A photo illustration representing a timeline of significant U.S. federal policies and events that have influenced present-day health disparities

How History Has Shaped Racial and Ethnic Health Disparities

A Timeline of Policies and Events

This timeline offers a historical view of significant U.S. federal policies and events spanning the early 1800s to today that have influenced present-day health disparities. It covers policies that directly impacted health coverage and access to care, relevant events in medicine, social and economic policies and developments that influence health, and efforts to tackle inequalities. Some events impacting people of color, like the Louisiana Purchase, Westward Expansion and the Transatlantic Slave Trade, predate this timeline. While not exhaustive, the timeline aims to provide context for addressing disparities, acknowledging the complex history that shapes racial and ethnic health and health care disparities that persist today.

Type of policy or event:

  • Health & Medicine
  • Broader Policies

1808 to 1890

Medical Exploitation of Enslaved Black Women

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The importation of enslaved people from foreign countries was outlawed in 1808. This ban had profound economic implications, as it increased the value of the existing enslaved populations and spurred slave owners to focus on their reproductive viability, contributing to medical experimentation on enslaved women. For example, while renowned for his contributions to the field of obstetrics and gynecology, Dr. J Marion Sims developed new surgical techniques through medical experiments on enslaved women, including Anarcha, Lucy, and Betsey in Alabama from 1845 to 1849. Dr. Francois Marie Prevost honed his cesarean surgical procedure by practicing on at least 30 enslaved women in Haiti and Louisiana during the 1830s. Dr. Ephraim McDowell, considered the father of abdominal surgery, developed surgical treatments for ovarian cancer in the early 1800s, often on enslaved women. The experimental procedures were often conducted without anesthesia due to the inaccurate belief that Black people felt less pain than White people. This racial bias in pain perception persists in modern medicine, affecting the way medical students and residents view and treat pain among different racial groups. In recent years, there have been efforts to reevaluate the ethics of these physicians’ work and acknowledge the exploitation of enslaved women in the development of modern reproductive surgical procedures, especially in the context of the ongoing maternal health crisis.

Federal Indian Boarding Schools

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While first initiated in 1819, the U.S. implemented policies establishing and supporting Indian boarding schools across the nation into the late 20th century. These schools were designed to culturally assimilate American Indian, Alaska Native (AIAN), and Native Hawaiian children by forcibly removing them from their families and communities as part of efforts to dispossess them from their native lands. The children suffered severe abuse and neglect. Many children died at these institutions and were buried in unmarked and marked graves on the school grounds. In 2022, an investigation by the Bureau of Indian Affairs identified ongoing impacts of the school system, including loss of life, territories and wealth, negative impacts on physical and mental health and Tribal and family relations, and erosion of the use of Tribal languages as well as religious and cultural practices. 

The Indian Removal Act and the Trail of Tears

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The Supreme Court’s Johnson v. McIntosh decision established legal doctrine surrounding Indigenous ownership of land in 1823. The decision determined that American Indian people did not have legal ownership of the land they inhabited, laying down the foundation for the forced displacement of American Indian Tribes. The Indian Removal Act of 1830 authorized the forced relocation of American Indian Tribes from the Southeast U.S. to the Midwestern and Western parts of the country and started the Trail of Tears. The forced resettlement resulted in approximately 100,000 American Indian people losing their lives, homes and Tribal lands. The loss of lands and people from this period resulted in a substantial loss of Indigenous knowledge, languages, and traditions and continues to impact American Indian people today. 

Dred Scott v. John F.A. Sandford

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Dred and Harriet Scott, enslaved persons in the state of Missouri, sought freedom from their enslavers in 1846 under the assumption that their temporary residence in a free state/territory freed them from slavery. Their judicial fight for freedom continued for 11 years and gained notoriety as slavery became a major political issue in the U.S. In 1857, Chief Justice Taney read the majority opinion stating that enslaved people were not citizens of the U.S. and, therefore, could not file cases at the federal level. Further, it established that the federal government did not have the power to prohibit slavery in its territories.

The Emancipation Proclamation

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The proclamation declared the end of slavery in the Confederacy. While it did not codify the illegality of slavery, it signaled a shift in the purpose of the Civil War from one that focused on the preservation of the Union to one that was focused on the end of slavery. The Emancipation Declaration was a significant milestone that helped pave the way for the Reconstruction Amendments that outlawed slavery and involuntary servitude.

Reconstruction Amendments

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The Thirteenth, Fourteenth, and Fifteenth Amendments, collectively known as the Reconstruction Amendments, outlawed slavery and involuntary servitude; granted citizenship to anyone born in the U.S. and equal protection to all people; and extended the right to vote to Black men, respectively. The Reconstruction Amendments were designed to enforce the declaration of the end of slavery, provide equality for freed Black people, and provide people with legislative pathways to uphold equal rights and treatment under the law. However, they were quite unsuccessful in fulfilling their objectives, particularly in states where lynchings, Black Codes, and Jim Crow laws were established to further disenfranchise Black people. The Reconstruction Amendments served as foundational documents for the civil rights movements of the 1950s and 1960s, as well as other equal rights movements.

Freedmen’s Bureau Acts of 1865 and 1866

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The Acts established a Bureau for the Relief of Freedmen and Refugees whose role was to provide social, economic, and occupational resources to displaced Southerners and freed Black people after the Civil War. Like many other Reconstruction Era actions, the Bureau was shut down in 1872 due to pervasive racism and lack of funding. The Freedmen’s Bureau is recognized as one of the earliest examples of race-conscious or affirmative action in the U.S. The Bureau has a complicated legacy because, while it provided medical assistance to more than a million freed people and established over 1,000 schools for Black people in the American South, including Historically Black Colleges and Universities, it made little to no headway in land redistribution and the advancement of civil rights for Black people. 

Alaska Purchase

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The U.S. purchased Alaska from Russia on October 18, 1867 as part of American expansionist efforts. The Alaska Purchase, also known as the Treaty of Cession, excluded Alaska Natives from the rights provided to White people under the new U.S. government, including ownership of most of the land. Prior to the Alaska Purchase, the Alaska Native population had already dwindled due to the introduction of new diseases by the Russians. After the U.S. took over, the Alaska Native population continued to experience disenfranchisement and loss of their ancestral lands. In 1921, the Snyder Act eventually provided them full citizenship and the right to vote, and, in 1971, President Nixon ceded 44 million acres of federal land back to Alaska Native people.

Historically Black Medical Schools

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Historically Black Colleges and Universities (HBCUs) are institutions of higher education that were established before 1964 to educate persons of African descent. HBCUs were founded in response to the exclusion of African American students from traditional colleges and universities due to segregation. In the late 19th century, there were seven Black medical colleges. After the 1910 Flexner report, only two remained — Meharry Medical College and Howard University. Today, Black doctors remain underrepresented in the health care workforce, and HBCU graduates make up 70% of Black doctors and dentists.

Chinese Exclusion Act

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The law implemented a ten-year ban on Chinese laborers immigrating to the U.S., representing the first example of federal law restricting entry of an ethnic group. The initial ten-year ban was extended until 1943, ending after China and the U.S. established an alliance during World War II. The Act was informed by the 1877 Joint Special Committee to Investigate Chinese Immigration, which found that White laborers opposed Chinese immigration out of fear of loss of employment due to the low wage labor provided by Chinese immigrants. The Exclusion Act set a precedent for restricting immigration on the basis of race and fueled xenophobic sentiment and mistreatment of Chinese people in America that is still present today and rose amid the COVID-19 pandemic.

Dawes Act and the Dawes Commission

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As part of efforts to break up reservation and Tribal lands, the Dawes Act authorized the president to distribute reservation land commonly held by Tribal members into allotments to individuals. In addition, the Dawes Commission created methods for identifying Tribal membership, including the development of the Dawes Rolls that identify ancestry through Tribal lineage. In the 1930s, some Tribes began using blood quantum requirements to determine eligibility for land distribution and other entitlements. While the policy was portrayed as an effort to protect American Indian property rights and alleviate poverty among American Indians, it reflected beliefs that American Indian people should assimilate to White culture and principles. These policies contributed to weakening of Native American conditions, as the land allotted to individuals included areas that were unsuitable for farming, some nomadic Native cultures did not easily adapt to an agricultural existence, and millions of acres of Tribal land were ultimately lost when sold to non-Native people.

1891 to 1899

Immigration Act of 1891

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The Act centralized the immigration enforcement authority of the federal government, extended immigration inspection to land borders, and expanded the list of excludable and deportable immigrants to include people who are likely to become a public charge, as well as those with infectious diseases. The law was passed during a period of increased immigration into the U.S. and led to further immigration exclusions following the Chinese Exclusion Act in 1882. The 1891 law set precedent for the Immigration Acts of 1903, 1907, and 1917, which established health and certain work status restrictions as well as literacy requirements for immigration that resulted in limiting immigration primarily from Asia and Mexico and reinforcing xenophobic sentiment.

U.S. Public Health Service (USPHS) Medical Inspections of Immigrants

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With increasing immigration starting in the 1880s and through the next century and growing concern about job displacement by immigrants and the potential spread of infectious diseases, the USPHS carried out medical examinations of immigrant populations entering the U.S. and identified whether they would become public charges (i.e., likely to become dependent on the government for support). In the late 19th and early 20th century, Asian and Mexican immigrants and Jewish immigrants from Eastern Europe were disproportionately impacted by these activities. Public charge determinations continue to be applied to immigrants in the U.S. today. The Trump Administration made changes to public charge determinations that extended them to take into account the use of non-cash government programs, including health care. These changes have since been rescinded by the Biden Administration, although many immigrant families continue to have fears and concerns about accessing health care and other non-cash assistance programs even if they and/or their children are eligible.

Plessy v. Ferguson

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This Supreme Court ruling validated racial segregation by finding that the equal protection principles mandated by the Fourteenth Amendment could be honored with facilities that were “separate but equal.” Plessy v. Ferguson occurred in the aftermath of Reconstruction, during a time when conservative Democrats sought to roll back the gains made by Black people. The ruling has had long-term negative impacts on Black people’s access to opportunities, including quality health care, particularly in states that adopted laws upholding segregation within medical facilities, agencies, and societies. The legacy of the “separate but equal” ruling continued through state and local statutes (Jim Crow laws) through the mid-1960s (until its abolition by the Civil Rights Act in 1964). Ultimately, the combined effects of these statutes denied Black people the right to vote and attain educational or vocational opportunities, contributing to income, wealth, and health inequities that persist today.

Annexation of the Republic of Hawai’i

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Sanford Dole and the U.S. government dethroned the Hawaiian monarch Queen Lili’uokalani, following concerns that Hawai’i may become part of the European empire. Hawai’i, an independent sovereign nation, was officially annexed in 1898, as part of U.S. efforts to extend its territory and political power in the Pacific. Following Hawai’i’s occupation by Western people in the 1800s, the Native Hawaiian population was decimated due to the introduction of multiple infectious diseases, and their language and culture eroded with the institution of Christian and English boarding schools, as well as U.S. Federal Indian Boarding Schools. Despite some efforts by the U.S. government to make amends for the overthrow of Hawai’i’s monarchy, the legacy of colonization and cultural genocide contribute to ongoing health disparities for Native Hawaiian people.

The Spanish-American War

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The peace treaty signed at the end of the war between the U.S. and Spain in 1898 provided independence to Cuba and gave the U.S. control of Puerto Rico, Guam, and the Philippines, with the Philippines eventually gaining independence in 1946. While residents of Puerto Rico and Guam are U.S. citizens, they are denied voting rights. The U.S. occupation and actions in these areas have had adverse impacts on the health of local and Indigenous people due to exposure to residual toxic waste disposed by the U.S. military and destruction of fertile land, negatively impacting diets and contributing to high rates of chronic conditions.

1900 to 1929

American Eugenics and the Forced Sterilization of Women of Color and Low-Income Women

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The American Eugenics movement had origins in emerging theories of White supremacy and the belief that society would be improved without physical or mental illness. The American Eugenics movement eventually became legalized through eugenic sterilization laws in the early 1900s. Forced sterilization efforts targeted low-income communities of color as well as people with disabilities. In 1927, the U.S. Supreme Court made a decision in Buck v. Bell that upheld the Virginia Eugenical Sterilization Act of 1924, allowing the Commonwealth to sterilize people they considered to be unfit to have children. The decision helped pave the way for the enactment of other state sterilization laws. A study by the U.S. General Accounting Office found that between the years 1973-1976, more than 3,000 American Indian and Alaska Native women were sterilized without their permission. The mass sterilizations were influenced by the Family Planning Services and Population Research Act of 1970, which subsidized sterilizations for Medicaid and Indian Health Service patients. In 1974, a case found that two adolescent Black sisters in Montgomery, Alabama were coerced into federally funded sterilizations. The case revealed that many women of color had been sterilized under government programs. As a result of this case, a requirement was established for doctors to obtain informed consent before performing sterilization procedures. Evidence suggests that inappropriate sterilization practices have continued in the modern day, including among women detained by U.S. Immigration and Customs Enforcement.

The Flexner Report

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The Flexner report was a landmark study funded by the American Medical Association and the Carnegie Foundation to assess the state of medical education in Canada and the U.S. The report’s recommendations contributed to the closure of five out of seven established medical schools that primarily trained Black physicians. In subsequent years, the number of trained Black physicians diminished greatly, while the number of White physicians increased. Today, Black physicians remain underrepresented in the health care workforce, with most of them training at the remaining two historically Black medical schools: Meharry Medical College and Howard University. In 2008, the American Medical Association issued a public apology for its past discriminatory practices against Black physicians and has since developed a policy and strategic framework aimed at addressing health equity, including creating a Center for Health Equity.

Tulsa Race Massacre

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The destruction of Tulsa was a continuation of many racially-motivated massacres that began in 1917 and continued into the early 1920s. Known as the Red Summer, this period was marked by violence against Black people and was influenced by the Great Migration of Black people from the South to the Northern U.S. and the return of Black veterans from World War I. The Tulsa massacre was one of the worst instances of racial violence in U.S. history and resulted in the displacement of approximately 10,000 people and the destruction of nearly 1,500 homes and businesses. Estimates of mortality from this event range from 30 to 300 deaths. In 1997, Oklahoma formed the Tulsa Race Riot Commission to document and investigate the Tulsa massacre.

Ozawa v. United States, United States v. Thind, and The Immigration Act of 1924 (Johnson-Reed Act)

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In 1922 and 1923, the Supreme Court ruled that Takao Ozawa and Bhagat Singh Thind were ineligible for naturalization because they were not White. Following the United States v. Thind ruling, many Asian Indian American people who had been naturalized had their citizenship status rescinded. The Immigration Act of 1924 continued the legacy of exclusion of Asian immigrants from entry into the U.S., particularly people from Japan. These two Supreme Court cases and the exclusionary immigration policies of the time specified that Asian people were not “free White persons” and, therefore, were excluded from becoming naturalized U.S. citizens. These policies were enacted following the Red Scare of 1919-1920, a period when many people in the U.S. feared the rise of perceived support of communist, socialist, or anarchist ideology, which prompted nationalist ideologies within the U.S. and fears of immigrants and foreigners.

Snyder Act

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The Snyder Act gave U.S.-born American Indian people full citizenship and provided them with the right to vote (as American Indian people had been excluded from voting rights despite the passage of the Fifteenth Amendment in 1870). However, states did not implement voting rights universally for American Indian people until nearly a half-century following the Snyder Act. The exclusion of American Indian voters persists today via voter registration and literacy barriers, as well as poor investment into resources and infrastructure on reservations.

1930 to 1939

The U.S. Public Health Service (USPHS) Untreated Syphilis Study at Tuskegee

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The Untreated Syphilis Study at Tuskegee was a 40-year experiment conducted by the U.S. Public Health Service that studied the progression of untreated syphilis in 600 poor, Black sharecroppers without their consent. Participants were told they were receiving free government medical care but not that they had syphilis. They were left untreated when treatment for syphilis became available so researchers could study the progression of the disease. Years later, in 1974, the National Research Act created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which developed principles of ethical research conduct and informed consent standards. The history of Tuskegee and other instances of medical experimentation on Black people is one factor contributing to mistrust of researchers and the health care system and has contributed to increased mortality among Black men due to decreased use of health care services. In 2024, the CDC Foundation launched an endowed scholarship program to support the Voices For Our Fathers Legacy Foundation scholarships in recognition of the experiences of the Black men involved in the Untreated Syphilis Study at Tuskegee. The program seeks to raise a $5 million endowment that will provide annual $100,000 scholarships for the descendants of the Black men who were a part of the study.

The Home Owners’ Loan Corporation Act

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The Home Owners’ Loan Corporation was authorized by the federal government to grade residential neighborhoods based on their mortgage security. Neighborhoods that were considered low risk for banks and other mortgage lenders were marked green, while neighborhoods that were considered hazardous were marked red (redlining). One of the factors that determined the grading of neighborhoods was the racial makeup of the community that lived there. Redlining resulted in racial segregation and large inequities in economic opportunity that have ongoing negative associations with health today, including disproportionate exposure to environmental health risks, such as extreme heat.   

The Social Security Act (SSA) and Social Security Amendments

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Amidst the Great Depression, the SSA was passed to create a federal safety net and general welfare system for older adults, persons who were unemployed, and persons with disabilities. In 1954, the SSA Amendments initiated a disability insurance program (Social Security Disability Insurance) providing additional economic protections for workers with disabilities aged 50-64 and for retired or deceased workers’ dependent adult children who developed disabilities before the age of 18. Social Security plays a large role for income in retirement for people of color, who are less likely to have accumulated wealth or benefits from pensions or retirement savings, which has implications for health. Research suggests that the improvements in socioeconomic status resulting from the Social Security program are associated with improvements in health among older adults in the U.S., including declines in mortality.

Title V Maternal and Child Health Block Grant Program

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Enacted as part of the Social Security Act, the Title V program’s original purpose and design focused on addressing the impacts of poverty on maternal and child health following the Great Depression. Today, the program provides grant funding to states and jurisdictions to provide services to pregnant women, infants, and children, including children with special health care needs.

National Labor Relations Act (NLRA)

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The NLRA expanded union rights resulting in higher wages and benefits (such as health insurance) but excluded multiple industries (such as service, domestic, and agricultural workers and independent contractors) and allowed unions to discriminate against workers of color in other industries. The Fair Labor Standards Act passed in 1938 established standards pertaining to minimum wage, overtime pay, recordkeeping, and youth employment, but also excluded agricultural workers until the 1960s. The NLRA’s exclusion of domestic and agricultural industries had disproportionate impacts on people of color, resulting in a higher proportion of people of color working in lower-earning jobs and in jobs that do not provide benefits, including health insurance.

1940 to 1959

Japanese American Incarceration During World War II (WWII)

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In reaction to the attacks on Pearl Harbor and the ensuing war, President Roosevelt signed an Executive Order that established Japanese incarceration camps, wherein people of Japanese descent, including U.S. citizens, were incarcerated. The Supreme Court ruled incarceration camps during WWII as constitutional despite the inhumane conditions of the camps. In addition to forced displacement and loss of livelihood, Japanese American people lived under hazardous conditions in the camps. They experienced long-term health impacts including post-traumatic stress disorder and poorer physical health, which have ongoing intergenerational impacts on health and well-being today. In recognition of the harms done to Japanese American people during their incarceration in WWII, the Office of Redress Administration (ORA) was established under the Civil Liberties Act of 1988. The ORA was tasked with administering a ten-year restitution program that provided a non-taxable $20,000 payment to eligible people of Japanese ancestry.

Hospital Survey and Construction Act

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The Hospital Survey and Construction Act (informally known as the Hill-Burton Act) provided construction grants and loans to build public hospitals in high need areas. Many facilities in the South used Hill-Burton funds, which disallowed blatant discrimination against Black patients but continued to codify the idea of “separate but equal.” Federal funds from the Act were used to build, maintain, and expand “separate but equal” hospitals and other health facilities that segregated patients and medical providers by race. Following growth in hospital capacity resulting from the funds, a study found that, in the South, only 6% of hospitals offered unrestricted services to Black people, 31% did not admit any Black people to their facilities under any conditions, and 47% had segregated wards for White and Black people, while in the North, 83% of hospitals reported some degree of integrated services.

HeLa Cell Line

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Following her death due to cervical cancer in 1951, scientists at Johns Hopkins Hospital took and used samples of cancerous cells for medical research from Henrietta Lacks, a 31-year-old Black mother of five from Virginia, without her or her family’s knowledge or consent. Lacks’ cells have become one of the most vital cell lines (HeLa Cell Line) in medical research and have been used to develop the polio vaccine and in cancer, AIDS, and COVID-19 research. The use of Lack’s cells is part of a long line of non-consensual and uninformed medical research and experimentation practices on Black people. In recent years, scientific boards have revised the Federal Policy for the Protection of Human Subjects (The Common Rule) to increase protections of people who participate in research studies. Johns Hopkins recognizes that the collection of Lacks’ cells was reflective of the lack of consent laws in the 1950s and that the practice would be considered unethical today. Over the years, Johns Hopkins has worked with the Lacks family to honor Henrietta Lacks and her contribution to science and health advancement as well as to improve research practices.

The Immigration and Nationality Acts (INA) (McCarren-Walter Act and the Hart-Celler Act)

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The INA of 1952 reformed aspects of immigration law, including ending Chinese exclusion from immigration and adding an immigration system of preference for skilled workers and those who were family members of U.S. citizens and lawful permanent residents. However, the law still upheld the national origins quota that mainly affected people of Asian origin. The INA of 1965 reversed the U.S. policy of restricting immigration by national origin, banning discrimination in the issuance of visas by “race, sex, nationality, place of birth and/or residence.” The shift in policy reflected the rapidly changing global geopolitical climate, with many countries in Asia, Africa, and Central and South America gaining independence and the formation of multilateral organizations. After the passage of the law, the U.S. experienced a large increase in immigration and a reversal of trends, with a dramatic decrease in the proportion of immigrants from Europe and an increase in immigration from other regions.

“Operation Wetback”

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The derogatory termed “Operation Wetback” initiative resulted in the deportation of at least one million Mexican people. The program was enacted during a time when Southwestern states were reliant on agricultural labor from Mexico and encouraged temporary migration into the U.S. through the Bracero Program. In 1951, a Commission on Migratory Labor released a report that blamed Mexican workers for low wages and expressed concerns that returning soldiers and citizens would be unable to find work in the Southwest. The cross-border collaboration between the Mexican and U.S. governments during “Operation Wetback” expanded migration control along the U.S.-Mexico border. “Operation Wetback” was a continuation of a pattern of deportation of Mexican and Mexican American people, including the repatriation of close to 2 million Mexican and Mexican-American people during the 1930s. The mass deportation of immigrant populations and people of color during difficult economic times has occurred throughout American history and was brought back to the forefront of American consciousness during the Trump Administration. 

Brown v. Board of Education

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The National Association for the Advancement of Colored People (NAACP) began challenging segregation in public education in the late 1940s by encouraging Black parents to enroll their children in all-White schools. The all-White schools rejected the Black students’ applications. Following the rejections, the NAACP filed class action lawsuits that claimed that the education offered at Black schools was inferior to that offered at White schools, which violated the Fourteenth Amendment equal protection clause. The Supreme Court agreed and ruled that having separate educational facilities for Black and White students was unequal. The Brown v. Board of Education decision struck down the “separate but equal” doctrine of the Plessy v. Ferguson decision and was a key precursor to the Civil Rights Movement.

Establishment of the Indian Health Service (IHS)

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The federal government has a trust responsibility to meet the health care needs of American Indian and Alaska Native people. Established in 1955, the IHS is the primary mechanism through which the federal government fulfills its trust responsibility to provide health care to AIAN people. However, the IHS is not health insurance and has been historically underfunded and unable to meet their health care needs. AIAN people continue to have lower life expectancies than other racial and ethnic groups and fare worse across numerous health measures. 

Civil Rights Movement

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The mid-1900s were marked by a Black people-led nationwide movement that included sit-ins in North Carolina, the Montgomery bus boycott, the March on Washington, and other key events that sought to end racial segregation and achieve equal rights. In 1957, President Eisenhower enacted the Civil Rights Act of 1957, which established the Civil Rights Section of the Justice Department and the federal Civil Rights Commission. It provided the federal government with the ability to investigate obstacles to individuals’ right to vote and instances of discrimination, as well as to develop solutions to address them.

1960 to 1969

President’s Committee on Equal Employment Opportunity and Affirmative Action

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President Kennedy established the President’s Committee on Equal Employment Opportunity via Executive Order and required government employers to practice nondiscrimination in their hiring practices and “take affirmative action to ensure that applicants are employed and that employees are treated during employment, without regard to their race, creed, color, or national origin.” The Executive Order was implemented in the wake of World War II and during the Civil Rights Movement. As military members began returning to the U.S., gains made by people of color and women in employment and other sectors began to recede. The Executive Order sought to rectify this situation and ensure equitable hiring practices.

Simkins v. Moses H. Cone Memorial Hospital

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Dr. Simkins, a dentist frustrated with the conditions of the all-Black hospitals he worked in, filed a lawsuit against two local hospitals with the assistance of the National Association for the Advancement of Colored People. Dr. Simkins won this landmark federal case, arguing that the hospitals, as Hill Burton funding recipients, failed to provide equal protection as required by the Constitution. The case set the precedent for ending overt segregation and discrimination in hospital settings. The 1964 Civil Rights Act prohibited programs that receive federal funds from discriminating on the basis of race, creed, or national origin. The subsequent establishment of Medicare in 1965, which included federal funding to support hospitals and made them subject to the Civil Rights Act, led to the eventual desegregation of hospitals and health care facilities.

Supplemental Nutrition Assistance Program (SNAP)

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SNAP was established by the U.S. Department of Agriculture to address food insecurity and hunger in the U.S. by providing support to lower income families. SNAP grew out of the Food Stamps program, which was introduced in the 1930s during the Great Depression to address poverty and food insecurity. Overall, people of color are more likely to experience food insecurity and to have incomes below poverty compared to White people. Research shows that SNAP reduces poverty and food insecurity, promotes positive health outcomes, lowers health care costs, and reduces disparities in food insecurity.

Federally Qualified Health Centers and the Health Center Program

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The Economic Opportunity Act of 1964 was passed as part of efforts to combat poverty in the U.S. The Act sought to increase educational and training opportunities to expand employment options and to address many social and economic drivers of poverty. A major health-related legacy of the Economic Opportunity Act was the development of Federally Qualified Health Centers or community health centers (CHCs). The nation’s first CHCs were launched in 1965 as part of a small demonstration program within the Office of Economic Opportunity and made permanent by Congress. CHCs were placed in areas with high levels of poverty and were tasked with providing comprehensive health services to low-income residents of those neighborhoods. Today, hundreds of CHCs across the U.S. serve low-income, medically underserved communities. Some health centers focus on meeting the needs of specific populations. For example, members of the Association of Asian Pacific Community Health Organizations are located in areas with high concentrations of medically underserved Asian American, Native Hawaiian, and Pacific Islander people and lead efforts to provide linguistically and culturally appropriate care for these groups. The federal Migrant Health Program funds health centers across the country that specialize in providing care to farmworkers and their families.

Civil Rights Act and the Voting Rights Act

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The Civil Rights Act of 1964 and the Voting Rights Act of 1965 prohibited discrimination by race, sex, religion, color, or national origin, enforced the desegregation of schools, and guaranteed the right to vote as well as equality in employment, use of and access to federally funded programs, and access to public areas. While the Civil Rights Acts did not end discrimination, they ended the Jim Crow era laws and provided legal and legislative avenues for people to uphold these ideals and challenge instances of discrimination and inequitable treatment. The impact of the Voting Rights Act was immediate; a quarter of a million new Black voters were registered in 1965. Research suggests that civil rights protections for people of color have positively impacted health.

Legacies of Malcolm X and Dr. Martin Luther King Jr.

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Dr. Martin Luther King Jr. and Malcolm X were prominent leaders of the Civil Rights Movement. While both leaders had different approaches to addressing racial inequality, they had shared missions of uplifting Black people within the U.S. and globally. Malcolm X was assassinated in 1965 and his legacy continues to this day. He popularized Black pride, autonomy, and independence among Black people. Dr. Martin Luther King was assassinated in 1968; his liberation work continues to inspire civil rights movements and liberation movements across the globe.

The Chicano Movement

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The Chicano Movement sought to achieve equity in labor and politics for Mexican American people. Amid growing political and social activism following World War II, the National Farm Workers Association (NFWA) was founded by Cesar Chavez and other Chicano activists to defend farmworker rights. The NFWA was a predecessor to the United Farm Workers Organizing Committee, which made major gains in voter registration among Mexican American people, gained labor contracts, and improved working conditions for farmworkers. The Chicano Movement has had many impacts including increased equality in education and increasing Mexican American representation among teaching staff, working to ensure that health care forms are available in both Spanish and English, and solidifying the Hispanic community as an important voting bloc in the U.S.

Medicare and Medicaid

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The 1965 Social Security Amendments (SSA Amendments) established Medicare as a nationwide health insurance program for adults age 65 and older and some younger people with disabilities. The SSA Amendments also established Medicaid as a joint federal-state health insurance program for certain low-income adults and children and long-term care program for adults 65 and older and younger adults with disabilities. Medicare and Medicaid were preceded by the Kerr-Mills Act in 1960 that provided funds to states that chose to cover health care services for older adults with incomes above levels needed to qualify for public assistance. Today, Medicaid, along with the Children’s Health Insurance Program, which was established in 1997, provide health and long-term care coverage to millions of low-income individuals in the U.S. and are a key source of funding for hospitals, community health centers, physicians, and nursing homes. Medicaid is a major source of coverage for people of color, helping to ensure access to care and providing financial protection from health care costs. Medicare provides coverage to more than 60 million people ages 65 and older and younger adults with long-term disabilities. Nearly a quarter of beneficiaries are people of color. The program has helped to mitigate racial and ethnic inequities in health care, including leading to the desegregation of hospitals.

Loving v. Virginia

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Through the mid-20th century, Jim Crow and other state anti-miscegenation laws banned interracial marriages throughout many parts of the U.S. In 1958, Richard and Mildred Loving, a married interracial couple, were arrested and convicted of violating Virginia’s Racial Integrity Act. Amongst other racially discriminatory policies, the law prohibited interracial marriage. In 1964, the Lovings sought to have their sentences vacated, stating that the court’s decision violated their Fourteenth Amendment rights to equal protection under the law. After several losses in the lower courts, in 1967, the Supreme Court decided in favor of the Lovings, stating that anti-miscegenation laws did violate the Fourteenth Amendment equal protection clause by restricting marriage due to race. By allowing interracial couples to marry, Loving v. Virginia expanded access to government benefits associated with marriage. The case also informed later Supreme Court decisions on the right to marry, including Obergefell v. Hodges, which extended the right to marry to same sex couples across the nation, and, in turn, extended access to benefits, including health insurance coverage.   

The Fair Housing Act (Title VIII of the Civil Rights Act of 1968)

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Expanding on previous legislation, the Act prohibited discrimination based on race, religion, national origin, sex, disability, and family status for the sale, rental, and financing of housing. Despite this law, racial disparities in home ownership and wealth and housing segregation have persisted. Research documents a strong connection between housing and health. The impacts of housing segregation on health are manifold but have been associated with poorer pregnancy outcomes and increased mortality, particularly for Black communities.

1970 to 1979

Title X Family Planning Program

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The Title X Family Planning Program was established to address the rise in adverse reproductive health outcomes and unplanned pregnancies in the mid-20th century and aimed to ensure that all people had access to comprehensive and preventive reproductive health care regardless of income. Since their development, Title X clinics have been a key source of reproductive care for low-income women and women of color. Over the years, Title X clinics have faced programmatic changes in federal funding for abortion services, which have impacted people’s access to and use of Title X clinics and reproductive health care.  

Roe v. Wade

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In this Supreme Court case, Jane Roe challenged a Texas law that made abortion illegal in all cases except when necessary to save a woman’s life, arguing that the law violated the Constitutional right to privacy. The court’s decision decriminalized abortion nationwide. Following the court’s decision, Congress enacted the Hyde Amendment, which prohibited the use of federal funds in Medicaid and other public programs to pay for abortions outside of the exceptions of rape, incest, or if the abortion is deemed medically necessary. The Hyde Amendment disproportionately impacts people of color, who are more likely to be insured by Medicaid. The June 2022 Supreme Court ruling in Dobbs v. Jackson  overturned the longstanding Constitutional right to abortion and eliminated federal standards on abortion access that had been established by earlier decisions, allowing states to establish laws protecting or restricting abortion. The overturning of Roe v. Wade will likely disproportionately impact people of color, as they are more likely to seek abortions and more likely to face structural barriers that will make it more difficult to travel out of state for an abortion, including more limited access to health care and fewer financial and transportation resources. Increased barriers to abortion for people of color may widen the already existing large disparities in maternal and infant health, have negative economic consequences for families, and increase the risk of criminalization for people of color.

Earned Income Tax Credit (EITC)

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The EITC was established in 1975 to provide financial assistance to low-income, working families with children and is the largest refundable tax credit for low-to-middle-income families. Evaluations of the EITC have found that it lowers overall inequality between Black and White households. The EITC has boosted the incomes of millions of women of color, with some evidence that receiving EITC benefits is associated with increased birthweight for infants born to Black women. Other research suggests that income from the EITC has long-term benefits for educational attainment and greater health improvements with more generous EITC benefits. 

Indian Self Determination and Education Assistance Act (ISDEAA)

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The ISDEAA was enacted in the midst of many civil rights movements and aimed to reverse some of the paternalistic policies directed toward American Indian people and to strengthen and restore Tribal sovereignty. The Act allowed the U.S. Department of Interior and the U.S. Department of Health and Human Services to contract with federally recognized Tribes for federal services. Over time amendments have been made to the ISDEAA, many of which have sought to make the self-governance legislation permanent as well as further strengthen Tribal sovereignty.

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

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WIC is a federal program that provides funding to states to help them provide nutritious foods, health care referrals, and nutritional information to low-income women and children under the age of five who may be at risk of or are experiencing food insecurity. Research has found that participation in WIC is associated with improved infant health outcomes (reduced likelihood of preterm birth and decreased infant mortality), with some evidence of reduced inequities for low-income mothers and mothers of color.

The Indian Child Welfare Act (ICWA)

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The ICWA governs jurisdiction over the removal of American Indian children from their families in custody, foster care, and adoption cases and gives Tribal governments exclusive jurisdiction over children who live on a reservation. The Act was put in place during a time when many American Indian children were being separated from their families and being adopted by White, non-Native families. Often, the rationale for separating these children from their families was rooted in the assimilation doctrine of the time and not performed in the best interest of the children or their families. Over time, the ICWA helped in the reversal of efforts to forcibly assimilate American Indian people into White dominant culture.

1980 to 1989

The HIV/AIDS epidemic

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The first cases of what would later become known as acquired immunodeficiency syndrome (AIDS) were reported in the U.S. in 1981. Although there have been some promising trends such as reductions in new HIV infections among some groups, HIV continues to have a disproportionate impact on certain populations, particularly people of color, gay and bisexual men, men who have sex with men, and transgender women. Because of these disproportionate impacts, overall federal investment in HIV plays an important role in addressing the epidemic for these groups. In 1998, President Clinton created the Minority AIDS Initiative (MAI) in response to advocacy efforts by leaders in the Black community and Centers for Disease Control and Prevention data that showed the disproportionate impact of HIV on Black people. The MAI is the first program with resources focused on addressing the impact of HIV in disproportionately affected communities. It aimed to strengthen organizations serving communities of color in an effort to improve HIV-related health outcomes and reduce HIV-related disparities. Though a relatively small investment compared to other federal HIV funding, the initiative plays an important role in providing direct services to historically marginalized racial and ethnic groups. In August 2022, the White House Office of National AIDS policy developed and released the National HIV/AIDS strategy (2022-2025), which outlined the nation’s action plan for ending HIV in the U.S. by 2030 and recognized racism as a driver of persistent disparities in the HIV epidemic.

The Migrant and Seasonal Agricultural Worker Protection Act (MSPA)

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Lack of clear guidance on responsibilities and obligations of agricultural employers to guarantee migrant worker protections led to the passage of the MSPA, the main federal law protecting farmworkers. The MSPA requires farm labor contractors to register with the U.S. Department of Labor and establish employment standards pertaining to wages, housing, transportation, and working conditions for migrant and seasonal agricultural workers. Despite these protections, migrant farmers continue to be subject to many labor abuses such as wage theft, unsafe working, and substandard living situations. Migrant farmworkers, a large majority of whom are Mexican immigrants, have higher morbidity and mortality compared to the general population due to occupational hazards (including higher exposures to pesticides, carcinogens, and extreme weather conditions), substandard living conditions, and barriers to accessing health care services.

Report of the Secretary’s Task Force on Black and Minority Health and Establishment of the Office of Minority Health

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The Report of the Secretary’s Task Force on Black and Minority Health, also known as the Heckler Report, was the first government-led national comprehensive study on the health status of people of color. The report quantified excess deaths due to health disparities and identified the predominant causes of mortality for people of color. The report also outlined recommendations to reduce health disparities and identified a need to improve national data collection for Hispanic, Asian American, and American Indian and Alaska Native populations. The establishment of the Office of Minority Health within the U.S. Department of Health and Humans Services (HHS) was one of the Heckler Report’s most significant outcomes. It was established to improve health outcomes among communities of color and eliminate health disparities among racial and ethnic groups through the development of government-level health policies and programs. In 2010, the Affordable Care Act established Offices of Minority Health within each of the six agencies within HHS and redesignated the National Center on Minority Health and Health Disparities within the National Institutes of Health as the National Institute on Minority Health and Health Disparities.

Anti-Drug Abuse Act

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The Act introduced mandatory minimum sentencing for trafficking cocaine, with harsher punishments for crack than for powder cocaine. The law resulted in disproportionately longer sentencing for Black people compared to White people. Prior to its enactment, the average federal drug sentence for Black people was 11% higher than for White people. Four years later, the average federal drug sentence for Black people was 49% higher than White people’s sentences. Mandatory minimum sentences for drug offenses continue to be used in federal courts today. Research shows racial and ethnic disparities in incarceration rates and finds that people with a history of incarceration have worse mental and physical health compared to the general population.

Immigration Reform and Control Act (IRCA)

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The Act introduced civil and criminal penalties for the conscious hiring of immigrants or individuals unauthorized to work in the U.S while offering legalization to undocumented immigrants who had immigrated prior to 1982. Building upon IRCA, the Illegal Immigration Reform and Immigration Responsibility Act of 1996 added resources for border policing and verification of employment credentials to enforce immigration restrictions. The legislation had multiple economic and health impacts on undocumented workers, including increased barriers to work, loss of benefits, such as health insurance, and higher likelihood of working in low-wage professions with no rights or protections from discrimination.

Emergency Medical Treatment and Active Labor Act (EMTALA)

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EMTALA required hospital emergency departments that accept Medicare payments to provide appropriate medical screening examinations and stabilization services to anyone seeking treatment for medical conditions, regardless of citizenship, immigration status, or ability to pay. EMTALA was enacted to mitigate concerns around “patient dumping,” a practice of hospitals transferring patients to another hospital without appropriate medical screening or treatment. However, recent research points to ongoing disparities in access to hospital care, finding that uninsured patients and patients with Medicaid coverage are more likely to be transferred to another hospital compared to patients with private coverage even when accounting for hospital care capabilities and patient characteristics. It also finds that uninsured patients are more likely to be discharged from the emergency department. Given that people of color are more likely to be uninsured and covered by Medicaid, they may be disproportionately affected by these transfer and discharge patterns.

1990 to 1999

The Americans with Disabilities Act (ADA)

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The ADA established civil rights to promote equal opportunity and independent living for all people with disabilities and banned discrimination based on disability in the realms of daily life as well as employment, schooling, and transportation. While this law was passed more than thirty years ago, people with disabilities still face challenges to accessing health care and disparities in health. American Indian and Alaska Native and Black people have a higher prevalence of disability compared to other groups.

The Disadvantaged Minority Health Improvement Act

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The Act amended the Public Health Service Act to address health concerns among individuals from disadvantaged communities, including people of color’s access to health care and health professionals. The Act established the provision of grants to provide primary health services to residents of public housing and replaced provisions and added new eligibility requirements related to grants provided to health professions schools for programs of excellence in education for minorities.

The National Institutes of Health (NIH) Revitalization Act

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The Act mandates the NIH to ensure the inclusion of women and people of color in NIH-funded clinical research in a manner appropriate to the research question under study to ensure generalizability to the entire population. However, challenges in achieving racial and ethnic diversity in clinical trials persist.  Analysis of data from 2000 to 2020 found that trials continued to under-enroll participants from underrepresented racial and ethnic groups. In 2022, the U.S. Food and Drug Administration issued new draft guidance aimed at increasing diversity in clinical trials.

The Family Medical Leave Act (FMLA)

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The FMLA requires certain employers to provide covered workers with unpaid, job-protected leave for family and medical reasons, including the birth or adoption of a child or care for serious illness or injury. While FMLA has been associated with positive impacts on parental and infant health outcomes, parental leave inequities persist, particularly in terms of access to paid leave. The FMLA has provided job security to millions of workers who need to take time off work for a qualifying reason; however, many workers remain unprotected by FMLA because small employers are exempt, and, even in covered worksites, not all employees are eligible. Bureau of Labor Statistics analyses have found that Hispanic and Black workers are less likely than their White counterparts to have access to paid family leave, and Black women are more likely than White women to report losing pay for missing work to care for kids who are sick and cannot attend school.

Violent Crime Control and Law Enforcement Act

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The Violent Crime Control and Law Enforcement Act of 1994, commonly referred to as the Clinton Crime Bill, was the largest federal crime bill, providing extensive federal funding for prisons, criminal prevention programs, police expansion, and the Justice Department. The bill contained provisions increasing law enforcement accountability and protections for survivors of sexual assault but increased the presence of police enforcement in neighborhoods of color, exacerbating racial disparities in criminal justice involvement. Black people are more likely to be killed by police than White people, and over the course of a lifetime 1 in every 1,000 Black men can expect to be killed by the police. Further, larger shares of Hispanic, Black, and American Indian and Alaska Native adults report recent experiences with police mistreatment compared with White adults. This disproportionate exposure to police violence has been found to have negative mental health outcomes for Black people. Research has found that people who live in neighborhoods with more stop-and-frisk encounters are more likely to have poor health outcomes.

Executive Orders that Address Climate Change and Environmental Justice

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President Clinton announced an Executive Order on Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations in 1994. The Executive Order directs federal agencies to identify and address disproportionate health and environmental impacts on “minority and low-income populations,” develop an environmental justice strategy, and promote nondiscrimination in federal programs that affect health and the environment as well as provide information to disproportionately impacted communities. In 2021, the Biden Administration issued an Executive Order on Tackling the Climate Crisis at Home and Abroad, which emphasizes a government-wide approach to address the climate crisis and established the National Climate Task Force and Office of Climate Change and Health Equity. In April 2023, the White House announced the Executive Order on Revitalizing Our Nation’s Commitment to Environmental Justice for All that reaffirms the whole-of-government commitment to environmental justice, directs federal agencies to consider measures to address and prevent disproportionate environmental and health impacts on communities, strengthen engagement with communities in decision making, advance science and research related to environmental justice, establish a new Office of Environmental Justice, and implement federal agency assessments of environmental justice efforts.

Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)

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The PRWORA, also known as the Welfare Reform Act, changed the federal financing structure for cash assistance for low-income families, established new eligibility criteria for accessing cash benefits, including mandatory work requirements, and imposed time limits on the receipt of cash benefits. The Act also established a new restriction that prevented many lawfully present immigrants from receiving federal non-cash public assistance benefits, including Medicaid, until five years after receiving “qualified” immigration status. Following the law, there were substantial declines in lawfully present immigrants’ use of all major benefit programs, including Medicaid, leading to increases in uninsured rates among immigrants. There were also declines in program participation among citizen children in low-income immigrant families. Disparities in coverage among lawfully present immigrants and children in mixed immigration status families persist today.

The Children’s Health Insurance Program (CHIP)

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CHIP is a joint federal-state program that provides health insurance coverage to uninsured children in families whose incomes are too high to qualify for Medicaid but who can’t afford private coverage that was created (originally as the State Children’s Health Insurance Program) as part of the Balanced Budget Act of 1997. Since its enactment, CHIP has played a pivotal role in reducing the uninsured rate for children, providing health insurance for many children of color and reducing racial disparities in children’s coverage, particularly for Black and Hispanic children. The program also has been found to have positive implications for school performance and long-term educational attainment.

2000 to 2019

Minority Health and Health Disparities Research and Education Act

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Congress passed this Act to support research on minority health and health disparities in addition to medical training for students from underrepresented backgrounds in 2000. The Act created the National Center on Minority Health and Health Disparities within the National Institutes of Health (NIH), which was redesignated as the National Institute on Minority Health and Health Disparities in 2010. The Center developed the first NIH Health Disparities Strategic Plan and Budget aimed at reducing and eliminating health disparities.

Hurricane Katrina

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Hurricane Katrina ravaged the Gulf Coast region in August 2005, with Louisiana, Mississippi, and Alabama bearing the brunt of the damage. The storm led to substantial loss of life and property damage and had significant health impacts, including negative impacts on people’s quality of life, worsening their financial situations, housing, health outcomes and health care access. Many of the storm’s adverse impacts were disproportionately distributed across racial and ethnic groups, with African American people being more likely to report financial troubles and issues with health coverage and housing compared to White people. Ten years after the storm, fewer African American residents reported that they felt helped by recovery efforts compared to White people.

The Immigrant Children’s Health Improvement Act (ICHIA)

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The ICHIA option was adopted as a part of the broader Children’s Health Insurance Program reauthorization law (CHIPRA). It allows states to receive federal funds for providing Medicaid and CHIP coverage to lawfully residing immigrant children and pregnant people without the five-year waiting period established by the Personal Responsibility and Work Opportunity and Reconciliation Act. Over time, a growing number of states have adopted the ICHIA option for children and pregnant individuals. While ICHIA has increased public insurance coverage for lawfully present children and pregnant people, there is no option to eliminate the five-year wait for lawfully present immigrant adults.

Patient Protection and Affordable Care Act (ACA)

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The ACA implemented a comprehensive set of health reforms, including large expansions in health insurance coverage through both the creation of health insurance Marketplaces with tax subsidies and an expansion of Medicaid to low-income adults. Data show that following implementation of the ACA coverage expansions in 2014, there were large gains in health coverage across racial and ethnic groups, with larger increases for people of color compared to White people that narrowed disparities in coverage. Despite these gains, racial and ethnic disparities in coverage remain. Adoption of the Medicaid expansion in the remaining non-expansion states could help further close coverage disparities. Research suggests that Medicaid expansion is linked to increased access to care and improvements in some health outcomes and has contributed to reductions in racial disparities in health coverage.

Deferred Action for Childhood Arrivals (DACA)

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The DACA policy was created through executive action by President Obama in 2012. DACA protects eligible young adults who were brought to the U.S. as children from deportation and provides them with work authorization for temporary, renewable periods. While DACA protects an individual from removal action for a certain time, it does not provide a pathway to U.S. citizenship. DACA has enabled over 900,000 immigrants to stay in the U.S., go to school, and contribute to the economy through gainful employment. Studies have found that DACA eligibility helps improve physical and mental health, and can improve the well-being of children of DACA recipients. However, people who are likely eligible for DACA are much more likely than U.S.-born individuals in their age group to be uninsured. When implemented, DACA recipients remained ineligible for federally funded health coverage. In April 2023, the Biden Administration began pursuing administrative action to expand eligibility for health coverage to DACA recipients.

Immigration to the U.S. from Central America

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Increases in migration into the U.S. from El Salvador, Guatemala, and Honduras in recent years have been fueled by political unrest, unprecedented levels of violence related to drug cartels, and gang activity in the Central American region. Changes in immigration and border policies have impacts on the health outcomes and experiences of immigrants, particularly at the U.S. border. Temporary Protected Status (TPS) for immigrants from El Salvador and Honduras was terminated in 2017 and 2018; however, effective June 9, 2023, people from these countries will be able to temporarily extend their TPS status. In 2023, the Biden Administration announced actions focused on increasing enforcement at the Southwest Border and extending TPS status for individuals from Venezuela.

Black Lives Matter (BLM) Movement

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The BLM movement was sparked by the murders of 17-year-old Trayvon Martin in 2012 and Michael Brown and Eric Garner in 2014. It has since become a clarion call to protest injustice against Black people internationally. In 2020, amplified by the police killing of George Floyd, the BLM movement inspired international protests against police brutality and brought attention to the systemic racism faced by the Black community. The combination of the COVID-19 pandemic, which disproportionately impacted communities of color, and the BLM protests shed light on the impact of racism and systemic discrimination on the health of people of color. Research also shows that Black people’s repeated and chronic exposure to stressors associated with racism and discrimination drive rapid biological aging and poorer health outcomes. Other recent research highlights the link between experiences with racism and discrimination and poorer health and well-being.

Travel Ban Executive Orders and Presidential Proclamations also Known as the “Muslim Travel Bans or Trump Travel Bans”

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Between 2017 and 2020, the Trump Administration issued  Executive Orders 13769 and 13780 and Presidential Proclamations 9645, 9723, and 9983 that limited the number of refugees admitted to the country, suspended the U.S. Refugee Admissions Program, and restricted travel into the United States from several countries, many of which are Muslim majority countries. In 2021, the Biden Administration issued the Proclamation on Ending Discriminatory Bans on Entry to the United States that revoked the Executive Orders and Presidential Proclamations. The series of Muslim Travel Bans was a continuation of racial profiling and Islamophobia directed toward Muslim people, Middle Eastern and North African people, and South Asian people, that had escalated following the September 11, 2001 attacks.

2020 to Present

COVID-19 Pandemic

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The COVID-19 pandemic negatively impacted the overall U.S. population, contributing to the most significant two-year decline in life expectancy experienced in the U.S. in roughly a century. However, the pandemic disproportionately affected some groups, including people of color, which may have long-term impacts on health and well-being and widen racial and ethnic disparities in health and health care. Following the onset of the pandemic, the federal government declared a public health emergency and enacted legislation to respond to COVID-19 and support people during the pandemic, including legislation that helped stabilize and expand health coverage. These changes included a temporary requirement that Medicaid programs keep people continuously enrolled during the pandemic in exchange for enhanced federal funds. However, the continuous enrollment provision in Medicaid ended in March 2023, and millions of people have been disenrolled since states began processing renewals.  

Increases in Anti-Asian Violence and Stop Asian Hate Movement

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Amid the COVID-19 pandemic, there was a significant rise in hate crimes against Asian people in the U.S. These recent events are reflective of ongoing discrimination against Asian and Native Hawaiian or Pacific Islander (NHOPI) people dating back to the 1800s. Growing awareness of anti-Asian violence and discrimination have heightened attention to addressing mental health needs among Asian and NHOPI people and improving availability of disaggregated data to understand their health needs. In response to the rise in anti-Asian actions, the Biden Administration implemented the COVID-19 Hate Crimes Act and an Executive Order on Advancing Equity, Justice, and Opportunity for Asian Americans, Native Hawaiians, and Pacific Islanders, which established the White House Initiative on Asian American, Native Hawaiians, and Pacific Islanders.

Addressing Disparities in Clinical Algorithms, Tools, and Guidelines

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Amid the COVID-19 pandemic, awareness of disparities stemming from clinical tools, algorithms, and guidelines increased. For example, low accuracy of pulse oximeters in measuring oxygen saturation in darker skin was found to potentially contribute to worse outcomes for Black and Hispanic patients with COVID-19. In addition, clinical calculators across multiple specialties assign differential risk for certain diseases or conditions based on race, which may contribute to undertreatment and overtreatment of some groups and lead to delays in diagnosis and clinical care. Race also plays a factor in some medication prescribing decisions. For example, the U.S. Food and Drug Administration approved BiDil as a race-specific drug to treat heart failure among Black people in 2005. While the drug is still approved as a race-based drug, there has been critique for misguided marketing due to inaccurately using race as a proxy for genotype. The health care system is increasingly using artificial intelligence and algorithms to guide health decisions. Research has shown that these algorithms may have racial bias because the underlying data on which they are trained may be biased and/or may not reflect a diverse population. There have been growing efforts within the medical community to re-evaluate and revise practices around the use of race within clinical care, including the American Medical Association’s adoption of new policies recognizing race as a social construct and the removal of race from clinical calculators in some institutions.

Title 42 Restrictions on Border Entry

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Title 42 is a public health authority that authorizes the Director of the Centers for Disease Control and Prevention to suspend entry of individuals into the U.S. to protect public health. This authority was implemented in response to the COVID-19 pandemic to allow for quick expulsion of migrants, including asylum seekers, seeking entry into the U.S. at the land borders. Research suggests that Title 42 expulsions negatively impacted the health and well-being of migrant families. Title 42 border restrictions were lifted on May 11, 2023, contributing to concerns about the potential impacts of rising immigration activity at the border

Declaration of Racism as a Serious Public Health Threat

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The Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report documented systemic racism as a major cause of racial health disparities in the United States in 2003. However, it was not until nearly twenty years later that the federal government declared racism a public health threat and identified addressing disparities and advancing racial health equity as key federal priorities. The stark impact of the initial COVID-19 pandemic on communities of color and growth in recognition of the harms caused by systemic racism following the police killings of George Floyd and Breonna Taylor highlighted the underlying impact of racism on health and well-being. Amid this growing recognition, the Centers for Disease Control and Prevention declared racism to be a serious public health threat and highlighted new efforts to address racism as a driver of racial and ethnic health inequities. Other medical societies and organizations, such as the American Medical Association, American Psychological Association, and states and localities also formally acknowledged the role of racism as a public health issue and outlined planned actions to address systemic racism and advance health equity.

Executive Orders on Advancing Equity

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President Biden issued an Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government on January 20, 2021. The Executive Order outlined equity as a priority for the federal government broadly, as well as a key part of the pandemic response and recovery efforts. Federal agencies were directed with developing Equity Action Plans that outlined concrete strategies and commitments to addressing systemic barriers across the federal government. Later in 2021, President Biden issued an Executive Order on Diversity, Equity, Inclusion, and Accessibility in the Federal Workforce.

Dobbs v. Jackson

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The June 2022 Supreme Court ruling in Dobbs v. Jackson overturned the longstanding Constitutional right to abortion and eliminated federal standards on abortion access that had been established by earlier decisions, allowing states to establish laws protecting or restricting abortion. People of color are likely to be disproportionately affected by state actions to prohibit or implement extensive restrictions on abortion, as they are more likely to seek abortions and more likely to face structural barriers that will make it more difficult to travel out of state for an abortion, including more limited access to health care and fewer financial and transportation resources. Increased barriers to abortion for people of color may widen the already existing large disparities in maternal and infant health, have negative economic consequences for families, and increase risk of criminalization for people of color.

Students for Fair Admissions Inc v. President and Fellows of Harvard College

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In June 2023, the Supreme Court ruled that institutions of higher education could no longer explicitly consider race as a factor in admissions decision-making processes. This decision is expected to decrease diversity in higher education, a trend that has been observed in states that eliminated affirmative action and experienced declines in enrollment for Black, Hispanic and Indigenous people. Leaders in the fields of medicine and public health have decried the decision stating that it could harm efforts to diversify the physician workforce, which could widen health disparities. Black and Hispanic people remain underrepresented in the U.S. physician workforce. Research shows that a racially and ethnically diverse health care workforce positively impacts health and health care access among underserved groups. Research also shows that Hispanic, Black, and Asian adults who have more visits with health care providers who share their racial or ethnic background report more frequent positive and respectful interactions with health care providers.

KFF would like to thank Dean Daniel Dawes, School of Global Health, Meharry Medical College; Dr. Gilbert Gee, Fielding School of Public Health, University of California, Los Angeles; and Dr. Michelle Tong, University of California, San Francisco School of Medicine for their invaluable inputs, insights, suggestions, and support throughout the planning and development of this project.

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