Prelude: I would like to thank the editorial staff of Times of Israel for deleting several similar submissions. Rather than focusing on serious study of healthcare issues facing the entire American diaspora, the staff are more than content to waste time, money, and effort publishing mediocre works about holiday preparation, family values, and religious observance. I’m consequently pleased that policymakers and executives in London and New York can benefit from this content.
Medicaid functions as the primary healthcare safety net for approximately 70 million Americans, constituting one-fifth of all healthcare expenditures in the United States. The system presently covers 40% of American children and more than 80% of children living in poverty. Despite this expansive coverage, American healthcare remains fundamentally fractured, with over 32 million individuals lacking any form of health insurance whatsoever. Health equity policies implemented since 2020 have attempted to address these systemic disparities through legislative and administrative means. The Affordable Care Act, while enabling 20 million previously uninsured Americans to secure coverage, has not eliminated the persistent barriers that disproportionately affect vulnerable populations. This situation presents a particularly troubling prospect when considering that Medicaid currently serves as the nation’s largest funder of mental health and substance use disorder care, providing approximately 60% of all paid services supporting individuals with disabilities.
I contend that a more nuanced analysis of these equity-focused policies is necessary to fully comprehend their impact on vulnerable communities. In the forthcoming sections, I shall examine both the intended benefits and unintended consequences of these initiatives. This examination will encompass the shifts in resource allocation, the practical challenges of implementation, and strategies to ensure that policy modifications genuinely serve those most requiring healthcare access and support. The question is not merely whether such policies exist, but rather if they function as intended for those most vulnerable to systemic healthcare inadequacies.
The COVID-19 pandemic functioned as an unprecedented revelatory mechanism, exposing the profoundly entrenched healthcare inequities that pervade American society. By March 2020, the disproportionate impact of the virus on racial and ethnic minority groups had become unmistakably apparent, catalyzing rapid policy responses across multiple governmental programs [1]. I’ve found it particularly instructive to conceptualize the pandemic not merely as a public health crisis but rather as a complex “syndemic” – a confluence of political, economic, and social factors that fundamentally shaped infection and mortality risks [1]. Communities subjected to structural racism experienced markedly elevated COVID-19 infection and mortality rates, necessitating a fundamental reconceptualization of health equity policy frameworks [1]. The concurrent police killings of George Floyd, Breonna Taylor, and others during 2020 further intensified national awareness of the systemic racism that undergirds health inequities [2].This conjunction of public health emergency and heightened racial consciousness created what policy theorists term a “policy window.” Before 2020, health equity initiatives certainly existed but lacked both comprehensive coordination and adequate resources. The pandemic transformed this landscape entirely, shifting health equity from peripheral concern to central policy priority as empirical evidence accumulated demonstrating that Black, Latinx, and Indigenous populations suffered substantially higher rates of COVID-19 hospitalization and death [3].
The Centers for Disease Control and Prevention (CDC) established its Chief Health Equity Officer Unit in May 2020—the first such unit in the agency’s history during an emergency response [3]. This landmark development coincided with the creation of CDC’s COVID-19 Health Equity Strategy, structured around four foundational approaches: employing data-driven methodologies, expanding programs for at-risk populations, supporting essential workers, and building an inclusive workforce [3].
The federal government directed substantial resources toward these objectives, including:
- Approximately $100 million distributed among 120+ projects expanding access for populations at elevated risk [3]
- $13 million allocated specifically to supporting essential and frontline workers [3]
- $583 million awarded to 1,385 Federally Qualified Health Centers (FQHCs), serving communities where over 22% of patients identify as African American [4]
- Payment provisions for COVID-19 care for uninsured individuals through the $175 billion Provider Relief Fund [4]
The Biden administration subsequently expanded these initiatives in 2021, establishing a government-wide pandemic health inequities task force and allocating $785 million in American Rescue Plan Act funding to support community health workers and organizations in underserved communities [5].
States demonstrated remarkable innovation in policy approaches addressing COVID-19-related health inequities. According to the National Academy for State Health Policy, states primarily adopted three strategic approaches: establishing health equity task forces, developing targeted programs for pandemic-related social needs, and implementing comprehensive approaches utilizing CARES Act funding [5].
Many states constructed dedicated infrastructure for equity initiatives. Washington created an Office of Equity with $2.5 million in funding and eight staff members to develop a five-year equity plan [1]. Georgia’s Department of Public Health similarly formed a COVID-19 Health Equity Council specifically focused on vaccination education and distribution in communities most affected by the virus [1]. State legislatures contributed actively to this policy evolution. Maine enacted legislation requiring racial impact statements in the legislative process [1]. North Carolina utilized COVID-19 relief funding to establish the Andrea Harris Social, Economic, Environmental, and Health Equity Task Force, which provides biannual recommendations to the governor addressing disparities in historically marginalized populations [5].
What I find most noteworthy is how some states transcended immediate crisis response to incorporate equity considerations into broader policy frameworks. Michigan prioritized addressing disparities in maternal and infant health through its 2024 strategic plan [2]. California established the Reducing Disparities Project targeting behavioral and mental health inequities among specific populations [2]. Oregon required its Health Authority to create an implementation plan for a public health insurance system designed to eliminate health disparities within a decade [6]. Some states have simultaneously enacted legislation prohibiting activities related to diversity, equity, and inclusion (DEI) [2].
The financial architecture of health equity initiatives has undergone a profound metamorphosis since 2020, fundamentally reconfiguring resource allocation throughout the healthcare system. Actuarial analyses indicate that health inequities presently account for approximately $320 billion in annual healthcare expenditures [7], generating an unsustainable fiscal burden that weighs upon both healthcare systems and vulnerable populations. While lawmakers acknowledge the critical importance of addressing disparities, fiscal constraints frequently necessitate redirecting funds from existing healthcare programs rather than generating entirely new revenue streams. State budgets, typically approved annually or biennially, constitute the primary mechanism through which health equity initiatives receive funding [8]. Oregon’s legislature, for instance, enacted HB 4052 in 2022, directing its Health Authority to establish a pilot program aimed at improving health outcomes for residents impacted by racism [8].
This legislative action naturally required reallocating funds that might otherwise have supported alternative healthcare priorities. I find it particularly troubling that one prominent trend involves the chronic underfinancing of Medicaid, which demonstrably worsens health disparities for beneficiaries by restricting their access to care [9]. The differential payment rates between Medicaid and other insurance programs create a structural disadvantage for providers serving predominantly low-income populations. Consequently, budget redistributions that fail to address these fundamental payment disparities risk perpetuating existing inequities rather than resolving them. Furthermore, resource reallocation frequently diverts funding from treatment-focused interventions toward prevention and social determinants of health. As institutions integrate health equity considerations across sectors, they often redirect funding from direct clinical services to address social and economic factors2. This approach acknowledges that approximately 80% of health outcomes are influenced by factors outside traditional healthcare settings [10]. Nevertheless, such transitions inevitably create short-term service delivery gaps that disproportionately affect vulnerable populations.
Federal and state governments have constructed new funding mechanisms specifically targeting health equity initiatives. The American Rescue Plan Act allocated $785 million to support community health workers and organizations in underserved communities [11]. Similarly, states have established dedicated funding streams, exemplified by Washington’s $2.5 million allocation to create an Office of Equity [2]. These new funding streams, however, confront significant limitations. Primarily, macroeconomic pressures threaten their sustainability. Rising inflation and debt levels have subjected social sector expenditures, including health equity programs, to intense scrutiny [12]. Without sustained commitment, these initiatives risk devolving into temporary responses rather than systemic solutions. As I contend, technical implementation barriers similarly impede effective resource utilization. Many funding mechanisms demand sophisticated data collection and reporting capabilities that exceed the technical capacity of rural healthcare settings and smaller community-based organizations [2]. Consequently, organizations ideally positioned to address local health inequities often struggle to access available funding due to administrative requirements.
Another limitation stems from siloed funding structures that constrain holistic approaches to health equity. Evidence indicates that addressing social determinants of health necessitates greater public and private financing of critical social services beyond medical care [9]. Current funding models that focus exclusively on healthcare delivery therefore fail to address the broader social and economic factors driving health disparities.The potential return on investment for health equity initiatives remains substantial despite these limitations. Each year of life expectancy gained through improved health equity raises GDP per capita by approximately 4%[12]. Estimates suggest that improving health equity could add $2.8 trillion to the US GDP by 2040 [10], demonstrating that despite initial costs, well-designed health equity investments yield significant long-term economic benefits. Health equity policies implemented since 2020 have generated considerable administrative challenges for healthcare providers throughout the American healthcare landscape. While these policies ostensibly aim to reduce care disparities, their implementation necessitates substantial resources, imposing additional burdens upon already strained healthcare systems. The administrative requirements permeate multiple operational aspects, from documentation protocols to staffing allocations to technological infrastructure investments.
Value-based payment programs and quality reporting initiatives increasingly incorporate health equity measurement approaches, compelling providers to document and report disparities in care delivery. These measurement methodologies must conform to specific guidelines, optimally being predicated upon measures where disparities are known to exist or that address culturally appropriate care. Such measures must reflect available evidence concerning relationships between social risk factors and health outcomes while simultaneously incentivizing achievement or improvement for at-risk beneficiaries through valid benchmarking [13]. State Medicaid programs have instituted reporting requirements that oblige health plans to satisfy equity-focused quality measures. Many states have proceeded further, employing payment adjustments—including withholding payments—to incentivize narrowing extant healthcare quality gaps [14]. These documentation requirements transcend basic demographic data to encompass detailed stratification across multiple social risk factors including race, ethnicity, preferred language, and country of origin. Providers must establish measurability requirements that reliably distinguish performance in health equity domains, often capturing information about small subgroups while limiting the influence of imprecise estimates [13]. This granular level of data collection demands sophisticated protocols that numerous healthcare organizations struggle to implement.
The collection of Race, Ethnicity, and Language (REaL) data constitutes a substantial administrative burden, necessitating staff training and continuous support. Healthcare organizations must furnish employees with standardized scripts and educational materials explaining why this information is collected. Henry Ford Health System, for instance, provides patients with a multilingual brochure titled “We Ask Because We Care,” elucidating how this information supports quality improvement efforts [15]. Public health agencies report that workforce capacity remains a formidable barrier to measuring health equity effectively. Many agencies cite challenges related to complex concepts, evolving needs, and strategic skills required to advance equity initiatives [16]. For small, non-metropolitan healthcare providers, these challenges manifest with particular acuity, as they typically operate with fewer staff and reduced funding compared to metropolitan counterparts [17]. Staff time must additionally be allocated to analyze collected data, develop improvement strategies, and implement changes. In rural settings, limited technical capacity frequently prevents healthcare providers from fully utilizing equity data, essentially compelling organizations to redirect clinical staff toward administrative functions [17]. These demands create competing priorities, forcing providers to balance immediate patient care needs against long-term equity objectives. Time allocation becomes a zero-sum game within fixed resource constraints.
References
[1] – https://nashp.org/states-address-racial-and-ethnic-disparities-in-their-covid-19-responses-and-beyond/
[2] – https://www.kff.org/racial-equity-and-health-policy/issue-brief/state-reported-efforts-to-address-health-disparities-a-50-state-review/
[3] – https://pmc.ncbi.nlm.nih.gov/articles/PMC8795842/
[4] – https://www.hhs.gov/sites/default/files/hhs-fact-sheet-addressing-disparities-in-covid-19-impact-on-minorities.pdf
[5] – https://www.healthaffairs.org/do/10.1377/hpb20220210.360906/
[6] – https://www.ncsl.org/health/health-disparities-legislation
[7] – https://www2.deloitte.com/us/en/insights/industry/health-care/economic-cost-of-health-disparities.html
[8] – https://www.astho.org/globalassets/resources/astho-health-equity-policy-toolkit.pdf
[9] – https://pmc.ncbi.nlm.nih.gov/articles/PMC10684035/
[10] – https://www2.deloitte.com/us/en/insights/industry/health-care/health-equity-economic-impact.html
[11] – https://www.ey.com/en_us/insights/health/america-s-health-equity-investment-marginal-return
[12] – https://pmc.ncbi.nlm.nih.gov/articles/PMC11015166/
[13] – https://aspe.hhs.gov/sites/default/files/private/pdf/265566/developing-health-equity-measures.pdf
[14] – https://wpcdn.ncqa.org/www-prod/wp-content/uploads/2023/02/NCQA-MeasuringHealthEquity-Whitepaper-FINAL_WEB.pdf
[15] – https://www.ihi.org/sites/default/files/IHI_ImprovingHealthEquity_BuildInfrastructureGuide.pdf
[16] – https://www.astho.org/globalassets/report/measuring-health-equity.pdf
[17] – https://journals.lww.com/jphmp/fulltext/2025/03000/challenges_and_supports_for_implementing_health.8.aspx
[18] – https://legacy.himss.org/resources/public-health-information-and-technology-infrastructure-modernization-funding-report
