Proceedings of a Workshop—in Brief

Convened October 9, 2024

Exploring the Changing Diversity, Equity, and Inclusion Legislation and Policy Landscape and Its Impact on Health and Public Health’s Workforce, Education, Training, and Research
Proceedings of a Workshop—in Brief

After the June 2023 Supreme Court ruling against affirmative action in colleges and universities, many states introduced legislation in higher education to cease diversity, equity, and inclusion (DEI) efforts. As of August 2024, 86 bills in 28 states have introduced legislation for colleges and universities to disband diversity offices or staff and prohibit mandatory diversity training, use of diversity statements in hiring and promotion, or consideration of race, sex, ethnicity, or national origin in admissions or employment (Chronicle of Higher Education, 2024). To explore these recent changes in state DEI legislation and policies affecting the health care and public health workforce, the National Academies of Sciences, Engineering, and Medicine (the National Academies) Roundtable on the Promotion of Health Equity held a public workshop¹ on October 9, 2024. Presentations focused on the impact of these policy changes on medical and public health training, curriculum, and health research, as well as student recruitment and faculty recruitment and retention for educating and training the health and public health workforce. Discussions also explored potential solutions for mitigating adverse impacts of policy changes. This Proceedings of a Workshop—in Brief summarizes the presentations and discussions expressed during the workshop and should not be construed as consensus or recommendations among the workshop participants, planning committee, members of the Roundtable on the Promotion of Health Equity, or the National Academies.

THE HISTORY, EVOLUTION, AND CURRENT STATE OF DEI LEGISLATION AND POLICY LANDSCAPE AND RELEVANT IMPACTS ON HEALTH AND PUBLIC HEALTH

Jeremy Greene, Johns Hopkins University, provided an overview of the history of DEI legislation and where it exists in the national landscape. David Acosta, Association of American Medical Colleges (AAMC), David Allison, Indiana University School of Public Health—Blooming-ton, and Mark Lazenby, University of California, Irvine School of Nursing (UCI), offered their perspectives on the evolution and state of DEI legislation and policies and recent developments in the context of health professionals, education, training, research, and student and faculty impacts.

History of DEI Legislation

Greene provided a historical analysis of homogeneity, inequity, and exclusion in medical education, centering on the complex legacy of Abraham Flexner’s 1910 report on medical education. Flexner’s reforms standardized and improved medical education quality but

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also made it more expensive and exclusive, leaving just two of seven Black medical schools open and closing all women’s medical schools (Wright-Mendoza, 2019). Greene emphasized that while Flexner’s views on race were considered progressive for his time, the reforms he championed nonetheless caused a deliberate reduction in the diversity of the physician workforce and raised new barriers to equitable access to medical care for many people. He highlighted the current backlash across legislative, executive, and judicial branches against DEI in form (e.g., workforce diversity) and content (e.g., how DEI affects the nature of medical knowledge production). He cited recent examples where DEI in form has influenced DEI in content, as more inclusive cohorts of medical trainees came to challenge the use of racialized algorithms in pulmonology, nephrology, dermatology, OB/GYN, and critical care and their role in increasing racialized health disparities. Greene also analyzed the backlash to equity efforts, highlighting organizations like Do No Harm that characterize any attempt to address racialized health disparities as “woke medicine,” noting that these ideas can move quickly in the media and federal and state legislatures as soundbites, but they ignore substantial empirical basis regarding social determinants of health. He emphasized the importance of presenting evidence-based arguments for the value of DEI efforts in improving health care outcomes.

The Current State of DEI Legislation in Health Care

Acosta discussed challenges facing DEI initiatives in academic medicine, noting that resistance is not limited to laws alone but includes other significant factors, such as restrictions on women’s reproductive rights and gender-affirming care. He emphasized the importance of data collection and storytelling in demonstrating DEI’s value to all key stakeholders. Acosta also highlighted emerging trends in medical school enrollment, noting concerning decreases in underrepresented minority (URM) student numbers at several institutions. Given the potential for over-stating the scope of the laws, it will continue to be important to work closely with counsel to understand and comply with applicable legal requirements.

Allison emphasized the importance of empirical evidence in DEI work while acknowledging the role of feelings and morality in decision making. He shared his school’s success in increasing faculty diversity from 12 percent to more than 35 percent URM—making it one of the top four schools of public health nationally in this category. He attributes this to unwavering commitment rather than pro forma measures. He stressed the importance of strategic thinking in resource allocation and suggested focusing on assistant professor recruitment as a key leverage point for building diverse academic communities.

Lazenby provided perspective on DEI challenges within California’s legal framework, especially the impact on recruitment and admissions that Proposition 209 has had; it banned the use of race, ethnicity, national origin, or sex as criteria in admissions decisions since 1996. He described innovative approaches to maintaining diversity within legal constraints, including holistic admissions processes and curriculum changes to incorporate cultural competency. Lazenby also stressed how important it is to take a dual approach, addressing both student recruitment and faculty diversity. While student populations may reflect community demographics, he said, faculty representation often lags significantly behind.

Discussion

The panel discussion highlighted some of the current issues surrounding DEI legislation and its impact in the fields of medicine, nursing, and public health, innovative approaches and opportunities to advance DEI efforts in the respective fields, strategic approaches to messaging, perspectives on both short- and medium-term future outlooks for DEI accreditation standards, and strategies and approaches to consider when developing DEI initiatives.

Current State and Immediate Impacts

Across health care education disciplines, institutions are facing challenges to DEI. In nursing, Lazenby shared his experience in California, detailing how Proposition 209 has created significant barriers despite high admissions application numbers. His program at UCI receives 6,000–7,000 applications for just 50 slots, he said, yet struggles to achieve representative diversity. He emphasized that despite California being a majority-minority state, the nursing program’s demographics fail to reflect the population, with Hispanic representation under 20 per-

cent and Black representation at merely 5 percent. Most concerning to him was the complete absence of Hispanic tenured faculty (besides himself) in the nursing schools, despite the state’s 40 percent Hispanic population. Looking at public health education, Allison speculated about a potential troubling trajectory, characterizing it as a “regression to the mean” in diversity efforts. Institutions that have been investing both efforts and funds heavily in DEI may now be facing greater economic and political pressures that may constrain those efforts and financial resources.

Acosta provided a broader systemic perspective, introducing the concept of a “conglomerate effect” where multiple challenging factors are converging simultaneously. He emphasized that DEI legislation is not operating in isolation but rather combines with other restrictive policies that are concerning to some faculty physicians and residents on reproductive rights, gender-affirming care, and LGBTQIA+ issues. He presented early evidence of a “brain drain” in states like Florida and Texas and highlighted troubling trends in admissions in several undergraduate institutions that serve as medical school feeders, citing Massachusetts Institute of Technology’s dramatic drop from 15 to 5 percent URM representation as a warning sign that may have significant impact on ensuring a diverse health professions’ workforce for the future.

Innovative Solutions and Opportunities

Given these critical challenges, panelists described creative approaches to maintaining DEI progress within states being impacted by DEI legislation. Lazenby highlighted a multipronged strategy at UCI that includes working with undergraduate admissions to implement holistic evaluation processes. His program has introduced innovative requirements, such as community care statements from applicants, and developed pipeline programs targeting middle and high school students from underrepresented communities. Perhaps most significantly, it has secured alternative funding through partnerships with CalOptima Health and is developing metrics to demonstrate the impact of these initiatives on patient outcomes. For public health education, Allison introduced the concept of “enclaving”—a strategic approach to faculty recruitment that focuses on building supportive departmental communities rather than dispersing diverse faculty across departments. He argued that focusing resources at the assistant professor level rather than on expensive senior hires can create better mentorship opportunities and attract more diverse student populations. He also emphasized that success comes not from perfunctory efforts but from unwavering institutional commitment. In medicine, Acosta described how some U.S. MD-granting medical schools are leveraging accreditation requirements, particularly the Liaison Committee on Medical Education Element 3.3, to maintain workforce diversity efforts. It is important to continue developing alternative funding streams to support these efforts (e.g., through philanthropy and alumni giving), Acosta said, as many successful graduates are willing to support DEI initiatives that helped them succeed in their educational journey. He advocated for building broader coalitions across institutions to share resources and strategies, emphasizing the need for better data collection to demonstrate DEI’s impact on health care outcomes. Other suggestions included summer programs targeting students in underrepresented communities and developing forums for respectful dialogue between groups on various sides.

Strategic Approaches to Messaging

Allison shared a nuanced perspective on messaging and engagement that challenged conventional approaches within academic medicine. He emphasized the need for greater emotional intelligence in DEI advocacy, citing his personal experiences interacting with people holding opposing viewpoints. He said that his experiences with people ranging from professional scholars to fishermen, hunters, ride-share drivers, and weightlifters, to name just a few, led him to conclude that many who hold different views from many of those who favor DEI initiatives are not malicious but rather often have different value-based beliefs. To address this, he suggested a more compassionate approach to dialogue, acknowledging that the academic community’s tendency toward being “politically correct,” meaning we have good ideas, but not as open-minded of opposing viewpoints, sometimes prevents meaningful engagement. He specifically referenced the Open to Debate platform as a model for rational, respectful discussion of controversial topics.

Acosta focused on the practical aspects of messaging, emphasizing the need for medical schools and teaching hospitals to develop a narrative on the value and importance of DEI in achieving health equity for every community served. He argued that advocates cannot assume that key stakeholders, like legislators or the public, inherently understand the value of DEI and its importance, making it crucial to develop clear, evidence-based narratives that resonate at local, state, and national levels. He stressed the importance of moving beyond enrollment numbers to demonstrating evidence-based health outcomes, particularly in terms of health equity and patient care. Messaging needs to be customized for different audiences, he added, noting that what resonates with audiences in one state might not resonate in another.

Short- and Medium-Term Future Outlook

In thinking about the future, speakers offered suggestions to consider in the next 3–5 years and next 5–15 years. For the more near term, Lazenby predicted that nursing schools following the American Association of Colleges of Nursing accreditation standards will see improved curricula regarding culturally congruent care, regardless of state-level DEI restrictions. This improvement would be driven by the standards rather than legislation, he said, providing some protection against the latter. Acosta projected that within 5 years, clearer enrollment trend data would show the full impact of DEI legislation in some states. He particularly emphasized the need to watch faculty attrition patterns and their impact on patient care in affected states. Allison conjectured that short-term impacts might be counterintuitive due to political polarization, saying that legislation might actually re-energize DEI efforts by inspiring the DEI-supportive community, including grant reviewers, editors, and philanthropists, to greater efforts.

Thinking about medium-term projections, Lazenby predicted that initial curriculum improvements would lead to measurable patient outcome data after 10 years, demonstrating how diverse workforces improve care quality. By year 15, he anticipates more tenured Hispanic faculty across the country if pipeline programs prove successful. Similarly, Allison was hopeful that more sophisticated approaches to diversity would emerge, suggesting that the field might move beyond rigid categorical thinking about race and ethnicity toward more nuanced understandings of disadvantage and equity. He emphasized the potential to develop more inclusive frameworks that address multiple forms of diversity simultaneously, including religious, gender identity, and ability status. Acosta suggested that a new generation of health care professionals would emerge, primarily millennials and Generation Z, who are inherently more DEI conscious and could become strong advocates. He also saw the potential for better data collection and analysis to demonstrate impact and more sophisticated ways of demonstrating the value of DEI to all key stakeholders. Last, he saw an opportunity for stronger coalitions among institutions and specialty/sub-specialty disciplines and their societies to address ongoing health disparities. Throughout this medium-term outlook, Lazenby, Allison, and Acosta emphasized the critical role of accreditation bodies in sustaining DEI standards and the importance of developing alternative funding sources to support these efforts.

Protecting Faculty

A participant asked how to address faculty fears about speaking out given tenure system threats, and speakers responded with multiple strategies. Lazenby suggested embedding DEI work within a broader strategic plan and creating framework pillars that address DEI without explicitly mentioning it. Greene acknowledged this challenge and suggested advocating for bottom-up institutional support and training faculty to be intentional about their approach in both design and communication of their efforts to promote health equity.

ACADEMIC HEALTH INSTITUTIONS’ STRATEGIES AND APPROACHES FOR ADVANCING DEI

This section examined academic health institutions’ strategies in states that have been impacted by DEI legislation and institutions that have not been, seeking to understand strategies that they have employed to continue advancing DEI work. Speakers included Leon McDougle, Ohio State University; Tanya K. Hernandez, Fordham University; Bertha Hidalgo, University of Alabama at Birmingham; and Thomas LaVeist, Tulane University.

Stating the Value of DEI

McDougle emphasized DEI’s role in building “inclusive excellence ecosystems” that can provide competitive advantages in recruitment and retention and the curric-

ulum and education for cross-cultural care delivery. He also reiterated the importance of relationship-centered care across various levels and intersections, which can be improved and strengthened with racial concordance. Hernandez highlighted the importance of DEI for cultural competency in health care delivery. She argued that being “colorblind” by removing DEI initiatives is in itself a racial preference, not a neutral position. It is detrimental to our institutions, she declared, as it ignores the documented disparities and barriers while maintaining structural inequities. She cited research indicating that diverse teams were more likely to be higher performing, innovative, and achieve better outcomes. Last, Hernandez offered background reading on the research (71 UCLA Law Review Discourse 282, 2024).²

Hidalgo provided context for DEI within the legal framework of recent Supreme Court decisions and Alabama state Senate Bill 129, which prevents sponsoring DEI initiatives. Since it was just passed in 2023, the impacts remain unclear, she said, but it will be important to take a proactive approach through information gathering and communication to follow the effects. Historically, DEI has played a critical role in understanding how diversity can raise awareness of the systematic exclusion of people in spaces such as research and education. She shared the breakdown of postsecondary faculty based on data from the National Center for Education Statistics: 72 percent White, 13 percent Asian, 7 percent Black, and just 3 percent Latina women like herself.³ LaVeist added that U.S. demographics are changing, and he predicted by the middle of the 21st century, those currently thought of as “racial minorities” will be the majority. People served in public health institutions are disproportionately Brown and Black, he said, but the knowledge creators and generators are not. This leads to suboptimal interventions, since those producing the knowledge and interventions do not have sufficiently nuanced understanding of the communities they serve. As this transition continues, LaVeist argued, it should be a core competency requirement for public health professionals to understand the diversity of the population and the cultural differences in groups being served.

The Impact of DEI on Health Outcomes

Unpacking the effects of DEI on health outcomes, McDougle focused on Penchansky and Thomas’s Five As of access of public health. Specifically, he highlighted acceptability, with the challenge many LGBTQIA+ individuals have encountered. After being treated disrespectfully by providers, many are avoiding preventive care, he explained. Hernandez spoke from her perspective as a patient, citing the differences in care quality when a provider has some cultural competency training. The lack of a diversified workforce as a result of legal changes may mean adverse outcomes in populations already suffering, added Hidalgo. This can lead to additional distrust of the medical system and providers; without a diverse workforce, it is easy for people to feel isolated, misunderstood, and marginalized. Finally, LaVeist called for training and diversifying the workforce beyond just the clinician level. This can include even parking attendants and security guards, he said, as negative interactions during any part of the health care visit can lead to a poor experience at the institution even if the clinician provides competent care.

Strategies to Navigate the Current Environment and Changes to DEI

At Ohio State, McDougle noted, the changes have resulted in removing specific language directing scholarships to people within protected classes. It is shifted toward people who have a focus or history of involvement among those communities, with selection criteria based on types of descriptors versus identities. The Ohio attorney general has expanded the interpretation to include scholarships. This has also provided an opportunity to build more partnerships and coalitions in rural communities across the state because of the common interest, he said. Thinking about strategies to mitigate any adverse effects, he shared the experience engaging with government relations experts and other colleges and sharing core requirements from national associations, such as the Accreditation Council for Graduate Medical Education and the Joint Commission, to work on addressing inequities.

Hernandez said that the Supreme Court decision limits but does not outlaw affirmative action. She emphasized the continued institutional responsibilities under Title VI and VII and shared a report from the Leadership Confer-

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ence on Civil and Human Rights summarizing them.⁴ She advocated an interdisciplinary approach to legal compliance methods and suggested a report from the New York State Bar Association that highlights methods for advancing diversity.⁵

Hidalgo commended the University of Alabama at Birmingham for its commitment to an inclusive environment and suggested that institutions of higher education should perhaps focus on fostering and stimulating critical thinking staying true to the core tenets of higher education by teaching students how to think rather than what to think. She said that she believed that the core values of equity and inclusion can still be discussed, allowing for deep exploration of systemic issues while complying with legal limitations. She also underscored the ongoing theme of communication and ensuring information gathering is long and thorough. After robust research on the Supreme Court decision and potential bills, her office was able to articulate the changing legal landscape implications so that the impacts did not feel as sudden. Moving forward, she said, office hours are hosted for faculty that have questions. Last, her office had numerous conversations with legal counsel and university leadership, ensuring that they have the right information to be compliant.

While Louisiana hasn’t faced some of the legislative barriers at the state level just yet, LaVeist said the Supreme Court decisions have made Tulane take a closer look at the admissions process and student selection. Thus far, it has found no significant changes in the diversity of the student body, he said, but it remains vigilant in watching admissions and the state legislature for such effects. He echoed similar strategies from other speakers, such as in-service learnings for faculty about how to facilitate class discussions that are critical but not divisive. The university has also placed a lot of focus on pipeline programs and recruitment to maintain student diversity. Public health work inherently requires cultural competency, he argued, and as a global school, it sends students all around the world who will need to know how to function within different environments and cultures and not inflict harm. That type of training is critical to the coursework and program and will continue, he said, regardless of what is done with state law.

Discussion

The discussion among academic health institutions focused on tenure challenges and pipeline development for recruiting students. To oppose threats to tenure, McDougle emphasized the importance of faculty senate representation, and Hidalgo noted a pre-existing trend of reducing tenure availability at institutions. To address this in part, LaVeist described how Tulane recently modified its tenure criteria by requiring health equity impact statements that included DEI principles. This adds context for voters when they are deciding on tenure, he explained.

A participant asked about leadership pipeline development focused on building a health care workforce that reflects the diversity of the community it serves, particularly noting specific challenges of Asian American and Native Hawaiian Pacific Islander communities, who are often left out of conversations. The aggregation of Asian American data often sacrifices the community’s diversity, including the access needs for multiple languages. McDougle detailed Ohio State’s services for 107+ languages to support communication in its medical center but noted the challenges posed by the repeal of DEI initiatives. LaVeist emphasized the need for equity-minded individuals in leadership positions and noted how administrative power can effect change through resource allocation. For example, he was able to move university assets to Black-owned community banks to shift resource allocation in the community and also raised employee pay to a living wage. Last, Hidalgo emphasized the importance of recognizing heterogeneity and noted how challenges in Alabama actually led to increased partnerships between isolated institutions and departments. The interdisciplinary collaboration as a result of these challenges has allowed them to better address nuanced health care needs of their diverse stakeholders.

NATIONAL STUDENT ASSOCIATIONS’ PERSPECTIVES ON DEI LEGISLATION IN ACADEMIC HEALTH INSTITUTIONS

This session shared diverse perspectives from various National Student Associations on DEI legislation and academic health institutions. Speakers included Nina Uzoigwe, New York University Grossman School of Medicine,

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Student National Medical Association (SNMA), Andre Harris, University of Houston Graduate College of Social Work, National Association of Social Workers (NASW), and Ethan Slocum, Case Western Reserve University Frances Payne Bolton School of Nursing, National Student Nurses Association (NSNA).

DEI Culture Across Institutions and Impacts of Legislation

Uzoigwe shared her perspective as a 4th-year M.D./Ph.D. candidate and first-generation Nigerian American, reflecting on her journey from the only Black girl in a class of ~900 at Stuyvesant High School to her current role as cochair of the National Diversity Research Committee at the SNMA. Uzoigwe explained how the 2023 Supreme Court ruling on affirmative action has severely impacted DEI efforts, specifically in health care. She emphasized the critical timing of these setbacks, citing the AAMC’s projections of an 86,000-physician shortage by 2036 (AAMC, 2024, 2023). Uzoigwe noted that statistics show that although the makeup of the U.S. population is 13 percent Black, only about 5 percent of Black physicians are represented in the medical workforce (U.S. Census Bureau, 2024; AAMC, 2023). These racial disparities, Uzoigwe stated, demand attention due to the various ways they manifest in health care, yielding life- or-death consequences. The impact of these changes on the hundreds of SNMA chapters across universities has been substantial, she argued, with local chapters losing funding for community service programs addressing mental health, violence prevention, and organ donation education. These restrictions can affect everything from basic community-building activities, like pizza parties where students discuss daily challenges, to crucial career development opportunities through visiting clerkships.⁶

Harris brought a unique dual perspective as both a Ph.D. social work student and sickle cell disease advocate. He detailed the immediate and practical impacts of Texas Senate Bill 17, which took effect in September 2023 (Texas Senate Bill, 2023) and resulted in universities getting rid of DEI efforts. One of the first impacts seen at University of Houston was the closure of the LGBTQIA+ Resource Center, and DEI centers were reorganized into student advocacy centers. As part of these changes, many people were laid off, he added.

Slocum shared insights into the impacts in nursing education, noting that DEI legislation has not been passed yet at the state level in Ohio. But, looking at the national level, prohibitive DEI legislation reinstates many barriers (e.g., lack of financial, academic, and mentorship support) to entry for prospective minoritized nurses. He also echoed earlier comments about the importance of racial concordance and the connection between a diverse nursing workforce and the ability to provide quality patient care. Citing data from the Health Resources and Services Administration, he explained that the nursing field is 67 percent White, 11 percent Black, 9 percent Asian, 9 percent Hispanic, 4 percent Pacific Islander or multiple races, and less than 1 percent American Indian or Alaskan Native. This is contrasted with more than 40 percent of the U.S. population identifying as being from various racial and ethnic backgrounds. Slocum emphasized the critical nature of this misalignment, given nursing’s position as the largest patient-facing profession with 4.7 million practitioners.

Challenges and Areas for Opportunity and Support

Uzoigwe emphasized that these policies are not just affecting administrative processes but actively driving out racially and ethnically diverse physicians from a workforce already experiencing shortages, leading to quantifiable impacts on patient care and mortality rates. She reminded participants that racial concordance in health care delivery significantly improves outcomes, making these setbacks particularly concerning for community health.

Harris emphasized the particular challenge this presents for social work education, where DEI principles are intrinsically woven into the profession’s code of ethics. Providing examples of the law’s impact on academic operations, he shared how faculty members on dissertation committees have left, directly affecting Ph.D. students’ academic progress. As a personal example, he shared that his own work in sickle cell disease has been limited by these policies, as the American Red Cross can no longer explicitly target Black donors for sickle cell patients, despite the clear medical necessity because 90 percent of these patients are Black. In his administrative role, he also observed the rapid removal of racial justice principles from university websites and public documents, although

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the underlying principles remain crucial to social work education. Harris emphasized how the funding restrictions from state legislatures effectively tie the hands of university leadership, creating a situation where even supportive administrators are limited in their ability to maintain DEI initiatives. If they do not comply with the rule, university funding could be cut. He said that they have tried various methods to push back, including marching and picketing, but it does not necessarily change the outcome. He particularly highlighted the loss of safe spaces and support systems for marginalized students, noting that while students can still gather independently, the loss of institutional support creates significant barriers to community building and professional development.

Slocum described concerns emerging from his work with NSNA across the country where students propose and debate nursing policy resolutions. One of the key challenges he noted is the lack of standardization across curricula, resulting in inconsistent cultural competency education across states, which creates varying levels of preparedness for patient care. A divide is emerging relating to a gap in education on a variety of issues, he said, including reproductive rights, trauma-informed care, support for populations experiencing homelessness, and LGBTQIA+ education across states. Slocum stressed that these challenges not only affect current education but have long-term implications for health care delivery and patient outcomes, particularly in underserved communities.

Future Needs for Students

Harris suggested the importance of understanding the DEI issues that students are tasked to address (e.g., learning to work collaboratively with peers of different backgrounds and cultures in preparation for serving various populations), because people in legislatures, state houses, and Congress also need to advocate for these issues from the perspective of the code of ethics with the NASW lens, to think about how policy impacts people. He said while policy informs practice and vice versa, people now only view the practice as informing policy. Social workers rely on clinical and cultural competency, said Harris, and this requires a framework of DEI, which is impossible to talk about without acknowledging CRT. CRT provides a framework of understanding government processes and how policies have emerged, and that institutions and structures are inherently racist.

Uzoigwe also emphasized the importance of having physicians, medical students, residents, and resident attendings engage with literature, such as Medical Apartheid by Harriet Washington and Legacy by Uche Blackstock, that highlights how current practices in medicine perpetuate systemic racism. She noted that this issue often lacks sufficient focus and that it is crucial for students to reflect on past shortcomings and ongoing practices that continue to lead to suboptimal patient outcomes. Slocum called for more engagement of students when academic leaders are trying to mitigate the adverse effects of DEI legislation, as they are the ones directly impacted.

Discussion

During the discussion, speakers touched on supporting URM students, addressing systemic barriers and ways to continue advocating. Uzoigwe highlighted the work of SNMA through events to provide resources and mentorship to help minoritized students overcome barriers, such as the “leaky pipeline” in education, resulting in lower levels of them at higher levels of education. Thinking about systemic barriers, Harris stressed the importance of educating health professionals on the impact of language. Uzoigwe emphasized that open discussions and programming are important to address barriers, such as hidden curricula (i.e., unwritten and unofficial lessons, values, and perspectives that students learn in classrooms that are not explicitly part of the curriculum. An example is reinforcing gender stereotypes in career aspirations), that perpetuate inequities. Collaborating at the national level can continue to advance initiatives, as Slocum described engagements with other national health care associations to foster interdisciplinary collaboration. Uzoigwe suggested offering support for premedical and medical URM students to engage and network at local, regional, and national conferences to help improve representation in the health care workforce.

THE IMPACT OF DEI LEGISLATION IN HEALTH PROFESSIONS ACCREDITATION AGENCIES

Speakers provided background on their organizations and insights from the accreditation perspective. William McDade, Accreditation Council for Graduate Medical Education (ACGME), explained that it is the single accreditor for graduate medical education programs, with a connection to $22 billion in annual Centers for Medicare and Medicaid Services (CMS) funding and board certification

requirements. Barry Eckert, Commission on Accreditation of Allied Health Education Programs (CAAHEP), shared that it oversees 31 allied health professionals with standardized accreditation templates. Last, Laura Rasar King, Council on Education for Public Health (CEPH), said that it is a voluntary organization but has been accrediting public health programs for 50 years.

Guidance for Institutions

To provide guidance for institutions affected by DEI legislation, McDade detailed ACGME’s requirement 1C, which mandates systematic approaches to diversity and inclusion, emphasizing its continuation even after the Supreme Court decision. He highlighted its “Equity Matters” program⁷ and upcoming resource collection featuring 104 vetted initiatives. Eckert described CAAHEP’s strategic use of general language in its standards, emphasizing alignment with university mission statements as a key strategy for navigating DEI challenges. He noted that this approach helps programs maintain compliance while avoiding political controversy. King outlined CEPH’s comprehensive approach through two main channels: broad diversity standards addressing institutional climate and specific curriculum requirements addressing structural inequities. She emphasized its flexible compliance pathways and described how it works individually with institutions to navigate state law constraints while maintaining accreditation standards.

Value of Accreditation and Impact on Health Care Quality

Speakers also discussed how accreditation can play a role in improving health care quality. McDade identified the elimination of health disparities as the fundamental goal when improving health care outcomes, explicitly linking quality care to equitable care. He argued that accepting health disparities contradicts claims of delivering highest-quality care. Eckert emphasized accreditation’s dual purpose of quality assurance and program improvement, particularly highlighting the importance of maintaining national consistency amid varying state DEI laws. He expressed concern about potential divergence in educational quality across states due to differing DEI restrictions. King highlighted the unique value of incorporating both academic and practitioner perspectives in standards development, emphasizing how this dual input ensures relevance to the current practice needs. She also highlighted a regular revision cycle as a key element to maintaining current, practice-relevant standards.

Noncompliance with Standards and Institutional Impact

McDade detailed ACGME’s nuanced approach to compliance assessment, describing its progressive system from “continuous accreditation” through warning stages to potential withdrawal. He emphasized the serious implications of probationary status for institutions, including recruitment restrictions and mandatory applicant notifications. He highlighted the financial impact through loss of CMS funding and the critical consequence of graduates’ ineligibility for board certification. Eckert also described the cascading effects of accreditation issues, emphasizing how reputational damage affects student recruitment quality, board pass rates, and clinical placement opportunities. He noted how these factors can create a “vicious cycle” of declining program quality. King, while acknowledging public health accreditation’s voluntary nature, emphasized its normative role in the field and described a collaborative approach to achieving compliance. She also agreed that loss of accreditation can significantly impact student recruitment and practicum placement opportunities, even in unlicensed fields.

Impact of DEI Legislation on Health Education and Training

McDade provided extensive analysis of how removing DEI offices affects institutional support systems, particularly highlighting the impact on learning disability assessments and standardized testing accommodations. Economic disparities affect early learning disability diagnosis, he noted, creating downstream effects in medical education. He cited ACGME data showing disproportionate dismissal rates for Black compared to White residents and described how negative training experiences discourage minoritized physicians from pursuing academic medicine careers. Eckert emphasized how reduced DEI support affects students’ preparation for diverse practice environments, expressing concern about all graduates’ readiness to serve diverse populations effectively. King described an emerging “chilling effect” on faculty and curriculum delivery, citing specific examples of professors refusing to teach health disparities courses due to concerns about new legislation. She noted early impacts on admissions demographics while emphasizing that full workforce impacts remain to be seen. Speakers empha-

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sized the interconnected nature of DEI support, educational quality, and health care delivery outcomes.

Discussion

The panel discussion focused on cross-program learning, the disconnect with programs to emerging state laws, and the flexibility of accreditation standards. A participant asked panelists about nonmedical programs learning from medical programs’ DEI compliance strategies. McDade emphasized that many strategies in their Equity Matters collection, such as cluster hiring,⁸ are universally applicable across academic disciplines. Eckert suggested sharing faculty resources and strategic language shifts, such as focusing on “access to health care” rather than “workforce diversity.” King highlighted existing cross-professional learning through the Association of Specialized and Professional Accreditors.

When challenged about potentially not allowing programs to comply with DEI state legislation, panelists offered nuanced responses. King emphasized the importance of understanding specific state law details and carve-outs, stating that accreditors cannot force institutions to violate state laws. Eckert warned about the “trickle-down effects” on students, faculty, and communities if institutions purposefully become noncompliant. McDade drew parallels to other challenging situations, such as gynecology training after Roe v. Wade, noting that while requirements remain unchanged, programs can find creative compliance solutions.

Last, there were important clarifications about accreditation standards. Eckert noted that attorneys general appear less inclined to fight accreditation standards than DEI as a general topic, and King emphasized that none of their agencies had changed their standards in response to new state or federal laws. Various panelists agreed that while compliance demonstration methods may vary, their fundamental standards for accreditation remain consistent and enforceable.

MINORITY-SERVING INSTITUTION (MSI) PERSPECTIVES AND STRATEGIES ON SUSTAINING DEI

This session explored faculty perceptions at MSIs, including lessons and strategies for sustaining DEI. Speakers included Valerie Montgomery Rice, Morehouse School of Medicine; Quinn Capers, IV, Howard University; Kent Smith, Oklahoma State University, Center for Health Sciences (OSUCHS); and Iveris Martinez, California State University, Long Beach.

Key Challenges

Outlining some of the key obstacles and challenges to promoting DEI within institutions, Rice said that although Morehouse does not face racial diversity challenges, inclusion still remains key. For example, she highlighted the tendency for research labs to self-segregate often based on nationality or ethnicity and stressed the need to address unconscious biases at both the leadership and grassroots levels. Inclusion can mean being uncomfortable, she said, but also helps solve difficult problems. These uncomfortable conversations are important and necessary for growth. Smith added that he personally experienced the challenge of a lack of a broad and deep awareness and understanding of DEI among university leadership and the overall institutional community. The journey to having a dedicated DEI office at OSUCHS took 15 years, he said, but people have been welcoming in creating these spaces for underrepresented medical students.

Capers shared the experiences of legal prohibition of DEI offices or even diversity statements. As an example, in Texas, he said, you cannot ask a potential job candidate about their plans to promote diversity and inclusion. It is an illegal question, which demonstrates some of the barriers being encountered. He also highlighted the importance of implicit bias trainings to help people understand some of the unconscious associations their mind may make. But states that have passed these types of DEI legislation prohibit certain trainings, which can have an important effect on talking about racism and the impacts on health. Capers also cautioned just rebranding an office name, as people in state legislature can request meeting minutes to audit and will look closely to ensure everything at those meetings is in compliance.

Martinez shared that at her university, 50 percent of students are Latino/a, and 25 percent are Asian—numbers that are largely representative of their community in Southern California. But only 11 percent of tenure-track and tenured faculty are Latino/a, she said, and even fewer are Black. Although many faculty have not thought it is their role to create inclusive environments, she said, the university’s pipeline programs are designed to

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accommodate students with competing needs, including jobs and intergenerational family responsibilities.

Strategies for Sustaining DEI

In terms of strategies moving forward, Martinez highlighted several programs focused on first-generation and lower-income students succeeding in college education, where they acknowledge challenges and provide support. However, she noticed that the medical school had a mission to increase diversity but did not provide enough support services. To build diversity in the research process, it established faculty equity advocates to mitigate bias, encouraging job searches to be more equitable and go beyond people that the investigators already know. To address the equity and inclusion challenges at Morehouse, Rice said that it is seeking to understand what incentivizes young people to be interested in health care and biomedical careers. In Georgia, she explained, 149 of the 159 counties are medically underserved, and approximately 15 of those have never graduated someone who has gone on to medical school. With this in mind, Morehouse focuses on pipeline programs, getting students interested in science, and being intentional about where it recruits and generates interest based on needs in the community. Smith highlighted sustainability as a key strategy for recruitment and being intentional in hiring—including more URM positions in administration and as decision makers. He said that OSUCHS also has several pathway programs to reach out to younger students using peer and near-peer mentorship. For example, it started a program in 2010 with the Chickasaw Nation, and in 2025, he will see one of the initial middle schoolers graduate with a Ph.D. in STEM. Faculty need to be intentional in recruiting people and developing programs, he emphasized. Capers agreed with Smith on the importance of student programs and mentorship and reiterated the importance of looking deep into the supply chain for building the workforce. He shared a study asking third graders what they wanted to be when they grew up; equal proportions of races reported wanting to be a doctor, but Hispanic girls and Black boys were significantly less likely to say that when asked again in eighth grade. So even high school programs might be too late to start talking about recruitment and pathways, he said. Capers also suggested being transparent and open about having a diverse patient population, even at majority institutions, as that can be a tool for recruiting URM faculty who want to serve their communities.

Navigating the Legislative and Policy Landscape

On the surface, legislative changes have forced a renaming of the official DEI office, said Smith, but its mission remains the same. He emphasized its focus on recruiting and training URM students and is pleased to note that the proportion of them in residency programs continues to be strong. Martinez also highlighted a rebranding, to the Office of Belonging and Inclusion. She noted the National Institutes of Health diversity statement that is still in place and can act as a guide and the funding opportunities available to diversify the workforce. Opportunities still remain to fund programs that address issues important to DEI, she said, in addition, there needs to be intention in collecting data and showing the impact of the programs on health equity.

Discussion

In response to a question by a participant regarding the value of Historically Black Colleges and Universities (HBCUs) and rhetoric seeking to diminish their historical significance, Rice emphasized their necessity and the importance of cultural sensitivity and awareness in education, even in an integrated society. Capers noted the evidence-based argument for the importance of HBCUs and data showing their disproportionate role in producing professionals. He mentioned clear results showing HBCUs transforming society: despite only making up one tenth of colleges, they are responsible for a large percentage of engineers, lawyers, doctors, etc.

A participant asked about Asian American and Pacific Islander representation, as people of that descent are often underrepresented in medicine, yet these communities also have numerous health inequities that need to be addressed. Rice highlighted the partnership created between Morehouse School of Medicine and Common Spirit Health to build regional medical campuses and recruit students from Asian American and Pacific Islander populations to increase providers in those communities that need them. Martinez emphasized disaggregated “Asian” populations, given many diverse groups included in that category that have different issues. She suggested adding inclusive cultural celebrations alongside traditional milestones, such as graduation, to help families celebrate in their own way and feel included.

FINAL REMARKS

Participants were also provided a viewing of the film Power to Heal, produced by Barbara Berney,⁹ retired associate professor at the City University of New York School of Public Health. She explained that the film’s mission was to share the historic struggle to secure equal access to health care for all people in the United States and how Medicare played a critical role in hospital desegregation across the country. She emphasized that progress on equity often faces backlash and noted the need for continued attention on advancing health equity. Women’s representation in medical schools has reached 50 percent, she acknowledged, but racial diversity has not changed significantly. Organizing and fighting for equal rights are essential for creating change, concluded Berney.

In closing, planning committee and roundtable member Reginald D. Tucker-Seeley, principal and owner of Health Equity Strategies and Solutions, reviewed takeaways from the various panels and discussions. He emphasized the role of deans in setting initiatives and the challenges of addressing misinformation and balancing impact versus intention. Similarly, thinking about academic health institutions, Tucker-Seeley reiterated the importance of workforce diversity beyond the physician workforce, but the need for a comprehensive DEI approach across all health care staff. For student leaders, he highlighted the importance of cross-disciplinary perspectives and acknowledged the impact of DEI office closures on student safety and support. Tucker-Seeley also underscored the value of accreditation boards in ensuring consistency across education programs and the importance of such efforts in eliminating health disparities. He stressed the comments from speakers that input from the practice community needs to be incorporated in the accreditation process, and flexibility in implementing DEI standards to allow for unique needs of institutions. Last, he agreed on the importance of representation at MSIs and the significance of personal lived experiences. DEI is not a zero-sum game, he said, and complex systems thinking at multiple levels is required for success. Managing the sustained backlash against initiatives will continue to be a challenge, but it is critical to continue to work toward health equity for both patients and the workforce and develop health care systems that provide the right support where needed.

References

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DISCLAIMER: This Proceedings of a Workshop—in Brief has been prepared by Megan Snair and Ronique Taffe as a factual summary of what occurred at the meeting. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution. Planning committee members included Winston Wong (Chair), Kaiser Permanente UCLA Center for Health Equity; Yvette Calderon, Icahn School of Medicine at Mount Sinai; Ned Calonge, University of Colorado; Kendall M. Campbell, University of Texas; Luther T. Clark, Merck & Co., Inc; Mario R. De La Rosa, Florida International University; Kristi C. Guillory, Kristi Guillory Reid Enterprises LLC; Aletha Maybank, American Medical Association; Melissa A. Simon, Northwestern University; and Reginald D. Tucker-Seeley, Health Equity Strategies and Solutions.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Wasiuddin Najam, Indiana University—Bloomington, and Mytien Nguyen, Yale University. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop was partially supported by Blue Shield of California Foundation; Department of Veterans Affairs (36C10X24P0057); and Merck.

STAFF Ronique Taffe, Roundtable Director; Rose Marie Martinez, Senior Board Director; Y. Crysti Park, Program Coordinator.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/43784_10–2024_exploring-the-changing-diversity-equity-and-inclusion-legislation-and-policy-landscape-and-its-impact-on-health-and-public-healths-workforce-education-training-and-research-a-workshop.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2025. Exploring the changing diversity, equity, and inclusion legislation and policy landscape and its impact on health and public health’s workforce, education, training, and research: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/29075.

Health and Medicine Division Copyright 2025 by the National Academy of Sciences. All rights reserved.