeing. Racial and ethnic inequities in gun homicides and recent increases in firearm suicide among young Black adults suggest the need for more evidence-based policies that can prevent harm.
• Conclusion 7-2: There are clear racial and ethnic inequities in policing. Improved data collection is needed to increase accountability, better understand the extent of these inequities, and determine which policy changes may help reduce them.
• Conclusion 7-3: The criminal legal system is an important driver of health across the life course, as well as the health of communities and families. Racially and ethnically minoritized communities have experienced and continue to experience disproportionate contact with the criminal legal system. Evidence suggests that policies regarding mandatory minimum sentences, long sentences, and mass incarceration merit re-examination.
• Conclusion 7-4: Generations of Black, American Indian, Alaska Native, Native Hawaiian, Pacific Islander, Latino/a, and Asian communities have been negatively affected by past actions, practices, policies, and laws that inflicted lasting harm and undermined access to social, economic, and political resources and opportunities, contributing to current racial and ethnic health inequities. There is a need to continue to study and address the impacts of historical and contemporaneous laws and policies that sustain racial inequity.
• Conclusion 7-5: Research demonstrates that civic engagement and belonging have powerful effects on population health, well-being, and health equity. Civic infrastructure and civic engagement are important factors in building social cohesion and inclusionary decision making that lead to better design and implementation of policies that affect health equity.
• Conclusion 7-6: Important considerations when crafting federal action on health equity include leveraging existing policies and authority, considering the limitations of executive orders, and articulating elements that build belonging, community inclusion, and civic muscle into federal agency policy development processes.

CHAPTER 8: ROADMAP TO HEALTH EQUITY

• Conclusion 8-1: The widespread inequities in education, income, and other factors that impact health are the result of the disparate and harmful impact of trauma, laws, and policies at all levels of government, both past and present. Health inequities are prevalent,

• persistent, and preventable and federal policy is an important tool for correcting historical and contemporary harms.
• Conclusion 8-2: Federal policy can play a key role in eliminating health inequities by collecting and employing high-quality and accurate data, doing a better job of including and empowering communities that are most affected, and coordinating and holding those who implement policy accountable.