Health Equity Guidelines For President Biden and the 117th Congress
The Health Equity Collaborative invites your organization to join us in sending a letter to President Biden and Members of the 117th Congress, urging them to prioritize elevating health equity and addressing social determinants of health to address pervasive health disparities faced by our communities. The pandemic has disproportionately impacted underserved Americans, intensifying the growing gaps in health outcomes. Therefore, policymakers must engage directly with community-based organizations and public health advocates when developing policies to address health equity inadequacies.

We hope you will join in asking President Biden and Congress to consider the information and guidelines outlined in the letter below as they pursue future healthcare initiatives.

The full text of the letter follows, and you can add your organization by filling out the form underneath.

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Dear President Biden and Members of the 117th Congress,

We, the undersigned organizations, who represent diverse communities across the country, congratulate the Biden Administration and new Congress on the immediate progress your collective leadership has made during these devastating health and economic crises our country is facing. We write to you to support your leadership in elevating health equity and addressing social determinants of health to effectively address pervasive health disparities faced by our communities.

The pandemic's disproportionate impact on America’s underserved has only magnified longstanding gaps in health outcomes that have been manifested for generations. It is imperative that public policymakers engage directly with community-based organizations and public health advocates when developing interventions to measurably improve health equity. As lawmakers, we urge your consideration of the following information and guidelines as you and your colleagues pursue future healthcare initiatives. The priorities we outline below enjoy broad support and are directly responsive to the issues that affect diverse communities in America today.

Ensuring an Equitable Response to COVID-19 and Pandemic Preparedness:

The COVID-19 pandemic has impacted communities of color at disproportionately high rates. African Americans and Latinos are four times as likely as non-Hispanic whites to be hospitalized with COVID-19 and about three times as likely to die from the virus.  Asian Americans, as an aggregate, have the third highest COVID-19 attributable deaths.

People of color are more likely to be frontline or essential workers, live in overcrowded housing, and be denied access to testing, treatment, and PPE. The current vaccine rollout prioritizes healthcare workers and those over the age of 75, yet communities of color within those two groups are still being vaccinated at lower rates than their non-Hispanic white counterparts.  The lack of clear policies aimed at protecting frontline or essential workers increases the precarity of these communities to COVID-19.  Nearly one third of the nurses who have died from COVID-19 are Filipino, even though they make up only 4% of the nurse population in the US.  The federal government should commit to a leadership role in ensuring there is equitable allocation and uniform distribution of the COVID-19 vaccine to all people living in the United States. This commitment must include noncitizens who, despite working in high-risk essential industries, have been largely overlooked in the pandemic response. Complex healthcare challenges like COVID-19 require a reliable and diverse healthcare supply chain capable of mitigating shortages and assisting our most vulnerable communities. Future pandemic preparedness must feature true collaboration between the private sector, government agencies, and community-based health organizations committed to disseminating science and evidence-based information in culturally and linguistically appropriate materials for non-English speaking populations.

Acknowledging Workplace Inequities:

Many people of color work in physically demanding labor-intensive jobs which often fail to provide full benefits and adequate income to access appropriate health care and experience, higher rates of work-related diseases, injuries, and psychological distress. Therefore, the federal government should propose and support policies to ensure that workers have access to affordable and quality health care and enforce laws to protect the health and safety of workers.  

Prioritizing Racial Equity and Support for Underserved Communities:

We commend President Biden’s Executive Order on advancing racial equity and support for underserved communities.   Also, we applaud the President for the issuance of a Presidential memorandum condemning xenophobia. While this is welcome and necessary progress, sustained commitment and establishment of an adequate infrastructure is needed to effectuate meaningful change and overcome racial injustices. Last year, the murders of George Floyd, Breonna Taylor, and Ahmad Arbury brought to light systemic racism in the criminal justice system that our communities have always experienced first-hand. Flagrant xenophobia and hate crimes against the Asian American and Pacific Islander (AAPI) communities have greatly increased and have resulted in tragic deaths especially among the elderly. Just this week, a doctor in Florida was charged with a hate crime for attacking a Hispanic man at a grocery store.  Outright condemnation of these acts is pivotal to confronting systemic racism and healing the soul of our nation, but more is required to solve for these continued injustices.

Combating Food Insecurity and Nutritional Disparities:

Throughout our communities, nutrition education with regards to making healthful dietary choices is lacking. Thirty percent communities of color have limited access to food compared to non-Hispanic white Americans. Issues such as gentrification and redlining need closer attention, as they are directly related to the ability of some communities to access healthy, affordable food.  Additionally, current dietary recommendations are not adequate to address diverse populations' unique diets. Current dietary recommendations need to be adapted and translated for diverse populations, and the influence of sociocultural and socioeconomic factors on dietary practices and health status must be examined. Above all, hunger, particularly among children is being exacerbated by extended periods of school closures. For far too many children in the United States, their only source of regular, hot meals is school. Assistance programs such as SNAP are vital to addressing the immediate hunger needs of students and families.

Making Social Determinants of Health (SDOH) a National Imperative:

To fully improve America’s health, greater attention must be given to social determinants of health (SDOH) including the deep inequities in education, housing, and financial insecurity. The consequences of racial and economic segregation remain a fact of daily life for millions of African American and Latino children with schools more segregated today than they were in the late 1960s. Chronically underfunded schooling prevents students from their right to quality education. Discriminatory housing practices, such as redlining, continue to systemically exclude people of color from securing proper housing.  Communities of color are more dependent on regular income with little or no retirement or other savings, and less able to work remotely. The federal government has a critical role to play in understanding and overcoming these disparities. Historic underinvestment and a lack of coordination has hindered real progress in SDOH areas that impact opportunity and health. Prioritizing SDOH as a national imperative means a government wide commitment to enhanced coordination and standardization of policies and practices as well as increased funding for research and program interventions to address SDOH.

Addressing Gender and Race Pay Gaps:

Roughly fifty percent of the workforce consists of women, almost ten per cent of whom are employed in the healthcare system. These women are often the only provider, thirty-three percent whose income supports the entire household. African American and Latina women earn less than White women in identical positions, highlighting pay discrimination, and, by extrapolation, in hiring or promotions. These findings affirm that these workers are not paid less simply because they are women. Absent any evidence to the contrary, these women appear to be paid less because they are not White. Job losses due to the pandemic have devastated women of color and their families even more than low wages. According to the National Women’s Law Center, all 140,000 jobs lost in December 2020 belonged to women, and more than 2 million fewer women were in the workforce than at the beginning of the year.  Economic reform will require making women heads of households whole again by paying equitable wages and establishing a national paid family and medical leave policy.

Expanding Healthcare Coverage for All Americans:

The Trump Administration has critically undermined public health and jeopardized insurance coverage for America’s most vulnerable, over the last four years. From encouraging the usage of block grants and budgetary caps to numerous unprecedented changes to Medicaid eligibility and a last-ditch effort to strip Medicare Part D Protections, it has threatened coverage for millions of Americans, including people of color, people with disabilities and chronic health conditions, immigrants, low-income populations, LGBTQ+ community, and the elderly. Despite historic gains by the Obama Administration as a result of the Affordable Care Act (ACA) to help over 20 million people gain insurance coverage, destructive Trump-era policies have led to a rise in the number of uninsured Americans by 2.3 million from 2016 to 2019.  These uninsured rates disproportionately affect people of color who account for over half of the total nonelderly uninsured population. The Biden Administration and new Congress must take steps to undo the damage done during Trump’s presidency and adopt new policies that expand enrollment and coverage while strengthening ACA’s marketplaces for all Americans.  We applaud the Administration for the Executive Order to reopen the exchanges from February 15-May 15, 2021, to allow individuals to access health insurance.

Establishing a Blueprint for Mental Health Reform:

COVID-19 has brought focus to the ongoing mental health crisis in America. Communities of color are less likely to have access to mental health services, less likely to utilize community mental health services, and more likely to depend on inpatient hospitalization and emergency departments for primary mental healthcare. Resources and funding from failed systems, such as mass incarceration, racialized surveillance, and policing, must be directed into programs and systems addressing mental health reform.

Declaring Racism as a Public Health Crisis:

The United States healthcare sector has significant work to do in addressing the past atrocities committed against communities of color and tribal communities. There has been an ugly history of racist exploitation in the medical industry, spanning from the notorious Tuskegee syphilis study to the tragedy of Henrietta Lacks, whose cancer cells were harvested without her permission by researchers in 1951. More work must be done to commit to an actively anti-racist country and the healthcare system. This work should include acknowledging these past grievances, including unethical medical experiments, and highlighting the measures implemented in the clinical trial process over the years around informed consents, data privacy, and overall safety of trial participants. There needs to be clear communication around this issue and efforts to enact change.

Increasing Diversity in Clinical Trials:

Having strong representation from diverse communities in medical research and clinical trials ensures that the treatments developed meet the various, unique needs of patients. Yet, communities of color are disproportionately underrepresented within medical research. This gap contributes to a lack of credibility within clinical trials and endangers potential significant public health advancements. Notably, this underrepresentation is even true among diseases and illnesses that disproportionately impact people of color, including diabetes, heart disease, Alzheimer's disease, and cancer.  We applaud industry-led commitments to address this issue but urge that actionable steps are taken to ensure this pledge leads to increased participation and involvement by people of color in clinical trials.  It is critical to ensure outreach to historically underrepresented communities for participation in trials is culturally appropriate and sensitive, including increasing clinical trial awareness and educational programs. We must work with trusted messengers in the communities to encourage communities of color participation in clinical trials. Physicians must also have access to trained medical interpreters to ensure diverse populations receive the highest quality of care in the language that is most comfortable to them.

Solving the Maternal Health Crisis:

The United States is in the midst of a maternal health crisis that disproportionately affects our communities of color. African American mothers face a particularly grim reality — they are three to four times more likely to die from pregnancy complications than white mothers. These women have access to lower-caliber hospitals, are less likely to be insured, and experience high rates of comorbid chronic conditions. Experts estimate that “stress, trauma, food insecurity, neighborhood violence, and access to prenatal care”, all of which disproportionately affect African American women, likely contribute to maternal racial health disparities.  Compounding the challenges are racial biases that remain entrenched within the healthcare system. A third of African American women report being discriminated against in healthcare settings due to their race, and one in five have forgone treatment altogether for fear of such discrimination.  Elevating culturally competent care, preventing needless pregnancy-related deaths, and keeping families together are universally beneficial objectives. Policymakers should do their best to ensure that all women, regardless of race, receive the care they deserve.

Developing Workforce Diversity in Healthcare:

Research shows that African Americans and Latinos are much less likely to trust physicians and hospitals; thus, are significantly less likely to seek treatment.  Increasing the diversity of America’s healthcare workforce is essential to gaining diverse communities’ trust and ensuring all segments of our society receive quality care. People of color make up nearly one-third of the population yet only account for 14 percent of our nation’s primary doctors.  A culturally competent and diverse workforce leads to improved access to high-quality care for all Americans. Pro-diversity policies, such as establishing nationwide recruitment and support for pipeline training programs and STEM diversity initiatives to remove socioeconomic barriers for minorities and people with disabilities seeking careers in healthcare, are essential to building a healthcare workforce that draws on the strengths of all segments of our society.

Confronting the Rising Cost of Healthcare:

The rising cost of healthcare in the United States translates into higher insurance costs, under-resourced hospitals, and a lack of quality health access for marginalized communities. Insurers continue to price underserved populations out of healthcare. Pharmacy Benefit Managers (PBM) are largely unregulated yet have excessive influence over pharmacies and patients. PBM’s near-monopoly results in high drug prices, pharmacy anti-competitiveness, and reimbursement issues.  Exorbitantly high cost of healthcare is exacerbated by surprise medical bills that millions of Americans receive annually. Every sector of the healthcare industry needs to be held accountable for predatory practices such as surprise and unfair medical bills, exploitation of federal program loopholes at the expense of patients, and rampant profiteering by middlemen in the drug supply chain. Increased government oversight and fundamental reforms are necessary to curb this waste, fraud, and abuse to ensure savings are passed directly to patients.

Promoting Value-Based Treatment and Clinical Care:

We should champion alternative assessments that allow the usage of health disparities and SDOH as criteria to evaluate new therapies and race-based algorithms in clinical care for treatment, diagnostics, and healthcare delivery systems.  The use of race and ethnicity without proper scientific basis only contributes to poor health outcomes for minorities and deepens healthcare disparities. The use of the current cost-effectiveness analyses using the Quality-Adjusted Life Year (QALY) metric is a discriminatory measure. Using the QALY metric discriminates against people with chronic conditions and disabilities, contributes to increased racial disparities within the medical field, and does not address vital factors such as SDOH.

Supporting Breakthrough Medical Technologies and Innovation:

The COVID-19 pandemic has served as a catalyst for innovation in healthcare. The race to rapidly develop preventative and therapeutic interventions to combat the virus as well as the widespread adoption of super-regional health systems vis-à-vis telehealth and virtual care exemplify this acceleration of innovation. The work of public and private healthcare stakeholders is far from over with the threat of new variants and mutations of COVID-19 looming as well as unknown pandemics on the horizon. Smart innovation policies that strengthen our intellectual property system and promote equitable access are vital to combating future health crises. As the Biden Administration and Congress lead pandemic relief efforts it is pivotal lawmakers foster an innovation ecosystem capable of combating the challenges ahead. Additionally, there is a great need for research and development of treatments directed towards sickle cell disease, Alzheimer’s, asthma, and other diseases greatly impacting communities of color and other diverse communities. Infrastructure must be put in place to ensure all Americans have access to the latest advancements in healthcare technology. We urge lawmakers and private industry actors to remain committed in their pursuit for new treatments as more innovation and further medical breakthroughs are needed.

Collecting, Analyzing, and Releasing Demographic Subgroup Data:

Disaggregated data broken down by race, ethnicity, gender, and age, and other sociodemographic characteristics is critical for understanding health challenges faced by underserved communities. Unfortunately, early data collected and reported on COVID-19 was largely incomplete with many instances of chronic undercounting as experienced by underserved populations including the South Asian community.  In order to react to public health crises in an evidence-based manner, the timely collection, analysis, and distribution of disaggregated data by public health agencies is paramount. As response and recovery strategies evolve, it is imperative that accurate, and transparent data is available to address the unique health issues faced underserved communities.

Sincerely,


[i] https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
[ii] https://doi.org/10.1007/s11606-020-06497-4
[iii] https://apnews.com/article/race-and-ethnicity-health-coronavirus-pandemic-hispanics-d0746b028cf56231dbcdeda0fba24314
[iv] https://www.nationalnursesunited.org/sites/default/files/nnu/graphics/documents/0920_Covid19_SinsOfOmission_Data_Report.pdf
[v] https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/
[vi] https://www.nbcmiami.com/news/local/south-florida-doctor-charged-with-hate-crime-against-hispanic-man/2388250/
[vii] https://www.ers.usda.gov/webdocs/publications/42711/12716_ap036_1_.pdf
[viii] https://www.nokidhungry.org/blog/snap-feeds-families-and-feeds-our-economy
[ix] https://nwlc.org/wp-content/uploads/2021/01/December-Jobs-Day.pdf
[xi] https://www.census.gov/data/tables/time-series/demo/health-insurance/historical-series/hic.html
[xii] https://mhanational.org/ceos-mental-health-america-and-14-top-mental-health-organizations-join-together-prioritize-response
[xiii] https://www.medicalnewstoday.com/articles/increasing-diversity-in-clinical-trials-what-can-doctors-regulators-and-patients-do
[xiv] https://triblive.com/opinion/earl-fowlkes-to-save-lives-clinical-trials-need-diversity/
[xv] https://www.ajmc.com/view/racial-disparities-persist-in-maternal-morbidity-mortality-and-infant-health
[xvi] https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why
[xvii] https://www.sciencedirect.com/science/article/abs/pii/S0049089X15001325?via%3Dihub
[xviii] https://www.deseret.com/2019/3/20/20668770/guest-opinion-the-u-s-health-care-system-needs-more-diversity
[xix] https://ncpa.org/sites/default/files/2020-12/pbm-business-practices-one-pagers.pdf
[xx] https://www.nmqf.org/nmqf-media/traditional-value-assessment-methods
[xxi] https://pubmed.ncbi.nlm.nih.gov/22751960/
[xxii] https://www.thecity.nyc/coronavirus/2020/4/26/21247099/nyc-south-asian-leaders-say-community-covid-toll-undercounted
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