The National Academies of Sciences, Engineering, and Medicine has issued a comprehensive report on how federal government policies have created and perpetuated racial, ethnic, and tribal health inequities, and how reversing and changing those policies could advance health equity.
According to the report, health equity is the state in which everyone has a fair opportunity to attain full health potential and well-being, and no one is disadvantaged from doing so because of social position or any other socially defined circumstance. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequali- ties and historical and contemporary injustices and eliminate health and health care disparities due to past and present causes. It is about fairness and ensuring that no one suffers inequitable outcomes in health and well- being, everyone’s voice is heard, and everyone at the table has the power to inform action. When individuals thrive, families, communities, and the entire nation thrive.
The report uses the Healthy People 2030 social determinants of health framework to understand health and health equity, including economic stability, health care access and quality, education access and quality, social and community context, and features of neighborhoods and built environments, in recognition that health is influenced by more than health care insurance or utilization of health care services.
Rather than referring to “racial and ethnic minorities,” “members of minority groups,” or “underrepresented minorities,” the report uses the term “minoritized,” which refers to people from groups that have been historically and systematically socially and economically marginalized or underserved based on their race or ethnicity as a result of racism (such as American Indian and Alaska Native, Asian, Black, Latino/a, and Native Hawaiian and Pacific Islander communities). The report uses this term to make the distinction that being minoritized is not about the number of people in the population but rather about power and equity.
Although membership in a particular racial, ethnic, or tribal group does not predict a given outcome, and each of the broad categories of race and ethnicity has considerable heterogeneity, the available data on health outcomes and other measures of well-being tell a consistent story of wide disparities in health. Research demonstrates that the inequitable patterns of these social risk factors across race and ethnicity are in large part a consequence of structural disadvantages for minoritized communities that were, in no small measure, initiated by historical federal policy decisions.
The report identifies four action areas through which the federal government can better support states, localities, tribes, territories, and communities to advance health equity.
- Implement sustained coordination among federal agencies;
- Prioritize, value, and incorporate community voice in the work of government;
- Ensure collection and reporting of data are representative and accurate; and
- Improve federal accountability, enforcement, tools, and support toward a government that advances optimal health for everyone.
The report makes 13 recommendations to advance racial, ethnic, and tribal health equity (several of these recommendations have additional details in the report):
Recommendation 1: To improve health equity, the president of the United States should create a permanent and sustainable entity within the federal government that is charged with improving racial, ethnic, and tribal equity across the federal government. This should be a standing entity, sustained across administrations, with advisory, coordinating, and regulatory powers. The entity would work closely with other federal agencies to ensure equity in agency processes and outcomes.
Recommendation 2: The president of the United States should appoint a senior leader within the Office of Management and Budget (OMB) who can mobilize assets within OMB to serve as the cochair of the Equitable Long-Term Recovery and Resilience Steering Committee.
Recommendation 3: The federal government should assess if federal policies address or exacerbate health inequities by implementing an equity audit and developing an equity scorecard.
Recommendation 4: The federal government should prioritize community input and expertise when changing or developing federal policies to advance health equity.
Recommendation 5: The Office of Management and Budget (OMB) should require the Census Bureau to facilitate and support the design of sampling frames, methods, measurement, collection, and dissemination of equitable data resources on minimum OMB categories— including for American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino/a, and Native Hawaiian or Pacific Islander populations—across federal statistical agencies. The highest priority should be given to the smallest OMB categories—American Indian or Alaska Native and Native Hawaiian or Pacific Islander.
Recommendation 6: The Office of Management and Budget (OMB) should update and ensure equitable collection and reporting of detailed origin and tribal affiliation data for all minimum OMB categories through data disaggregation by race, ethnicity, and tribal affiliation (to be done in coordination with meaningful tribal consultation), including populations who self- identify as American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino/a, and Native Hawaiian or Pacific Islander.
Recommendation 7: The Centers for Disease Control and Prevention should coordinate the creation and facilitate the use of common measures on multilevel social determinants of racial and ethnic health inequities, including scientific measures of racism and other forms of discrimination, for use in analyses of national health surveys and by other federal agencies, academic researchers, and community groups in analyses examining health, social, and economic inequities among racial and ethnic groups.
Recommendation 8: Congress should increase funding for federal agencies responsible for data collection on social determinants of health measures to provide information that leads to a better understanding of the correlation between the social environment and individual health outcomes.
Recommendation 9: The president of the United States should convert the Equitable Data Working Group, currently coordinated between the Office of Management and Budget (OMB) and the Office
of Science and Technology Policy, into an Office of Data Equity under OMB with representation from the Domestic Policy Council, with an emphasis on small and underrepresented populations and with a scientific and community advisory commission, to achieve data equity in a manner that is coordinated across agencies and informed by scientific and community expertise.
Recommendation 10: Congress and executive agencies should leverage the full extent of federal authority to ensure equitable implementation of federal policies and access to federal programs.
Recommendation 11: The President of the United States should direct the Office of Management and Budget to review federal programs that exclude specific populations, such as immigrants and those with a criminal record and, in some cases, currently incarcerated people (e.g., Medicaid coverage), to assess the rationale and implications for equity of excluding these populations, including potential impacts on their families and communities. A report on the findings and suggested changes (when applicable) should be made publicly available.
Recommendation 12: The federal government should undertake the following actions to advance health equity for American Indian and Alaska Native communities in both urban and rural settings by raising the prominence of the agencies that have jurisdiction.
Recommendation 13: The Departments of Health and Human Services, Defense, Veterans Affairs, Homeland Security, and Justice, as federal government purchasers and direct providers of health care, should undertake strategies to achieve equitable access to health care across the life span for the individuals and families they serve in every community. These strategies should prioritize access to effective, comprehensive, affordable, accessible, timely, respectful, and culturally appropriate care that addresses equity in the navigation of health care. While these strategies have a greater chance of success when everyone has adequate health insurance, there are ways the executive branch can improve and reinforce access to care for the adequately insured, the underinsured, and the uninsured.
NASEM also has prepared a 4-page summary of the report, including the recommendations:
Ignatius Bau 