HHS’s Elimination of Disparate Impact to Determine Discrimination: Potential Implications for Health and Health Care

Introduction

On July 23, 2026, the Department of Health and Human Services (HHS) finalized revisions to regulations implementing Title VI of the Civil Rights Act of 1964 to eliminate disparate impact as a basis for determining whether discrimination has occurred in programs, services, or activities receiving HHS federal financial assistance. It was issued following Executive Order 14281, “Restoring Equality of Opportunity and Meritocracy,” and similar actions by other federal agencies, including the Department of Justice (DOJ), Department of Education (DOE), and Department of Housing and Urban Development (HUD). This issue brief provides background on Title VI, summarizes the key changes in the 2026 final rule, and discusses the potential implications for racial and ethnic health disparities.

The rule marks a significant change in the federal government’s approach to enforcing civil rights protections, which may have significant implications for its enforcement of civil rights law and health and health care disparities. The changes under the rule narrow the scope for administrative enforcement of civil rights law; may allow for policies and practices that lead to disparate outcomes in health and health care to remain in place, which may exacerbate disparities; and may reduce proactive review of whether policies and practices have unintended disproportionate effects on certain racial or ethnic or other protected groups.

Overview of the HHS Title VI Civil Rights Rule

Title VI of the Civil Rights Act of 1964 is a federal law that prohibits discrimination based on race, color, or national origin in programs and activities receiving federal financial assistance. It was enacted during the Civil Rights Movement in response to widespread racial discrimination by institutions receiving federal funds, including hospitals that refused to treat Black patients, maintained segregated wards and waiting rooms, or otherwise provided unequal care. Title VI has since served as a cornerstone of federal civil rights enforcement across health care, education, and other federally funded programs.

While the Supreme Court has interpreted Title VI to prohibit intentional discrimination, federal agencies historically implemented broader protections against discrimination through regulations. In its initial regulations implementing Title VI, HHS (then the Department of Health, Education and Welfare) and other federal agencies also prohibited disparate-impact discrimination. Disparate impact refers to policies or practices that have a disproportionately adverse effect on people of a particular race, color, or national origin, even when there is no evidence of intentional discrimination. These regulations recognized that facially neutral policies can perpetuate or exacerbate inequities in access to programs, services, and benefits.

In health care, disparate impact can arise from inequities embedded in institutional policies and practices, although intentional discrimination still persists. For example, historical discriminatory policies, such as redlining, have lasting effects today, leading to residential segregation of Black and Hispanic people into urban neighborhoods with more limited resources and increased health risks. Within medicine, disproven beliefs about biological differences by race persist today and have led to race permeating clinical decision making and treatment in multiple ways, including through its use in clinical algorithms, tools, and treatment guidelines. Similarly, language barriers can reduce the quality of care patients receive and increase the risk of adverse outcomes or medical errors. Studies have found that inadequate language assistance can delay patients’ access to timely care and contribute to suboptimal care and dissatisfaction with the care received, leading to poor chronic disease management and resulting in worse health outcomes. 

The federal government has used disparate-impact regulations for over 50 years to investigate and resolve policies and procedures of recipients of federal financial assistance that disproportionately negatively affect a protected group. For example:

• HHS’s Office for Civil Rights (OCR) investigated the proposed closure of University of Pittsburgh Medical Center (UPMC) Braddock, a hospital serving a predominantly Black community in Pennsylvania, to assess whether the closure would have a disparate impact on Black residents’ access to care. The investigation resulted in a voluntary resolution agreement requiring UPMC to implement measures to reduce potential barriers to care, including expanded transportation services, enhanced primary care and behavioral health services, and ongoing monitoring of the closure’s impact on the affected community.
• Similarly, OCR entered into a voluntary resolution agreement with Mee Memorial Hospital (MMH) following an investigation into allegations that the hospital had failed to provide meaningful language assistance to Triqui-speaking patients with limited English proficiency (LEP). Although the hospital was not intentionally withholding services from Mexican indigenous patients, it’s lack of language assistance disproportionately prevented them from receiving effective care. The agreement required the hospital to strengthen its language access policies, interpreter services, staff training, and monitoring.
• More recently,in 2021, HHS’s OCR and the DOJ investigated the Alabama Department of Public Health (ADPH) over concerns that its wastewater and public health practices disproportionately burdened Black residents of Lowndes County. The agencies reached an interim resolution agreement requiring ADPH to take steps to address the community’s longstanding exposure to raw sewage, including improving access to functioning septic systems, suspending criminal enforcement against residents unable to afford compliant systems, and strengthening public health data collection and infrastructure planning. In 2024, HHS and DOJ reported progress in implementing these reforms. However, in April 2025, the Trump Administration terminated the agreement, ending the federal agencies’ enforcement of the reforms.

Disparate-impact standards have also shaped HHS guidance to recipients about designing and administering programs and policies. For example, HHS issued guidance on serving individuals with LEP explaining that recipients could violate Title VI by using criteria or methods that had the effect of discriminating based on national origin and translated this standard into expectations for providing meaningful access to care. HHS’s Office of Minority Health (OMH) National Culturally and Linguistically Appropriate Services (CLAS) Standards also reflect principles underlying disparate-impact protections, particularly in their language access standards. During the COVID-19 pandemic, HHS’s OCR issued guidance advising that Title VI applied to procedures, criteria, and methods of administration that have a disparate impact based on race, color or national origin. The guidance specifically identified examples of disparate-impact discrimination that could arise in COVID-19 vaccination programs, such as requirements for vaccines to be distributed solely through pharmacies or appointments needing to be scheduled online, which could disproportionately limit access in communities of color, even in the absence of discriminatory intent. HHS also advised vaccine providers to review policies for barriers, collect and analyze demographic data, address language and transportation barriers, and locate vaccination sites in historically underserved communities. HHS also incorporated disparate-impact principles into a training curriculum for medical students by including examples of facially neutral health care policies that could disproportionately limit access for racial and ethnic communities and instructing participants to consider whether less discriminatory alternatives could achieve the same objectives.

Potential Implications of Eliminating Disparate Impact Enforcement

The 2026 final rule eliminates disparate impact as a basis for administratively enforcing Title VI under HHS’s implementing regulations. Under the revised regulations, HHS will enforce Title VI only when there is evidence of intentional discrimination based on race, color, or national origin. As a result, a policy or practice that disproportionately affects a protected group, by itself, is no longer sufficient to establish a violation of Title VI under HHS regulations. HHS states that these revisions are intended to align its regulations with the text of Title VI, Supreme Court precedent, and Executive Order 14281, “Restoring Equality of Opportunity and Meritocracy,” issued by President Trump on April 23, 2025, directing federal agencies to eliminate the use of disparate-impact liability. The final rule also clarifies that statistical evidence showing racial or ethnic disparities may still be considered as part of an investigation, but disparities alone are not sufficient to establish discrimination absent evidence of intentional discriminatory treatment.

The 2026 final rule marks a shift in HHS’s approach to investigating and resolving Title VI complaints and will likely have a range of implications for enforcement of civil rights law and health disparities. The changes under the rule:

• Narrow the scope for administrative enforcement of civil rights law. The rule changes what the federal government will identify as discrimination in its activities and investigations since the federal government will no longer enforce policies and procedures that result in disparate effects for protected groups but cannot be tied to intentional discrimination. Moreover, parties seeking administrative enforcement of the law will face a higher burden to demonstrate discrimination, since they must be able to show intentional discrimination.
• May allow for policies and practices that lead to disparate outcomes in health and health care to remain in place, which may exacerbate disparities. As noted, even in the absence of intentional discrimination, policies and procedures may lead to disparate impact for protected groups. For example, hospital or clinic closures; reductions in obstetric, behavioral health, or specialty services; provider network changes; transportation or service relocation decisions; eligibility or enrollment procedures; lack of effective language access services; and resource allocation decisions may lead to or exacerbate disparities because of longstanding differences in where individuals live and the resources they have available, where health care services are located, insurance coverage, transportation, and other social and economic factors. Moreover, the increasing use of artificial intelligence (AI) in health care and language services may exacerbate cases of disparate impact because underlying data, model design, or implementation may reinforce or widen existing disparities.
• Reduce incentives for HHS and recipients of federal financial assistance to ensure policies and practices are equitable and do not disproportionately adversely affect certain racial or ethnic groups or other protected groups. Without disparate impact as an enforcement standard, the federal government has reduced incentive to investigate policies and procedures for discrimination unless there are claims of intentional discrimination. Despite civil rights statutes remaining in full effect, federal funding recipients may have less incentive to proactively assess the equity implications of institutional decisions, policies, and procedures. Some organizations may continue to focus on equitable practices as a part of their accreditation standards, state laws, Medicaid requirements, quality improvement initiatives, or organizational priorities, but they will not be subject to federal enforcement to ensure equitable impacts or outcomes for the groups they serve unless there is evidence of intentional discrimination.

In the absence of Title VI disparate impact enforcement, other federal and state authorities may provide mechanisms for addressing disparate impacts, but these protections may have more limited reach and may apply to different protected groups, entities, programs, jurisdictions, or forms of discrimination than Title VI. For example, Section 1557 of the Affordable Care Act continues to prohibit discrimination in covered health programs based on race, color, national origin, disability, age and sex and includes requirements related to providing meaningful language access. However, the Administration has indicated it will make changes to Section 1557 implementing regulations. Medicaid also provides mechanisms for addressing disparities, particularly through managed care contracting practices, although efforts vary across states. States may also retain or establish their own protections against disparate-impact discrimination. For example, California statute prohibits discrimination in state-funded programs and activities based on a broader range of protected characteristics than Title VI with state regulations prohibiting practices with discriminatory effects, providing a state-level disparate impact standard similar to one the one eliminated from HHS’s Title VI regulations. Illinois also enacted the Civil Rights Safeguard Act in 2026, expanding existing state protections against disparate impact discrimination in employment, financial credit, and public accommodations, including health care.  However, without a federal standard of enforcement, protections and mechanisms to address discrimination will vary across states.