HHS Action Plan to Reduce Racial and Ethnic Health Disparities

HHS Action Plan to Reduce

Racial and Ethnic

Health Disparities:

Implementation

Progress Report

2011-2014

November 2015

About This Report

This document is an implementation progress report of the U.S. Department of Health and Human

Services (HHS) Action Plan to Reduce Racial and Ethnic Health Disparities (HHS Disparities Action

Plan). The HHS Disparities Action Plan represents an ongoing commitment by HHS to coordinate

efforts and assess the nation’s progress toward addressing racial and ethnic disparities in health and

health care. This report outlines the HHS Disparities Action Plan’s goals and strategies, describes a

sample of the specific actions being taken across HHS agencies to reduce these disparities, and

highlights major accomplishments to date.

Suggested citation: U.S. Dept. of Health and Human Services, Office of the Secretary, Office of the

Assistant Secretary for Planning and Evaluation and Office of Minority Health. HHS Action Plan to

Reduce Racial and Ethnic Health Disparities Implementation Progress Report. Washington, DC:

Office of the Assistant Secretary for Planning and Evaluation, 2015.

Contents

HHS Action Plan to Reduce Racial and Ethnic Health Disparities: Implementation

Progress Report — Executive Summary ......................................................................................... 1

HHS Action Plan to Reduce Racial and Ethnic Health Disparities: Implementation

Progress Report—Full Report ......................................................................................................... 6

Background ................................................................................................................................. 6

Addressing the Major Dimensions of Racial and Ethnic Health Disparities .............................. 6

HHS Action Plan to Reduce Racial and Ethnic Health Disparities ............................................ 8

Goal I: Transform Health Care ............................................................................................................. 11

Goal II: Strengthen the Nation’s Health and Human Services Infrastructure and

Workforce ...................................................................................................................................... 15

Goal III: Advance the Health, Safety, and Well-Being of the American People ................................. 19

Goal IV: Advance Scientific Knowledge and Innovation .................................................................... 23

Goal V: Increase Efficiency, Transparency, and Accountability of HHS Programs ............................ 25

Conclusion ............................................................................................................................................ 27

References ............................................................................................................................................. 28

Appendix A: Glossary of Acronyms................................................................................................... A.1

Appendix B: Overview of HHS Action Plan to Reduce Racial and Ethnic Health

Disparities .................................................................................................................................... B.1

iii

HHS Action Plan to Reduce Racial and

Ethnic Health Disparities: Implementation

Progress Report — Executive Summary

Introduction

The U.S. Department of Health and Human Services Action Plan to Reduce Racial and Ethnic

Health Disparities (HHS Disparities Action Plan) is the most comprehensive federal commitment

to date for reducing, and eventually eliminating disparities in health and health care. Through the

HHS Disparities Action Plan, the Department of Health and Human Services (HHS) provides a

coordinated framework for departmental agencies and offices to streamline and institutionalize

programmatic and policy efforts, as well as promote integrated approaches and evidence-based

programs, so that all Americans have the chance to live the healthiest lives possible. This report

provides an overview of the four Secretarial priorities and five goals that make up this strategic

plan. The report also describes some of the major actions and activities that agencies have

undertaken to implement the HHS Disparities Action Plan since its original publication in April

2011. The implementation progress report is not meant to be an exhaustive list of all of the current

research, policies, and programs the Department is supporting to improve minority health, but

rather provide several illustrative examples of important work in this area.

Secretarial Priorities

The overarching Secretarial priorities represent the cross-cutting issues that the HHS Disparities

Action Plan addresses to ensure the coordination of HHS programmatic and policy efforts to

effectively advance health equity. Presented below are the four priorities and examples of

corresponding activities.

1. Assess and heighten the impact of all HHS policies, programs, processes, and resource

decisions to reduce health disparities. This priority supports monitoring HHS agencies’ stra-

tegic plans, programs, and regulations to ensure that the HHS Disparities Action Plan goals,

strategies, and actions are included to the fullest extent possible in the agencies’ work.

• In FY 2013, the Substance Abuse and Mental Health Services Administration (SAMHSA)

incorporated health disparity impact statements into all new Requests for Applications for

grant programs. These statements helped grantees build their capacity to collect and use data

to develop strategies addressing differential access, utilization, and outcomes of behavioral

health interventions among diverse populations.

Increase the availability, quality, and use of data to improve the health of minority populations.

High-quality data is fundamental to HHS’s ability to understand the causes of health disparities,

design effective responses, and evaluate progress in reducing disparities.

• As called for by Section 4302 of the Affordable Care Act, HHS adopted new standards for the

collection of data by race, ethnicity, primary language, sex, and disability status within major

self-reported population health surveys. The new standards provide additional granularity for

the Asian race category and Hispanic ethnicity, and distinguish Native Hawaiian from Pacific

Islander race categories. The specificity provided by the new standards will allow for

improved demographic data collections and tracking of health differences among these

populations, as well as an increased ability to target interventions appropriately.

3. Measure and provide incentives for better health care quality for minority populations. As

racial and ethnic minorities often receive a poorer quality of care and face more barriers to

seeking care than Whites, providing incentives for quality care in these populations is critical

for improvement in patient outcomes.

• From 2011-2014, the Centers for Medicare & Medicaid Services (CMS) Disparities National

Coordinating Council (DNCC) offered technical assistance to Quality Improvement

Organizations (QIOs) to improve care provided to Medicare beneficiaries within underserved

populations. For example, QIOs in Arkansas, California, and Michigan engaged in the

Cardiac Health Disparities Project, which focused on prevention of cardiovascular disease

among racial and ethnic minorities. QIOs in West Virginia, New York, and Texas engaged

in the Everyone with Diabetes Counts (EDC) special innovation project. During this project,

Medicare and Dually Eligible beneficiaries from rural and minority underserved populations

were enrolled in diabetes self-management education (DSME) classes to maximize patient

engagement and improve health literacy, with the goal of decreasing the disparity in diabetes

care provided to these populations.

4. Monitor and evaluate the Department’s success in implementing the HHS Disparities Action

Plan. The HHS Health Disparities Council, co-chaired by the Assistant Secretary for Health

and the Assistant Secretary for Planning and Evaluation (ASPE), is composed of senior-level

HHS agency representatives and serves as the venue to share information, coordinate activities,

oversee implementation, and track progress of the strategies and actions of the HHS Disparities

Action Plan.

Goal I: Transform Health Care

Creating an equitable health system requires efforts to (1) expand opportunities for racial and

ethnic minorities to obtain and understand how to use insurance coverage; (2) expand access to

health care services; and (3) improve the quality of care provided to racial and ethnic minority

populations. To achieve these aims, Goal I of the HHS Disparities Action Plan includes the

specific actions below, among others:

Expansion of Medicaid and Introduction of the Health Insurance Marketplace. The Affordable

Care Act offers an opportunity for millions of racial and ethnic minorities to gain affordable and

quality health insurance coverage. At the time of this report, 29 states, including the District of

Columbia, have expanded Medicaid eligibility so that all individuals up to 133 percent of the

federal poverty level (FPL) qualify for coverage. The new Health Insurance Marketplace is

making coverage available to others who do not qualify for Medicaid, with tax credits available

to help defray the premium cost for those that qualify.

From Coverage to Care (C2C) Initiative. The CMS Office of Minority Health (OMH) launched

the From Coverage to Care (C2C) Initiative in June 2014. The C2C Initiative is designed to

answer consumer questions about new health coverage opportunities, provide information

about new benefits, including primary care and preventive services, and provide resources for

health care providers to promote patient engagement in care. The C2C launch marked the

release of the new Roadmap to Better Care and a Healthier You, which includes eight steps to

help consumers and health care providers be informed about the diverse benefits available

through their coverage and how to use it appropriately to access primary care and preventive

services. The Roadmap is available in English, as well as seven secondary languages. The

CMS OMH also developed an Enrollment Toolkit: Helping Consumers Choose the Health Plan

That’s Right for Them, to support the C2C Initiative.

The Health Resources and Services Administration’s (HRSA) National Health Service Corps

(NHSC). The NHSC offers loan repayment and scholarships to primary care providers and

students for serving at NHSC sites in communities with shortages of health professionals. In FY

2013, 8,899 NHSC clinicians provided care to more than 9.3 million Americans with otherwise

limited access to health services.

Goal II: Strengthen the Nation’s Health and Human

Services Infrastructure and Workforce

Strengthening the nation’s health and human services infrastructure and workforce involves

increasing the number and diversity of health care professionals, and incorporating cultural and

linguistic knowledge among the health care workforce. Goal II of the HHS Disparities Action Plan

supports the following actions, among others:

National Standards for Culturally and Linguistically Appropriate Services in Health and Health

Care (National CLAS Standards). The Office of Minority Health (OMH) released the enhanced

National CLAS Standards in April 2013, marking the first update since the original standards

were published in 2000. The enhanced National CLAS Standards are intended to advance health

equity, improve quality, and help eliminate health disparities by providing a blueprint for

individuals and health and health care organizations to implement culturally and linguistically

appropriate services.

Health Profession Opportunity Grants (HPOG). Authorized by the Affordable Care Act and

administered by the Administration for Children and Families (ACF), HPOG provides edu-

cation and training to Temporary Assistance to Needy Families (TANF) recipients and other

low-income individuals to help them pursue jobs in health care. As of December 2013, there

were 20,382 enrolled individuals in HPOG health care and occupation training programs, and

12,384 individuals had completed such programs.

Goal III: Advance the Health, Safety, and Well-Being

of the American People

Health disparities are also driven by community and environmental factors beyond those

embedded in the health care system. Strategies that create healthy and safe environments promote

healthy behaviors to improve the well-being of the American people. The following actions

support Goal III:

Public-Private Partnerships to Improve Vaccination Rates. For the 2010–2011 influenza

season, OMH established the Walgreens-HHS Co-Sponsorship Agreement, which provides

uninsured individuals with free seasonal influenza vaccination. Walgreens has committed over

$10 million annually to support this effort, and the partnership has successfully vaccinated more

than half a million individuals who otherwise would not receive the influenza vaccination due to

cost. Between April 2012 and September 2013, the National Vaccine Program Office (NVPO)

offered grants to support community-level efforts to deliver culturally appropriate immunization

interventions and developed a web tool to map flu vaccine disparities.

Community Transformation Grants (CTG) Program. The CTG Program, which had been

supported by the Prevention and Public Health Fund created by the Affordable Care Act,

enabled awardees to design and implement community-level prevention programs that placed

special emphasis on reaching people who experience the greatest burden of death, disability,

and suffering from chronic conditions. The CDC Community Transformation Grants Program

implemented, evaluated, and disseminated evidence-based community preventive health

activities. Funded communities worked across multiple sectors to reduce heart attacks, cancer,

and strokes by addressing a broad range of risk factors and conditions including poor nutrition

and physical inactivity, tobacco use, and others. By promoting healthy lifestyles, especially

among population groups experiencing the greatest burden of chronic disease, these grants

improved health, reduced health disparities, and controlled health care spending.

Goal IV: Advance Scientific Knowledge and

Innovation

To inform initiatives for increasing health equity, Goal IV promotes the collection of race and

ethnicity data and strengthening of information systems to improve the quality of health care and

biomedical research through the following actions, among others:

Native Hawaiian/Pacific Islander National Health Interview Survey. This landmark project,

launched by the CDC’s National Center for Health Statistics (NCHS) and OMH, aims to

enhance the availability and quality of data on health outcomes and health care utilization of

Native Hawaiian and Pacific Islanders (NHPIs). To support participation in the survey and

increase response rates, NCHS, OMH, and the Census Bureau collaborated to provide outreach

and education on the project to NHPI stakeholders. Policymakers, community leaders, and

others will use these findings for designing policies and programs to improve NHPI health and

well-being.

Community Networks Program Centers (CNPCs). To address cancer and other related

co-morbidities with documented health disparities, the National Institutes of Health/National

Cancer Institute (NIH/NCI) funded 23 Community Networks Program National and Regional

Centers for Reducing Cancer Health Disparities (CNPCs). CNPCs use community-based par-

ticipatory research (CBPR) methods to increase knowledge of, access to, and use of preventive

screening, diagnosis, and treatment in communities, and thus reduce cancer disparities among

racial and ethnic minority populations.

Goal V: Increase Efficiency, Transparency, and

Accountability of HHS Programs

To ensure that programs and policies are efficient, transparent, and accountable, HHS supports

information sharing across agencies to minimize duplication of efforts. These processes include

tracking existing performance measures and other government data on health system indicators

and making them available to the public.

Health System Measurement Project. The ASPE Health System Measurement Project provides

public access to data that track trends in racial and ethnic health and health care disparities. Data

can be accessed and used by individuals and organizations inside and outside of government to

track changes in these health system characteristics over time and identify areas that require

improvement.

Conclusion

Agencies contributing to the HHS Disparities Action Plan have developed an extensive, mul-

tifaceted set of activities that span a wide range of populations, address a multitude of individual

and system-level barriers to health and quality health care, and support the growth of a more

diverse health care workforce. Guided by the HHS Secretary’s priority to eliminate health

disparities and the HHS Disparities Action Plan, HHS agencies have demonstrated their com-

mitment to reducing racial and ethnic health disparities, and built their capacity to address these

disparities. HHS efforts related to implementation of the HHS Disparities Action Plan have

generated ideas, materials, and data that will help the Department advance toward its vision of a

nation free from disparities in health and health care.

HHS Action Plan to Reduce Racial and Ethnic

Health Disparities: Implementation Progress

Report 2011-2014—Full Report

Background

The United States (U.S.) continues to face significant and persistent racial and ethnic health disparities,

with racial and ethnic minority populations

bearing a disproportionate burden of illness, disability, and

premature death.

2, 3, 4

Healthy People 2020, which identifies and monitors 10-year national objectives for

improving the health of all Americans, defines a health disparity as “a particular type of health difference

that is closely linked with social, economic, and/or environmental disadvantage”.

Extensive research

shows that populations that have systematically experienced this kind of disadvantage, such as racial and

ethnic minorities, face greater obstacles to optimal health.

These obstacles include difficulty in accessing

health insurance and quality health care, as well as differential access to high-quality education,

employment, housing, and income—factors known as the social determinants of health.

These social

determinants of health are often the underlying causes of health disparities.

Many leading health indicators, such as those from the Healthy People 2010 Final Review and the Agency

for Healthcare Research and Quality (AHRQ) National Healthcare Disparities Report, have shown little

reduction in racial and ethnic health disparities over the past decade.

As such, a significant and

well-coordinated effort to reduce and eventually eliminate health disparities is necessary to ensure that all

Americans have the chance to live the healthiest lives possible. The U.S. Department of Health and

Human Services (HHS) Action Plan to Reduce Racial and Health Disparities (HHS Disparities Action

Plan) is an integral part of this effort. Through the HHS Disparities Action Plan, HHS promotes integrated

approaches, evidence-based programs, and promising practices to reduce racial and ethnic health

disparities.

Addressing the Major Dimensions of Racial and Ethnic

Health Disparities

Addressing disparities in health and health care requires a multifaceted approach, including the following:

Expanding access to quality health care. The Institute of Medicine’s 2002 report Unequal Treatment:

Confronting Racial and Ethnic Disparities in Health Care and AHRQ’s annual National Healthcare

Disparities Report have identified the lack of health insurance as a significant driver of health care

disparities. These reports have consistently documented the lower rates of health insurance and receipt

of recommended care among racial and ethnic minorities as compared to non-Hispanic Whites.

9, 10, 11, 12

Furthermore, these reports demonstrate disparities in the quality of care provided to different

populations, even when access to care is ensured through adequate health insurance coverage. The

Institute of Medicine has noted that even when racial and ethnic minority patients have the same types

of health insurance as White patients, they tend to receive a lower quality of care.

Addressing diversity and cultural competence in the health care workforce. Racial and ethnic diversity

in the health care workforce is associated with improved access to care. Providers who are culturally

competent provide care directly related to greater consumer satisfaction among racial and ethnic

minorities.

The diversity of the public health and health care workforces, however, continues to lag

behind the growing racial and ethnic diversity of the U.S. population.

15, 16

For example, Latinos and

African-Americans comprise nearly one-third of the nation’s population, but they account for only

slightly more than one-tenth of U.S. physicians.

Further, physician shortages in underserved areas

often inhabited by racial and ethnic minority populations can also contribute to inequities in health care.

Supporting population health. Many racial and ethnic minority populations experience higher rates of

disease and premature death than Whites. For example:

– Non-Hispanic African-American adults are at least 50 percent more likely than non-Hispanic

Whites to die prematurely from heart disease or stroke.

– Asian/Pacific Islander adults are 60 percent more likely to have acute Hepatitis B, a major cause of

liver disease, than non-Hispanic Whites.

– African-American, Native Hawaiian/Other Pacific Islander (NHPI), and Hispanic adults all have

rates of HIV infection diagnosis that range from three to nine times the rate of non-Hispanic

Whites.

– Hispanics, non-Hispanic Blacks, and those of mixed race all have higher rates of diabetes than

non-Hispanic Whites.

– The mortality rates for non-Hispanic Black infants and American Indian/Alaska Native infants are

far higher than those of non-Hispanic White infants.

Enhancing data collection and research. Incomplete and poor quality data on race, ethnicity, and

language prevent a comprehensive and accurate characterization of health disparities, factors

contributing to these disparities, and results from actions taken to address them.

Establishing and

implementing standards for data collection, reporting, and tracking can generate knowledge that can be

used to inform policy and programmatic decision making.

HHS Infrastructure to Address Racial and Ethnic Health Disparities

The HHS Office of Minority Health (OMH) was established in 1986, one year after the Report of the

Secretary’s Task Force on Black and Minority Health (the Heckler Report) outlined the tremendous

racial and ethnic minority health inequities in the United States. OMH is dedicated to improving the

health of racial and ethnic minority populations through the development of health policies and

programs that will help eliminate health disparities. OMH was reauthorized under the Patient

Protection and Affordable Care Act of 2010. OMH is led by the Deputy Assistant Secretary for

Minority Health who reports directly to the Secretary of HHS.

The Affordable Care Act established Offices of Minority Health within six agencies, including the

Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention

(CDC), the Food and Drug Administration (FDA), the Health Resources and Services Administration

(HRSA), the Centers for Medicare & Medicaid Services (CMS), and the Substance Abuse and Mental

Health Services Administration (SAMHSA).

The Affordable Care Act elevated the National Center on Minority Health and Health Disparities to an

institute level at the National Institutes of Health (NIH).

The HHS Health Disparities Council is composed of the Deputy Assistant Secretary for Minority

Health, the directors of the agency OMHs, the director of the National Institute on Minority Health and

Health Disparities, and senior staff in other agencies. The HHS Health Disparities Council coordinates

the efforts of HHS operating and staff divisions on a cohesive set of strategies to reduce health

disparities and advance health equity.

HHS Action Plan to Reduce Racial and Ethnic Health

Disparities

Recognizing the complex and multiple approaches necessary to address health disparities, in April 2011

HHS released the first strategic plan to eliminate health disparities—the HHS Action Plan to Reduce

Racial and Ethnic Health Disparities (HHS Disparities Action Plan). This plan complements the 2011

National Stakeholder Strategy for Achieving Health Equity; a product of the National Partnership for

Action to End Health Disparities.

The National Stakeholder Strategy, was developed from the input of

thousands of individuals and organizations across the country in an effort to mobilize a nationwide,

community-driven approach to combating health disparities and achieving health equity.

The HHS Disparities Action Plan is the most comprehensive federal commitment to addressing health

disparities to date. Its vision is to help create “a nation free of disparities in health and health care.” This

unprecedented strategic plan provides a coordinated framework and guide for all HHS agencies. The HHS

Disparities Action Plan is designed to streamline and unify programmatic and policy efforts to reduce

racial and ethnic minorities health and social disparities.

The HHS Disparities Action Plan builds upon

the foundation of the Affordable Care Act, which includes a number of provisions that strive to improve

the health of racial and ethnic minorities and other underserved or vulnerable populations by addressing

many of the factors long associated with health disparities. For example, the Affordable Care Act includes

permanent reauthorization of the Indian Health Care Improvement Act, which extends current law and

authorizes new programs and services within the Indian Health Service. For American Indians and Alaska

Natives, the Affordable Care Act helps to address health disparities by investing in prevention and

wellness and increasing access to health coverage.

The HHS Disparities Action Plan contains four overarching Secretarial priorities and five specific goals.

As shown in figure 1, Goals I−IV include one or more related strategies subdivided into actions. Actions

are composed of activities undertaken by federal agencies to address racial and ethnic minority health

disparities. Subsequent sections of this report describe progress toward the Secretarial priorities and five

goals of the HHS Disparities Action Plan by highlighting some of the major actions and activities

undertaken since April 2011.

Figure 1.

Progress on the Overarching Secretarial Priorities

The overarching Secretarial priorities to reduce racial and ethnic minorities’ health disparities represent

the cross-cutting issues that the HHS Disparities Action Plan addresses. They are intended to ensure the

coordination of existing and new HHS programmatic and policy efforts so they will be used effectively to

advance health equity. Ultimately, the combination of goals, strategies, and actions that are implemented

should result in meeting these priorities. Below are the four priorities and examples of activities

corresponding to them.

1. Assess and heighten the impact of all HHS policies, programs, processes, and resource decisions

to reduce health disparities. This priority supports ongoing monitoring and assessment of HHS

agencies’ strategic plans, programs, and regulations to ensure that the goals, strategies, and actions in

the HHS Disparities Action Plan are included to the fullest extent possible. This priority also requires

program grantees, as applicable, to submit health disparity impact statements and supports the use of

this information to score grant applications and inform HHS programmatic and policy efforts. It also

supports ongoing assessment of the effects of proposed programs and policies on health disparities,

such that these disparities are monitored and addressed.

• The Substance Abuse and Mental Health Services Administration (SAMHSA) incorporated

health disparity impact statements into its Requests for Applications for four grant programs in

fiscal year 2012. These statements helped grantees build their capacity to collect and use data

to develop strategies addressing differential access, utilization, and outcomes of behavioral

health interventions among diverse populations. Because of the success of this pilot, in fiscal

year 2013, SAMHSA expanded the health disparity impact statement pilot to all new Requests

for Applications.

2. Increase the availability, quality, and use of data to improve the health of minority populations.

Collecting and analyzing high-quality data is fundamental to HHS’s ability to understand the causes of

health disparities, design effective responses, and evaluate progress in reducing disparities. Strong

surveillance systems must monitor trends in health and quality of care measures, as well as

patient-centered research activities.

• As called for by Section 4302 of the Affordable Care Act, in October 2011, HHS developed and

adopted new standards for the collection of data by race, ethnicity, sex, primary language, and

disability status within major self-reported population health surveys.

26, 27

The new standards

provide additional granularity for the Asian race category and Hispanic ethnicity, and also

distinguish Native Hawaiian from Pacific Islander race categories. In addition, for the first time,

HHS surveys will provide uniform self-reported data on primary language and disability status. The

specificity provided by the new standards will allow for improved demographic data collections and

tracking of health differences among these populations, as well as an increased ability to target

interventions appropriately.

3. Measure and provide incentives for better health care quality for minority populations. Racial

and ethnic minorities often receive a poorer quality of care and face more barriers to seeking care than

non-Hispanic Whites. Providing incentives for quality care for these populations is critical for

improving patient outcomes and creating a high-value health care system that promotes equity.

• Toward this end, the Centers for Medicare & Medicaid Services (CMS) Disparities National

Coordinating Council (DNCC) supported efforts by Quality Improvement Organizations (QIOs)

between 2011 and 2014 to improve the quality of care provided to Medicare beneficiaries within

underserved populations. The DNCC offered technical assistance and consultation to QIOs,

analyzed data related to special innovative disparities projects, and worked with QIOs to ensure

that Medicare providers and practitioners were supported and incentivized to provide high-quality

health services for all beneficiaries, regardless of race, ethnicity, or gender. For example, QIOs in

Arkansas, California, and Michigan engaged in the Cardiac Health Disparities Project, which

focused on prevention of cardiovascular disease among racial and ethnic minorities.

• QIOs in West Virginia, New York, and Texas engaged in the Everyone with Diabetes Counts

(EDC) special innovation project. During this project, Medicare and Dually Eligible

beneficiaries from rural and minority underserved populations were enrolled in diabetes

self-management education (DSME) classes to maximize patient engagement and improve health

literacy, with the goal of decreasing the disparity in diabetes care provided to these populations.

4. Monitor and evaluate the Department’s success in implementing the HHS Disparities Action

Plan. HHS is committed to ensuring program integrity, effective program performance, and

responsible stewardship of federal funds. Monitoring implementation and assessing progress are

important steps in ensuring that HHS is moving toward achieving the vision and goals of the HHS

Disparities Action Plan. Assessing progress on action steps in the HHS Disparities Action Plan allows

the Department to track implementation and observed outcomes, identify achievements and challenges

across agencies, and make midcourse corrections to improve agencies’ effectiveness in the long term.

Furthermore, the HHS Health Disparities Council serves as the venue to share information, coordinate

activities, and oversee implementation of the strategies and actions. The Council is co-chaired by the

Assistant Secretary for Health and the Assistant Secretary for Planning and Evaluation (ASPE), and

comprises senior-level HHS agency representatives, including the Deputy Assistant Secretary for

Minority Health, the directors of the individual OMHs, and the director of the National Institute on

Minority Health and Health Disparities.

Goal I: Transform Health Care

Creating an equitable health system requires efforts to ensure that all Americans have access to

high-quality health care services. This involves transformative strategies that will (1) expand

opportunities for members of racial and ethnic minority populations to obtain and understand how to use

preventative services provided by high-quality, affordable insurance coverage; (2) expand access to

needed health care services; and (3) improve the quality of care provided to racial and ethnic minority

populations. To achieve these aims, Goal I of the HHS Disparities Action Plan includes the strategies and

specific agency actions listed below.

Reduce disparities in health insurance coverage and access to care

Health insurance coverage is a critical part of any effort to remove financial barriers to care.

28, 29

Research

shows that uninsured individuals are less likely to receive needed health care services.

30, 31

The expansion

of health insurance availability and affordability made possible because of the Affordable Care Act, offers

an opportunity to address disparities in insurance coverage, which in turn can be used to promote

enrollment, access, and utilization of care.

Expansion of Medicaid and Introduction of the Health Insurance Marketplace. The Affordable Care

Act offers an opportunity for millions of racial and ethnic minorities to gain affordable and quality

health insurance coverage. As part of this work, the Centers for Medicare & Medicaid Services (CMS)

is overseeing the implementation of the Health Insurance Marketplace (Marketplace). At the time of

this report, 29 states, including the District of Columbia, have expanded Medicaid eligibility so that all

individuals up to 133 percent of the federal poverty level (FPL) qualify for coverage.

For states that

chose to expand Medicaid, this newly covered group includes childless adults who were previously

ineligible for Medicaid in most states prior to the Affordable Care Act. For those not eligible for

Medicaid, the new Marketplace is making coverage available to those who previously could not access

private insurance, with tax credits to help defray the cost for qualified individuals with incomes

between 100 and 400 percent of FPL.

From Coverage to Care (C2C) Initiative. The CMS Office of Minority Health (OMH) launched the

From Coverage to Care (C2C) Initiative in June 2014. The C2C Initiative is designed to answer

consumer questions about new health coverage opportunities, provide information about new benefits,

including primary care and preventive services, and provide resources for health care providers to

promote patient engagement in care. The C2C launch marked the release of the new Roadmap to Better

Care and a Healthier You, which includes eight steps to help consumers and health care providers be

informed about the diverse benefits available through their coverage and how to use it appropriately to

access to primary care and preventive services. The Roadmap is available in English, as well as seven

secondary languages. The CMS OMH also developed an Enrollment Toolkit: Helping Consumers

Choose the Health Plan That’s Right for Them, to support the C2C Initiative.

Figure 2.

Estimated number of Americans who have preventive services coverage with zero cost sharing

White Latino Black Asian American and Pacific Islanders American Indian/Alaska Native

111 million 17 million 15 million 8 million 1 million

Note: The numbers presented in Figure 2 sum to more than the total number of Americans with preventative services with no cost sharing because

individuals reporting Latino ethnicity also reported a race category.

Source: ASPE Data Point. The Affordable Care Act is Improving Access to Preventive Services for Millions of Americans. May 2015.

http://aspe.hhs.gov/health/reports/2012/ACA-Research/index.cfm

Figure 3.

Estimated number of uninsured racial and ethnic minorities eligible for Medicaid, Children’s Health

Insurance Program (CHIP), or Marketplace premium tax credits, beginning January 1, 2014

African Americans American Indian/Alaska Natives Asian Americans and

Pacific Islanders

Latinos

6,800,000 579,000 2,000,000 10,200,000

Sources: ASPE Issue Brief. Eligible uninsured African Americans: 6 in 10 could receive health insurance Marketplace tax credits, Medicaid, or CHIP.

http://aspe.hhs.gov/health/reports/2013/UninsuredAfricanAmericans/ib_UninsuredAfricanAmericans.cfm

. Published December 2013.

HHS.gov/HealthCare Fact Sheet. The Affordable Care Act and American Indian and Alaska Native People.

http://www.hhs.gov/healthcare/facts/factsheets/2011/03/americanindianhealth03212011a.html

. Published 2013.

HHS.gov/HealthCare Fact Sheet. The Affordable Care Act and Asian Americans and Pacific Islanders.

http://www.hhs.gov/healthcare/facts/factsheets/2012/05/asian-americans05012012a.html. Published 2013.

ASPE Issue Brief. Eligible uninsured Latinos: 8 in 10 could receive health insurance Marketplace tax credits, Medicaid, or CHIP.

http://aspe.hhs.gov/health/reports/2013/UninsuredLatinos/rb_uninsuredLatinos.pdf. Published February 11, 2014.

ASPE Data Point. The Affordable Care Act is Improving Access to Preventive Services for Millions of Americans. May 2015.

http://aspe.hhs.gov/health/reports/2012/ACA-Research/index.cfm

Reduce disparities in access to primary health care service

Racial and ethnic minority populations continue to face major barriers in accessing health care.

Although having a medical home increases the chance that people receive the preventive and other

services they need to stay healthy, approximately 23 percent of Hispanic or Latino adults do not have a

usual source of medical care, as compared to less than 12 percent of non-Hispanic or Latino adults.

Moreover, even as access to insurance increases, many parts of the country still lack the provider capacity

to offer needed primary health care services. The Health Resources and Services Administration (HRSA)

is addressing this issue by increasing the number of providers offering care in health professional shortage

areas, as well as expanding the ability of health centers to care for more patients. Of the 21.7 million

patients served by community health centers in 2013, nearly two out of three patients were members of

racial and ethnic minority populations.

HRSA’s National Health Service Corps (NHSC). For 40 years, the NHSC has supported primary health

care providers dedicated to serving areas with limited access to health care. Recognizing the need to

further expand access to primary care, the Affordable Care Act is investing $1.5 billion to support the

NHSC. In fiscal year 2013, 8,899 NHSC clinicians—including primary care physicians, physician

assistants, dentists, dental hygienists, nurse practitioners, certified nurse midwives, and behavioral

health professionals—provided needed health services to more than 9.3 million Americans.

The

program has more than doubled since 2008, when approximately 3,600 clinicians participated. NHSC

clinicians also provide needed primary care services to American Indian/Alaska Native populations,

with 620 Tribal health programs across the country approved as NHSC service sites as of October

2013. This represents a tenfold increase since 2010, when 60 Tribal health programs served as NHSC

sites.

Linking Low-Income Men to Medicaid. The Office of Minority Health (OMH), Assistant Secretary for

Planning and Evaluation (ASPE), and the Administration for Children and Families (ACF) are funding

research to identify promising outreach, enrollment, and messaging strategies to connect low-income

men to health insurance and care. A major component of the study is to identify strategies for key

subpopulations of low-income men, including racial and ethnic minorities.

HRSA’s New Access Point Awards. In 2012 and 2013, HRSA awarded nearly $150 million in New

Access Point awards to support 251 health center sites across the country. These centers provide

culturally competent and comprehensive primary care services to medically underserved communities.

HRSA’s new awards will promote health care access by providing primary health care services for an

additional 1.25 million patients.

The Indian Health Service (IHS) Improving Patient Care (IPC) Program. The IPC Program works to

transform the Indian health care system by developing high-performing, innovative health care teams

to improve the quality of and access to care by utilizing a patient-centered medical home model.

Participating IHS/Tribal/Urban Indian health programs receive training to deliver comprehensive

services through coordinated care across all elements of the health system to improve continuity of

care, enhance access, and partner with community-based health programs and Tribal organizations.

Using evidence-based medicine in guiding shared decision making with patients and families, a

positive relationship among the health system, care team, individual, family, community, and tribe is

strengthened. Currently, 172 federal, tribal and urban sites have participated in or are currently

participating in the Improving Patient Care (IPC) Program.

Reduce disparities in the quality of health care

Though quality of care for racial and ethnic minority populations is slowly improving, significant

disparities persist between the quality of care received by Whites and that received by many racial and

ethnic minorities.

For example, African Americans are far more likely than non-Hispanic Whites to be

hospitalized for heart failure. Within the state of Hawaii, Native Hawaiians and Other Pacific Islanders

also have higher rates of hospital admissions for heart failure than Whites.

Although some

hospitalizations for heart failure are considered unavoidable, rates of hospitalization can be linked to the

quality of outpatient care received.

Other disparities exist in the quality of care received; for example,

Asian Americans are less likely than Whites to receive recommended hospital care for pneumonia.

another example, African American mothers are less likely than White mothers to receive adequate

prenatal care.

The quality and quantity of prenatal care pregnant women receive may influence a range

of birth outcomes, including low birth weight and preterm birth.

HHS is taking a range of actions to address such disparities in quality, including promoting the

development of interventions to prevent the leading causes of premature death among racial and ethnic

minority populations.

Million Hearts

Initiative. Million Hearts™ is a multifaceted public-private partnership that aims to

prevent one million heart attacks and strokes by 2017. The initiative has brought together 86 partners to

implement programs, policies, and campaigns to promote cardiovascular health.

Specific activities

have included use of quality improvement strategies to increase the quality of care provided for high

blood pressure and high cholesterol, as well as broader public health education campaigns to reduce

smoking and sodium intake. In 2013, Million Hearts™ launched its Hypertension Control Challenge to

reward health systems and clinicians who are successful in working with their patients to achieve 70

percent hypertension control rates.

100 Congregations for Million Hearts

The 100 Congregations for Million Hearts initiative was launched in February 2013. Its goal is to

encourage faith-based organizations to increase awareness and action around heart disease prevention and

blood pressure control. As part of the initiative, congregations:

Designate a Million Hearts Advocate who serves as a resource for heart health information and links

individuals to needed services;

Establish and/or strengthen relationships with community pharmacists, health centers, and health

workers;

Distribute messages about the importance of controlling high blood pressure and action steps taken to

promote this control;

Promote the Heart Health Mobile App that helps determine and reduce an individual's heart attack and

stroke risk; and

Distribute blood pressure tracking wallet cards.

Since its inception, 51 congregations have committed to the 100 Congregations for Million Hearts

initiative.

Goal II: Strengthen the Nation’s Health and

Human Services Infrastructure and Workforce

Patient-provider relationships are shaped by the experiences, culture, values, and expectations of both the

provider and the patient. Racial and ethnic minority patients tend to have more mistrust of health care

professionals and perceive more discrimination in the health care system than do non-Hispanic Whites.

Further, a lack in providers’ knowledge about the culture and language of their patients can lead to

misunderstandings in patient and provider interactions. Patients from racial and ethnic minority

populations often report greater satisfaction with health care from providers of the same race, ethnicity, or

culture. That commonality makes a provider more successful at gaining patients’ trust and improves the

ability to communicate in a more culturally and linguistically competent manner.

This evidence

underscores the need for health professionals with diverse backgrounds and improved competencies to

care for and serve racial and ethnic minority populations. Currently, the racial and ethnic makeup of the

health care workforce lags behind that of the U.S. population. For example, although 13 percent of

Americans are Black and 16 percent are Latino, only 6 percent of physicians are Black and 5 percent

Latino.

49, 50

Increasing the number of health professionals from racial and ethnic minority populations may

help increase the quality of patient-provider interactions, thereby helping to improve these populations’

patient experiences.

Thus, strengthening the nation’s health and human services infrastructure and workforce involves both

incorporating cultural and linguistic knowledge among the health care workforce, and increasing the

number and diversity of health care professionals. Goal II of the HHS Disparities Action Plan supports the

following strategies and actions:

Increase the ability of all health professions and the healthcare system to identify and

address racial and ethnic health disparities

HHS agencies are engaged in several activities to promote provision of care and services respectful of and

responsive to the cultural and linguistic needs of diverse communities. These include developing tools to

help health and health care organizations identify the cultural and linguistic needs of the communities they

serve, and enhancing standards for culturally and linguistically appropriate services in health and health

care.

National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care

(National CLAS Standards). OMH released the enhanced National CLAS Standards in April 2013,

marking the first update since the original standards were published in 2000.

The enhanced National

CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care

disparities by providing a blueprint for individuals and health and health care organizations to

implement culturally and linguistically appropriate services. The enhancements to the National CLAS

Standards reflect the nation’s increasing diversity and the tremendous growth in the fields of cultural

and linguistic competency over the past decade, and help to ensure relevance to new national policies

and legislation, such as the Affordable Care Act.

Medical Schools Curriculum Initiative. Through this Initiative, the Office for Civil Rights’ (OCR)

enhances medical school instruction by helping future medical practitioners appreciate their role in

reducing health disparities. The curriculum, “Stopping Discrimination Before It Starts: The Impact of

Civil Rights Laws on Health Care Disparities,” was developed with funding and support from the

National Institutes of Health and the Stanford University School of Medicine. The curriculum is

published in the Association of American Medical Colleges’ (AAMC) MedEdPORTAL. Currently,

Emory University, the University of Colorado, and the University of Kansas have incorporated the

curriculum into their medical school programs. Most recently, OCR introduced the curriculum to

nearly 1,000 students at 12 medical and dental schools participating in the AAMC’s Summer Medical

and Dental Education Program (SMDEP).

Promoting Effective Communication in Health Care Organizations. OCR conducted compliance

reviews of 45 Critical Access Hospitals (CAH), one hospital in each of the 45 states served by the CAH

program. The purpose of the reviews was to improve language access services in rural communities for

individuals with limited English proficiency. OCR reviewed service area data; evaluated language

access policies and procedures; conducted on-site visits; interviewed hospital staff and community

stakeholders; provided technical assistance; and secured corrective actions for compliance issues.

Additionally, OCR, in collaboration with the American Hospital Association, provided technical

assistance to hospital associations in 17 states to help hospital administrators and staff understand the

applicable federal anti-discrimination laws, and implement practices that ensure meaningful access to

individuals who are limited English proficient (LEP) or deaf or hard of hearing.

Promoting effective communication in healthcare organizations

The Office for Civil Rights (OCR) and the South Dakota Association of Healthcare Organizations,

together with the Centers for Medicare & Medicaid Services (CMS), distributed “I Speak” language cards

to health care organizations throughout the state. The cards include both Native American languages and

foreign languages spoken in the state, and explain individuals’ rights to free interpretation and translation

services.

Promote the use of community health workers and promotores de salud

Community health workers (CHWs) and promotores de salud increase access to and utilization of care by

providing health insurance enrollment assistance and health education to their communities.

52, 53, 54

They

act as a bridge between the community and the health care system, providing community members with

social support and education, and facilitating access to care as needed. In recognition of their critical role,

HHS agencies are using multiple approaches to utilize CHWs and promotores de salud to increase the

health system’s ability to provide culturally and linguistically competent care to diverse communities.

National Hispanic Council on Aging (NHCOA) Portal e-Comunidad. OMH supported NHCOA in the

development of Portal e-Comunidad, an e-learning platform to provide promotores de salud with an

easy-to-use and accessible platform to learn about and promote health literacy among Latino seniors in

their communities. The platform currently consists of five modules of 20 to 40 minute lessons given via

narrated PowerPoint presentations, “managing medications at home” and “how to get the most out of a

doctor’s visit” are examples of the topics presented. Tools like the Portal e-Comunidad help connect

promotores de salud who serve hard-to-reach audiences, such as Hispanic older adults, with relevant,

important, and necessary learning opportunities to which these audiences may not have easy access

through other channels.

Figure 4.

Increase the diversity of the health care and public health workforces

HHS has demonstrated a commitment to promoting medical and scientific educational opportunities for

individuals from racial and ethnic minority populations that are underrepresented in the public health and

health care professions. Such opportunities aim to increase the proportion of health and human services

providers with the same linguistic and cultural backgrounds as the individuals they serve, thereby

increasing the provision of culturally and linguistically appropriate care and services. One of the largest

and longest-standing programs reflecting HHS efforts under this strategy is the NHSC, administered by

HRSA, which provides scholarships and loan repayment support to health care professionals who enter

into service in underserved areas. More than half of the 1,100 NHSC Scholars in the pipeline are members

of racial and ethnic minority populations.

Additional HHS programs and activities that strive to

increase diversity in the public health, health care,

and research workforces are highlighted below.

Centers for Disease Control and Prevention

(CDC) Undergraduate Public Health Scholars

(CUPS) Program. This program, funded through a

cooperative agreement with CDC, supports four

academic institutions in their efforts to increase

interest in public health and biomedical sciences

among students from underrepresented racial and

ethnic minority populations. The program consists

of a 10-week summer internship at state and local

health departments, hospitals, community-based

organizations, or CDC, complemented by

employment guidance and support for considering

public health as a career choice. It is expected that

exposure to public health practice will heighten

awareness of, and interest in, public health careers

and thus increase the diversity of the workforce. In

the first three years of the program, 8,407 students

applied to the program, and 578 students were

accepted and completed the CUPS program.

Historically Black Colleges and Universities

(HBCUs) Center for Excellence in Behavioral

Health. This center, overseen by the Substance

Abuse and Mental Health Services Administration

(SAMHSA), supports HBCUs in promoting

behavioral health education, expanding behavioral

health service capacity, and facilitating workforce

development. It aims to increase the diversity and

cultural competence of the behavioral health

workforce by training teams of clinicians, faculty,

and students from HBCUs on best practices in

behavioral health promotion and prevention,

screening and referral services, and intervention

Improving the Cultural Competency and Diversity of the Behavioral Health

Workforce

In FY 2013, the Historically Black Colleges and Universities (HBCUs) Center for Excellence in

Behavioral Health:

– Awarded 86 Behavioral Health Capacity Expansion mini-grants to institutions that established

more than 550 behavioral health internships for undergraduate and graduate students;

– Trained 477 faculty, 572 students, and 120 military veterans via the Kognito At-Risk online behav-

ioral health training tool;

– Provided internship opportunities to 89 undergraduate and graduate students: 10 interns were

offered extended employment opportunities;

– Hosted webinars with more than 675 participants on topics such as addiction; bullying; and work-

ing with lesbian, gay, bisexual, transgender, and queer youth; and

– Trained 970 students, 134 faculty/staff, 155 peer educators, and 160 other campus community

individuals in behavioral health suicide prevention and mental health skills.

• Health Profession Opportunity Grants (HPOG). Authorized by the Affordable Care Act and

administered by the Administration for Children and Families (ACF), HPOG provides education and

training to Temporary Assistance to Needy Families (TANF) recipients and other low-income

individuals to pursue jobs in health care. ACF has awarded 32 five-year grants to organizations in 23

states. These organizations—including community colleges, community-based organizations, and

Tribal organizations—offer training and credentials for nurse aides, home health aides, registered

nurses, medical assistants, and pharmacy technicians.

Increasing Training and Education Opportunities for Low-Income Individuals in

Health Care Occupations

As of December 2013:

– 20,382 individuals had enrolled in Health Profession Opportunity Grants (HPOG) health care

occupation training programs

– 12,384 individuals had completed HPOG health care occupation training programs

Increasing Training and Education Opportunities for American Indians and Alaska

Natives in Health Care Occupations

Through the HPOG program, five demonstration project grants were awarded to Tribal organizations and

colleges in 2010 to increase American Indian and Alaska Native (AI/AN) representation in the health care

workforce. Funded entities offer courses for health care careers, including certified nursing assistant

(CNA), licensed practical nurse (LPN), registered nurse (RN), emergency medical technician (EMT), and

medical billing and coding. In the first two years of the program:

– All sites have enrolled participants into training programs, with enrollment ranging from 36−208

students

– 25−41 percent of program participants have obtained employment after program completion

– Many CNA participants have continued their education at two- or four-year nursing programs

Building Infrastructure Leading to Diversity (BUILD) Initiative. The BUILD initiative aims to increase

the diversity of the National Institutes of Health (NIH) funded workforce by supporting collaborative

programs that include novel approaches for enhancing undergraduate education, training, and

mentorship, as well as infrastructure support and faculty development to facilitate those approaches. In

2013, BUILD planning grants were awarded to 15 colleges and universities to help these institutions

develop the necessary partnerships and infrastructure needed to be competitive for the BUILD

initiative.

National Disaster Medical System (NDMS). Disasters affect communities unequally. Low-income,

minority populations often live and work near risk-prone locations; for example, areas prone to

flooding, landslides, and industrial hazards; areas with non-compliant building code housing and

buildings; and places with greater dependence on public transportation. Areas with fewer economic

resources can be predicted to be less resilient when faced with a disaster. Examples of this include

low-income, minority individuals and families may be less resilient when facing the adverse effects of

disasters due to challenges in storing emergency food and supplies or having the capacity to evacuate to

safety. During a response well-meaning outside, responders cannot necessarily understand the

challenges and needs of these communities. The Office of Assistant Secretary for Preparedness and

Response (ASPR) has developed an action plan that includes strategies to increase representation of

racial and ethnic minorities in the public health emergency preparedness and response workforce. This

plan includes conducting outreach about the NDMS at HBCU medical and nursing schools, sponsoring

workshops at key professional meetings, and offering public-private community disaster graduate

fellowships. ASPR also promotes cultural competency among ASPR staff and NDMS personnel by

providing online training in Psychological First Aid, a disaster-specific behavioral health intervention

for providers offered through the National Association of City & County Health Officials (NACCHO)

that helps providers meet the needs of diverse populations.

Building the Capacity of the Preparedness and Response Workforce

As of January 2013, 53 languages/dialects were represented among staff members of the National Disaster

Medical System (NDMS).

As of September 2012, more than 2,800 NDMS and U.S. Public Health Service personnel had taken an

online Psychological First Aid training course as part of wider cultural competency efforts. This

70-minute online training is offered through the National Association of City & County Health Officials

(NACCHO).

Goal III: Advance the Health, Safety, and

Well-Being of the American People

Health disparities are an outcome of community and environmental factors, not just those in the health

care system. These factors, sometimes referred to as the social determinants of health, are conditions in the

environments in which people are born, live, learn, work, play, worship, and age that affect a wide range

of health, functioning, and quality-of-life outcomes and risks.

Resources that enhance quality of life,

such as access to safe and affordable housing, education, public safety, healthy foods, and health services,

can have a significant influence on population health outcomes.

Therefore, approaches that go beyond

the health care system are needed to reduce health disparities and promote health equity among racial and

ethnic minority populations. Community-based and ecological approaches that support the creation of

healthy and safe environments, that promote healthy behaviors, and that are implemented in the

community, at the workplace, and through policy are promising strategies for advancing the health, safety,

and well-being of the American people.

58, 59

Figure 5.

Recognizing the potential of community-based and ecological approaches to eliminate health disparities,

Goal III supports building community capacity to develop and implement health initiatives that reach

racial and ethnic minority populations. Specifically, Goal III supports the following two strategies:

Reduce disparities in population health by increasing the availability and

effectiveness of community-based programs and policies

HHS agencies support a wide range of community-based programs to promote healthy behaviors and

prevent disease among racial and ethnic minority populations. These programs focus on providing health

education, enabling access to services, and linking individuals to community resources. They target a

variety of health problems, including chronic disease prevention and management, tobacco cessation,

maternal and child health, and mental health.

Public Awareness Campaign to Increase Patient Participation in Health Decision Making. In the

Toma las Riendas (Take the Reins) campaign, AHRQ is partnering with organizations that primarily

serve the Hispanic community to promote Spanish-language resources that encourage consumers to

become more active partners in their health care. These materials convey information on the benefits

and risks of treatment options for multiple conditions, and encourage shared decision making between

patients and their health teams. Information is available in print through condition-specific consumer

guides, brochures, and postcards, and is disseminated via the AHRQ website, Facebook and Twitter,

radio advertisements, and placement of print materials in public venues.

Tips From Former Smokers Tobacco Education Campaign. In March, 2012, Centers for Disease

Control and Prevention’s Office on Smoking and Health launched the first ever paid national tobacco

education campaign called Tips From Former Smokers (Tips). The development of the Tips campaign

was based on evidence from both national and international literature, which shows that graphic ads

linking smoking to health damage and that evoke strong negative emotions, are the most effective in

promoting tobacco use cessation among adults and reducing initiation in youth. The primary target

audience of the campaign is low SES smokers, ages 18 to 54 and secondary audiences include parents;

family members; health care providers; and the faith-based community.

Since it began in 2012, the Tips campaign has reached diverse population groups including those

groups experiencing the highest rates of tobacco use disparities. Most recently, the 2014 Tips campaign

reached diverse groups through its national media buy, including running Spanish language TV ads on

Spanish-language stations. The national reach to African American audiences was augmented in local,

high smoking prevalence markets by emphasizing media placements that focused on African American

audiences in markets where they were predominant. The national reach to lesbian, gay, bisexual, and

transgender (LGBT) audiences was enhanced through focused digital and print advertising in media

properties that specialize in reaching them. Tips print ads also ran in Asian-language newspapers across

the country. The ads included Chinese, Vietnamese and Korean-language executions, promoted

asiansmokersquitline.org and offered free nicotine replacement therapy. Local radio, magazines and

newspapers that serve reservations and American Indian and Alaska Native communities also ran Tips

ads.

In an article published in The Lancet in September, 2013, CDC reported on main outcomes from our

evaluation of the Tips 2012 Campaign. Among the findings were that an estimated 1.6 million

Americans tried to quit smoking because of the 2012 Tips Campaign and, at a minimum, more than

100,000 Americans quit smoking long-term because of Tips. The campaign is also incredibly cost

effective: As reported in the American Journal of Preventive Medicine, the 2012 campaign prevented

at least 17,000 premature deaths and saved nearly 180,000 quality adjusted life years.

Consortium of National Networks to Impact Populations Experiencing Tobacco-Related and Cancer

Health Disparities. Since FY 2013, CDC has provided funding for a consortium of population-specific,

public health-oriented, national networks to impact tobacco-related and cancer health disparities

among specific target populations. The networks enhance the quality and performance of specific

public health programs, public health data and information systems, public health practice and services,

public health partnerships, and public health resources that focus on tobacco-related and cancer health

disparities in specific populations. The target populations are: 1) African Americans; 2) American

Indians/Alaskan Natives; 3) Asian Americans/Pacific Islanders/Hawaiian Natives; 4)

Latinos/Hispanics; 5) Lesbian, Gay, Bisexual and Transgender persons; 6) persons with low

socioeconomic status; 7) persons with mental health and substance abuse disorders; and 8)

geographically defined populations with high commercial tobacco use and related health disparities.

Encouraging Spanish speakers to be active partners in their health care

Since the Toma las Riendas campaign launch in November 2011:

– The Spanish-language Facebook page has received 14,425 unique page visits.

– 89 media outlets have published the press release.

– Nearly 3,000 versions of placards have been placed in public venues, including buses, transit

shelters, and malls, reaching a potential audience of more than 36 million people.

Population Assessment of Tobacco and Health Study (PATH). In 2013, the Food and Drug

Administration (FDA) and NIH launched a five-year study of more than 50,000 people ages 12 and

older to examine tobacco use attitudes and behaviors across racial and ethnic minority populations, and

investigate the effectiveness of interventions aimed at reducing tobacco use, such as tobacco-free

policies, quitline promotion, and various tobacco cessation programs. Results from the PATH study

will inform educators about how to tailor prevention and cessation programs to diverse communities.

Public-Private Partnerships to Improve Vaccination Rates. Immunization disparities are a persistent

public health problem that require targeted intervention at both the community and national levels.

Some causes of these disparities include cost factors, lack of access, perceived lack of susceptibility to

vaccine-preventable diseases, and a lack of culturally appropriate education. OMH initially established

for the 2010−2011 influenza season the Walgreens-HHS Co-Sponsorship Agreement, which provides

uninsured individuals with free seasonal influenza vaccination. Walgreens has committed over $10

million annually to support this effort; since 2010, the partnership has successfully vaccinated more

than half a million individuals who otherwise would not receive the influenza vaccination due to cost.

Utilizing Walgreens’ local pharmacies and pharmacists, HHS provides linkages to underserved

communities through its Regional Health Administrators and Regional Minority Health Consultants

for the coordination of community health education and vaccination clinics and events.

HHS-collaborating agencies include the National Vaccine Program Office (NVPO), CDC, the

Administration for Community Living (ACL), and the Office of the Assistant Secretary of Health

(OASH) regional offices. NVPO coordinates and ensures collaboration between federal agencies and

private organizations involved in vaccination and immunization activities. Between April 2012 and

September 2013, NVPO offered grants to support community-level efforts to deliver culturally

appropriate immunization interventions. NVPO also has developed a real-time web tool to map flu

vaccine disparities across geographic regions.

Improving vaccination rates

Between April 2012 and September 2013, the National Vaccine Program Office (NVPO):

Partnered with the National Institute on Minority Health and Health Disparities (NIMHD) to fund three

grants to increase influenza vaccine coverage. Funded interventions included the following:

– A virtual patient advocate system, with communication tailored to pregnant African American

women and their primary care providers;

– An evidence-based demonstration to increase influenza vaccination rates among low-income

pregnant women who receive health care at Federally Qualified Health Centers (FQHCs) in Puerto

Rico; and

– Evidence-based approaches to increase influenza and pertussis vaccination among low-income

racial and ethnic minority adults with diabetes.

Conduct and evaluate pilot tests of health disparity impact assessments of selected

proposed national policies and programs

HHS supports the use of health disparity impact assessments as a method for creating and disseminating

information about the likelihood of proposed policies and programs for increasing or decreasing health

and healthcare disparities among racial and ethnic minority populations.

Equity in All Policies. The National Partnership for Action to End Health Disparities (NPA) is

implemented at the federal level through the activities of the Federal Interagency Health Equity Team

(FIHET). The FIHET currently comprises 12 federal agencies, including HHS and other agencies, such

as the Departments of Justice, Veterans Affairs, Transportation, and Agriculture. The FIHET convenes

on the central theme of health equity and is intended to increase dialogue between traditionally siloed

programs in ways that enhance cross-agency coordination, maximally leverage existing resources, and

ultimately increase the impact of federal resources in communities. The FIHET has identified “Equity

in All Policies that Affect Health and the Social Determinants of Health” as one of its project areas. The

overarching objective for this project area is to “promote the consideration of equity in the development

and implementation of all policies and programs of public and private organizations, in recognition

that all policies and programs have the potential to impact health and the social determinants of

health.” In selecting this project area and overarching objective, the FIHET aims to provide leadership

on health equity through several activities, including those that (a) identify promising practices and

opportunities to ensure the conditions for optimal health for all people; and (b) convene subject matter

experts and stakeholders to share knowledge, experience, and promising practices for promoting the

consideration of equity in programs, policies, and practices.

Promoting Equity in All Policies Among Internal and External Stakeholders

In September 2013, the Federal Interagency Health Equity Team (FIHET) Equity in All Policies work

group conducted a panel session at the National Health Impact Assessment conference in Washington, DC

on ongoing efforts to integrate or consider equity in policies and programs in the public health, private

health, and non-health sectors. The panel highlighted state-of-the-art strategies with respect to approaches

for considering equity in programs and policies, the role of partnerships in driving systemic change, and

practical applications of assessment tools and methods in efforts to consider and integrate equity. Featured

panelists represented federal, state, and local government organizations. The panel also highlighted

process, data, and methodology challenges, and research needs to inform a more robust evidence base for

integrating the social determinants of health into effective policies.

Goal IV: Advance Scientific Knowledge and

Innovation

Efforts to advance scientific knowledge and innovation can improve prevention and health care services

for all populations, and increase the quality of health, public health, and biomedical research. More

specifically, health disparities research can inform initiatives to improve the health of racial and ethnic

minorities by bridging the gap between knowledge and practice. However, the capacity of HHS to identify

health and health care disparities and monitor efforts to address them is limited by a lack of high-quality

health data that include details about race, ethnicity, and language, as well as a scarcity of research that

specifically addresses the health care needs of racial and ethnic minorities. For this reason, the HHS

Disparities Action Plan includes a goal to explicitly support the promotion of the collection of race and

ethnicity data, especially in a standardized format; evaluate existing and new biomedical and public health

approaches that reduce health disparities, thereby improving the evidence base; and strengthen

information systems to support dissemination and sharing of data and results.

Increase the availability and quality of data collected and reported on racial and

ethnic minority populations

To support efforts to identify effective strategies to reduce health disparities, agencies have conducted

activities to improve the availability, specificity, uniformity, and quality of data collection and reporting;

improve public access to HHS data on racial and ethnic minorities; and regularly publish estimates of

health outcomes for racial and ethnic minority populations.

Native Hawaiian/Pacific Islander (NHPI) National Health Interview Survey (NHIS). This project, led

by CDC’s National Center for Health Statistics (NCHS), aims to enhance the availability and quality of

data on the health outcomes and health care utilization of NHPIs. NHPIs comprise 0.4 percent of the

total U.S. population, which can make it difficult to include them in sufficient numbers in most

population-based health surveys. Although the limited data currently available on NHPIs indicate that

they experience significant health disparities, the lack of more reliable data has made it difficult to

monitor these disparities and plan interventions. To support participation in the survey and increase

response rates, NCHS, OMH, and the Census Bureau partnered to provide outreach and education on

the project to NHPI stakeholders. NHPI NHIS data collection began in February 2014, and findings

will be made available in mid-2015. These findings will be used by policymakers, community leaders,

and others to design policies and programs to improve NHPI health and well-being.

The National Healthcare Quality and Disparities Report (QDR). AHRQ plays a critical role in

increasing the availability and quality of data collected and reported on racial and ethnic minority

populations by annually producing the National Healthcare Disparities Report. AHRQ’s National

Healthcare Quality Report provides a comprehensive view of access to and the quality of health care in

the U.S. Both reports track more than 250 measures of health care quality and access among different

racial and ethnic populations. In 2014, AHRQ combined the National Healthcare Disparities Report

with the National Healthcare Quality report. This combined report provides a comprehensive picture of

the state of health care experienced by the general population and racial and ethnic minorities. To

support data queries by specific parameters the QDR unified web tool supports data searches utilizing

numerous social, race, and ethnic parameters.

Patient-Centered Outcomes Research (PCOR). PCOR can help providers and patients make sound

health care decisions by providing evidence on the effectiveness, benefits, and harms of different

treatment options. By working collaboratively with research and health care institutions, HHS is

working to develop, implement, and test strategies to increase the adoption and dissemination of

interventions based on PCOR among racial and ethnic minority populations. To advance this type of

research, AHRQ funded 21 three-year grants to research institutions that focused on content

customizations of comparative effectiveness research materials for populations underserved or

unserved by the health care system, including racial and ethnic minorities.

Conduct and support research to inform disparities reduction initiatives

To gather accurate data, understand the root causes of health disparities, and evaluate the effectiveness of

interventions aimed at reducing persistent racial and ethnic health disparities, HHS supports research in a

variety of areas, such as obesity, cancer, diabetes, and access to preventive services. It also promotes the

use of emerging methodologies, such as PCOR and community-based participatory research (CBPR)

methods. HHS encourages collaborative research across federal departments, promotes the dissemination

of evidence-based interventions, and expands training opportunities and supportive infrastructure among

institutes of higher education. Together, these activities are expected to bridge the gap between knowledge

and practice, and lead to the development of more effective interventions to help attain health equity.

Community Networks Program Centers (CNPCs) and Regional Centers for Reducing Cancer Health

Disparities. To address cancer and other related co-morbidities with documented health disparities, the

NIH/National Cancer Institute (NCI) funded 23 CNPCs. CNPCs use CBPR methods to increase

knowledge of, access to, and use of preventive screening, diagnosis, and treatment in communities, and

thus reduce cancer disparities among racial and ethnic minority populations. The CNPCs also provide

mentorship and training to new researchers—particularly those from underrepresented

backgrounds—in the fields of CBPR and cancer health disparities research.

Supporting Research and Training Opportunities for Reducing Cancer Disparities

Since October 2012:

23 Community Networks Program Centers (CNPCs) have been funded;

221 individuals have received training in community-based participatory research (CBPR) methods;

CNPCs have collaborated with more than 150 clinical partners to provide appropriate screening,

follow-up, and treatment services to underserved populations;

24% (871) of individuals who attended workshops and community presentations provided by CNPCs

reported increases in knowledge about cancer health disparities after the event; and

85% (2119) of individuals who attended workshops and community presentations provided by CNPCs

reported increases in their use of beneficial and behavioral biomedical procedures.

Goal V: Increase Efficiency, Transparency, and

Accountability of HHS Programs

Because of the complexity of health disparities, no one office or agency can solve the problem of health

disparities alone; thus, HHS promotes collaboration across the Department to maximize efforts and

optimize results. To ensure that programs and policies are efficient, transparent, and accountable, HHS

has established systems to support information sharing across agencies and minimize duplication of

efforts. HHS also has implemented processes to track, assess, and report on the impact of programmatic

and policy efforts to address health disparities. These processes include tracking existing performance

measures and other government data on health system indicators and making them available to the public

(such as those available via the Health System Measurement Project).

Figure 6.

Health System Measurement Project. The Assistant Secretary for Planning and Evaluation (ASPE)

Health System Measurement Project allows public access, via a website, to data that provide a picture

of the evolving status of the U.S. health system,

including trends in racial and ethnic health and health

care disparities. The project tracks measures in 10

topic areas, such as health care costs and affordability,

health care coverage, the health care workforce, and

population health. The data can be used by individuals

and organizations inside and outside of government to

track changes in these health system characteristics

over time and identify areas that require improvement.

Recognizing the importance of tracking changes in

disparities in health and health care, the project

includes a dashboard dedicated to “Vulnerable

Populations,” which tracks measures that consistently

have been associated with disparities across

populations.

The Health System Measurement Project:

Vulnerable Populations Dashboard

The dashboard tracks and allows public access to

measures known to reflect consistent health disparities,

including the following:

The percentage of people who have a usual source of

medical care;

The percentage of infants born at low birth weight;

The percentage of people with high blood pressure that is controlled;

The percentage of people who experience good communication with their health care provider; and

Website available at https://healthmeasures.aspe.hhs.gov/topic/I.

Conclusion

Agencies contributing to the HHS Disparities Action Plan have developed an extensive, multifaceted set

of activities that span a wide range of populations, address a multitude of individual and system-level

barriers to health and quality health care, and support the growth of a more diverse health care workforce.

Guided by the HHS Secretary’s strategic priority to eliminate health disparities and the HHS Disparities

Action Plan, HHS agencies have demonstrated their commitment to reducing racial and ethnic health

disparities, and built their capacity to address these disparities. Goal I activities have expanded access to

health insurance and health care for millions of racial and ethnic minorities through the Affordable Care

Act, while agencies working on Goal II have taken steps to increase access to a highly qualified, diverse,

and culturally competent public health and health care workforce. Public awareness campaigns conducted

under Goal III have employed culturally sensitive messaging techniques to promote healthy behaviors

among racial and ethnic minorities. Agencies working on Goal IV have conducted research to support the

development of innovative, evidence-based interventions to address health disparities and are monitoring

their effectiveness. With regard to Goal V, HHS agencies are tracking, evaluating, and reporting on efforts

to address health disparities so that results are optimized. HHS efforts related to implementation of the

HHS Disparities Action Plan have generated ideas, materials, and data that will help the Department

advance toward its vision of a nation free from disparities in health and health care.

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Appendix A: Glossary of Acronyms

ACA Patient Protection and Affordable Care Act of 2010

ACF Administration for Children and Families

ACL Administration for Community Living

AHRQ Agency for Healthcare Research and Quality

AI/AN American Indian and Alaska Native

ASA Assistant Secretary for Administration

ASPE Assistant Secretary for Planning and Evaluation

ASPR Office of Assistant Secretary for Preparedness and Response

CDC Centers for Disease Control and Prevention

CLAS Culturally and Linguistically Appropriate Services

CMS Centers for Medicare & Medicaid Services

FDA Food and Drug Administration

FIHET Federal Interagency Health Equity Team

FPL Federal Poverty Level

FQHC Federally Qualified Health Center

FY Fiscal Year

HBCUs Historically Black Colleges and Universities

HHS U.S. Department of Health and Human Services

HRSA Health Resources and Services Administration

IHS Indian Health Service

NCHS National Center for Health Statistics

NCI National Cancer Institute

NDMS National Disaster Medical System

NHDR National Healthcare Disparities Report

NHPI Native Hawaiian and Pacific Islander

NHSC National Health Service Corps

NIH National Institutes of Health

NIMHD National Institute on Minority Health and Health Disparities

NPA National Partnership for Action to End Health Disparities

NVPO National Vaccine Program Office

OASH Office of the Assistant Secretary of Health

OCR Office for Civil Rights

OMH U.S. Department of Health and Human Services Office of Minority Health

ONC Office of the National Coordinator of Health Information Technology

A.1

SAMHSA Substance Abuse and Mental Health Services Administration

A.2

Appendix B: Overview of HHS Action Plan to

Reduce Racial and Ethnic Health Disparities

SEE APPENDIX B in PDF for formatted version.

B.1