This report is one section of of Healthy People, Healthy States: Promising Practices to Address Health Disparities. See the full resource guide.
States are shifting the health disparities paradigm from the more narrow focus on chronic condition interventions to cross-agency/cross-sector approaches to identifying and addressing health disparities. Many are changing how government and state partners do business.19 Transformative strategies fold in leadership; data strategy; financing and funding approaches; community collaborations aimed at planning, implementing, and evaluating community-level solutions; and communications strategies. Transformation at the agency or whole government level can also include establishing organizational policies that address health disparities, systemic and shared accountability, designing culturally appropriate health care, and diversifying decision-makers.
Leadership and vision are key to driving reforms. Transformative strategies evoke change, and leadership can communicate the vision for the change in strategy, mobilize resources, establish a governmental culture shift, and support communication and resource alignment across agencies and with private partners. Leadership support at the community level also plays a key role in transforming state health disparities strategies, which ties to community interest and capacity. Internally, state health disparities strategies are being promoted through state agency hiring, training, promotion, and policy-making practices. Some states are emphasizing recruiting a workforce that reflects the communities being served20 and offering current staff opportunities to evaluate practices to recalibrate and implement new policies that promote equity.21 Policy approaches and strategic planning initiatives are driving cross-agency collaboration with dual purposes of addressing health disparities and changing state agency culture. This is reflected in internal and external-facing reforms such as agency staff implicit bias trainings, developing health disparities/health equity advisory positions and groups, and reprioritizing direct community outreach.22
The linchpin for community engagement is successful communication, and some states are reconsidering their messaging, outreach, and funding approaches, tailoring them to reflect more inclusive social narratives.23 Establishing a glossary of terms or a lexicon ensures a shared understanding of terminology.24 This can help build and strengthen trusting relationships between communities and state officials and can be accomplished, in part, by using language that is relevant and accessible to the intended audience.25
Below are examples of multi-pronged state approaches that knit together leadership, vision, communication strategies, and complementary internal and external reforms.
Minnesota
In Minnesota, leadership and common vision have been key drivers in the Minnesota Department of Health’s (MDH) successful transition to an equity lens throughout the entire state. In 2013, the Minnesota legislature directed MDH and its partners to complete and submit a report on advancing health equity in the state, and in 2022 the MDH commissioner championed the creation of, and funding for, the new Health Equity Bureau, which now houses the department’s Center for Health Equity. With input from MDH’s Health Equity Advisory and Leadership (HEAL) Council and Internal Health Equity Advisory & Leadership Team Hub (I-HEALTH), the bureau functions as a network hub of information, technical assistance and training, resources, and leadership across all MDH and the state enterprise. The Center for Health Equity works closely to support local public health through the Health Equity Networks and with priority populations to improve access to vaccination, testing, masks, and information through community engagement and contracts and grants to community-based organizations. The state has also worked to expand inclusive messaging and communication during the COVID-19 pandemic by partnering with diverse media contractors to create COVID-19 health resources. As a result, information and messaging regarding COVID-19 was developed in direct collaboration with community members and disseminated through local and culturally based news outlets to build trust and provide health information that is “culturally relevant, linguistically appropriate, and accurate.”
Indiana
Indiana Governor Eric Holcomb delivered an address in which he committed to concrete actions to improve equity in the state, including creating a new cabinet-level position of chief equity, inclusion, and opportunity officer, in response to disparities in COVID-19-related deaths and the killings of unarmed Black men and women. The inaugural chief equity, inclusion, and opportunity officer set six strategic pillars, including addressing K–12 literacy rates and post-pandemic learning loss of historically underrepresented students; supporting entrepreneurship and access to capital for diverse businesses; using equity-focused, data-driven, and evidence-based methods to improve quality of life outcomes for historically underrepresented populations; and creating a pathway to sustainability of the office beyond the Holcomb administration. Additionally, to assist statewide diversity, equity, and inclusion (DEI) officers with their efforts, the chief equity, inclusion, and opportunity officer has since developed a Diversity, Equity and Inclusion Strategic Communications Toolkit to guide DEI leaders across all state agencies. The toolkit outlines several priorities, including:
- Creating a common definition of diversity, equity, and inclusion.
- A commitment to meeting everyone where they are, centering civility, respect, and empathy in discussions, and using inclusive language.
- Securing leadership buy-in of DEI goals by supplementing data with qualitative information from the community.
- Creating a formal advisory council from a coalition of supporters across the state in the business, nonprofit, education, and faith communities to ground the state’s work in the needs of the community and inform legislative proposals.
Ohio
Ohio Governor Mike DeWine created the Minority Health Strike Force in 2020, in response to the significant health inequities exposed by the COVID-19 pandemic, and provided a plan of action. Through the strike force, Ohio leveraged community feedback from virtual community forums, town hall meetings, and a community needs assessment performed by the Ohio State University College of Public Health, pairing equity goals (better health outcomes for communities of color) with equity-based processes aimed to transform the health system. Using data and population health measurements, the strike force highlighted gaps in the current system to identify need, then linked that need to a vision of the future and 34 recommended actionable steps broken down into five areas. Efforts also included a commitment to the state and local government hiring a workforce that represents the state’s demographics, as communities of color are underrepresented in many key areas.
Wisconsin
Wisconsin’s Climate and Health Program, housed within the Department of Health Services, has created resources to address the effects of rising heat and other extreme weather events through a health disparities-based lens. Governor Tony Evers also announced the development of the Wisconsin Environmental Equity Tool in October 2021. Four state agencies, including the Department of Health Services, Department of Administration, Wisconsin Economic Development Corporation, and Department of Natural Resources, are collaborating on this project. Drawing from resources created by California, Maryland, and Washington state, the Wisconsin Environmental Equity Tool will serve to visualize health, environmental, climate change, and socioeconomic data to “assess environmental and public health needs statewide” through an accessible online platform. While this resource is still in development, project leaders regularly meet with community members to best tailor the resource to address health and environmental inequities.
Profiles of Pioneering Models
Several states are viewed as pioneers in transforming state systems to reduce or eliminate health disparities. Approaches vary, but all hinge on leveraging financing, incentivizing new payment and delivery approaches, and prioritizing community-identified needs. Detailed case examples of four states — Rhode Island, North Carolina, Oregon, and Washington — are provided below. These examples represent often decades-long capacity building, cross-sector engagement, and state-community infrastructure-building approaches. States interested in comprehensive health disparities transformation may consider these approaches, where deep policy work also reflects lessons learned and opportunities for future learning through continuous quality improvement.
Rhode Island
Recognizing a pattern of inadequate investment in upstream interventions and barriers to community engagement and reducing health inequities, the Rhode Island Department of Health (RIDOH) created the Health Equity Zone (HEZ) initiative in 2015. HEZs are equity-centered, place-based, community-led platforms to address the SDOH. Each Health Equity Zone is led by a collaborative that represents the diversity of the community and is tasked with conducting a needs and assets assessment and developing and implementing an action plan to address the root causes of health inequity in that community. The model engages residents in efforts to eliminate poverty and repair injustices in education, health, criminal justice, and transportation systems.
Traditional public health funding mechanisms are siloed and targeted for specific programs, with each source accompanied by its own often conflicting or duplicating requirements. RIDOH determined that for HEZs to be successful and not limited by funding sources, the state needed to take on the responsibility of identifying and braiding funding to support specific HEZ initiatives.26 Braided funds come from federal, state, and philanthropic foundation grants and are allocated based on need, eligibility, appropriateness, and competitiveness of the application. RIDOH ensures that HEZs have adequate funds for infrastructure and start-up costs, as well as project-based funding, and assists HEZs with securing external funding to support long-term sustainability. RIDOH also provides support in the form of training and technical assistance to ensure implementation is in line with core public health principles.27
To measure outcomes, RIDOH uses the Rhode Island Health Equity Measures, which include measures relating to integrated health care, community resilience and engagement, physical environment, socioeconomics, and community trauma. In the first four years of the HEZ initiative, reported outcomes include:
- 44 percent decrease in childhood lead poisoning
- 24 percent decrease in teen pregnancy
- 13 percent decrease in feelings of loneliness
- 5–7 percent decrease in body weight
- 40 percent increase in redemption of SNAP farmers market incentives
- 36 percent increase in access to fruits and vegetables
- 163 percent increase in community engagement
HEZs, which by their nature were embedded in the community, were poised to quickly respond to critical needs relating to the COVID-19 pandemic, beginning in 2020.28 HEZs became essential resources for providing information, offering testing and vaccines, and connecting individuals to services and supports. HEZs received CARES Act funding to support these efforts in June 2020. Similarly, as Rhode Island began thinking about recovery and allocating State and Local Fiscal Recovery Funds (Rhode Island was allocated $1.2 billion), RIDOH prioritized recovery with an equity, choice, and community-engagement focus. Rhode Island officials mapped the various American Rescue Plan funding streams and associated requirements to determine how funds could be allocated and braided to match state recovery planning objectives. RIDOH initiatives prioritize behavioral health, early childhood initiatives, housing, and support to small business.
Rhode Island is currently charting a path forward for expanding the impact of place-based strategies and sustaining HEZs long term. The state plans to phase in community participatory budgeting, a democratic process in which facilitators assist members of the community in identifying community priorities and resource allocation. Participatory budgeting engages community members upstream to develop, vote on, and implement a public budget that includes prioritizing community needs. This approach is used by 600 state and local governments across the country and promotes individual civic engagement through decision-making for how public funds are budgeted. This is a critical piece of Rhode Island’s efforts to provide community members with decision-making power over resources supporting community-identified needs and health improvement efforts.
North Carolina
In 2015, North Carolina’s legislature passed Session Law 2015-245 (with amendments in 2016 and 2018) to implement managed care in the Medicaid program. The North Carolina Department of Health and Human Services (NCDHHS) embarked on an extensive “stakeholder feedback process” that informed their approach, including the importance of addressing SDOH.
As NCDHHS embarked on the major transformation of the Medicaid program, it identified four initial priority domains of SDOH that underpin their approach: food, housing, transportation, and interpersonal safety and toxic stress. Through a wide-ranging set of initiatives, including a Section 1115 Demonstration Waiver approved in 2018 by CMS, NCDHHS created a statewide framework and infrastructure to address SDOH for North Carolinians most in need of support. North Carolina’s approach emphasizes the innovation already happening in the private sector and provides the infrastructure and support necessary to build on those innovations. Specific activities and initiatives include:
- An interactive map includes demographic and SDOH indicators by local health department regions.
- While screening for unmet health-related social needs are not required, NCDHHS developed standardized screening questions that providers may use.
- NCCARE360, a statewide resource platform, connects individuals with identified needs to community resources and tracks and monitors referrals.
- Healthy Opportunity Pilots evaluate providing non-medical evidence-based interventions to Medicaid enrollees in need of services related to SDOH. The program includes up to $650 million over five years for three regions of the state; $100 million of that can be used for capacity building. NCDHHS expects to serve approximately 25,000 to 50,000 beneficiaries through the pilots.
- Community input to inform recommendations to build an infrastructure to support community health workers, including through a standardized curriculum and certification process. In addition, NCDHHS has partnered with the University of North Carolina School of Social Work to implement course development and certification for peer support specialists.
To learn more about North Carolina Healthy Opportunities, please visit the NCDHHS website.
Oregon
The Oregon Health Authority (OHA) has a singular bold goal: to eliminate health inequities in Oregon by 2030. To achieve this goal, OHA first set out to develop a common language and define what health equity means for the state.
OHA’s Health Equity Definition
“Oregon will establish a health system that creates health equity when all people can reach their full health potential and well-being and are not disadvantaged by their race, ethnicity, language, disability, age, gender, gender identity, sexual orientation, social class, intersections among these communities or identities, or other socially determined circumstances. Achieving health equity requires the ongoing collaboration of all regions and sectors of the state, including Tribal governments to address equitable distribution or redistribution of resources and power; and recognizing, reconciling, and rectifying historical and contemporary injustices.”
OHA’s Equity and Inclusion Division works “with diverse communities to eliminate health gaps and promote optimal health in Oregon.” OHA identified that its success depended on trusting relationships with community members and community-based organizations (CBOs), not just to define health equity for the state but also to reach the goal of eliminating health inequities. Therefore, OHA prioritizes authentic inclusion of community voices in the policymaking process. The division is guided by the Community Advisory Council and collaborates with the Health Equity Committee. The Health Equity Committee was established in 2017 by the Oregon Health Policy Board (OHPB) to develop policy that proactively promotes health equity. Members include representatives from CBOs, federal qualified health centers, universities, coordinated care organizations, hospital and health systems, Tribes, and members of the community. OHA and the division support 10 Regional Health Equity Coalitions, which are autonomous, community-led groups that build on the strengths of local communities to increase health equity for underserved and underrepresented populations. In addition, in April 2022 OHA launched a new program to fund CBOs to address local priorities and meet health equity goals. Between April and June 2022, OHA awarded $31 million to 147 CBOs.
OHA also operates the Medicaid program and identified the state’s accountable care organizations (coordinated care organizations, or CCOs, in Oregon) as an important locus of action. CCOs were originally implemented in Oregon in 2012 to integrate physical, behavioral health, and other types of care and to provide flexibility to support new patient-centered models of care and reduce health disparities. Partnerships between CCOs and CBOs have been central to the initiative since the beginning. In January 2020, Oregon launched a second phase of its CCO program, CCO 2.0, with the goal of improving the behavioral health system, increasing value, addressing SDOH and health equity, and maintaining sustainable cost growth.
In 2017, Oregon’s governor and legislature asked the OHPB to build on its initial work by identifying specific policy changes that would increase CCO focus (and spending) on addressing health equity and SDOH in their communities. Policy changes that emerged from this process included embedding requirements that fostered CCO-CBO partnerships in the CCO selection process and 2020 CCO contract, as well as modifying CCO planning and state oversight activities. The contract now indicates that the CCO’s community advisory council (CAC) must play a role in directing the CCO’s investments in social determinants of health and equity and in the CCO’s community benefit initiatives.
In 2018, the legislature also passed HB 4018, which requires CCOs to spend a portion of their previous year’s net income or reserves on services to address health disparities and SDOH in line with the CCO’s community health improvement plan, beginning in 2021. The OHPB recommended specific policies to guide the implementation of HB 4018, including requiring the CACs to have a role in spending, requiring alignment with a statewide housing priority, and requiring a portion of the funding go directly to SDOH and equity partners through a formal agreement. Oregon renamed this legislative requirement the Supporting Health for All through REinvestment (SHARE) Initiative.
In September 2022, CMS approved amendments that further Oregon’s goals, including expanded continuous eligibility for children and coverage of targeted clinically appropriate health-related social needs.
For additional details, please see OHA’s legislation, administrative rules, contractor selection process, and contracts.
Washington
Washington Governor Jay Inslee and the state legislature initiated a whole-of-government approach to equity beginning in April 2020 when they partnered to create the Washington State Office of Equity. The Office of Equity promotes access to equitable opportunities, supports state agencies, partners with internal and external partners to develop a strategic plan and outcome measures, and reports on the effectiveness of programs in reducing disparities. In December 2020, Inslee committed to actions to support Washington becoming an anti-racist state. The Office of Health Equity worked with thousands of community members, state employees, and other partners to inform the first five-year Washington State Pro-Equity Anti-Racism (PEAR) Plan & Playbook. The PEAR Plan & Playbook created a unified vision for the whole of government, goals for the state, and a step-by-step playbook for implementing PEAR. It also established the PEAR Equity Impact Review framework to inform any proposed changes to policy, programs, or practices.
Washington state identified 15 determinants of equity that guide the Office of Equity’s goals and expected outcomes:
- Affordable, healthy, local food
- Access to health and human services
- Access to parks, recreation, and natural resources
- Transportation and mobility
- Housing and home ownership
- Community and public safety
- Early childhood development
- Economic justice
- Equity in state and local practices
- Equity in justice systems and laws
- Equity in jobs and job training
- Heathy built and natural environments
- Quality education
- Strong, vibrant neighborhoods
- Digital equity
In March 2022, Gov. Inslee signed Executive Order 22-04, which directs the Office of Equity to communicate the PEAR Plan & Playbook to all state agencies, support state agencies in developing and implementing their own PEAR plans, and hold agencies accountable to and publicly report on performance measures. Through the same executive order, state agencies were charged with developing, implementing, and reporting on agency-specific PEAR Strategic Action Plans; establishing a PEAR team; and partnering with those affected by the agencies’ programs and policies to complete a PEAR Equity Impact Review.
The Washington State Health Care Authority (HCA) submitted its PEAR Strategic Action Plan in 2022. It established four service lines: leadership operations and services, data strategy and reporting, engagement and community partnerships, and HCA workforce equity. In addition, HCA established a PEAR team representing each division across the agency, a PEAR Community Advisory Team, and PEAR workstream teams for each of the four service lines. The Washington Department of Health (DOH) defines health equity as “when all people have the opportunity to achieve their full health potential” and recognizes that not everyone in the state currently has that opportunity. The DOH embedded equity as a cornerstone value for the department and central to its vision and actions in its August 2022 Transformational Plan.
References
Below, you will find references for this section of Healthy People, Healthy States: Promising Practices to Address Health Disparities. Find more references for this resource guide.
- “State Strategies for Overcoming Barriers to Advance Health Equity.” Manatt Health, 2020. shvs.org/wp-content/uploads/2020/11/State-Strategies-for-Overcoming-Barriers-to-Advance-Health-Equity.pdf.
- “Handbook for Recruiting, Hiring, & Retention: Applying an Equity Lens to Recruiting, Interviewing, Hiring, and Retaining Employees.” City of Tacoma, Office of Equity and Human Rights, 2015. cms.cityoftacoma.org/OEHR/facilitatingchange/COT_Handbook_for_Recruitment_and_Hiring_October_2015.pdf.
- “State Health Department Organizational Self-Assessment for Achieving Health Equity: Toolkit and Guide for Implementation.” National Association of Chronic Disease Directors, 2014. chronicdisease.org/resource/resmgr/healthequity/he_toolkit.pdf.
- “COVID-19 Ohio Minority Health Strike Force Blueprint.” COVID-19 Minority Health Strike Force and Health Policy Institute of Ohio, 2020. coronavirus.ohio.gov/static/MHSF/MHSF-Blueprint.pdf.
- “Advancing Health Equity: Guide to Language, Narrative and Concepts.” American Medical Association, 2022. ama-assn.org/system/files/ama-aamc-equity-guide.pdf.
- “Advancing Health Equity: Guide to Language, Narrative and Concepts.” American Medical Association, 2022. ama-assn.org/system/files/ama-aamc-equity-guide.pdf.
- “Using a Health Equity Lens.” Centers for Disease Control and Prevention, 2022. cdc.gov/healthcommunication/Health_Equity_Lens.html.
- “Health Equity Zones: A Toolkit for Building Healthy and Resilient Communities.” ChangeLab Solutions and Rhode Island Department of Health, 2021. health.ri.gov/publications/toolkits/health-equity-zones.pdf.
- “Health Equity Zones: A Toolkit for Building Healthy and Resilient Communities.” ChangeLab Solutions and Rhode Island Department of Health, 2021. health.ri.gov/publications/toolkits/health-equity-zones.pdf; “Rhode Island’s Health Equity Zones: A Model for Building Health, Resilient Communities.” Rhode Island Department of Health, 2022. health.ri.gov/publications/factsheets/RIsHealthEquityZones.pdf.
- “Rhode Island’s Health Equity Zone Initiative: Annual Report Executive Summary for the Fiscal Year 2020–2021.” Rhode Island Department of Health, 2021. health.ri.gov/publications/annualreports/2020-2021HEZ.pdf.
