Greenlining Institute: Filling in the Gaps – A Racial Equity Framework for Successful Implementing the Affordable Care Act

This policy brief from the Greenlining Institute proposes a racial equity framework for the federal and state governments to consider in the implementation of the Patient Protection and Affordable Care Act.

According to the policy brief, “racial equity” focuses on achieving comparable favorable outcomes across racial and ethnic groups, regardless of the resources and input allocated.   A racial equity framework also uses an intersectional lens to recognize differences within and across communities impacted by racial and ethnic oppression. The theory of intersectionality describes the ways in which race, ethnicity, class, sex, gender identity, sexual orientation, ability, nationality, age, geography, and other markers of difference intersect to explain and inform an individual’s life experiences.  A racial equity framework that uses an intersectional lens, thus, allows social change leaders to identify shared goals and tactics in promoting racial justice while also recognizing differences across and within communities of color. The political, economic, and institutional systems that uphold racial and ethnic inequality are the same systems used to uphold oppressive policies and practices based on gender, class, sexual orientation, and other markers of difference.

The policy brief proposes the following guiding principles for its racial equity framework:

Diversity and Inclusion: Recruit diverse community stakeholders – including but not limited to racial and ethnic minorities, women, youth, and LGBTQ individuals – and involve them as active participants in all stages of decision-making, policy-implementation, and program evaluation processes. Resulting programs and policies should be inclusive and representative of the needs of the communities that they will impact.

Transparency and Accountability: Maintain openness and fairness to diverse communities, such as low income communities, communities of color, and geographically isolated communities in all phases of planning, decision-making, program development, program implementation, documentation, program evaluation, and advocacy.

Healthy Environments – Pay active attention to eliminating existing disparities to achieve outcomes that maximize the health, safety and well-being of all individuals and communities.

Equal Opportunity: All individuals should have full and fair access to opportunities and benefits of resulting policies and programs without bias, unnecessary barriers or extra burden.

Accessibility:  Ensure that all individuals receive the basic information, resources, and opportunities necessary to create healthy and prosperous futures for themselves and their children.

Sustainability: Implement equity-enhancing programs and policies with the support, protections, and enforcement necessary for long-term positive impact in diverse communities.

The framework then uses six steps to analyze any policy issue:

Step 1: Gathering Information

Review the purpose of the policy that will be implemented and begin identifying additional information needed to ensure equitable outcomes.

1. What specific issue(s) are we intending to address?
2. What is the purpose of the policy we are making and/or implementing?
3. What quantitative and qualitative evidence of inequity exists around the issue that this policy is supposed to address?
4. How might implementation play out differently in different communities?
5. What additional information is missing or needed?

Step 2: Engaging Stakeholders

Assemble a team of stakeholders with diverse perspectives who can help policymakers holistically analyze the implementation process. Any policy-driven process should include robust stakeholder input and a program to ensure successful implementation in all communities.

1. Who are the stakeholders (including community members and members of various racial/ethnic groups) who may be positively or negatively affected by this policy? How can we best inform them?
2. How can we engage potentially affected stakeholders as active participants in the decision-making, planning, and implementation processes in an impactful way?
3. Are we meaningfully considering the needs and concerns of stakeholders during final decision-making processes?
4. Who is missing and how can we engage them?

Step 3: Identifying Policy Holes

Identify the positive and negative outcomes that a policy would have in diverse communities if implemented without recognizing the unique circumstances of various racial and ethnic groups. The input of diverse community stakeholders is extremely valuable during this step.

1. What adverse impacts or unintended consequences could result from this policy if enacted as written?
2. How would different racial and ethnic groups be impacted (either positively or negatively) if this policy were enacted or implemented as written?
3. What additional barriers might prevent individuals in certain racial/ethnic groups from benefitting fully if this policy were implemented as written? Consider language, gender, SES, digital inequality, LGBTQ status, (dis)ability, employment status, immigration status, education level, geography, environment, religious beliefs, culture, history of incarceration, etc.

Step 4: Filling in the Holes

Identify additional steps policy-implementers and advocates should take to ensure that the policy will impact all communities positively and equitably.

1. What steps could we take to prevent or minimize adverse impacts or unintended consequences?
2. What steps could we take to address additional barriers that could prevent various racial/ethnic groups from accessing the policy fully?
3. Are there further ways to maximize equitable outcomes?

Step 5: Examining Sustainability

Ensure that the implementation process and its equity framework are both transparent and sustainable.

1. Do this policy and additional equity-enhancing measures related to this policy have adequate funding? Are mechanisms in place to ensure successful implementation and enforcement?
2. Are there provisions to ensure ongoing stakeholder participation and public accountability of policy implementers and enforcers?

Step 6: Evaluation

Measure the success of equitable policy implementation.

1. Are there provisions to ensure ongoing collection of data (that can be disaggregated by race/ethnicity) and public reporting of data?
2. Are there clear markers of short term and long term success as well as timelines for meeting markers of success?
3. What are the mechanisms we will utilize to ensure that goals are met?
4. What are the consequences if goals are not met?
5. Is there a process for those impacted by the policy to express grievances or satisfaction and to ensure that concerns are met?

Finally, the policy brief applies the racial equity framework to California’s implementation of the ACA, noting opportunities and recommendations to advance racial equity as the state implements the national health care reform legislation.

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