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U.S. Should Create a Federal Entity Responsible for Advancing Racial, Ethnic, and Tribal Health Equity, and Implement a Health Equity Policy Audit and Score Card

National Academies
July 27, 2023


WASHINGTON — To improve health equity in the U.S., the president should create a permanent federal body responsible for improving racial, ethnic, and tribal equity across the federal government, says a new report from the National Academies of Sciences, Engineering, and Medicine. In addition, Congress should create a new score card to assess how all proposed federal legislation might impact health equity in the future. The report also recommends federal agencies conduct an equity audit of their current policies. 

Racial, ethnic, and tribal health inequity in the U.S. is widespread and persistent, and federal policy can play a role in reducing health inequities, the report says. Education, income, health care access, and neighborhoods — and the policies that shape them — can all contribute to either hindering or advancing health equity.

Racially and ethnically minoritized populations experience higher rates of illness and death for many important health conditions, such as infant mortality, maternal death, and chronic conditions such as heart disease. These populations also have lower life expectancies compared to non-Hispanic White people — in 2019, life expectancy for the non-Hispanic White population was 78.9 compared to 75.3 for the Black population and 73.1 for the American Indian and Alaska Native populations. Health inequities also have consequences for the economy, national security, and businesses. Although the committee that wrote the report was asked to focus on racial, ethnic, and tribal health equity, the report acknowledges that sex, age, disability status, citizenship, and many other factors can also interact to impact health equity. 

Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity reviews the impact of economic, education, health care, infrastructure, housing, public safety, and other policies on health equity, focusing on policies that affect a large percentage of minoritized communities — including historical policies that continue to cause harm. The report found increases to the federal minimum wage and closing achievement gaps through federal spending on education, for example, can both improve health equity. Medicaid and the Children’s Health Insurance Program are the most important federal policies that address racial and ethnic inequities in access to health care, according to the report.  

The report pays special attention to American Indian and Alaska Native populations, which are often overlooked in large national reports and in the U.S. are worse off than all other racial and ethnic groups for most measures of health. To improve health equity for American Indian and Alaska Native populations, Congress should authorize funding of the Indian Health Service at parity with other health care programs through mandatory advance appropriations. The House of Representatives should reestablish the Indian Affairs Committee, and the director of IHS should be raised to the level of an assistant secretary. 

Recommendations also address collecting more accurate and complete population data for minoritized communities, improving coordination among federal agencies, supporting better inclusion of community input, and increasing federal support and access for state and local programs. 

“The health inequities experienced by millions of people living in the U.S. today are in part the result of past and current policies that exclude or deprioritize these populations — putting them at a disadvantage that affects their well-being and life expectancy,” said Sheila Burke, the committee’s co-chair and an adjunct lecturer at the John F. Kennedy School of Government at Harvard University, and chair of the Government Relations and Policy Group at Baker Donelson. “The time to act is now, and we lay out specific steps in our report that the federal government can take to advance health equity.”  

“Including community voices in the policy process is of paramount importance to the nation’s path to health equity,” added Daniel Polsky, committee co-chair and Bloomberg Distinguished Professor of Health Economics and Policy in the Bloomberg School of Public Health and the Carey Business School at Johns Hopkins University. “Our recommendations call for steps from the executive and legislative branches to increase transparency and boost community representation.” 

“Addressing the nation’s racial and ethnic health disparities is an imperative for the medical community, and a crucial goal the National Academy of Medicine has worked toward for years,” said Victor J. Dzau, president of the National Academy of Medicine. “This report’s recommendations are a path forward for improving equity in the federal policies, systems, and structures that shape our health and well-being.” 

Improved Coordination 

Improved and sustained coordination among federal agencies can advance health equity. The White House Office of Management and Budget should review federal programs that exclude specific populations, such as immigrants or individuals with a criminal record, to assess the impact of this exclusion on health equity and on communities. The report also recommends OMB lead the development of the federal equity audit.  

Agencies should leverage their full authority to ensure equitable access to federal programs and implementation of policies — including improving how assistance programs are administrated to make it easier for individuals and families to access them. The report specifically recommends federal agencies that purchase and directly provide health care — the departments of Health and Human Services, Defense, Veterans Affairs, Homeland Security, and Justice — achieve equitable access to health care for every community they serve.   

Representative and Accurate Data 

The lack of accurate data about minoritized communities has left government unprepared to understand, let alone eliminate, health inequities — and poses a major roadblock to health equity efforts in federal policy, says the report. Congress should increase funding for federal agencies responsible for collecting data on social factors that impact health, such as housing or education.  

The report also recommends the Centers for Disease Control and Prevention coordinate the creation of common measures for inequity, including a scientific measure of racism and other forms of discrimination to use in national health surveys and research.  

Sample sizes in national surveys are often too small to obtain high-quality and representative samples required to monitor inequities. OMB should require the Census Bureau to design and share resources on sampling and collecting data for minoritized groups, with priority given to American Indian and Alaska Native and Native Hawaiian and Pacific Islander populations — the smallest populations measured by OMB. OMB should also ensure reporting of detailed origin and tribal affiliation by requiring disaggregation of data by race, ethnicity, and tribal affiliation.  

The study — undertaken by the Committee on the Review of Federal Policies that Contribute to Racial and Ethnic Health Inequities — was sponsored by the Office of Minority Health in the U.S. Department of Health and Human Services. 

The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, engineering, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. 


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