Achieving Health Equity E-Book

Y. Tony Yang

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 698

Veröffentlichungsjahr: 2024

Beschreibung

Unveiling the Path to Health Equity: A Transformative Guide to Law and Policy

Achieving Health Equity: The Role of Law and Policy offers a groundbreaking exploration of how legal and policy frameworks shape health outcomes for marginalized populations, with a particular focus on racial minorities in the United States. This comprehensive guide dissects the complex interplay of factors determining health: 20% healthcare, 30% health behaviors, 40% social and economic factors, and 10% physical environment.

Amid the backdrop of the COVID-19 pandemic and a national reckoning on racism, this timely work provides an urgent call to action and a practical roadmap for transformative change. It examines how laws and policies across sectors intersect to perpetuate or dismantle health inequities, offering concrete strategies for reform.

Key features include:

• An ecosystem approach exploring four critical domains: healthcare access and quality, health behaviors, social and economic factors, and physical environment
• Analysis of emerging issues such as addressing the impact of climate change on health disparities, strategies for mitigating algorithmic bias in healthcare AI, and promoting equity in organ transplantation and clinical trials
• Examination of cross-cutting themes like community engagement, civil rights protections, and data disaggregation to guide targeted interventions
• Case studies and policy tools for dismantling structural drivers of health inequity

Written in accessible language without sacrificing depth, this book illuminates complex concepts through relatable examples. It serves as an invaluable resource for a diverse audience including health system administrators implementing diversity, equity, and inclusion initiatives, public health officials and policymakers, legal professionals and advocates, researchers and students in health-related fields, community organizers and racial justice activists.

Achieving Health Equity provides a comprehensive blueprint for leveraging law and policy to build a more just, equitable, and healthy future for all.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

Foreword

Acknowledgment

1 Empowering Marginalized Communities: Legal and Policy Levers for Health Equity

1.1 Navigating Law, Policy, and Health Inequities

1.2 The Purpose and Importance of Examining Health Equity Through Law and Policy

1.3 Key Concepts and Definitions

1.4 An Ecosystem Approach to Health Equity Law and Policy

1.5 An Urgent Imperative

1.6 Conclusion: A Roadmap for Equitable Policy Change

References

Part I: Health Care: Examining Access and Quality

2 Narrowing Health Access Disparities: The Affordable Care Act and Medicaid Expansion

2.1 Health Disparities and Insurance Coverage in America: A Century of Change

2.2 The ACA's Mechanics and Effectiveness

2.3 Ramifications of an ACA Repeal

2.4 Conclusion: The ACA's Impact on Health Equity Amid Ongoing Challenges

References

3 Tackling Insulin Affordability: Addressing Systemic Failures and Policy Solutions

3.1 Insulin Affordability: Progress, Disparities, and the Need for Systemic Change

3.2 State Initiatives on Insulin Affordability: An Overview

3.3 Federal Efforts and the Inflation Reduction Act for Insulin Affordability

3.4 Policy Recommendations

3.5 Conclusion: Addressing Systematic Failures for Equitable Insulin Access

References

4 Ensuring Equitable Healthcare: Overcoming Language Barriers Through Policies

4.1 Challenges and Implications of Language Barriers in Healthcare

4.2 Federal Laws Addressing Language Needs in Healthcare

4.3 State Initiatives

4.4 Recent Developments and Practical Challenges

4.5 Conclusion: Charting a Path to Linguistically Inclusive Healthcare

References

5 Confronting the US Maternal Mortality Crisis: Addressing Racial Disparities

5.1 Racial Disparities Fuel US Maternal Mortality Crisis

5.2 Preventable Deaths: Addressing Systemic Barriers via Policy

5.3 Overcoming Fragmentation: Collaboration and Bias Training

5.4 Conclusion: Strengthening Legislation: Equity‐Focused Interventions

References

6 Mitigating Algorithmic Bias in Healthcare AI for Equitable Care

6.1 Addressing Algorithmic Bias in AI to Ensure Fair Healthcare

6.2 Legal Landscape and Challenges in Regulating Algorithmic Bias in Healthcare AI

6.3 Collaborative Efforts to Address Algorithmic Bias in Healthcare AI

6.4 Conclusion: Overcoming Challenges in Addressing Racial Bias in Medical AI

References

7 Confronting Inequities in the US Organ Transplant System

7.1 Inequities in Organ Transplantation Disproportionately Affect Communities of Color

7.2 Barriers to Specialist Referrals and Data Gaps Perpetuate Inequities

7.3 Race‐Based Clinical Policies Hinder Equitable Waitlist Placement

7.4 Waitlist Policies Favor Socioeconomically Advantaged Patients

7.5 Communication Barriers and Resource Limitations Hinder Diverse Organ Donation

7.6 Provider Bias and Insurance Disparities Impede Black Patients' Transplant Access

7.7 OPTN Mandates Race‐Neutral Transplant Eligibility Calculations

7.8 Recommendations for Improving Equity at Each Stage of the Transplant Process

7.9 Discrimination Based on Disability in Organ Transplantation Persists

7.10 A Comprehensive, Multistage Approach for Equitable Organ Allocation

References

8 Transforming Blood Donation: Path to Inclusivity and Science‐Based Guidelines

8.1 Updated FDA Blood Donation Guidelines Promote Inclusivity and Safety

8.2 The Evolution of FDA Blood Donation Policies for Men Who Have Sex with Men

8.3 Challenging the Constitutionality of FDA's MSM Blood Donation Policies

8.4 FDA's New Guidelines Combat Stigma and Promote Inclusivity

8.5 Conclusion: Rebuilding Trust and Encouraging Inclusive Blood Donation

References

9 Addressing Barriers and Disparities in Clinical Trials: FDA's Diversity Plan

9.1 Enhancing Diversity in Clinical Trials: Addressing Barriers and Disparities

9.2 Legislative and Regulatory Efforts to Enhance Clinical Trial Diversity

9.3 Potential Impact of Diversity in Clinical Trials on Medical Outcomes

9.4 Limitations and Challenges in Enforcing Diversity Requirements

9.5 Strategies to Increase Access and Participation in Clinical Trials

9.6 Incentives and Post‐Approval Requirements to Promote Diversity

9.7 Conclusion: Future Steps and Expanding Diversity Efforts

References

10 Strengthening the Safety Net to Mitigate Reproductive Health Inequity After Dobbs

10.1 Reproductive Health Inequities Post‐Dobbs

10.2 Maternal Health Inequities Deepen Post‐Dobbs

10.3 The Critical Role of Safety‐Net Providers

10.4 Advancing Equity Through Research

10.5 Conclusion: Advancing Equity Amid Reproductive Crisis

References

11 Advancing Mental Health Equity Through Policies

11.1 Disparities in Mental Health Care

11.2 Major Shifts Needed

11.3 Addressing Root Causes

11.4 States as Laboratories for Innovation

11.5 Conclusion: Urgency for Mental Health Reform

References

Part II: Health Behaviors: Exploring the Influences of Exercise, Diet, and Drug Use

12 Promoting Physical Activity: Policy Strategies for Equity and Engagement

12.1 Tackling the Global Inactivity Crisis: WHO's Action Plan for a Healthier World

12.2 Addressing Inequities in Physical Activity: Inclusive Strategies and Community Engagement

12.3 Implementing Inclusive Health Equity Strategies: CDC Guidelines and Community Examples

12.4 Leveraging Legal Strategies and Policy Domains to Promote Physical Activity and Address Inequities

12.5 Conclusion: Overcoming Challenges in Promoting Physical Activity for Youth of Color

References

13 Reducing Sugary Beverage Consumption: Regulatory Measures

13.1 Consequences of Sugary Drink Consumption

13.2 Factors Driving Sugary Drink Consumption Disparities in Communities of Color

13.3 Limitations of Current Policies Addressing Sugary Drink Consumption

13.4 Policy Strategies for Reducing Sugary Drink Consumption

13.5 Conclusion: A Comprehensive Approach to Reducing Sugary Drink Consumption

References

14 Promoting Health Equity via Tobacco Control

14.1 Tobacco‐Related Disparities

14.2 Strategies for Policy Interventions to Foster Health Equity

14.3 Strategizing Policy Implementation to Enhance Health Equity

14.4 Conclusion: Achieving Equity in Tobacco Control

References

15 Tackling the Overdose Crisis Through Equitable Harm Reduction Policies

15.1 The Need for an Equity‐Centered, Harm Reduction Approach

15.2 Expanding Access to Naloxone

15.3 Providing Safer Use Supplies and Services

15.4 Expanding Access to Evidence‐Based Treatment

15.5 Addressing Structural Determinants and Promoting Health Equity

15.6 Investing in Community Development

15.7 Reforming the Criminal Justice System

15.8 Addressing Stigma and Misconceptions

15.9 Enhancing Data Collection and Oversight

15.10 Conclusion: Leveraging Resources and Centering Equity in the Fight Against the Opioid Crisis

References

16 Confronting the HIV/AIDS Epidemic: Progress, Challenges, and the Path Forward

16.1 Ending the HIV Epidemic: Addressing Social Disparities and Ensuring Access

16.2 Addressing Social Determinants: Key to Ending HIV Inequities

16.3 Effective HIV Prevention: Education, Access, and Comprehensive Strategies

16.4 Government Response: Progress and Persistent Challenges in HIV Policy

16.5 Dismantling HIV Discrimination: Reforming Laws and Addressing Stigma

16.6 Conclusion: Addressing HIV/AIDS Inequities, Ensuring Care for All

References

Part III: Social and Economic Factors: Education, Income, Rurality, and Structural Racism

17 Addressing Food Insecurity: Strengthening Assistance Programs and Promoting Equity

17.1 Food Insecurity, Health Risks, and COVID‐19: Exposing Systemic Inequities

17.2 Federal Food Assistance

17.3 Strategies for Enhancing Food Assistance Programs Amidst Challenges

17.4 Conclusion: Transforming Food Assistance for a Resilient Future

References

18 Promoting Access to Early Care and Education: Anti‐Racist Policies

18.1 Early Care and Education

18.2 Head Start and Early Head Start

18.3 Child Care Development Fund

18.4 Additional Federal Programs

18.5 Addressing Structural Issues in Childcare Provision

18.6 Conclusion: Enhancing Childcare Policies for Better Outcomes

References

19 Enacting Paid Family Leave for Health Equity

19.1 Barriers to Equitable Paid Family Leave in the United States

19.2 The Impact of Paid Leave Policies on Vulnerable Workers and the Far‐Reaching Benefits for Health and Equity

19.3 Designing Effective and Equitable Paid Family Leave Policies: Key Strategies for Inclusivity and Uptake

19.4 Conclusion: Paid Leave: A Crucial Step Toward Health and Economic Equity

References

20 Enhancing Rural, Remote, and Tribal Health Equity Through Policies

20.1 Challenges Facing Rural, Remote, and Tribal Health

20.2 Advancing Rural and Tribal Health Equity Through Federal Policies

20.3 State‐Level Policy Trends

20.4 Remaining Gaps and Recommendations

20.5 Conclusion: Seizing Opportunities, Achieving Equity

References

21 Addressing Medical Debt on Marginalized Communities: Potential Reforms

21.1 The Burden and Disproportionate Impact of Medical Debt

21.2 Government's Role in Addressing Medical Debt Disparities

21.3 Legislative and Policy Initiatives to Mitigate Medical Debt

21.4 Conclusion: Key Considerations for Policymakers

References

22 Preserving Diversity: Impact of Affirmative Action Ruling on Healthcare

22.1 Supreme Court Ruling Threatens Diversity in Healthcare Education

22.2 The Importance of Diversity in Healthcare

22.3 Impact of Overturning Affirmative Action

22.4 Maintaining and Improving Diversity Post‐ruling

22.5 Conclusion: Urgent Strategies Needed to Protect Diversity in Healthcare Education

References

23 Reforming the Public Charge Rule for Immigrant Health Equity

23.1 Barriers to Immigrant Healthcare Access: The Public Charge Rule's Impact

23.2 Comparing Trump and Biden Public Charge Rules

23.3 The Chilling Effect: Immigrant Hesitancy to Access Public Benefits Despite Policy Changes

23.4 Limited Policy Solutions to Address Immigrant Distrust and Expand Access to Benefits

23.5 Strategies to Rebuild Trust and Increase Immigrant Access to Public Benefits

23.6 The Need for Legislative Action to Provide Certainty and Stability for Immigrants

References

24 Promoting Health in All Policies (HiAP) Approach

24.1 Integrating HiAP: A Strategic Approach to Achieving Health Equity

24.2 Legal Frameworks Facilitating Multi‐sector Collaboration for HiAP

24.3 Establishment and Impact of California's HiAP Task Force

24.4 Strategies for Enhancing and Sustaining HiAP Initiatives

24.5 Challenges and Strategic Insights for Implementing HiAP Amidst a Pandemic

24.6 Conclusion: Lessons and Challenges in Implementing HiAP

References

25 Rethinking Preemption for Health Equity

25.1 The Double‐Edged Sword of Preemption in Public Health Regulation

25.2 Preemption During the COVID‐19 Pandemic: Challenges and Consequences

25.3 Preemption's Disproportionate Impact on Vulnerable Populations and Inequities

25.4 Conclusion: Toward an Equity‐First Preemption Framework

References

26 Achieving Health and Economic Equity Through Broadband Access and Policy

26.1 Broadband: A Crucial Determinant of Health Equity

26.2 The Digital Divide: Perpetuating Systemic Inequities

26.3 Lawmakers' Role in Achieving Equitable Broadband Access

26.4 Conclusion: A Public Value Essential for Health and Economic Equity

References

27 Expanding Vaccine Equity: Policy Strategies

27.1 Vaccine Inequity: Disparities in Access and Health Outcomes

27.2 Government Efforts to Address Vaccine Inequity: Successes and Challenges

27.3 Addressing Persistent Vaccine Inequities: Proposed Solutions and Global Efforts

27.4 Federalism and Vaccine Inequity: Challenges, Criticisms, and Federal Efforts

27.5 Data Gaps: Hindering Efforts to Address Vaccine Inequities

27.6 Conclusion: Addressing Vaccine Inequity: Lessons, Strategies, and a Call to Action

References

28 Disaggregating Data: Unveiling the Diversity and Disparities Within the AAPI Population

28.1 Diversity and Disparity: The Complexity of AAPI Data Aggregation

28.2 Model Minority Myth: Masking AAPI Health Disparities Through Aggregation

28.3 State‐Led Initiatives: Advancing AAPI Data Disaggregation Amid Federal Inconsistency

28.4 Barriers to Disaggregation: Sample Sizes and Community Opposition

28.5 Conclusion: Disaggregation Imperative

References

Part IV: Physical Environment: The Role of Housing, Transit, Water, and Climate Change

29 Achieving Health Equity Through Housing Laws and Policies

29.1 Housing and Health: The Impact of Segregation

29.2 How Laws and Policies Post‐fair Housing Act Have Furthered Residential Segregation

29.3 Positive Legal Interventions

29.4 Conclusion: Addressing Residential Segregation for Better Health

References

30 Advancing Transportation for Health Equity Through Policies

30.1 The State of Transportation Inequity

30.2 An Agenda for Transportation Justice Policy

30.3 Conclusion: Transportation Justice Drives Health Equity

References

31 Providing Access to Clean Water for Health Equity Through Policies

31.1 Water Insecurity in America

31.2 Causes of Water Insecurity and Access Inequities

31.3 Health Disparities of Water Insecurity

31.4 Comprehensive Policy Solutions

31.5 Conclusion: Achieving Water Equity Through Policy

References

32 Addressing Climate Change‐Induced Health Disparities Through Policy and Planning

32.1 Climate Change: A Threat Multiplier Exacerbating Health Inequities

32.2 Frontline Communities: Disproportionate Climate Impacts and Inadequate Support

32.3 Addressing Climate Inequity: Challenges and Progress in Policy and Legislation

32.4 Equitable Climate Policies: Engaging Communities, Strengthening Health Responses, and Prioritizing Research

32.5 Conclusion: Embracing Health Equity as a Cornerstone of Climate Policy

References

Index

End User License Agreement

Guide

Cover Page

Title Page

Copyright Page

Table of Contents

Foreword

Acknowledgment

Begin Reading

Index

WILEY END USER LICENSE AGREEMENT

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Achieving Health Equity

The Role of Law and Policy

Y. Tony Yang

George Washington University

Washington DC, USA

This edition first published 2025© 2025 by John Wiley & Sons Ltd

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Foreword

As a public health leader who has spent my career working to advance health equity, particularly for racial and ethnic minoritized people and people living in medically under‐resourced communities, I am deeply encouraged by this vital and timely book. Achieving Health Equity: The Role of Law and Policy provides an essential roadmap for addressing one of the most pressing moral and public health imperatives of our time – eliminating unjust and avoidable differences in health outcomes that stem from systemic racism and discrimination.

My experiences serving as the health director in the Nation’s Capital for nearly a decade, during some of the most challenging times in public health including the COVID‐19 pandemic, drove home just how critical it is that we transform the legal and policy frameworks that shape health outcomes. The pandemic, in particular, laid bare in stark terms the deadly consequences of long‐standing health inequities, as communities of color experienced dramatically higher rates of infection, hospitalization, and mortality. At the same time, the national reckoning on racial justice in the wake of high‐profile police murders of George Floyd and Breonna Taylor increased public recognition of racism as a public health crisis.

As we emerge from the acute phase of the pandemic, there is growing awareness that we cannot simply return to a pre‐pandemic “normal” that was plagued by pervasive and growing health inequities rooted in systemic injustice. We have a once‐in‐a‐generation opportunity – and obligation – to build a more equitable and resilient public health system and society. This book provides an invaluable guide for seizing that opportunity.

By taking an ecosystem approach to examining how laws and policies across sectors intersect to shape health equity, this volume illuminates the powerful role that legal and policy frameworks play in perpetuating or dismantling health inequities. It offers a comprehensive look at key policy levers across the major domains that determine health outcomes – from healthcare access and quality, to health behaviors, social and economic factors, and the physical environment.

Importantly, this book goes beyond simply describing problems to offer concrete policy strategies, case studies, and tools for enacting laws and policies that can dismantle structural drivers of health inequity. It provides a practical blueprint for policymakers, public health practitioners, healthcare and social service providers, community advocates, and other stakeholders committed to advancing policies that give everyone a fair and just opportunity to live their healthiest life.

As someone who has been met with the responsibility for translating health equity principles into practice, I appreciate how this volume consolidates complex concepts into an accessible format for a wide readership. Whether you are a student, health system administrator, public health official, policymaker, or researcher, you will find valuable insights to inform your work.

The path to achieving health equity requires transformative changes to laws and policies that center racial justice and equity, as well as collective action from health and equity allies across all sectors and levels of government. This book accelerates those efforts by equipping advocates with both an understanding of how law and policy created – and can help dismantle ‐ health inequities, along with practical tools and strategies for driving policy change.

The health equity movement stands at an inflection point, facing unprecedented challenges but also new possibilities. This volume serves as both a call to action and a roadmap for the critical work ahead to build a more just, equitable, and healthy future for all. I hope it will inspire and empower a new generation of leaders to take up this vital cause.

LaQuandra S. Nesbitt, MD, MPH

Former Director, the Washington, D.C. Department of Health (2015‐2022)

Executive Director, GW SMHS Center for Population Health Sciences and Health Equity

Senior Associate Dean for Population Health and Health Equity

Bicentennial Endowed Professor of Medicine and Health Sciences

The George Washington University School of Medicine and Health Science

Acknowledgment

This book is the product of the collective wisdom, guidance, and support of many individuals and organizations, to whom I owe my deepest gratitude.

First and foremost, I express my heartfelt appreciation to my dedicated community health partners, whose tireless work in advancing health equity has been a constant source of inspiration. Supported through various federal grants, these remarkable organizations—including the Health Betterment Initiative‐DC, Emerson Diversity Health Foundation, Alliance of Concerned Men, SDM‐1 STOP Clinic, American Diversity Group, Arlington Free Clinic, and Social Capital Solutions—are instrumental in shaping healthier, more equitable communities. Your unwavering commitment is at the heart of this book.

I am also profoundly grateful to the many esteemed scholars and colleagues who have influenced my thinking and contributed to my understanding of the intricate role of law and policy in health equity. While it is impossible to mention everyone, I particularly acknowledge Sara Rosenbaum, Michelle Mello, David Studdert, Scott Burris, Wendy Parmet, Ross Silverman, Dorit Reiss, and William Sage. Your contributions to the field continue to inspire my work.

The support from my institutional colleagues has been invaluable throughout this journey. I offer special thanks to my coauthors over the years who have shaped my perspectives on health equity and policy: Carla Berg, Sawali Sudarshan, Jana Shaw, Robert Olick, Sarah Schaffer DeRoo, Paul Delamater, and Brian Chen. Your collaboration has been deeply enriching, and I am grateful for the insights we have shared.

Lastly, I owe an immeasurable debt of gratitude to my family, whose encouragement has been my constant source of strength. To my wife, Katie Yang, thank you for your unwavering support and invaluable contributions to our shared mission of promoting health equity. This book would not have been possible without you.

1Empowering Marginalized Communities: Legal and Policy Levers for Health Equity

Abstract

This chapter introduces “Achieving Health Equity: The Role of Law and Policy,” a comprehensive guide exploring how legal and policy frameworks shape health outcomes of marginalized populations, especially racial minorities in the United States. It establishes the purpose and importance of examining health equity through law and policy, defining key concepts like health equity, social determinants of health, marginalized populations, and structural discrimination. The chapter outlines the book's ecosystem approach, organized around four key health‐determining domains: healthcare access and quality, health behaviors, social and economic factors, and physical environment. It highlights cross‐cutting themes and policy levers, such as resource investment, community engagement, safety net strengthening, civil rights protections, and data disaggregation. Underscoring the COVID‐19 pandemic's illumination of deep‐rooted health inequities and racism as a public health crisis, the chapter frames the book as an urgent call to action. It positions the guide as a roadmap for equitable policy change, offering concrete strategies and tools to dismantle structural drivers of health inequity. The chapter concludes by identifying the book's wide‐reaching intended audience, including students, healthcare administrators, public health officials, regulators, and researchers, emphasizing its potential for advancing the critical work of building a more just, equitable, and healthy future for all.

Keywords health equity; legal frameworks; policy levers; marginalized populations; social determinants of health; structural discrimination; COVID‐19 pandemic; racial justice

1.1 Navigating Law, Policy, and Health Inequities

In the United States, many individuals face a multitude of challenges that can have detrimental effects on their health and well‐being. Discrimination, social exclusion, poverty, disenfranchisement, and unequal access to opportunities are just a few of the obstacles that marginalized populations encounter on a daily basis. Communities of color, low‐income populations, those with low education levels, and other underserved groups continue to experience dramatically poorer health outcomes compared to their more privileged counterparts.

“Achieving Health Equity: The Role of Law and Policy” is an extensive exploration of how legal and policy frameworks influence the health outcomes of marginalized populations, with a particular focus on racial minorities in the United States. While primarily centered on US law and policy, the insights and lessons presented in this book have global relevance, as the United States serves as an influential model worldwide, including in how it has relied on systemic racism to shape healthcare, public health, and access.

This book primarily caters to learners in health‐related disciplines and professionals in health fields exploring the confluence of health, race, law, and policy [1]. While its foundation is academic, there's a significant crossover potential, reaching audiences not only across various disciplines but also beyond academia, particularly among activists and professionals in racial justice and health equity domains.

The primary goal of this book is to enhance understanding of the critical role that law and policy play in achieving health equity. The content is informed by research indicating that health is determined by a complex interplay of factors, with healthcare accounting for 20%, health behaviors for 30%, social and economic factors for 40%, and the physical environment for 10% [2]. By breaking down these determinants, the book demonstrates how law and policy can be leveraged to promote more equitable health outcomes.

This accessible guide is tailored for nonlegal audiences who are keen on grasping the key aspects of health equity law and policy. It fills a notable gap in the literature by consolidating health equity principles in an approachable format for a wide readership, including health system administrators implementing diversity, equity, and inclusion initiatives, public health officials, regulators, researchers, and more [3]. The COVID‐19 pandemic has only heightened interest in and the urgency of addressing health inequities, making this book a timely and essential resource.

1.2 The Purpose and Importance of Examining Health Equity Through Law and Policy

The most powerful determinants of health are the laws and policies that have perpetuated legacies of racism, discrimination, and segregation [4]. Unjust laws and practices embedded in our political, economic, and social systems have shaped unhealthy physical environments, limited economic and educational opportunities, and created barriers to accessing quality healthcare for marginalized groups over many generations [5].

As a result of these systemic inequities, low‐income communities and communities of color experience higher rates of chronic diseases, maternal mortality, infant mortality, and premature death compared to wealthier, predominantly white communities [6]. These health inequities are deeply entrenched and, in many cases, growing wider despite overall public health gains [7].

Attempting to reduce health inequities requires different strategies than efforts to improve public health overall [8]. Rather than a “rising tide lifts all boats” approach, a combination of targeted and universal interventions is needed to redistribute key health determinants, such as healthy environments, economic resources, power, and opportunities.

Law and policy are essential tools for this paradigm shift because they have the power to express societal values against bias, unfairness, and injustice [9, 10]. They influence how money, power, and opportunities are distributed and can transform unjust structures and systems that have perpetuated health inequities [11]. Law and policy enable widespread, population‐level change by focusing on structural determinants rather than individual behaviors [12]. They guide and coordinate multisector actions to improve health equity and sustain positive changes over the long term.

Enacting more equitable laws and policies requires policymakers, public health practitioners, healthcare and social service providers, community advocates, and other stakeholders to work together in new ways [13, 14]. It requires examining how every policy decision, across sectors, will affect health equity [15]. And it requires authentic community engagement to center solutions on the lived experiences and priorities of marginalized groups [16].

This book provides a practical blueprint for advocates committed to advancing policies that give everyone a fair and just opportunity to live their healthiest lives. It offers concrete policy strategies, case studies, and tools for enacting laws and policies that dismantle structural drivers of health inequity.

1.3 Key Concepts and Definitions

To lay the foundation for delving into health equity law and policy, it's important to establish shared language around core concepts. Health is defined as a state of complete physical, mental, spiritual, cultural, and social well‐being, not merely the absence of disease or infirmity [17]. Health equity refers to a state in which everyone has the opportunity to attain their full health potential, and no one is disadvantaged in achieving this potential because of social position or any other socially defined circumstance [18].

Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality‐of‐life outcomes and risks [19]. Key domains include healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment [20].

Marginalized populations are groups that have been systematically excluded from accessing resources and opportunities that enable health and well‐being [21]. These groups include communities of color, low‐income populations, LGBTQ+ people, immigrants, people with disabilities, and those living in rural communities, among others.

Structural discrimination, or structural racism, refers to a system of structuring opportunity and assigning value based on race or other socially defined characteristics that perpetuate unfair disadvantages for some and unearned advantages for others, across multiple systems and institutions [22]. Structural drivers of inequity are created and maintained by mutually reinforcing systems of stigma, stereotypes, and bias; discriminatory practices and policies; uneven distribution of resources and opportunities; and imbalanced power [23].

While often used interchangeably, this book makes a distinction between law and policy: policy refers to a written statement of a public agency's or organization's position, decision, or a course of action. The law refers specifically to the codification and institutionalization of a policy by a government in the form of an ordinance, statute, or regulation. Thus, all laws are policies, but not all policies are laws.

1.4 An Ecosystem Approach to Health Equity Law and Policy

This book takes an ecosystem approach to examining how laws and policies across sectors intersect to shape health equity. While healthcare is an important determinant, access to quality housing, education, jobs, transportation, and other social and economic resources are equally vital [24].

The book is organized around four key domains that determine health and health equity: healthcare access and quality (20% of health), health behaviors (30% of health), social and economic factors (40% of health), and physical environment (10% of health).

In the healthcare access and quality domain, which accounts for 20% of health outcomes, the book explores a range of critical policy issues and levers. It examines how the Affordable Care Act and Medicaid expansion have helped to narrow health access disparities [25], and discusses initiatives by state and federal governments to cap insulin costs, making this life‐saving medication more affordable for those who need it. The book also delves into the importance of ensuring language access in healthcare settings, as well as policy measures to address the stark disparities in maternal health outcomes experienced by Black women [26]. Other key topics in this section include legal approaches to combat algorithmic bias in healthcare decision‐making [27, 28], efforts to promote equity in organ transplantation and blood donation policies, and the FDA's plan to drive diversity in clinical trials. The healthcare chapter also explores policy reforms to strengthen the social safety net and mitigate health inequities in the wake of the Dobbs decision, which overturned Roe v. Wade, as well as strategies to advance mental health equity.

The health behaviors section, which accounts for 30% of health outcomes, focuses on policies and laws that facilitate equitable access to resources and environments that promote healthy behaviors [29]. This includes strategies to promote physical activity in underserved communities, such as investing in safe parks, sidewalks, and bike lanes. The book also examines regulatory measures to reduce sugary beverage consumption, a key driver of obesity and related chronic diseases that disproportionately impact marginalized populations [30]. Other important topics in this section include policies to promote health equity through tobacco control, strategies to achieve equity in drug overdose response and prevention, and efforts to confront the ongoing HIV/AIDS epidemic, which continues to take a heavy toll on marginalized communities.

In the social and economic factors section, which accounts for 40% of health outcomes, the book takes a deep dive into the policies and laws that shape the social determinants of health [31]. It examines the growing movement to declare racism a public health crisis and explores the potential of reparations to address the health harms of historical and ongoing systemic racism [32]. The book also looks at legal measures to address food insecurity during the COVID‐19 pandemic and beyond, as well as anti‐racist early care and education policies that can help promote lifelong health and well‐being [33]. Other key topics in this section include paid family and medical leave policies, which are critical for promoting health equity [34], as well as strategies to advance rural, remote, and tribal health equity. The book also explores potential reforms to address the crushing burden of medical debt on marginalized communities [35], efforts to reform exclusionary zoning and promote inclusive communities, and strategies to preserve diversity in healthcare and higher education in the wake of legal challenges to affirmative action. Additionally, the social and economic factors section examines public charge rule reforms to advance immigrant health equity [36], the promise of Health in All Policies approaches to embed health and equity across sectors, the role of repealing state preemption laws in promoting local health equity innovation, and the importance of promoting vaccine equity and data equity to address disparities illuminated by the pandemic.

Finally, the physical environment section, which accounts for 10% of health outcomes, examines the policies and laws that shape the places where people live, work, play, and learn. This includes a deep dive into housing policies that can promote health equity, such as affordable housing development, tenant protections, and eviction prevention. The book also looks at transportation policies that can promote healthy, equitable communities, such as transit‐oriented development and Complete Streets approaches. Other key topics in this section include policies to ensure equitable access to clean water and air, as well as strategies to address the disproportionate impact of climate change on marginalized communities through resilient community design and planning [37].

Several crosscutting themes and policy levers emerge across these domains. These include investing resources proportionate to need in underserved communities, meaningfully engaging impacted communities in policy development and implementation, strengthening social and economic safety nets, improving the availability and affordability of health‐promoting resources, mitigating exposure to health risks, enhancing civil rights protections and anti‐discrimination enforcement, repealing preemptive laws that limit local innovations, leveraging governance levers like Health in All Policies to embed health and equity in decision‐making, and disaggregating data to make inequities visible and guide targeted interventions.

1.5 An Urgent Imperative

The COVID‐19 pandemic laid bare the deadly consequences of long‐standing health inequities, with communities of color experiencing infection, hospitalization, and mortality rates significantly higher than white populations across the United States [38]. The national reckoning on racism in the wake of high‐profile police killings of Black Americans also increased public awareness of racism as a public health crisis.

There is a growing recognition that returning to a pre‐pandemic “normal” is not enough, as normal was plagued with pervasive and growing health inequities rooted in systemic injustice [39]. The path forward requires transformative laws and policies that center health equity and racial justice, as well as collective action from health and equity allies across all sectors and all levels of government [40].

This book aims to accelerate those efforts by equipping advocates with an understanding of how law and policy are created and can help dismantle health inequities, along with practical tools and strategies for policy change. The health equity movement is at an inflection point, with unprecedented challenges and new possibilities on the horizon. The chapters ahead are a call to action and a roadmap for the work ahead to build a more just, equitable, and healthy future for all.

1.6 Conclusion: A Roadmap for Equitable Policy Change

“Achieving Health Equity: The Role of Law and Policy” provides a comprehensive and accessible examination of how legal and policy frameworks shape the health outcomes of marginalized populations, particularly racial minorities in the United States. By breaking down the complex interplay of factors that determine health, the book demonstrates how law and policy can be leveraged to promote more equitable health outcomes.

The book fills a notable gap in the literature by consolidating health equity principles in an approachable format for a wide readership, including health system administrators, public health officials, regulators, researchers, and more. It offers concrete policy strategies, case studies, and tools for enacting laws and policies that dismantle structural drivers of health inequity.

The COVID‐19 pandemic and the national reckoning on racism have underscored the urgent need to address long‐standing health inequities rooted in systemic injustice. This book aims to accelerate efforts to build a more just, equitable, and healthy future for all by equipping advocates with an understanding of how law and policy are created and can help dismantle health inequities, along with practical tools and strategies for policy change.

“Achieving Health Equity: The Role of Law and Policy” is a valuable resource for students pursuing studies in health‐related disciplines who are interested in gaining a comprehensive understanding of health equity. The book is suitable for both major and nonmajor students at the undergraduate and graduate levels. It is structured and written based on robust scholarly research, making it an excellent resource for mastering the subject area.

Furthermore, this book is useful for healthcare professionals involved in developing and implementing diversity, equity, and inclusion policies, as well as public health officials, regulators, and scientific researchers interested in health equity. The book can reach its intended audience through targeted advertisements in related scholarly journals, promotional campaigns via professional associations, and a strong presence on relevant social media platforms. To ensure accessibility, the book should be available in academic libraries and both physical and online bookstores frequented by professionals in these fields.

The chapters ahead provide a roadmap for the work ahead, exploring specific policy issues and levers across four key domains that determine health and health equity: healthcare access and quality, health behaviors, social and economic factors, and physical environment. By taking an ecosystem approach and examining cross‐cutting themes and policy levers, the book offers a comprehensive blueprint for advancing health equity through law and policy.

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Part IHealth Care: Examining Access and Quality

This part explores critical issues and policies aimed at improving access and quality of healthcare, particularly for marginalized communities. Chapter 2 discusses how the Affordable Care Act and Medicaid expansion have narrowed health access disparities, enhancing coverage for millions. Chapter 3 examines initiatives to cap insulin costs, addressing affordability through state and federal measures. Chapter 4 focuses on ensuring language access in healthcare, highlighting the importance of interpretation services for Limited English proficiency (LEP) populations. Chapter 5 addresses Black maternal health disparities, emphasizing policy measures to reduce mortality and improve outcomes. Chapter 6 tackles algorithmic bias in healthcare, presenting legal approaches and case studies to mitigate discriminatory practices. Chapter 7 promotes equity in organ transplantation policies, examining barriers and recommending inclusive strategies. Chapter 8 advocates for easing blood donation restrictions, discussing legal and scientific perspectives to enhance donor diversity. Chapter 9 highlights the FDA's diversity plan for clinical trials, aiming to drive health equity through inclusive research practices. Chapter 10 analyzes the impact of the Dobbs decision on reproductive health, emphasizing the need to strengthen the safety net for vulnerable populations. Chapter 11 advances mental health equity, proposing policies to address disparities and improve access to mental health services. Together, these chapters provide a comprehensive roadmap for achieving equitable healthcare access and quality.

2Narrowing Health Access Disparities: The Affordable Care Act and Medicaid Expansion

Abstract

This chapter examines the impact of the Affordable Care Act (ACA) on narrowing health access disparities in the United States, particularly among racial and ethnic minority populations. It begins by providing an overview of the historical context of health disparities and insurance coverage in America, highlighting the persistent gaps in life expectancy and disease rates between white Americans and minority groups. The primary barrier to accessing quality healthcare is identified as the lack of insurance coverage, which disproportionately affects people of color and low‐income households. The societal and economic costs of these disparities are also discussed. The focus then shifts to the ACA, exploring its mechanisms for increasing health insurance coverage, such as Medicaid expansion and the establishment of health insurance marketplaces. The ACA's effectiveness in reducing uninsured rates and narrowing disparities in healthcare access, particularly for black Americans and Hispanics, is assessed. The challenges faced by the ACA, including political opposition and attempts to repeal the law, are also acknowledged. The potential ramifications of an ACA repeal are examined, projecting increases in the number of uninsured individuals and the erosion of progress made in closing health insurance coverage gaps for people of color. In conclusion, the ACA's crucial role in reducing healthcare disparities and increasing access to care for millions of Americans, particularly those from minority communities, is emphasized. Policymakers, advocates, and the public are called upon to recognize the importance of the ACA and work to protect and strengthen its provisions for the benefit of all Americans.

Keywords Affordable Care Act (ACA); Medicaid expansion; health disparities; insurance coverage; racial and ethnic minorities; health equity; uninsured rates; policy impact

John, a 55‐year‐old black American, had been putting off a routine colonoscopy for years due to the high cost of the procedure. Without health insurance, he feared the financial burden would be too much for his family to bear. When he finally underwent the screening after gaining coverage through the Affordable Care Act (ACA), doctors discovered early‐stage colorectal cancer, which could have turned fatal if left undetected.

Sarah, a single mother working two part‐time jobs, struggled to make ends meet for her family. Neither of her employers offered health insurance, and she couldn't afford private coverage. When her daughter developed a severe ear infection, Sarah had to choose between paying for the doctor's visit and antibiotics or putting food on the table. The ACA's Medicaid expansion provided Sarah with the coverage she needed to get her daughter the care she required without sacrificing other essentials.

2.1 Health Disparities and Insurance Coverage in America: A Century of Change

Between 1900 and 2018, the average American life expectancy increased dramatically from 47.3 to 78.7 years, largely due to scientific and medical advancements that have enhanced the quality of life for many individuals [1]. Despite these improvements, significant health disparities persist among certain subsets of the American population, with black Americans experiencing a life expectancy of 3.8 years lower than white Americans and many minority groups facing higher rates of diseases such as cardiovascular disease and HIV/AIDS [2]. Experts attribute these disparities to a complex interplay of historical and contemporary social, cultural, economic, political, medical, and legal factors.

The primary barrier to accessing quality healthcare in the United States is not the availability of services, but rather the lack of insurance coverage. Uninsured adults are more likely to forgo necessary medical care and experience poorer health outcomes compared to their insured counterparts, particularly when managing chronic conditions like cancer and heart disease. The US healthcare system has long been plagued by significant disparities in health insurance coverage along racial and ethnic lines, with people of color more likely to live in low‐income households and lack access to affordable insurance options, even when employed full‐time. In the mid‐2000s, approximately 47 million Americans (16% of the population) were uninsured, with minority populations, especially black Americans and Hispanics, experiencing significantly higher uninsured rates than whites [3].

The consequences of lacking health insurance extend beyond individual health, imposing significant societal and economic costs. Uninsured individuals often rely on emergency rooms as their primary source of care, straining medical facilities and resulting in billions of dollars in unpaid services. Moreover, uninsured individuals receive an estimated $100 billion in annual healthcare services for conditions that could have been treated more cost‐effectively if diagnosed earlier [4]. Between 2003 and 2006, $229.4 billion (30%) of medical expenditures for black Americans, Asians, and Hispanics were excess costs attributable to health inequalities [5]. Reducing exposure to substantial medical expenses has been shown to improve credit scores and decrease the risk of bankruptcy, highlighting the potential for addressing health insurance disparities to mitigate economic inequality.

The ACA, signed into law by President Barack Obama on March 23, 2010, was designed to reduce health inequities based on race and ethnicity, with the original text containing 34 references to the term “disparities” [6]. The ACA expanded health insurance options for uninsured individuals in low‐ and middle‐income households, which are disproportionately represented by black Americans and Hispanics [7]. Since its implementation, the ACA has led to significant coverage gains among people of color, helping to narrow health coverage disparities. However, the ACA has faced persistent opposition from Republicans and conservatives, with numerous attempts to repeal the law and three Supreme Court challenges (2012, 2015, and 2020) [8]. Despite these challenges, the ACA has largely survived, but it is crucial to understand the potential consequences of its repeal. The following sections of this chapter will examine the ACA's mechanisms for addressing health coverage inequities, evidence of its successes, and the implications for public health policies should the law be repealed.

2.2 The ACA's Mechanics and Effectiveness

The ACA was designed to address gaps in health insurance coverage through a combination of private and public sector provisions targeting states, insurance companies, employers, and individuals. This section explores the various methods employed by the ACA to expand coverage and assesses the law's effectiveness in achieving its goals.

2.2.1 How Did the ACA Increase Health Insurance Coverage?

The ACA increased health insurance coverage through two primary mechanisms. First, it expanded state‐run Medicaid programs. Prior to the ACA, Medicaid eligibility was limited to unemployed parents with income below 37% of the federal poverty level (FPL) and employed parents with income below 63% of the FPL, with the FPL being determined annually by the Department of Health and Human Services. Most states denied Medicaid benefits to adults without dependent children, regardless of income [9]. The ACA required states to expand Medicaid coverage to all non‐Medicare eligible individuals under 65 with household income up to 133% of the FPL, threatening to withhold federal Medicaid funds from states that refused to comply.

However, in the 2012 case, National Federation of Independent Business (NFIB) v. Sebelius, the Supreme Court ruled that the ACA's Medicaid expansion was unconstitutionally coercive. Chief Justice John Roberts determined that when the federal government conditions grants of federal funds (in this case, for state Medicaid programs), it must provide states with a “genuine choice” in accepting the conditions [10]. In this instance, states lacked a genuine choice because refusing to accept the federal government's conditions would result in the loss of existing Medicaid funds. While the Court's decision ultimately retained the ACA's provisions, it effectively made Medicaid expansion optional for states. States that choose not to expand Medicaid coverage will forgo federal funds related to the expansion but cannot lose funds for existing Medicaid programs.

The second major way the ACA sought to increase health insurance coverage was through the establishment of health insurance marketplaces. These marketplaces provide access to insurance for individuals who cannot obtain coverage through employer‐sponsored plans. Although the ACA instructed states to set up their own exchanges, the vast majority opted to join the federal exchange (accessed at http://HealthCare.gov). Lower‐income families participating in these marketplaces can qualify for additional savings through premium tax credits and cost‐sharing reductions.

2.2.2 The ACA's Effectiveness

The ACA yielded immediate increases in health insurance coverage. In 2013, just before the ACA's main provisions took effect, 20.4% of working‐age adults in the United States were uninsured [11]. By 2018, that figure had dropped to 12.4%. Prior to 2013, black American and Hispanic adults reported significantly higher rates of cost‐related barriers to healthcare compared to white adults. Following the ACA's enactment, these populations experienced the largest overall improvements in healthcare access, narrowing the disparities between whites and black Americans/Hispanics in cost‐related access problems. For black Americans, the disparity fell from 8.1% to 4.7%, while for Hispanics, it dropped from 12.7% to 8.3% between 2013 and 2018.

The ACA's passage led to the most significant improvements in healthcare access for black Americans and Hispanics. In 2013, 23% of black American adults reported avoiding healthcare due to costs, which decreased to 17.6% after the ACA's implementation. Similarly, the percentage of Hispanics avoiding care due to costs dropped from 27.8% to 21.2%. In comparison, the percentage of whites avoiding care due to costs only decreased from 15.1% to 12.9%. The data is even more encouraging for residents of states that have opted to expand Medicaid.

Studies indicate that black American adults living in states with Medicaid expansion are less likely to be uninsured than white adults in states without the expansion [12]. Although Hispanic adults in both expansion and non‐expansion states reported lower uninsured rates, the healthcare access gains were more substantial in expansion states. Black Americans in expansion states are nearly as likely as white adults in those states to have a usual source of care. A comparison between Louisiana (an expansion state) and Georgia (a non‐expansion state) is particularly revealing. Between 2013 and 2015, white and black adults in both states with incomes under 200% of the FPL experienced health insurance access gains [13]