This policy brief will outline the US Department of Health & Human Services’ Action Plan to Reduce Racial and Ethnic Health Disparities. Strengths contained within will be discussed, as well as weaknesses and pieces that are missing.
Within the context of a public health equity framework, the HHS action plan contains useful information about the social determinants of health, as well as useful mid-stream strategies to address health disparities. Goals to work towards the HHS’s vision of “A nation free of disparities in health and health care” are described as follows:
I. Transform health care;
Transformation strategies at the healthcare institutional level include increasing access to health insurance through policies such as the ACA and Medicaid expansions, as well as policies meant to increase the number of providers in underserved localities, and other quality improvement policy strategies.
II. Strengthen the nation’s Health and Human Services infrastructure and workforce
This goal is addressed through institutional and interpersonal strategies meant to improve access to language interpreters through staff development. Staff development is also utilized as a means for transformation by training strategies for community health workers, as well as with policies meant to recruit more diverse clinicians within the health care work force.
III. Advance the health, safety, and well-being of the American people;
The HHS action plan addresses this goal by promoting personal-level preventative health activities, especially within populations experiencing health disparities. Disparities are also addressed through the dissemination of health information to the community, as well as through promotion of individual-level preventative health interventions, in order to transform health outcomes in communities.
IV. Advance scientific knowledge and innovation; and
This goal is addressed by utilizing data collection strategies meant to improve the representation of racial (and other forms of difference) minorities, as well as to inform health disparity reduction interventions moving forward.
V. Increase the efficiency, transparency, and accountability of HHS programs.
HHS addresses this goal with institutional level policy transformation, for quality improvement of all programs within the department.
The HHS action plan focuses primarily on here-and-now snapshots of health disparities. Importantly, the goals and strategies of the plan are framed by this snapshot. While the proposed strategies are useful, public health is better served through a health equity lens; that is to say, “The state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance” (Ford et al., 2019). With health equity as the goal, health disparities are re-framed as health inequities – “differences in health which are unnecessary and avoidable but, in addition, are also considered unfair and unjust” (Ford et al., 2019).
Health inequities are injustices. What does that mean? If ‘health disparities’ describe the current state of health outcome differences within minority communities, then ‘health inequities’ refers to those disparities within the social and historical contexts causing the disparities. Context is important; it is the why behind health outcomes. The nuance between ‘disparity’ and ‘inequity’ is vital. The causes and upstream determinants of health must be addressed in order to effectively serve the goal of health equity for all.
The HHS action plan has significant room for improvement from within a health equity framework. Many of the goals in the plan address institutional change within the healthcare system – this transformation is one of many vital steps towards health equity. The plan fails to address the impact of other institutions on the health of the community, however. The healthcare sector is a large part of health, but the social structures in which the community lives, works, plays, and ages play a much larger role. Achieving health equity will involve institutional changes in the structure of the government, of civil society, of business, and more (Agency for Toxic Substances and Disease Registry, 2011, Marmot, 2008).
The action plan also fails to consider the importance of community engagement as an equal partner in health. Health additionally happens at a cultural level, which means that dialogues must be had between public health and the community regarding their experiences of health inequity and about what is needed to achieve equity. Up-stream factors of health must be elucidated in order to form strategies that address the causes of health disparities in a community (ATSDR, 2011). This happens through, among other things, dialogue.
Investigating the root causes of poor access to competent health care can lead to strategies formed around the community’s true needs. This is an example of a health equity framework. Why else might the black community face greater rates of chronic illness, for instance? Is there something about the built environment in which they live, work, and play that could contribute to poorer health? Social and historical contexts play a large role in health – for example, a black family may remain trapped in a violent neighborhood due to the home foreclosure of their grandparents. In this case, inter-generational wealth differences associated with historical and institutional racism lead to higher stress levels today, which in turn lead to increased rates of chronic illnesses like cardiovascular disease and obesity (Ford et al., 2019). In this instance, the dissemination of preventative health information (as outlined in the 3rdgoal of the action plan) is certainly helpful to the black family. But mid-stream interventions alone neglect the root causes by failing to address social injustices that lead to outcome differences. These types of community health interventions are cheap and easy at the expense of true health equity.
If used alone, the HHS action plan will hurt the Kent County Health Department’s efforts to transform public health practice to a root-causes agenda. Of most concern is the language the plan uses to outline history, its vision, and the framework of its goals. The plan inadvertently implies that health disparities start and end at the level of healthcare delivery. The plan’s strategies are certainly useful mid-stream interventions, important for reduction of harm associated with health inequities. The overall goal of health equity in our community would be better served with the following restructuring of the HHS plan’s vision and goals:
“An equitable nation in which all people have safety and good health”
“Advance the health, safety, and well-being of the American people by reversing current and historical social injustices”
1. Restructure HHS infrastructure and healthcare delivery to improve access to healthcare for all
2. Advance scientific knowledge to improve interventions focusing on communities in need
3. Promote change within partnered institutions
4. Elevate communities as equal partners and assets for the obtainment of health equity
HHS recommendations outlined in the plan can meaningfully improve health equity in Kent County if and only if its language is restructured in the above manner. Mindfulness about the social injustices leading to health disparities remains crucial in the pursuit of health equity, especially in light of the harm that the black community here continues to experience due to police brutality (Evans, 2020).
Agency for Toxic Substances and Disease Registry. (2011). Principles of Community Engagement, 2nd ed. Centers for Disease Control and Prevention. https://www.atsdr.cdc.gov/communityengagement/pce_models.html
Alang, S., McAlpine, D., McClain, M. (2021). Police Encounters as Stressors: Associations with Depression and Anxiety across Race. Socius: Sociological Research for a Dynamic World Volume 7: 1-13. https://journals.sagepub.com/doi/10.1177/2378023121998128
Brummel, M. (n.d.). 2020 Kent County Community Health Needs Assessment. Kent County Health Department. https://accesskent.com/Health/CHNA/pdf/FINAL-2020-CHNA-REPORT.pdf
Department of Health and Human Services, USA. (n.d.). HHS Action Plan to Reduce Racial and Ethnic Health Disparities: A Nation Free of Disparities in Health and Health Care.
Evans, M. K. (2020). Health Equity – Are We Finally on the Edge of a New Frontier? N Engl J Med 383;11. https://www.nejm.org/doi/pdf/10.1056/NEJMp2005944?articleTools=true
Ford, C. L., Griffith, D. M., Bruce, M. A., Gilbert, K. L. (2019). Racism: Science & Tools for the Public Health Professional. American Public Health Association
Huffman, B. (2022). Grand Rapids police faced years of racial bias complaints before fatal shooting. BridgeMichigan. https://www.bridgemi.com/michigan-government/grand-rapids-police-faced-years-racial-bias-complaints-fatal-shooting
Kirkpatrick, D. D., Eder, S., Barker, K. (2022). Cities Try to Turn the Tide on Police Traffic Stops. The New York Times. https://www.nytimes.com/2022/04/15/us/police-traffic-stops.html
Marmot, M., Friel, S., Bell, R., Houweling, T. A. J., Taylor, S. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008;372:1661-69.
NAACP. (n.d.). The Origins of Modern Day Policing. Retrieved 4/17/22 from https://naacp.org/find-resources/history-explained/origins-modern-day-policing
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. U.S. Department of Health and Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html
Pazzanese, C. (2021). How unjust police killings damage the mental health of Black Americans. The Harvard Gazette. https://news.harvard.edu/gazette/story/2021/05/how-unjust-police-killings-damage-the-mental-health-of-black-americans/
The Washington Post. (2022). Fatal Force: 1,019 people have been shot and killed by police in the past year. https://www.washingtonpost.com/graphics/investigations/police-shootings-database/
Tobin-Tyler, E., Teitelbaum, J. B. (2019). Essentials of Health Justice: A Primer. Jones&Bartlett Learning.
United States Census Bureau. (n.d.). QuickFacts: Grand Rapids city, Michigan. Retrieved 4/17/22 from https://www.census.gov/quickfacts/fact/table/grandrapidscitymichigan/PST045221
Walsh, C. (2021). Solving racial disparities in policing. The Harvard Gazette. https://news.harvard.edu/gazette/story/2021/02/solving-racial-disparities-in-policing/