Achieving Health Equity

Dr. Y. Tony Yang is an endowed Professor of Health Policy and Associate Dean of Health Policy and Population Science at the George Washington University in Washington, D.C. He holds a position on the AcademyHealth Education Council and serves on the Board of Directors for The American Society of Law, Medicine and Ethics.

• Foreword xvAcknowledgment xvii1 Empowering Marginalized Communities: Legal and Policy Levers for Health Equity 11.1 Navigating Law, Policy, and Health Inequities 11.2 The Purpose and Importance of Examining Health Equity Through Law and Policy 21.3 Key Concepts and Definitions 31.4 An Ecosystem Approach to Health Equity Law and Policy 41.5 An Urgent Imperative 51.6 Conclusion: A Roadmap for Equitable Policy Change 5References 6Part I Health Care: Examining Access and Quality 92 Narrowing Health Access Disparities: The Affordable Care Act and Medicaid Expansion 112.1 Health Disparities and Insurance Coverage in America: A Century of Change 122.2 The ACA’s Mechanics and Effectiveness 132.2.1 How Did the ACA Increase Health Insurance Coverage? 132.2.2 The ACA’s Effectiveness 142.3 Ramifications of an ACA Repeal 142.4 Conclusion: The ACA’s Impact on Health Equity Amid Ongoing Challenges 15References 173 Tackling Insulin Affordability: Addressing Systemic Failures and Policy Solutions 193.1 Insulin Affordability: Progress, Disparities, and the Need for Systemic Change 203.2 State Initiatives on Insulin Affordability: An Overview 213.2.1 State-Mandated Diabetes Coverage: Benefits and Limitations 223.2.2 State Copay Caps: Limited Impact and Scope 223.2.3 State Insulin Safety Net Program: A Limited Solution 223.2.4 Biosimilar Insulin: Interchangeability, State Initiatives, and Challenges 233.3 Federal Efforts and the Inflation Reduction Act for Insulin Affordability 233.4 Policy Recommendations 243.5 Conclusion: Addressing Systematic Failures for Equitable Insulin Access 26References 264 Ensuring Equitable Healthcare: Overcoming Language Barriers Through Policies 294.1 Challenges and Implications of Language Barriers in Healthcare 304.2 Federal Laws Addressing Language Needs in Healthcare 314.2.1 Federal Authority and Related Standards and Guidance 314.2.2 The Affordable Care Act 324.2.3 Additional Federal Laws and Funding 334.3 State Initiatives 334.4 Recent Developments and Practical Challenges 344.5 Conclusion: Charting a Path to Linguistically Inclusive Healthcare 35References 365 Confronting the US Maternal Mortality Crisis: Addressing Racial Disparities 395.1 Racial Disparities Fuel US Maternal Mortality Crisis 405.2 Preventable Deaths: Addressing Systemic Barriers via Policy 415.2.1 Federal Initiatives: Driving Change in Maternal Health 415.2.2 State-Level Initiatives: Medicaid Expansion and Targeted Interventions 425.3 Overcoming Fragmentation: Collaboration and Bias Training 445.4 Conclusion: Strengthening Legislation: Equity-Focused Interventions 45References 456 Mitigating Algorithmic Bias in Healthcare AI for Equitable Care 476.1 Addressing Algorithmic Bias in AI to Ensure Fair Healthcare 486.2 Legal Landscape and Challenges in Regulating Algorithmic Bias in Healthcare AI 486.3 Collaborative Efforts to Address Algorithmic Bias in Healthcare AI 496.3.1 Enhancing Data Quality and Diversity to Address Algorithmic Bias 506.3.2 Regulatory Oversight and Transparency in Medical AI Development and Implementation 506.3.3 Diverse Teams and Inclusive Datasets: Strategies for Mitigating Algorithmic Bias 516.4 Conclusion: Overcoming Challenges in Addressing Racial Bias in Medical AI 52References 537 Confronting Inequities in the US Organ Transplant System 557.1 Inequities in Organ Transplantation Disproportionately Affect Communities of Color 567.2 Barriers to Specialist Referrals and Data Gaps Perpetuate Inequities 577.3 Race-Based Clinical Policies Hinder Equitable Waitlist Placement 577.4 Waitlist Policies Favor Socioeconomically Advantaged Patients 577.5 Communication Barriers and Resource Limitations Hinder Diverse Organ Donation 587.6 Provider Bias and Insurance Disparities Impede Black Patients’ Transplant Access 587.7 OPTN Mandates Race-Neutral Transplant Eligibility Calculations 587.8 Recommendations for Improving Equity at Each Stage of the Transplant Process 597.9 Discrimination Based on Disability in Organ Transplantation Persists 607.10 A Comprehensive, Multistage Approach for Equitable Organ Allocation 60References 618 Transforming Blood Donation: Path to Inclusivity and Science-Based Guidelines 658.1 Updated FDA Blood Donation Guidelines Promote Inclusivity and Safety 668.2 The Evolution of FDA Blood Donation Policies for Men Who Have Sex with Men 678.3 Challenging the Constitutionality of FDA’s MSM Blood Donation Policies 688.4 FDA’s New Guidelines Combat Stigma and Promote Inclusivity 708.5 Conclusion: Rebuilding Trust and Encouraging Inclusive Blood Donation 70References 719 Addressing Barriers and Disparities in Clinical Trials: FDA’s Diversity Plan 739.1 Enhancing Diversity in Clinical Trials: Addressing Barriers and Disparities 749.2 Legislative and Regulatory Efforts to Enhance Clinical Trial Diversity 759.3 Potential Impact of Diversity in Clinical Trials on Medical Outcomes 769.4 Limitations and Challenges in Enforcing Diversity Requirements 779.5 Strategies to Increase Access and Participation in Clinical Trials 779.6 Incentives and Post-Approval Requirements to Promote Diversity 789.7 Conclusion: Future Steps and Expanding Diversity Efforts 78References 7910 Strengthening the Safety Net to Mitigate Reproductive Health Inequity After Dobbs 8310.1 Reproductive Health Inequities Post-Dobbs 8410.2 Maternal Health Inequities Deepen Post-Dobbs 8510.3 The Critical Role of Safety-Net Providers 8610.4 Advancing Equity Through Research 8810.5 Conclusion: Advancing Equity Amid Reproductive Crisis 89References 8911 Advancing Mental Health Equity Through Policies 9311.1 Disparities in Mental Health Care 9411.2 Major Shifts Needed 9511.3 Addressing Root Causes 9611.4 States as Laboratories for Innovation 9711.5 Conclusion: Urgency for Mental Health Reform 98References 99Part II Health Behaviors: Exploring the Influences of Exercise, Diet, and Drug Use 10312 Promoting Physical Activity: Policy Strategies for Equity and Engagement 10512.1 Tackling the Global Inactivity Crisis: WHO’s Action Plan for a Healthier World 10612.2 Addressing Inequities in Physical Activity: Inclusive Strategies and Community Engagement 10612.3 Implementing Inclusive Health Equity Strategies: CDC Guidelines and Community Examples 10712.4 Leveraging Legal Strategies and Policy Domains to Promote Physical Activity and Address Inequities 10812.5 Conclusion: Overcoming Challenges in Promoting Physical Activity for Youth of Color 110References 11013 Reducing Sugary Beverage Consumption: Regulatory Measures 11313.1 Consequences of Sugary Drink Consumption 11413.2 Factors Driving Sugary Drink Consumption Disparities in Communities of Color 11413.2.1 Sugary Drink Consumption Disparities Among Racial and Ethnic Groups 11413.2.2 Targeted Marketing of Sugary Drinks to Minority Youth 11513.2.3 Limited Access to Healthy Options in Minority Neighborhoods 11513.3 Limitations of Current Policies Addressing Sugary Drink Consumption 11613.4 Policy Strategies for Reducing Sugary Drink Consumption 11713.4.1 A National Sugary Drink Tax: Recommendations and Considerations 11713.4.2 Promoting Healthier School Meals and Reallocating Agricultural Subsidies 11813.5 Conclusion: A Comprehensive Approach to Reducing Sugary Drink Consumption 118References 11914 Promoting Health Equity via Tobacco Control 12314.1 Tobacco-Related Disparities 12414.2 Strategies for Policy Interventions to Foster Health Equity 12514.2.1 Implementation of Smoke-Free Laws 12614.2.2 Investment in Anti-tobacco Education and Ad Campaigns 12614.2.3 Investment in Tobacco Cessation Programs 12614.2.4 Increase in the Cost of Tobacco Products 12714.2.5 Regulation of Tobacco Product Sales 12714.2.6 Raising the Minimum Age for Tobacco Purchases 12714.2.7 Strengthening Enforcement 12714.3 Strategizing Policy Implementation to Enhance Health Equity 12714.3.1 The Comprehensive Approach 12814.3.2 Minimizing Unintended Consequences 12814.3.3 Promoting Investment in Tobacco Control 12814.4 Conclusion: Achieving Equity in Tobacco Control 129References 13015 Tackling the Overdose Crisis Through Equitable Harm Reduction Policies 13315.1 The Need for an Equity-Centered, Harm Reduction Approach 13415.2 Expanding Access to Naloxone 13515.3 Providing Safer Use Supplies and Services 13515.4 Expanding Access to Evidence-Based Treatment 13615.5 Addressing Structural Determinants and Promoting Health Equity 13615.6 Investing in Community Development 13715.7 Reforming the Criminal Justice System 13715.8 Addressing Stigma and Misconceptions 13715.9 Enhancing Data Collection and Oversight 13815.10 Conclusion: Leveraging Resources and Centering Equity in the Fight Against the Opioid Crisis 138References 14016 Confronting the HIV/AIDS Epidemic: Progress, Challenges, and the Path Forward 14316.1 Ending the HIV Epidemic: Addressing Social Disparities and Ensuring Access 14416.2 Addressing Social Determinants: Key to Ending HIV Inequities 14416.3 Effective HIV Prevention: Education, Access, and Comprehensive Strategies 14516.4 Government Response: Progress and Persistent Challenges in HIV Policy 14616.5 Dismantling HIV Discrimination: Reforming Laws and Addressing Stigma 14716.6 Conclusion: Addressing HIV/AIDS Inequities, Ensuring Care for All 148References 149Part III Social and Economic Factors: Education, Income, Rurality, and Structural Racism 15317 Addressing Food Insecurity: Strengthening Assistance Programs and Promoting Equity 15517.1 Food Insecurity, Health Risks, and COVID-19: Exposing Systemic Inequities 15617.2 Federal Food Assistance 15617.2.1 SNAP and Temporary Relief Efforts 15717.2.2 Food Assistance Programs for Children and the Elderly 15717.3 Strategies for Enhancing Food Assistance Programs Amidst Challenges 15817.3.1 Evaluating Food Assistance Programs for Equity and Efficiency 15917.3.2 Improving SNAP: Tackling Barriers and Benefit Adequacy 16017.3.3 Strengthening Food Assistance: Expert Recommendations 16017.4 Conclusion: Transforming Food Assistance for a Resilient Future 161References 16118 Promoting Access to Early Care and Education: Anti-Racist Policies 16518.1 Early Care and Education 16618.2 Head Start and Early Head Start 16718.3 Child Care Development Fund 16718.4 Additional Federal Programs 16818.5 Addressing Structural Issues in Childcare Provision 16918.6 Conclusion: Enhancing Childcare Policies for Better Outcomes 169References 17119 Enacting Paid Family Leave for Health Equity 17519.1 Barriers to Equitable Paid Family Leave in the United States 17619.2 The Impact of Paid Leave Policies on Vulnerable Workers and the Far-Reaching Benefits for Health and Equity 17619.3 Designing Effective and Equitable Paid Family Leave Policies: Key Strategies for Inclusivity and Uptake 17719.4 Conclusion: Paid Leave: A Crucial Step Toward Health and Economic Equity 179References 17920 Enhancing Rural, Remote, and Tribal Health Equity Through Policies 18120.1 Challenges Facing Rural, Remote, and Tribal Health 18220.2 Advancing Rural and Tribal Health Equity Through Federal Policies 18320.3 State-Level Policy Trends 18420.4 Remaining Gaps and Recommendations 18620.5 Conclusion: Seizing Opportunities, Achieving Equity 187References 18821 Addressing Medical Debt on Marginalized Communities: Potential Reforms 19121.1 The Burden and Disproportionate Impact of Medical Debt 19221.2 Government’s Role in Addressing Medical Debt Disparities 19221.2.1 The No Surprises Act: Protections, Limitations, and Enforcement 19321.2.2 Medicaid Expansion and Enrollment Adjustments Reduce Medical Debt 19321.2.3 Expanding Appeal Rights and Funding Consumer Assistance Programs 19421.2.4 State Laws Surpassing Federal Protections and Ensuring Affordable Care 19421.3 Legislative and Policy Initiatives to Mitigate Medical Debt 19421.3.1 Arizona Ballot Initiative: Reforming Medical Debt Collection Practices 19521.3.2 Challenges of Medical Debt Cancellation Proposal 19521.3.3 Provider Interactions, Cost Controls, and Insurance Reforms 19521.3.4 Remove Medical Debt from Credit Reports 19521.4 Conclusion: Key Considerations for Policymakers 197References 19722 Preserving Diversity: Impact of Affirmative Action Ruling on Healthcare 20122.1 Supreme Court Ruling Threatens Diversity in Healthcare Education 20222.2 The Importance of Diversity in Healthcare 20222.3 Impact of Overturning Affirmative Action 20322.4 Maintaining and Improving Diversity Post-ruling 20422.4.1 Rethinking Merit and Applicant Evaluation 20422.4.2 Proxies and Race-Neutral Alternatives 20422.4.3 Invest in Pipeline Programs and Partnerships 20522.4.4 Revamp Recruitment and Yield Activities 20522.4.5 Reimagine Curriculum, Climate, and Inclusion 20622.4.6 Leadership, Accountability, and Collaboration 20722.5 Conclusion: Urgent Strategies Needed to Protect Diversity in Healthcare Education 207References 20823 Reforming the Public Charge Rule for Immigrant Health Equity 21123.1 Barriers to Immigrant Healthcare Access: The Public Charge Rule’s Impact 21223.2 Comparing Trump and Biden Public Charge Rules 21323.2.1 Defining Public Charge 21323.2.2 Difference in Application 21323.3 The Chilling Effect: Immigrant Hesitancy to Access Public Benefits Despite Policy Changes 21423.4 Limited Policy Solutions to Address Immigrant Distrust and Expand Access to Benefits 21523.5 Strategies to Rebuild Trust and Increase Immigrant Access to Public Benefits 21623.6 The Need for Legislative Action to Provide Certainty and Stability for Immigrants 216References 21624 Promoting Health in All Policies (HiAP) Approach 21924.1 Integrating HiAP: A Strategic Approach to Achieving Health Equity 22024.2 Legal Frameworks Facilitating Multi-sector Collaboration for HiAP 22124.3 Establishment and Impact of California’s HiAP Task Force 22124.4 Strategies for Enhancing and Sustaining HiAP Initiatives 22224.5 Challenges and Strategic Insights for Implementing HiAP Amidst a Pandemic 22424.6 Conclusion: Lessons and Challenges in Implementing HiAP 224References 22525 Rethinking Preemption for Health Equity 22725.1 The Double-Edged Sword of Preemption in Public Health Regulation 22825.2 Preemption During the COVID-19 Pandemic: Challenges and Consequences 22925.3 Preemption’s Disproportionate Impact on Vulnerable Populations and Inequities 22925.4 Conclusion: Toward an Equity-First Preemption Framework 231References 23326 Achieving Health and Economic Equity Through Broadband Access and Policy 23526.1 Broadband: A Crucial Determinant of Health Equity 23626.2 The Digital Divide: Perpetuating Systemic Inequities 23726.3 Lawmakers’ Role in Achieving Equitable Broadband Access 23726.3.1 Federal Efforts to Support Broadband Access and Digital Equity 23826.3.2 State-Level Strategies for Promoting Digital Equity 23826.3.3 Local Initiatives Addressing Community-Specific Digital Needs 24026.4 Conclusion: A Public Value Essential for Health and Economic Equity 240References 24127 Expanding Vaccine Equity: Policy Strategies 24527.1 Vaccine Inequity: Disparities in Access and Health Outcomes 24627.2 Government Efforts to Address Vaccine Inequity: Successes and Challenges 24727.3 Addressing Persistent Vaccine Inequities: Proposed Solutions and Global Efforts 24927.4 Federalism and Vaccine Inequity: Challenges, Criticisms, and Federal Efforts 25027.5 Data Gaps: Hindering Efforts to Address Vaccine Inequities 25127.6 Conclusion: Addressing Vaccine Inequity: Lessons, Strategies, and a Call to Action 252References 25328 Disaggregating Data: Unveiling the Diversity and Disparities Within the AAPI Population 25528.1 Diversity and Disparity: The Complexity of AAPI Data Aggregation 25628.2 Model Minority Myth: Masking AAPI Health Disparities Through Aggregation 25728.3 State-Led Initiatives: Advancing AAPI Data Disaggregation Amid Federal Inconsistency 25828.4 Barriers to Disaggregation: Sample Sizes and Community Opposition 25928.5 Conclusion: Disaggregation Imperative 259References 261Part IV Physical Environment: The Role of Housing, Transit, Water, and Climate Change 26529 Achieving Health Equity Through Housing Laws and Policies 26729.1 Housing and Health: The Impact of Segregation 26829.2 How Laws and Policies Post-fair Housing Act Have Furthered Residential Segregation 26829.2.1 The Low-Income Housing Tax Credit 26829.2.2 Nuisance Ordinances 26929.2.3 Rent Control 26929.2.4 Housing Choice Voucher Program 27029.2.5 Zoning Laws 27029.3 Positive Legal Interventions 27129.3.1 Land Banks 27129.3.2 Inclusionary Zoning 27229.3.3 Earned Income Tax Credit 27229.3.4 Other Policy and Legal Interventions 27229.4 Conclusion: Addressing Residential Segregation for Better Health 273References 27530 Advancing Transportation for Health Equity Through Policies 27730.1 The State of Transportation Inequity 27830.2 An Agenda for Transportation Justice Policy 27930.2.1 Participatory Community Planning 27930.2.2 Equitable Transportation Funding 28030.2.3 Antiracist Mobility Policies 28030.2.4 Accessible and Resilient Mobility Ecosystems 28030.2.5 Data-Driven and Community-Defined Metrics 28130.2.6 Capacity Building and Narrative Shift 28230.2.7 Cross-Sector Collaboration 28330.3 Conclusion: Transportation Justice Drives Health Equity 283References 28431 Providing Access to Clean Water for Health Equity Through Policies 28731.1 Water Insecurity in America 28831.2 Causes of Water Insecurity and Access Inequities 28831.2.1 Aging and Inadequate Infrastructure 28931.2.2 Inequitable Water Policies and Underinvestment 28931.2.3 Climate-Related Threats 29031.3 Health Disparities of Water Insecurity 29031.4 Comprehensive Policy Solutions 29131.5 Conclusion: Achieving Water Equity Through Policy 293References 29332 Addressing Climate Change-Induced Health Disparities Through Policy and Planning 29732.1 Climate Change: A Threat Multiplier Exacerbating Health Inequities 29832.2 Frontline Communities: Disproportionate Climate Impacts and Inadequate Support 29832.3 Addressing Climate Inequity: Challenges and Progress in Policy and Legislation 29932.4 Equitable Climate Policies: Engaging Communities, Strengthening Health Responses, and Prioritizing Research 30132.5 Conclusion: Embracing Health Equity as a Cornerstone of Climate Policy 303References 303Index 305