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Ending Unequal Treatment (2024) Supports public health liberation's characterization of the Fragmented Public Health Economy

The U.S. Public Health Economy: A PHL Perspective

The U.S. public health economy transcends mere financial transactions—it’s a complex ecosystem of structural determinants, including economic, political, and social forces, that dictate health outcomes and perpetuate inequities. Public Health Liberation (PHL) theory redefines this economy as a web of policies, power structures, and societal norms that systematically disadvantage minoritized communities. Using quotes from the Ending Unequal Treatment report, this essay examines how fragmentation, inefficiency, anarchy, and self-interest within this system sustain health disparities. PHL calls for a transformative vision: dismantling oppressive structures, empowering communities, and fostering a just system to achieve health equity.

Fragmentation: A Disjointed Ecosystem

Fragmentation in the public health economy isn’t just logistical chaos—it’s a structural flaw that splinters health systems, policies, and communities, deepening inequities. The report states, "The system is extraordinarily complex, dominated by fragmentation in care financing and delivery" (Page 26), highlighting a lack of coordination that burdens minoritized groups with navigating disconnected services. Beyond logistics, fragmentation reflects societal divides: "Social policies and rhetoric on such policies can also create hostile community environments for racially and ethnically minoritized individuals" (Page 216). PHL theory sees this as a failure of integration—health equity requires a cohesive system where economic, political, and social elements align to support communities, not divide them.

Inefficiency: Misallocated Power and Resources

Inefficiency in the public health economy goes beyond wasted dollars—it’s the misdirection of resources, attention, and influence away from addressing structural determinants like racism and poverty. The report notes, "Nearly 90 percent of U.S. health care spending is on chronic physical and behavioral health conditions" (Page 8), prioritizing treatment over prevention and systemic change. This inefficiency is compounded by neglect of root causes: "Efforts to affect the drivers of health and health care inequities without addressing historical and contemporary racism are unlikely to be effective" (Page 55). PHL demands a reallocation—not just of funds, but of power and focus—to tackle the underlying forces perpetuating health disparities.

Anarchy: A Governance Void

The public health economy’s anarchic state stems from a lack of accountability and oversight across its structural components, allowing inequities to persist unchecked. The report reveals, "No public or private entity is tasked with the overall responsibility for achieving health care equity" (Page 66), exposing a governance gap that spans economic, political, and social domains. This void is evident in unenforced reforms: "Civil rights reforms have not been implemented, with no accountability or penalty" (Page 26), and disjointed federal efforts that are "often siloed and disconnected, with no unified oversight" (Page 287). PHL diagnoses this as a liberation failure—without community-driven governance, the system remains unmoored, necessitating collective accountability to steer it toward equity.

Self-Interest: Prioritizing Power Over Equity

Self-interest in the public health economy isn’t limited to financial gain—it’s the prioritization of power, status, and influence by system actors over the collective good. The report observes, "Market forces in the health care system incentivize efforts to attract only the best payers and healthy patients" (Page 53), sidelining marginalized groups. This dynamic extends beyond economics: "Social norms and public policies interact with each other to create an unfair and unjust distribution of opportunity" (Page 52). PHL frames this as structural violence, where entrenched interests—political, social, and economic—resist equity. Liberation requires dismantling these priorities, centering community needs over individual or institutional gain.

Synthesis and Implications: A Call for Transformation

The public health economy, as illuminated by Ending Unequal Treatment, is a fragmented, inefficient, and anarchic system shaped by self-interest—a machine that sustains health inequities through its structural determinants. PHL theory asserts that incremental fixes fall short: "Time-limited and/or incremental reforms often fall short" (Page 282). The report’s evidence is stark: "Most racial and ethnic health care inequities have persisted, and some have worsened" (Page 25), driven by systemic failures like "a continued lack of universal, stable health insurance" (Page 25) and broader societal inequities. PHL envisions a transformed system—unified, community-led, and focused on dismantling root causes like racism and power imbalances—to achieve lasting equity.

Takeaway: Toward Liberation

The quotes from Ending Unequal Treatment expose a public health economy that fails minoritized communities through its structural design. PHL offers a radical antidote: liberation through empowered communities, accountable systems, and a focus on structural determinants over superficial fixes. A unified approach could mend fragmentation; redirected resources could address inefficiency; and community governance could end anarchy. Above all, PHL demands a shift from a system preserving power to one advancing justice. As the report urges, "substantive structural reforms" are essential (Page 170). The U.S. has the tools for health equity—only bold, liberatory action can unlock it.

Essay on Research Methods and Explanation of Themes

Introduction

Qualitative research is a powerful tool for uncovering patterns and meanings within complex textual data. In this analysis, I applied thematic analysis to examine 149 quotes from "Quotes_new.docx," a document that highlights the fragmented, anarchic, and inefficient nature of the U.S. public health economy. This essay details the qualitative methods used to categorize these quotes into five distinct themes, provides an explanation of each theme, and discusses their significance in understanding systemic challenges in U.S. healthcare.

Research Methods: Thematic Analysis

Thematic analysis is a systematic approach to identifying and interpreting patterns within qualitative data. To analyze the quotes, I followed a structured six-step process:

Familiarization with the Data: I read through the document multiple times to immerse myself in the content, noting initial impressions of recurring issues like fragmentation and inequities.
Generating Initial Codes: I assigned codes to segments of the quotes based on their key ideas. For example, phrases about "disparities" were coded as "inequities," while those about "cost" were coded as "economic issues."
Searching for Themes: I grouped related codes into broader themes. Codes about disjointed systems and lack of coordination, for instance, formed the "Systemic Fragmentation" theme.
Reviewing and Refining Themes: I refined the themes to ensure they were distinct and comprehensive, adjusting boundaries to avoid overlap. For example, I separated policy-related inefficiencies from economic ones.
Defining and Naming Themes: Each theme was given a clear definition and name reflecting its essence, such as "Health Care Inequities" for disparities in access and outcomes.
Writing Up the Analysis: I finalized the analysis by linking themes to specific quotes and calculating their frequency to assess their prominence.

To ensure reliability, I used a consistent coding framework and revisited the data to verify that each quote aligned with its assigned theme, maintaining mutual exclusivity.

Explanation of Themes

The analysis revealed five key themes, each shedding light on a critical aspect of the U.S. public health economy:

1. Systemic Fragmentation (11 quotes, 7.38%)

This theme reflects the lack of coordination among healthcare stakeholders, resulting in a disjointed system. For example, Quote 1 states, "The system is extraordinarily complex, dominated by fragmentation in care financing and delivery," highlighting how this complexity hampers effective care.

2. Health Care Inequities (41 quotes, 27.52%)

This theme addresses disparities in healthcare access and outcomes, particularly for marginalized groups. Quote 3 illustrates this: "Most racial and ethnic health care inequities have persisted, and some have worsened," pointing to systemic barriers like structural racism.

3. Economic Inefficiency (19 quotes, 12.75%)

This theme captures the high costs and poor outcomes of the U.S. system. Quote 2 notes, "The U.S. health care system fares poorly compared to similarly high-income countries... despite spending at least double the amount of money per person," emphasizing financial misalignment.

4. Policy and Implementation Failures (51 quotes, 34.23%)

The most prevalent theme, this category critiques ineffective policies and their execution. Quote 9 states, "Some civil rights reforms have not been implemented, with no accountability or penalty when measures are not obtained," revealing a lack of enforcement.

5. Research and Data Limitations (27 quotes, 18.12%)

This theme highlights gaps in health equity research. Quote 37 observes, "Most studies investigating the association between racism and health have focused on interpersonal racial and ethnic discrimination, with few studies attempting to explain the health effects of structural or systemic racism," indicating a need for broader inquiry.

Significance of Themes

These themes collectively illustrate a healthcare system plagued by inefficiency, inequity, and poor coordination. The dominance of "Policy and Implementation Failures" (34.23%) suggests that structural and governance issues are primary barriers to progress. "Health Care Inequities" (27.52%) underscores the urgent need to address disparities, while the interplay of fragmentation and inefficiency reveals systemic weaknesses that demand reform.

Conclusion

Using thematic analysis, I categorized 149 quotes into five themes that expose the core challenges of the U.S. public health economy. The methodical approach ensured a robust analysis, grounded in the data. These findings highlight the necessity for coordinated policy reform, improved research, and a focus on equity to transform the healthcare system.

Gaps in studying systemic issues like structural racism, combined with aggregated data that masks disparities, hinder effective policymaking. This lack of granular insight prevents targeted interventions and accountability for progress.

Perspective

Boosting investment in health equity research and mandating detailed data collection on social determinants could address these gaps. Federal prioritization of such studies, alongside privacy safeguards, is essential to inform evidence-based reforms.

Conclusion

The U.S. public health economy faces intertwined challenges of fragmentation, inequity, inefficiency, policy failures, and research shortcomings. Comprehensive reform, emphasizing equity, coordination, and evidence-based approaches, is urgently needed. While political and economic obstacles complicate progress, the insights from "Quotes_new.docx" underscore the necessity of a healthcare system that serves all Americans effectively and equitably.

Quotes Illustrating the Fragmented, Anarchic, and Inefficient Nature of the Public Health Economy

1. "The system is extraordinarily complex, dominated by fragmentation in care financing and delivery. This presents overwhelming challenges for individuals, families, and communities and provides little or no assistance in navigating these challenges." (Page 26)

2. "The U.S. health care system fares poorly compared to similarly high-income countries in terms of most performance measures, despite spending at least double the amount of money per person of peer wealthy countries." (Page 8)

3. "Most racial and ethnic health care inequities have persisted, and some have worsened. This report documents the lack of clear pathways to translate promising approaches into real and permanent change." (Page 25)

4. "The United States has the largest proportion of people without health insurance among high-income countries. The uninsured rate ranges from 8.4 percent to 9.6 percent." (Page 8)

5. "The health care system is designed to treat people who are sick. The sicker someone becomes, the more money the system makes. Payments are designed to incentivize curing disease, not preventing it." (Page 26)

6. "Nearly 90 percent of U.S. health care spending is on chronic physical and behavioral health conditions, leaving limited funding for disease prevention and health promotion." (Page 8)

7. "The poor performance of the nation’s health care system impacts everyone: The United States ranks last among high-income countries in life expectancy at birth, maternal and infant mortality, suicide, and preventable and treatable mortality." (Page 8)

8. "Insurance enrollment and affordability barriers continue to disproportionately affect minoritized groups." (Page 6)

9. "Some civil rights reforms have not been implemented, with no accountability or penalty when measures are not obtained." (Page 26)

10. "The financial gains reaped when people get sick are even greater when health inequities worsen. When sick people (many with preventable illnesses) fill a hospital, the hospital makes more money, but anyone who needs emergency care cannot get it efficiently." (Page 26)

11. "Poor health outcomes for minoritized communities contribute to lower-quality care and outcomes for everyone. Because inequitable policies and barriers make it difficult for minoritized populations to regularly access quality health care, they are often only able to access care when disease symptoms have advanced, and emergency department care is frequently their only option." (Page 12)

12. "The U.S. Department of Health and Human Services Office for Civil Rights remains underfunded. This has limited its efforts to enforce civil rights statutes and address the complaints it receives from individuals." (Page 6)

13. "Access to equitable health care remains a significant problem, driven at its core by a continued lack of universal, stable health insurance." (Page 25)

14. "Policies that fall short of the changes needed or are weakly implemented: The past 2 decades have seen major strides in policy, moving closer to a system of affordable coverage for all. However, owing to the structural limitations of key policy reforms, millions of people remain uninsured and underserved." (Page 26)

15. "Failure to invest in promising solutions: Extensive documentation points to highly promising models of health care, especially solutions that engage communities and are integrated into community settings. Yet, underfunding of such programs persists, and many have not been able to scale up or achieve sustainability." (Page 26)

16. "The way the U.S. health care system is organized, financed, delivered, and held accountable does not live up to its potential."

17. "Its health care system is broken and by its very design, delivers different outcomes for different populations, resulting in persistent and profound health care inequities."

18. "The poorly performing system and negative repercussions of health inequities go far beyond each individual's health and specific medical conditions to significant economic consequences for the entire nation."

19. "Persistent health and health care inequities lead to excessive health care expenditures and lost labor market productivity."

20. "No sustained trend shows year after year that inequity gaps have narrowed across racially and ethnically minoritized groups."

21. "Because inequitable policies and barriers make it difficult for minoritized populations to regularly access quality health care, they are often only able to access care when disease symptoms have advanced, and emergency department (ED) care is frequently their only option."

22. "This limited access to care can result in an overreliance on ED care, which is one of several contributors to ED overcrowding."

23. "Inequities persist across all states. This is true even in those states that have been found to have better health system performance or where health outcomes have improved over time."

24. "The health care system exists within the larger society, the conceptual framework highlights five key societal external forces, each representing a significant influence on equitable health care."

25. "The health care system has failed to adopt at scale many of the known solutions for improving health care equity."

26. "Structural limitations and legal challenges to the law have stalled broad implementation for many of its provisions."

27. "No widely agreed-upon systematic standards and procedures exist for acceptable performance measures to achieve equitable health care and optimal health for all."

28. "The variation in performance measures for health care equity impedes efforts to hold health care systems, organizations, and clinicians accountable for their performance in promoting equitable health care outcomes."

29. "The United States is the only industrialized nation without universal health insurance coverage and with substantial disparities in payments for services between payers (commercial, Medicaid, and Medicare)."

30. "These structural inequities result in unequal access to health care services. This means that the system is inherently separate and unequal."

31. "The U.S. health care system exists within the larger U.S. society and interfaces with this much larger societal system that shapes how health care is organized, financed, delivered, and accessed and also influences how and whether the health care system is held accountable to achieve optimal and equitable health care outcomes for all."

32. "Merely addressing factors contributing to inequitable health care access and quality alone cannot improve the factors contributing to poor health and health care outcomes across and between social groups."

33. "Market forces in the health care system incentivize efforts to attract only the best payers and healthy patients. Equity is not prioritized compared to optimizing service revenue based on organizations’ strategies, cultures, funding, processes, people, leadership, and systems."

34. "Health care providers are paid less for care delivered to patients whose insurance is Medicare or Medicaid, relative to those privately insured by employers. This differs from other national health care systems, where payment is standardized due to a larger role for universal coverage systems."

35. "The systematically higher representation of minoritized populations in lower-reimbursement health care, particularly in Medicaid, is a historical incentive to provide unequal treatment."

36. "Efforts to affect the drivers of health and health care inequities without addressing historical and contemporary racism are unlikely to be effective."

37. "Most studies investigating the association between racism and health have focused on interpersonal racial and ethnic discrimination, with few studies attempting to explain the health effects of structural or systemic racism on population health."

38. "Significant challenges arise in operationalizing and measuring structural racism, as established measures often examine single dimensions (e.g., the index of concentration at the extremes) or single domains (e.g., residential segregation)."

39. "Social norms and public policies interact with each other to create an unfair and unjust distribution of opportunity in society."

40. "Sectors lack shared responsibility for outcomes. For example, health care providers, insurance companies, employers, and government agencies have competing self-interests in an already fragmented health care system, avoiding a collective responsibility for comprehensively advancing health equity."

41. "The health care system lacks effective cooperation and collaboration among players in achieving overall population health goals."

42. "No public or private entity is tasked with the overall responsibility for achieving health care equity and optimal health for all."

43. "Due to systems of oppression described in this chapter, these health care systems often do not equitably value active community input and are not held accountable for diminishing community agency."

44. "A lack of strategy and coordination and the cost of implementation can hinder the effective integration of social needs in health care."

45. "Little progress can be made to advance equity without a will and commitment to change the status quo."

46. "Inequities in access to care exist across all inpatient and outpatient health care settings, including primary care, specialty care, emergency department (ED) and other hospital-based care, and rehabilitative, long-term, and prison care facilities." (Page 2)

47. "The overarching U.S. health care system payment paradigm incentives individual health care systems to invest in high-cost services to treat sickness rather than investing in robust primary care programs that promote optimal health for all." (Page 4)

48. "Racially and ethnically minoritized individuals are significantly less likely to have a usual source of primary care ... They are also more likely to report a facility or hospital as their usual source of care rather than an individual clinician, which can impede both care continuity and access to guideline-concordant care." (Page 3)

49. "Research reveals inequitable access to specialty care services ... Administrative data from the Medical Expenditure Panel Survey show widespread inequities in access to outpatient specialty care, with the largest differences between Black and White adults for specialties such as dermatology, otolaryngology, general surgery, orthopedics, and urology." (Page 4)

50. "Data on race and ethnicity-based differences in ED use show that visit rates are higher and more frequent ... among Black and Latino/a adults compared with White adults ... often serve as a surrogate marker for inequities in preventive care and access to outpatient primary and specialty care." (Page 5)

51. "Lack of insurance and underinsurance, each more prevalent among minoritized populations, are substantial barriers and associated with delayed or foregone care, including lower rates of use of preventive and primary care services." (Page 3)

52. "U.S. long-term care facilities remain highly segregated along racial and ethnic lines, often resulting in part from the marked geographic residential segregation that continues to be prevalent across the nation." (Page 6)

53. Facilities serving predominantly racially and ethnically minoritized residents rely frequently on limited financial resources, offer fewer clinical services, have lower staffing levels, and have more care deficiency citations." (Page 6)

54. "Research documents significant limitations and variability in health care access and quality in carceral settings, with an impact on outcomes, including long-term health effects on formerly incarcerated individuals." (Page 7)

55. “Equity-focused strategies, including addressing misinformation and disinformation on social media, addressing mistrust for health care, and mitigating structural barriers through community engagement, were implemented slowly." (Page 15)

56. "The development and rollout of COVID-19 vaccines were accompanied by racial and ethnic inequities in vaccine receipt accentuated by experiences of discrimination and structural barriers." (Page 16)

57. "These misaligned incentives further exacerbate primary care shortages for everyone." (Page 4)

58. "Critical gaps exist in the quality measurement landscape; many of the quality metrics used in the NHDQR are process measures with uncertain links to meaningful outcomes." (Page 9)

59. "NHQDR appendixes include the most comprehensive, longitudinal report on progress in addressing U.S. racial and ethnic health care inequities but lack data on people from highly marginalized groups, including incarcerated, undocumented, and gender diverse populations." (Page 9)

60. "Race-based differences in rates of preventable hospitalizations likely result from inequities in ambulatory care for underserved populations." (Page 5)

61. “First, it built on the existing incomplete and fragmented multipayer health insurance system, rather than attempting to replace it with a single, uniform source of health care financing for all." (Page 17)

62. "As a result, insurance coverage remains fragmented, with lower-income people—disproportionately people of color—more likely to depend on Medicaid, which has had lower payment rates compared to other forms of health insurance." (Page 17)

63. "Eligibility churn, which also affects people who must move between Medicaid and the marketplace, means that many people face frequent gaps in coverage." (Page 18)

64. "Thus, hospitals remain free to allocate their community benefit expenditures to activities that, although of value to them and their patients, may not be responsive to the deeper health needs identified by communities themselves." (Page 13)

65. "Although the intent of the amendments was to reduce and eliminate inequities, little progress has been made in implementing and enforcing them." (Page 15)

66. "This absence of ongoing routine data collection that captures disability, race, sex, and age characteristics of people served by covered entities has increased the challenges facing the federal government or private claimants as they attempt to identify potentially discriminatory patterns of health care that merit closer examination." (Page 15)

67. "The absence of enforcement and funding also means that the HHS OCR maintains no ongoing, published complaint system comparable to the routine data collection systems that characterize civil rights oversight of educational activities." (Page 15)

68. "Payment policies that reward performance may incentivize providers to avoid serving patients with more complex health needs for whom achieving high-performance scores may be more difficult and may also lead to financial difficulties for providers serving those patients." (Page 29)

69. "Many challenges have arisen with implementing a complicated, high-profile law. For its civil rights protections, serious underfunding has limited enforcement, and repeated litigation aimed at stopping implementation has essentially left the law without a comprehensive regulatory policy for implementation, a critical step given its complexity." (Page 19)

70. "Social and economic policies that have implications for health care equity vary across states, so racially and ethnically minoritized populations living in different states do not equitably benefit from such reforms." (Page 36)

71. "Nearly 12 years after the decision, 10 states have declined the expansion despite significant financial incentives." (Page 31, referring to the Supreme Court’s ruling making Medicaid expansion a state option)

72. "Many states fail to adhere to Medicaid’s 'federally qualified health center' (FQHC) payment rules, which require updates for medical inflation and changes in scope of services as health centers add covered physical or mental health care. Payment lags also can be considerable." (Page 11)

73. "Third, they failed to end the hospital practice of allocating these expenditures to their Medicaid shortfall, the difference between their costs and what Medicaid pays." (Page 13, regarding tax-exempt hospital community benefit expenditures)

74. "Conclusion 4.3. Structural limitations, lack of enforcement, and Supreme Court rulings on provisions of the Affordable Care Act have limited or stalled many of the laws and policies from being widely implemented, and, in some cases, have reversed them." (Page 36)

75. "Third, the ACA continues to leave more than 20 million people ineligible for affordable coverage." (Page 18)

76. “Public health, preventive care, and primary care in the United States have been chronically undervalued and underresourced, and most payment structures have traditionally rewarded care settings and providers who treat the sickest people.” (Page 170)

77. “This upside-down structure has long been associated with marked inequities in service access, quality, and outcomes, while simultaneously increasing economic costs and worsening population-level health outcomes relative to other high-income countries.” (Page 170)

78. “The dominant paradigm in U.S. health care remains focused on the individual, centered on the clinical workforce and biomedical interventions, and characterized by a highly medicalized view that prioritizes diagnosing and treating disease.” (Page 170)

79. “The system’s lack of progress in narrowing these inequities suggests that to achieve health care equity, the U.S. health care system requires substantive structural reforms that shift away from traditional paradigms for health care organization and delivery.” (Page 170)

80. “Institutional racism is reflected both at the level of the health care system as a whole and within specific health care organizations and manifests as unequal treatment and care outcomes.” (Page 169)

81. “Overall, general quality improvement efforts do not improve the health of racially and ethnically minoritized populations and may exacerbate health inequity because those with more social capital and resources can access health care innovation more quickly.” (Page 174)

82. “A national study assessing hospital compliance with CLAS standards found that it was inadequate… Only 13 percent of the hospitals surveyed met all CLAS standards, and 19 percent met none at all.” (Page 176) “The evidence on the impact of CHNA requirements on increased hospital community benefit spending is mixed.” (Page 177)

83. “The health care workforce is structured to support the sick care paradigm referenced at the beginning of this chapter and does not represent the diversity of the U.S. population.” (Page 180)

84. “There are no accountability levers in place for ensuring that Medicare graduate medical education funding is spent to ensure that adequate physicians are trained in areas shown to reduce health and health care inequities, such as public health, primary care, and mental health care.” (Page 181)

85. “The discourse about scope-of-practice restrictions for various health professions is frequently influenced by ‘turf wars’ between disciplines over authority, autonomy, and protected revenue streams.” (Page 184)

86. “Racially and ethnically minoritized populations remain significantly underrepresented among practitioners and trainees in a wide range of health care professions, which research has identified as a contributor to health care inequities.” (Page 184)

87. “Beyond the paucity of health care providers in underserved communities, the unequal use of health services among racially and ethnically minoritized communities has also been linked to a low trustworthiness of the health care system resulting from historical patterns and lived experiences of bias, discrimination, and culturally misaligned health service delivery.” (Page 185)

88. “Although it is increasingly recognized that multilevel interventions are required to address health inequities, designing, implementing, and measuring the effects of multilevel interventions remains challenging.” (Page 180)

89. “Conclusion 5.1. Current delivery models focused on disease treatment and management have not led to equity, but emerging models that prioritize prevention, health promotion, and restorative care show promise and need scaling.” (Page 200)

90. "Social policies and rhetoric on such policies can also create hostile community environments for racially and ethnically minoritized individuals that are detrimental to their health." (Page 216)

91. Community-based organizations often juggle competing needs and dedicate most of their time to their main work. Resources, time, and personnel constraints can pose challenges in CBPR and other health care-related work." (Page 228)

92. “A systematic review of community-based health promotion and prevention programs found that large-scale programs did not result in population-wide changes in health outcomes." (Page 228)

93. "The first [challenge] involves determining who represents the ‘community.’ Power dynamics may mean that leaders, such as church or community group leaders, may have more resources to engage, but they may not represent the diversity of the community and/or be most in tune with the specific health needs of its members." (Page 226)

94. "Moving successful CBPR models from research into practice is a major challenge. Logistical barriers, such as staff turnover, timespan, and loss of funding, can limit the sustainability and long-term implementation of CBPR interventions." (Page 222)

95. "Failure to enroll and retain interested participants has also been seen as a limitation to the generalizability or success of promising interventions." (Page 228)

96. "Simply including community members in discussions, however, is sometimes not enough to create meaningful and long-lasting connections and partnerships, especially considering the long history and pattern of exploitation in racially and ethnically minoritized communities." (Page 237)

97. "Some community-based models have shown to be effective in reducing racial and ethnic inequities in health care, but they have not been widely implemented in large-scale studies. Further, these models have not been implemented and scaled to serve all populations who need the services." (Page 238)

98. "A 2023 review of 152 studies on social care interventions with multiracial and multiethnic populations found that only 44 included race or ethnicity in the analyses, and only 21 looked for heterogeneous treatment effects among racially and ethnically minoritized populations." (Page 225)

99. "The literature clearly supports community-based approaches as efficacious and highlights their importance to health care delivery and equitable care, yet this has not been fully leveraged as part of a national response to eliminate health inequities and remains a critical promising opportunity to advance health equity." (Page 226)

100. "Community members have the institutional knowledge and resources to address many community issues… Partnerships with communities can lead to interventions at multiple places in the care continuum… [but] involvement from community members in developing interventions to improve health care access for minoritized communities is relatively rare." (Page 217-218)

101. "Social policies restricting undocumented immigrants’ access to resources and anti-immigrant rhetoric and sentiment adversely impact their health and health care and may even do so differentially, depending on the region." (Page 216)

102. "The efficacy and potential of an intervention depend on tailoring it to the community’s needs, yet this might create challenges regarding replicability or generalizability." (Page 228)

103. "CBPR successfully addresses ethical concerns of providing care to historically marginalized populations… [but] a recent scoping review identified facilitators of success in CBPR partnerships, which include diverse partners; trust, mutual respect, and transparency between partners; strong and shared leadership; and fair allocation of resources." (Page 219, implying that without these, self-interest can dominate)

104. "The recognition of the central role played by communities in health and health care dates to over 80 years ago and was the founding principle of federally qualified health centers (FQHCs) in the United States… [yet] interventions designed to achieve health and health care equity among U.S.-based Indigenous communities… prioritize community needs and community voices, with communities being involved in every aspect of them, facilitating accountability to the people they serve." (Pages 217, 237, highlighting the gap between historical recognition and current fragmented implementation)

105. "Historically, biomedical research has not focused on addressing health care inequities and advancing health equity. Health disparities and health equity topics have not been prioritized compared to other research topics." (Page 247)

106. "For decades, health equity topics have been undervalued and underfunded, and this disproportionately affects researchers from minoritized racial and ethnic groups, who are more likely to propose health equity topics compared to their White counterparts." (Page 248)

107. "Academic research enterprises have not incentivized the activities associated with health equity research, especially community engagement and community-based endeavors, which require long-term investments, demonstrating trustworthiness, and engaging individuals who have lived experience with inequities." (Page 248)

108. "A comprehensive review of the NIH portfolio finds that health disparity and health equity research account for only 4.3 percent of direct costs of NIH awards between 2012 and 2023. Although funding trends have increased in recent years, health equity and health inequities research funding are not evenly distributed across NIH Institutes and Centers." (Page 274, Conclusion 7.1)

109. "Community-engaged and community-driven research represents a small fraction of NIH-funded research." (Page 274, Conclusion 7.2)

110. "Researchers from minoritized racial and ethnic groups are significantly underrepresented in the scientific workforce. Structural barriers for health and health care equity research disproportionately impact researchers from racially and ethnically minoritized groups." (Page 274, Conclusion 7.3)

111. "Despite a recent influx of researchers into the health equity field, partly the result of more funding opportunities, there is a paucity of programs to provide health equity training and no standard/certification to ensure someone has ample training." (Page 274, Conclusion 7.4)

112. "Critically evaluating health equity research has been hindered by inconsistent practices in analyzing and reporting health equity research, lack of collection and use of common data elements across studies, and conflation of race and ethnicity with genetics." (Page 274, Conclusion 7.5)

113. "The current research infrastructure, including data sources, is insufficient to support the types and scale of health equity research needed." (Page 274, Conclusion 7.6)

114. "There are a limited number of interventional studies focused on eliminating racial and ethnic health care inequities and very few of them have been implementation science and comparative effectiveness studies testing multilevel and structural interventions." (Page 274, Conclusion 7.7)

115. "Concerns with both the current and newly revised OMB standards lie in not only how the data are collected but also how they are reported… Even when more granular data are collected, these are often collapsed into the minimum categories for reporting." (Page 259)

116. "Other national surveys have small sample sizes for certain minoritized populations… lead to the data being collapsed into nonspecific and arbitrary categories, such as 'other,' or even omitted entirely." (Page 259)

117. "The lack of sustained, community-based infrastructure for health equity research is also concerning given that patients in academic health centers do not represent the general population." (Page 263)

118. "Various factors influence [limited representation in clinical trials] spanning individuals, institutions that fund and design clinical trials, organizations that protect the rights and welfare of people recruited to participate in research activities, journals that publish the results, and national policies and practices governing research." (Page 264)

119. "Progress has been slow and incremental due to historically underfunded health equity research projects, programs, and investigators; exclusion of racially and ethnically minoritized groups from research; incomplete and inaccurate race, ethnicity, and SDOH data; and inadequate infrastructure and partnerships to rigorously conduct this research and translate findings into policies and practice." (Page 272)

120. "A major challenge has been a lack of accountability and processes to support sustained and measurable progress." (Page 282)

121. "The committee recognizes that many initiatives to change how the health care system functions have not been successful despite multiple national reports with actionable and thoughtful recommendations for improvement, and efforts to advance racial and ethnic health care equity have not resulted in long-term gains." (Page 282)

122. "However, these plans are often siloed and disconnected, with no unified oversight or evaluation of programs or policies." (Page 287)

123. "The many proposed federal policies and executive orders illustrate a strong national commitment to advancing health equity. However, few of these policies are effectively enforced, which speaks to the challenges of accountability within the federal government." (Page 287)

124. "Conclusion 8.1. Several HHS and other federal agencies have strategic plans, frameworks, or policy statements that aim to address health care inequities and advance health equity. These plans, frameworks, and policy statements are often disparate and siloed and do not represent coordinated efforts." (Page 302)

125. "Conclusion 8.2. There is no widely agreed-upon systematic standards and procedures for acceptable performance measures to achieve equitable health care and optimal health for all irrespective of race and ethnicity and socioeconomic background." (Page 302)

126. "Conclusion 8.3. No federal oversight body or professional organization has conducted or commissioned an evaluation of all the goals proposed or programs implemented by the health care equity-related strategic plans and other policy frameworks across the federal government." (Page 302)

127. "National goals, objectives, and standards for equity are needed, but the landscape has many different federal agencies and private and public sector organizations all working independently to achieve equity goals." (Page 302)

128. "Many of the individual federal reports and plans are valuable, but a specific national plan (similar to Healthy People, for example) would prevent a diffusion of efforts and allow limited resources to be used more effectively and efficiently." (Page 302)

129. "A major barrier to greater accountability in health care equity is a system designed to rely on market forces, when equitable outcomes are often not based on capitalist structures." (Page 301)

130. "Efforts to address this challenge have been based on pay-for-performance metrics, which have demonstrated issues in promoting equitable outcomes, as providers can 'cherry-pick' and refuse to care for more complex patients, including those with LEP." (Page 302)

131. "Variation in health care equity performance measures has posed significant challenges to accountability and advancing health care equity." (Page 296)

132. "However, the lack of agreed-upon standards for the appropriate use of these measures makes accountability through measurement and data tracking difficult." (Page 296)

133. "Despite significant oversight and accountability for federal insurers, such as Medicaid and Medicare, private insurance companies have far less accountability." (Page 299)

134. "A Government Accountability Office survey of state oversight of provider plans found minimal accountability practices in place for private and employee-based provider networks." (Page 299)

135. "The U.S. health care system underperforms compared to other high-income nations despite the enormous fiscal investment."

136. "The poor performance of the nation’s health care system affects everyone, but this underperformance has a disproportionate impact on racially and ethnically minoritized populations who experience persistent inequities in health care."

137. "Although the United States has made some progress in addressing inequities in health care, movement has been slow, uneven, inconsistent, and, at times, regressive among certain populations and across disease conditions."

138. "Despite better understanding these inequities, the nation has failed to translate this knowledge into sustainable actions that close longstanding gaps in the delivery of equitable health care to minoritized populations."

139. "Erosion of access to care, particularly to primary care, seems a regression due to structural limitations of the law and implementation failures."

140. "The nation has made little progress addressing this goal. Recent court decisions concerning diversity, equity and inclusion are likely to further limit progress in achieving a diverse workforce."

141. "Time-limited and/or incremental reforms often fall short of improving health care equity and may trigger unintended consequences that widen inequity gaps."

142. "Inadequate enforcement of current laws and policies that promote equitable health care to advance health equity has hindered progress."

143. "The health care system is lax and uneven in gathering, correlating, interpreting, and using race and ethnicity data such that many decisions are not data driven or informed by data.”

144. "Efforts are underway nationwide to inhibit data collection and reporting by race and ethnicity."

145. "The health care system has failed to adopt at scale many of the known solutions for improving health care equity."

146. "The variation in performance measures for health care equity impedes efforts to hold health care systems, organizations, and clinicians accountable for their performance in promoting equitable health care outcomes."

147. "Many current laws and regulations have been underused. The Office of Civil Rights, as one example, is under resourced limiting its efforts to enforce civil rights statutes."

148. "The U.S is the only industrialized nation without universal health insurance coverage and with substantial disparities in payments for services among payers (commercial, Medicaid, and Medicare)."

149. "These structural inequities disproportionately impact minoritized populations but addressing these inequities benefits everyone."

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