| Shape social conditions and structures that affect inequities. |
Mitigate or exacerbate poverty, racism, illness, market failure, racism, or individual behavior that harms others. |
Medicaid—Expand access to “mainstream” health care for low-income individuals and families.14
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Even before Medicaid expansion under the Patient Protection and Affordable Care Act of 2010 (ACA), Medicaid coverage was associated with a range of positive health behaviors and outcomes for vulnerable populations.15
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| Maintain social conditions at the federal, tribal, and state levels. |
Maintain current effects (eg, physical, mental, and emotional impacts) of laws and policies on the health and well-being of individuals and populations. |
In 1933, the Home Owners Loan Corporation (HOLC) began a program, institutionalized as the Wagner-Steagall Housing Act in 1937,16 to reduce home foreclosures during the Depression. Redlining was the unintended consequence. |
Residents of 8, historically redlined California cities shows neighborhoods are more than twice as likely as their peers to visit emergency departments for asthma. Redlined neighborhoods show higher levels of diesel particulate matter in the air.17
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| Distribute health and well-being across populations. |
Apply the law selectively based on characteristics of the individual or population. |
“Three Strikes, You're Out” laws—In 1993, Washington State was first to pass a policy mandating that anyone convicted of a third serious felony was sentenced to life in prison without possibility of parole.18 The policy's intent was to serve justice for crime victims; prevent crimes; and encourage criminals to leave the state, retire, or stop criminal behavior. |
The Three Strikes law disproportionately affected African Americans and the mentally ill.19
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| Require sufficient regulatory attention, funding, and enforcement. |
Negative influences on health and well-being can occur due to lack of regulatory attention, underfunding, or underenforcement of laws. |
A definitive 1992 study showed that primary care nurse practitioners are capable of providing cost-effective, safe, high-quality care, but their role has been severely limited by restrictions on their scope of practice, prescriptive authority, and eligibility for reimbursement. Eliminating these restrictions would enable advanced practice nurses to increase access to care while preserving quality and reducing costs.20
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In Pennsylvania, by state statute, nurse practitioners gained prescriptive authority in the 1970s. However, because nurses were overseen by the state board of medicine and nursing, regulations were never released. Thus, no prescriptive authority could take place.21,22 This example shows that the evidence is not driving law, policy, and regulation. If evidence were to drive changes in law and policy, a more equitable society with reduced health disparities could result. |
| Take on new meaning through their interpretation. |
In 2012, the US Supreme Court decided that the Affordable Care Act's Medicaid expansion could only be implemented by states on a voluntary basis, not a mandatory one.23
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Congress intended the Medicaid expansion to apply nationwide, since states risked Medicaid funding by not expanding.24
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As of January 2020, several million people across 14 states lacked access to Medicaid's benefits.25
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