Excerpted From: Neelam Salman, Golda Philip and Sarah Williams, Bridging Health Equity and Civil Rights: How Federal Funding Agencies Can Reduce Disparities and Discrimination in Healthcare Using Civil Rights Mechanisms, 21 Connecticut Public Interest Law Journal 1 (Spring, 2022) (218 Footnotes) (Full Document)


SalmanPhilipWilliamsThe civil rights movement was a social, legal, and political struggle by communities that are underserved to achieve equality across all facets of life. For decades, civil rights leaders advocated for legal protections based on individual characteristics, such as race, which formed the foundation of discriminatory structures and practices in the United States. The push to end inequality and segregation resulted in the passing of the Civil Rights Act of 1964, a landmark legislation outlawing discrimination on the basis of race, color, religion, sex, and national origin. Theafter, Congress enacted supplementary civil rights laws that extend protections to individuals discriminated against due to disability, age, race, familial status, and other bases.

Congress charged Executive departments to use federal civil rights law as a tool to address discrimination across healthcare, housing, education, and other social determinants of health (“SDOH”) that improve well-being and quality-of-life. SDOH, or the conditions in a social environment in which people are born, live, work, and play, affect a wide range of health and uality-of-life outcomes. Studies have shown that certain populations who have systematically experienced discrimination, based on race, sex, gender, age, disability, or other characteristics, also suffer disparities in health. Federal efforts to eliminate health disparities have taken an expansive approach given the complex relationship that exists between health disparities, access to care, socioeconomic status, and the environment. Because discrimination adversely affects health at the structural level (e.g., limiting opportunities, resources, and well-being of certain groups) and the individual level (e.g., being subjected to insensitive comments, violence, or other kinds of harm), federal civil rights laws play a significant role in the healthcare context.

Federal civil rights laws promote access for communities that are underserved to population-level SDOH, such as safe and affordable housing, higher education, and quality health care services, through two methods: enforcement and proactive education. Civil rights enforcement offices respond to specific instances of discrimination and the laws they enforce provide potential remedies for victims of discrimination when there is a violation. Members of the public have several options to initiate the enforcement process. Depending on the law, they may sue the discriminatory entity in federal court, file a complaint with a federal civil rights enforcement agency, or both. Federal agencies may also begin the enforcement process by initiating a compliance review to determine w her a federally funded entity is meeting its requirements under one or more civil rights laws.

Typically, the federal agency that provides financial assistance to a recipient is responsible for enforcing civil rights laws as appropriate. Outside of civil rights enforcement offices, funding agencies have several mechanisms available to strategically complement and enhance enforcement efforts to help recipients comply with federal civil rights laws. This article will cover what funding agencies currently do and how they can use proactive approaches--such as providing technical assistance, conducting data collection and research, and utilizing grant process mechanisms--to assist funding recipients with compliance and avoid civil rights violations.

This article will use the Department of Health and Human Services (“HHS”) and one of its funding agencies, the Health Resources and Services Administration (“HRSA”), as a case study to demonstrate how HRSA uses civil rights laws, proactive efforts, and funding mechanisms to promote health equity and reduce health disparities. In addition to highlighting HRSA's work, this article will explore approaches that funding agencies across the federal government can utilize to promote compliance and reduce health disparities.

On a departmental level, HHS incorporates advancing community health and well-being into its mission, focusing on providing effective health and human services, and fostering developments in medicine, public health, and social services. “Achieving health equity, ... eliminating health disparities, and ensuring optimal health for all Americans are overarching goals of [HHS sub-agencies.]”

HRSA is the primary funding agency for HHS focused on improving access to healthcare by people who are geographically isolated and economically or medically vulnerable. In addition to funding affordable and quality healthcare programs, HRSA educates recipients on civil rights laws as a means of reducing health disparities, achieving health equity, and ensuring compliance with federal law. Specifically, HRSA's Office of Civil Rights, Diversity, and Inclusion (“OCRDI”) provides funding recipients with resources, consultations, and technical assistance to help prevent discrimination before it results in harm to a person seeking health care and a costly enforcement action. Beyond avoiding harm, preventative interventions can result in more efficient spending by funding recipients on accessibility services and reduces the risk of liability-based actions related to discriminatory treatment.

Fifty years after Congress passed the Civil Rights Act, the federal government's efforts to fulfill its promise--to increase access by populations that are underserved to the conditions and services that improve the lives of every American--continue. Funding agencies have the unique opportunity to utilize methods outside of civil rights enforcement, such as providing technical assistance, conducting research/data collection, and utilizing grants mechanisms, to assist specific groups of funding recipients in ensuring compliance with the law. The implications of discrimination and mistreatment of certain populations are profound and require a multi-level approach on health that addresses the needs of all members of the population. The federal government's efforts are crucial in achieving these goals.

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Systemic discrimination and widespread health disparities demand federal action in addition to enforcement. Federal funding agencies--through grants, technical assistance, outreach, and partnerships with civil rights enforcement offices-- can help achieve equity across publicly funded programs and services. Through civil rights laws, federal funding influences policies that affect SDOH such as healthcare, education, climate, transportation, and other critical areas that impact health. Funding agencies provide a strategic complement to civil rights enforcement by not only affirming nondiscrimination in federally funded programs, but also educating funding recipients on how to devise, adapt, or extend programs and services in ways that prevent discrimination, increase access to healthcare, and promote health equity.

HRSA is in a unique position to help its funding recipients proactively integrate civil rights compliance in its policies, programs, and services. Interweaving civil rights requirements into grant administrative requirements supports applicants and recipients in understanding what is expected of them. HRSA takes this one step further by inviting its recipients to ask questions or request consultations on civil rights implementation in funded programs. Modern forms of discrimination and health inequities require federal departments, such as HHS, to extend nondiscrimination efforts beyond investigations of individual cases and towards guiding recipients, using funding mechanisms, on how to apply civil rights standards in their programs. The reach of civil rights laws through proactive efforts by federal funding agencies is significant, transformative, and necessary to further health equity.

Neelam Salman is the Section Chief for Civil Rights Coordination and Compliance within HRSA's Office of Civil Rights, Diversity, and Inclusion, where she serves as an agency expert in federal civil rights laws as they relate to diversity, equity, inclusion, and accessibility.

Golda Philip is the Senior Advisor for Equity for the HRSA Maternal and Child Health Bureau where she works to reduce disparities and achieve health equity in maternal and child health.

Sarah Williams serves as acting Deputy Office Head of the National Science Foundation's Office of Equity and Civil Rights.