Achieving Health Equity

Foreword xv Acknowledgment xvii 1 Empowering Marginalized Communities: Legal and Policy Levers for Health Equity 1 1.1 Navigating Law, Policy, and Health Inequities 1 1.2 The Purpose and Importance of Examining Health Equity Through Law and Policy 2 1.3 Key Concepts and Definitions 3 1.4 An Ecosystem Approach to Health Equity Law and Policy 4 1.5 An Urgent Imperative 5 1.6 Conclusion: A Roadmap for Equitable Policy Change 5 References 6 Part I Health Care: Examining Access and Quality 9 2 Narrowing Health Access Disparities: The Affordable Care Act and Medicaid Expansion 11 2.1 Health Disparities and Insurance Coverage in America: A Century of Change 12 2.2 The ACA’s Mechanics and Effectiveness 13 2.2.1 How Did the ACA Increase Health Insurance Coverage? 13 2.2.2 The ACA’s Effectiveness 14 2.3 Ramifications of an ACA Repeal 14 2.4 Conclusion: The ACA’s Impact on Health Equity Amid Ongoing Challenges 15 References 17 3 Tackling Insulin Affordability: Addressing Systemic Failures and Policy Solutions 19 3.1 Insulin Affordability: Progress, Disparities, and the Need for Systemic Change 20 3.2 State Initiatives on Insulin Affordability: An Overview 21 3.2.1 State-Mandated Diabetes Coverage: Benefits and Limitations 22 3.2.2 State Copay Caps: Limited Impact and Scope 22 3.2.3 State Insulin Safety Net Program: A Limited Solution 22 3.2.4 Biosimilar Insulin: Interchangeability, State Initiatives, and Challenges 23 3.3 Federal Efforts and the Inflation Reduction Act for Insulin Affordability 23 3.4 Policy Recommendations 24 3.5 Conclusion: Addressing Systematic Failures for Equitable Insulin Access 26 References 26 4 Ensuring Equitable Healthcare: Overcoming Language Barriers Through Policies 29 4.1 Challenges and Implications of Language Barriers in Healthcare 30 4.2 Federal Laws Addressing Language Needs in Healthcare 31 4.2.1 Federal Authority and Related Standards and Guidance 31 4.2.2 The Affordable Care Act 32 4.2.3 Additional Federal Laws and Funding 33 4.3 State Initiatives 33 4.4 Recent Developments and Practical Challenges 34 4.5 Conclusion: Charting a Path to Linguistically Inclusive Healthcare 35 References 36 5 Confronting the US Maternal Mortality Crisis: Addressing Racial Disparities 39 5.1 Racial Disparities Fuel US Maternal Mortality Crisis 40 5.2 Preventable Deaths: Addressing Systemic Barriers via Policy 41 5.2.1 Federal Initiatives: Driving Change in Maternal Health 41 5.2.2 State-Level Initiatives: Medicaid Expansion and Targeted Interventions 42 5.3 Overcoming Fragmentation: Collaboration and Bias Training 44 5.4 Conclusion: Strengthening Legislation: Equity-Focused Interventions 45 References 45 6 Mitigating Algorithmic Bias in Healthcare AI for Equitable Care 47 6.1 Addressing Algorithmic Bias in AI to Ensure Fair Healthcare 48 6.2 Legal Landscape and Challenges in Regulating Algorithmic Bias in Healthcare AI 48 6.3 Collaborative Efforts to Address Algorithmic Bias in Healthcare AI 49 6.3.1 Enhancing Data Quality and Diversity to Address Algorithmic Bias 50 6.3.2 Regulatory Oversight and Transparency in Medical AI Development and Implementation 50 6.3.3 Diverse Teams and Inclusive Datasets: Strategies for Mitigating Algorithmic Bias 51 6.4 Conclusion: Overcoming Challenges in Addressing Racial Bias in Medical AI 52 References 53 7 Confronting Inequities in the US Organ Transplant System 55 7.1 Inequities in Organ Transplantation Disproportionately Affect Communities of Color 56 7.2 Barriers to Specialist Referrals and Data Gaps Perpetuate Inequities 57 7.3 Race-Based Clinical Policies Hinder Equitable Waitlist Placement 57 7.4 Waitlist Policies Favor Socioeconomically Advantaged Patients 57 7.5 Communication Barriers and Resource Limitations Hinder Diverse Organ Donation 58 7.6 Provider Bias and Insurance Disparities Impede Black Patients’ Transplant Access 58 7.7 OPTN Mandates Race-Neutral Transplant Eligibility Calculations 58 7.8 Recommendations for Improving Equity at Each Stage of the Transplant Process 59 7.9 Discrimination Based on Disability in Organ Transplantation Persists 60 7.10 A Comprehensive, Multistage Approach for Equitable Organ Allocation 60 References 61 8 Transforming Blood Donation: Path to Inclusivity and Science-Based Guidelines 65 8.1 Updated FDA Blood Donation Guidelines Promote Inclusivity and Safety 66 8.2 The Evolution of FDA Blood Donation Policies for Men Who Have Sex with Men 67 8.3 Challenging the Constitutionality of FDA’s MSM Blood Donation Policies 68 8.4 FDA’s New Guidelines Combat Stigma and Promote Inclusivity 70 8.5 Conclusion: Rebuilding Trust and Encouraging Inclusive Blood Donation 70 References 71 9 Addressing Barriers and Disparities in Clinical Trials: FDA’s Diversity Plan 73 9.1 Enhancing Diversity in Clinical Trials: Addressing Barriers and Disparities 74 9.2 Legislative and Regulatory Efforts to Enhance Clinical Trial Diversity 75 9.3 Potential Impact of Diversity in Clinical Trials on Medical Outcomes 76 9.4 Limitations and Challenges in Enforcing Diversity Requirements 77 9.5 Strategies to Increase Access and Participation in Clinical Trials 77 9.6 Incentives and Post-Approval Requirements to Promote Diversity 78 9.7 Conclusion: Future Steps and Expanding Diversity Efforts 78 References 79 10 Strengthening the Safety Net to Mitigate Reproductive Health Inequity After Dobbs 83 10.1 Reproductive Health Inequities Post-Dobbs 84 10.2 Maternal Health Inequities Deepen Post-Dobbs 85 10.3 The Critical Role of Safety-Net Providers 86 10.4 Advancing Equity Through Research 88 10.5 Conclusion: Advancing Equity Amid Reproductive Crisis 89 References 89 11 Advancing Mental Health Equity Through Policies 93 11.1 Disparities in Mental Health Care 94 11.2 Major Shifts Needed 95 11.3 Addressing Root Causes 96 11.4 States as Laboratories for Innovation 97 11.5 Conclusion: Urgency for Mental Health Reform 98 References 99 Part II Health Behaviors: Exploring the Influences of Exercise, Diet, and Drug Use 103 12 Promoting Physical Activity: Policy Strategies for Equity and Engagement 105 12.1 Tackling the Global Inactivity Crisis: WHO’s Action Plan for a Healthier World 106 12.2 Addressing Inequities in Physical Activity: Inclusive Strategies and Community Engagement 106 12.3 Implementing Inclusive Health Equity Strategies: CDC Guidelines and Community Examples 107 12.4 Leveraging Legal Strategies and Policy Domains to Promote Physical Activity and Address Inequities 108 12.5 Conclusion: Overcoming Challenges in Promoting Physical Activity for Youth of Color 110 References 110 13 Reducing Sugary Beverage Consumption: Regulatory Measures 113 13.1 Consequences of Sugary Drink Consumption 114 13.2 Factors Driving Sugary Drink Consumption Disparities in Communities of Color 114 13.2.1 Sugary Drink Consumption Disparities Among Racial and Ethnic Groups 114 13.2.2 Targeted Marketing of Sugary Drinks to Minority Youth 115 13.2.3 Limited Access to Healthy Options in Minority Neighborhoods 115 13.3 Limitations of Current Policies Addressing Sugary Drink Consumption 116 13.4 Policy Strategies for Reducing Sugary Drink Consumption 117 13.4.1 A National Sugary Drink Tax: Recommendations and Considerations 117 13.4.2 Promoting Healthier School Meals and Reallocating Agricultural Subsidies 118 13.5 Conclusion: A Comprehensive Approach to Reducing Sugary Drink Consumption 118 References 119 14 Promoting Health Equity via Tobacco Control 123 14.1 Tobacco-Related Disparities 124 14.2 Strategies for Policy Interventions to Foster Health Equity 125 14.2.1 Implementation of Smoke-Free Laws 126 14.2.2 Investment in Anti-tobacco Education and Ad Campaigns 126 14.2.3 Investment in Tobacco Cessation Programs 126 14.2.4 Increase in the Cost of Tobacco Products 127 14.2.5 Regulation of Tobacco Product Sales 127 14.2.6 Raising the Minimum Age for Tobacco Purchases 127 14.2.7 Strengthening Enforcement 127 14.3 Strategizing Policy Implementation to Enhance Health Equity 127 14.3.1 The Comprehensive Approach 128 14.3.2 Minimizing Unintended Consequences 128 14.3.3 Promoting Investment in Tobacco Control 128 14.4 Conclusion: Achieving Equity in Tobacco Control 129 References 130 15 Tackling the Overdose Crisis Through Equitable Harm Reduction Policies 133 15.1 The Need for an Equity-Centered, Harm Reduction Approach 134 15.2 Expanding Access to Naloxone 135 15.3 Providing Safer Use Supplies and Services 135 15.4 Expanding Access to Evidence-Based Treatment 136 15.5 Addressing Structural Determinants and Promoting Health Equity 136 15.6 Investing in Community Development 137 15.7 Reforming the Criminal Justice System 137 15.8 Addressing Stigma and Misconceptions 137 15.9 Enhancing Data Collection and Oversight 138 15.10 Conclusion: Leveraging Resources and Centering Equity in the Fight Against the Opioid Crisis 138 References 140 16 Confronting the HIV/AIDS Epidemic: Progress, Challenges, and the Path Forward 143 16.1 Ending the HIV Epidemic: Addressing Social Disparities and Ensuring Access 144 16.2 Addressing Social Determinants: Key to Ending HIV Inequities 144 16.3 Effective HIV Prevention: Education, Access, and Comprehensive Strategies 145 16.4 Government Response: Progress and Persistent Challenges in HIV Policy 146 16.5 Dismantling HIV Discrimination: Reforming Laws and Addressing Stigma 147 16.6 Conclusion: Addressing HIV/AIDS Inequities, Ensuring Care for All 148 References 149 Part III Social and Economic Factors: Education, Income, Rurality, and Structural Racism 153 17 Addressing Food Insecurity: Strengthening Assistance Programs and Promoting Equity 155 17.1 Food Insecurity, Health Risks, and COVID-19: Exposing Systemic Inequities 156 17.2 Federal Food Assistance 156 17.2.1 SNAP and Temporary Relief Efforts 157 17.2.2 Food Assistance Programs for Children and the Elderly 157 17.3 Strategies for Enhancing Food Assistance Programs Amidst Challenges 158 17.3.1 Evaluating Food Assistance Programs for Equity and Efficiency 159 17.3.2 Improving SNAP: Tackling Barriers and Benefit Adequacy 160 17.3.3 Strengthening Food Assistance: Expert Recommendations 160 17.4 Conclusion: Transforming Food Assistance for a Resilient Future 161 References 161 18 Promoting Access to Early Care and Education: Anti-Racist Policies 165 18.1 Early Care and Education 166 18.2 Head Start and Early Head Start 167 18.3 Child Care Development Fund 167 18.4 Additional Federal Programs 168 18.5 Addressing Structural Issues in Childcare Provision 169 18.6 Conclusion: Enhancing Childcare Policies for Better Outcomes 169 References 171 19 Enacting Paid Family Leave for Health Equity 175 19.1 Barriers to Equitable Paid Family Leave in the United States 176 19.2 The Impact of Paid Leave Policies on Vulnerable Workers and the Far-Reaching Benefits for Health and Equity 176 19.3 Designing Effective and Equitable Paid Family Leave Policies: Key Strategies for Inclusivity and Uptake 177 19.4 Conclusion: Paid Leave: A Crucial Step Toward Health and Economic Equity 179 References 179 20 Enhancing Rural, Remote, and Tribal Health Equity Through Policies 181 20.1 Challenges Facing Rural, Remote, and Tribal Health 182 20.2 Advancing Rural and Tribal Health Equity Through Federal Policies 183 20.3 State-Level Policy Trends 184 20.4 Remaining Gaps and Recommendations 186 20.5 Conclusion: Seizing Opportunities, Achieving Equity 187 References 188 21 Addressing Medical Debt on Marginalized Communities: Potential Reforms 191 21.1 The Burden and Disproportionate Impact of Medical Debt 192 21.2 Government’s Role in Addressing Medical Debt Disparities 192 21.2.1 The No Surprises Act: Protections, Limitations, and Enforcement 193 21.2.2 Medicaid Expansion and Enrollment Adjustments Reduce Medical Debt 193 21.2.3 Expanding Appeal Rights and Funding Consumer Assistance Programs 194 21.2.4 State Laws Surpassing Federal Protections and Ensuring Affordable Care 194 21.3 Legislative and Policy Initiatives to Mitigate Medical Debt 194 21.3.1 Arizona Ballot Initiative: Reforming Medical Debt Collection Practices 195 21.3.2 Challenges of Medical Debt Cancellation Proposal 195 21.3.3 Provider Interactions, Cost Controls, and Insurance Reforms 195 21.3.4 Remove Medical Debt from Credit Reports 195 21.4 Conclusion: Key Considerations for Policymakers 197 References 197 22 Preserving Diversity: Impact of Affirmative Action Ruling on Healthcare 201 22.1 Supreme Court Ruling Threatens Diversity in Healthcare Education 202 22.2 The Importance of Diversity in Healthcare 202 22.3 Impact of Overturning Affirmative Action 203 22.4 Maintaining and Improving Diversity Post-ruling 204 22.4.1 Rethinking Merit and Applicant Evaluation 204 22.4.2 Proxies and Race-Neutral Alternatives 204 22.4.3 Invest in Pipeline Programs and Partnerships 205 22.4.4 Revamp Recruitment and Yield Activities 205 22.4.5 Reimagine Curriculum, Climate, and Inclusion 206 22.4.6 Leadership, Accountability, and Collaboration 207 22.5 Conclusion: Urgent Strategies Needed to Protect Diversity in Healthcare Education 207 References 208 23 Reforming the Public Charge Rule for Immigrant Health Equity 211 23.1 Barriers to Immigrant Healthcare Access: The Public Charge Rule’s Impact 212 23.2 Comparing Trump and Biden Public Charge Rules 213 23.2.1 Defining Public Charge 213 23.2.2 Difference in Application 213 23.3 The Chilling Effect: Immigrant Hesitancy to Access Public Benefits Despite Policy Changes 214 23.4 Limited Policy Solutions to Address Immigrant Distrust and Expand Access to Benefits 215 23.5 Strategies to Rebuild Trust and Increase Immigrant Access to Public Benefits 216 23.6 The Need for Legislative Action to Provide Certainty and Stability for Immigrants 216 References 216 24 Promoting Health in All Policies (HiAP) Approach 219 24.1 Integrating HiAP: A Strategic Approach to Achieving Health Equity 220 24.2 Legal Frameworks Facilitating Multi-sector Collaboration for HiAP 221 24.3 Establishment and Impact of California’s HiAP Task Force 221 24.4 Strategies for Enhancing and Sustaining HiAP Initiatives 222 24.5 Challenges and Strategic Insights for Implementing HiAP Amidst a Pandemic 224 24.6 Conclusion: Lessons and Challenges in Implementing HiAP 224 References 225 25 Rethinking Preemption for Health Equity 227 25.1 The Double-Edged Sword of Preemption in Public Health Regulation 228 25.2 Preemption During the COVID-19 Pandemic: Challenges and Consequences 229 25.3 Preemption’s Disproportionate Impact on Vulnerable Populations and Inequities 229 25.4 Conclusion: Toward an Equity-First Preemption Framework 231 References 233 26 Achieving Health and Economic Equity Through Broadband Access and Policy 235 26.1 Broadband: A Crucial Determinant of Health Equity 236 26.2 The Digital Divide: Perpetuating Systemic Inequities 237 26.3 Lawmakers’ Role in Achieving Equitable Broadband Access 237 26.3.1 Federal Efforts to Support Broadband Access and Digital Equity 238 26.3.2 State-Level Strategies for Promoting Digital Equity 238 26.3.3 Local Initiatives Addressing Community-Specific Digital Needs 240 26.4 Conclusion: A Public Value Essential for Health and Economic Equity 240 References 241 27 Expanding Vaccine Equity: Policy Strategies 245 27.1 Vaccine Inequity: Disparities in Access and Health Outcomes 246 27.2 Government Efforts to Address Vaccine Inequity: Successes and Challenges 247 27.3 Addressing Persistent Vaccine Inequities: Proposed Solutions and Global Efforts 249 27.4 Federalism and Vaccine Inequity: Challenges, Criticisms, and Federal Efforts 250 27.5 Data Gaps: Hindering Efforts to Address Vaccine Inequities 251 27.6 Conclusion: Addressing Vaccine Inequity: Lessons, Strategies, and a Call to Action 252 References 253 28 Disaggregating Data: Unveiling the Diversity and Disparities Within the AAPI Population 255 28.1 Diversity and Disparity: The Complexity of AAPI Data Aggregation 256 28.2 Model Minority Myth: Masking AAPI Health Disparities Through Aggregation 257 28.3 State-Led Initiatives: Advancing AAPI Data Disaggregation Amid Federal Inconsistency 258 28.4 Barriers to Disaggregation: Sample Sizes and Community Opposition 259 28.5 Conclusion: Disaggregation Imperative 259 References 261 Part IV Physical Environment: The Role of Housing, Transit, Water, and Climate Change 265 29 Achieving Health Equity Through Housing Laws and Policies 267 29.1 Housing and Health: The Impact of Segregation 268 29.2 How Laws and Policies Post-fair Housing Act Have Furthered Residential Segregation 268 29.2.1 The Low-Income Housing Tax Credit 268 29.2.2 Nuisance Ordinances 269 29.2.3 Rent Control 269 29.2.4 Housing Choice Voucher Program 270 29.2.5 Zoning Laws 270 29.3 Positive Legal Interventions 271 29.3.1 Land Banks 271 29.3.2 Inclusionary Zoning 272 29.3.3 Earned Income Tax Credit 272 29.3.4 Other Policy and Legal Interventions 272 29.4 Conclusion: Addressing Residential Segregation for Better Health 273 References 275 30 Advancing Transportation for Health Equity Through Policies 277 30.1 The State of Transportation Inequity 278 30.2 An Agenda for Transportation Justice Policy 279 30.2.1 Participatory Community Planning 279 30.2.2 Equitable Transportation Funding 280 30.2.3 Antiracist Mobility Policies 280 30.2.4 Accessible and Resilient Mobility Ecosystems 280 30.2.5 Data-Driven and Community-Defined Metrics 281 30.2.6 Capacity Building and Narrative Shift 282 30.2.7 Cross-Sector Collaboration 283 30.3 Conclusion: Transportation Justice Drives Health Equity 283 References 284 31 Providing Access to Clean Water for Health Equity Through Policies 287 31.1 Water Insecurity in America 288 31.2 Causes of Water Insecurity and Access Inequities 288 31.2.1 Aging and Inadequate Infrastructure 289 31.2.2 Inequitable Water Policies and Underinvestment 289 31.2.3 Climate-Related Threats 290 31.3 Health Disparities of Water Insecurity 290 31.4 Comprehensive Policy Solutions 291 31.5 Conclusion: Achieving Water Equity Through Policy 293 References 293 32 Addressing Climate Change-Induced Health Disparities Through Policy and Planning 297 32.1 Climate Change: A Threat Multiplier Exacerbating Health Inequities 298 32.2 Frontline Communities: Disproportionate Climate Impacts and Inadequate Support 298 32.3 Addressing Climate Inequity: Challenges and Progress in Policy and Legislation 299 32.4 Equitable Climate Policies: Engaging Communities, Strengthening Health Responses, and Prioritizing Research 301 32.5 Conclusion: Embracing Health Equity as a Cornerstone of Climate Policy 303 References 303 Index 305