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Empowering Marginalized Communities: Legal and Policy Levers for Health Equity

Abstract

This chapter introduces “Achieving Health Equity: The Role of Law and Policy,” a comprehensive guide exploring how legal and policy frameworks shape health outcomes of marginalized populations, especially racial minorities in the United States. It establishes the purpose and importance of examining health equity through law and policy, defining key concepts like health equity, social determinants of health, marginalized populations, and structural discrimination. The chapter outlines the book's ecosystem approach, organized around four key health‐determining domains: healthcare access and quality, health behaviors, social and economic factors, and physical environment. It highlights cross‐cutting themes and policy levers, such as resource investment, community engagement, safety net strengthening, civil rights protections, and data disaggregation. Underscoring the COVID‐19 pandemic's illumination of deep‐rooted health inequities and racism as a public health crisis, the chapter frames the book as an urgent call to action. It positions the guide as a roadmap for equitable policy change, offering concrete strategies and tools to dismantle structural drivers of health inequity. The chapter concludes by identifying the book's wide‐reaching intended audience, including students, healthcare administrators, public health officials, regulators, and researchers, emphasizing its potential for advancing the critical work of building a more just, equitable, and healthy future for all.

Keywords health equity; legal frameworks; policy levers; marginalized populations; social determinants of health; structural discrimination; COVID‐19 pandemic; racial justice

1.1 Navigating Law, Policy, and Health Inequities

In the United States, many individuals face a multitude of challenges that can have detrimental effects on their health and well‐being. Discrimination, social exclusion, poverty, disenfranchisement, and unequal access to opportunities are just a few of the obstacles that marginalized populations encounter on a daily basis. Communities of color, low‐income populations, those with low education levels, and other underserved groups continue to experience dramatically poorer health outcomes compared to their more privileged counterparts.

“Achieving Health Equity: The Role of Law and Policy” is an extensive exploration of how legal and policy frameworks influence the health outcomes of marginalized populations, with a particular focus on racial minorities in the United States. While primarily centered on US law and policy, the insights and lessons presented in this book have global relevance, as the United States serves as an influential model worldwide, including in how it has relied on systemic racism to shape healthcare, public health, and access.

This book primarily caters to learners in health‐related disciplines and professionals in health fields exploring the confluence of health, race, law, and policy [1]. While its foundation is academic, there's a significant crossover potential, reaching audiences not only across various disciplines but also beyond academia, particularly among activists and professionals in racial justice and health equity domains.

The primary goal of this book is to enhance understanding of the critical role that law and policy play in achieving health equity. The content is informed by research indicating that health is determined by a complex interplay of factors, with healthcare accounting for 20%, health behaviors for 30%, social and economic factors for 40%, and the physical environment for 10% [2]. By breaking down these determinants, the book demonstrates how law and policy can be leveraged to promote more equitable health outcomes.

This accessible guide is tailored for nonlegal audiences who are keen on grasping the key aspects of health equity law and policy. It fills a notable gap in the literature by consolidating health equity principles in an approachable format for a wide readership, including health system administrators implementing diversity, equity, and inclusion initiatives, public health officials, regulators, researchers, and more [3]. The COVID‐19 pandemic has only heightened interest in and the urgency of addressing health inequities, making this book a timely and essential resource.

1.2 The Purpose and Importance of Examining Health Equity Through Law and Policy

The most powerful determinants of health are the laws and policies that have perpetuated legacies of racism, discrimination, and segregation [4]. Unjust laws and practices embedded in our political, economic, and social systems have shaped unhealthy physical environments, limited economic and educational opportunities, and created barriers to accessing quality healthcare for marginalized groups over many generations [5].

As a result of these systemic inequities, low‐income communities and communities of color experience higher rates of chronic diseases, maternal mortality, infant mortality, and premature death compared to wealthier, predominantly white communities [6]. These health inequities are deeply entrenched and, in many cases, growing wider despite overall public health gains [7].

Attempting to reduce health inequities requires different strategies than efforts to improve public health overall [8]. Rather than a “rising tide lifts all boats” approach, a combination of targeted and universal interventions is needed to redistribute key health determinants, such as healthy environments, economic resources, power, and opportunities.

Law and policy are essential tools for this paradigm shift because they have the power to express societal values against bias, unfairness, and injustice [9, 10]. They influence how money, power, and opportunities are distributed and can transform unjust structures and systems that have perpetuated health inequities [11]. Law and policy enable widespread, population‐level change by focusing on structural determinants rather than individual behaviors [12]. They guide and coordinate multisector actions to improve health equity and sustain positive changes over the long term.

Enacting more equitable laws and policies requires policymakers, public health practitioners, healthcare and social service providers, community advocates, and other stakeholders to work together in new ways [13, 14]. It requires examining how every policy decision, across sectors, will affect health equity [15]. And it requires authentic community engagement to center solutions on the lived experiences and priorities of marginalized groups [16].

This book provides a practical blueprint for advocates committed to advancing policies that give everyone a fair and just opportunity to live their healthiest lives. It offers concrete policy strategies, case studies, and tools for enacting laws and policies that dismantle structural drivers of health inequity.

1.3 Key Concepts and Definitions

To lay the foundation for delving into health equity law and policy, it's important to establish shared language around core concepts. Health is defined as a state of complete physical, mental, spiritual, cultural, and social well‐being, not merely the absence of disease or infirmity [17]. Health equity refers to a state in which everyone has the opportunity to attain their full health potential, and no one is disadvantaged in achieving this potential because of social position or any other socially defined circumstance [18].

Social determinants of health are the conditions in the environments where 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 [19]. Key domains include healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment [20].

Marginalized populations are groups that have been systematically excluded from accessing resources and opportunities that enable health and well‐being [21]. These groups include communities of color, low‐income populations, LGBTQ+ people, immigrants, people with disabilities, and those living in rural communities, among others.

Structural discrimination, or structural racism, refers to a system of structuring opportunity and assigning value based on race or other socially defined characteristics that perpetuate unfair disadvantages for some and unearned advantages for others, across multiple systems and institutions [22]. Structural drivers of inequity are created and maintained by mutually reinforcing systems of stigma, stereotypes, and bias; discriminatory practices and policies; uneven distribution of resources and opportunities; and imbalanced power [23].

While often used interchangeably, this book makes a distinction between law and policy: policy refers to a written statement of a public agency's or organization's position, decision, or a course of action. The law refers specifically to the codification and institutionalization of a policy by a government in the form of an ordinance, statute, or regulation. Thus, all laws are policies, but not all policies are laws.

1.4 An Ecosystem Approach to Health Equity Law and Policy

This book...