U.S. Department of Health and Human Services Agency Equity

U.S Department of Health and Human Services

AGENCY EQUITY ACTION PLAN

2023 Update pursuant to Executive Order 14091 on "Further Advancing Racial Equity and

Support for Underserved Communities Through the Federal Government"

HHS Equity Action Plan Leads:

Arsenio Mataka, Counselor to the Secretary

Miranda Lynch-Smith, Deputy Assistant Secretary for Human Services Policy,

Performing the delegable duties of the Assistant Secretary for Planning and Evaluation

HHS Equity Action Plan

Message from the Agency Head

the U.S. Department of Health and Human Services (HHS), we strive every day to advance the health

and well-being of the American people. Our work – from critical social services to breakthrough

scientific discoveries – impacts millions of families across the country. HHS is committed to making sure

that our positive impact is reaching and helping everyone.

Last year, I launched a policy-focused Secretary’s Challenge on Equity, to inspire our dedicated

workforce to be innovative in uncovering opportunities to support a robust wellness system for all.

What we collectively learned from that Challenge is that we have more work to do, such as identifying

and correcting gaps in our data standards to address equity, communicating more effectively with

diverse audiences, and strengthening our role in facilitating an inclusive health and human services

workforce. HHS is actively advancing these efforts and making the question of whether our reach is for

everyone’s benefit a central part of how we continuously improve our services.

I am proud to share our equity action plan for the upcoming year. Our areas of focus are: keeping

children safely at home with their families, enabling access to quality health care, strengthening

behavioral health and maternal health, and diversifying clinical research. These areas were selected

intentionally because they have been raised by communities, health care practitioners, and partners as

areas where we can be most impactful in supporting all people and families to thrive.

I look forward to sharing our regular progress over the coming year and demonstrating HHS’s continued

commitment and support to equity and better outcomes for all.

Xav

ier Becerra

Advancing Equity Through Agency Mission

he mission of HHS is to enhance the health and well-being of all Americans, by providing for effective

health and human services and by fostering sound, sustained advances in the sciences underlying

medicine, public health, and social services. For those services and science to be effective and for us to

realize our goal of shifting from an illness care system to a wellness care system, we need to

acknowledge and incorporate equity considerations into what we do so that we can influence social

drivers and ensure that differential circumstances do not lead to differential outcomes. Our vision is that

all people, including underserved populations, have optimal opportunities for healthy and thriving lives

with the support of HHS policies and approaches that are structurally designed and implemented to

reach, facilitate, and advance health and well-being for all.

HHS Equity Action Plan

Executive Summary of Equity Action Plan

HHS h

as selected five areas of focus for our 2023 equity action plan. These actions are a selection of

HHS’s work to advance equity. They correspond with HHS 2022-2026 strategic plan

and key Biden-Harris

Administration priorities for HHS. The plan also sits in parallel to specific efforts related to equity within

HHS’s family of agencies, such as the

ational Institute of Health’s strategic plan for diversity, equ

ity,

inclusion, and accessibility, the Administration for Children and Families’ equity in action commitments,

the Centers for Disease Control and Prevention’s

CORE commitment to equity and the Centers for

Medicare and Medicaid Services’

framework for equity. As such, this plan should be considered a

portion, but not the total, of our efforts to ensure that all people can enjoy optimal health and well-

being.

he five areas of this plan represent important opportunities for several HHS agencies to work together

to collectively advance equity in support of public health, medical care, human services, and well-being.

They include:

• Preventing Child Welfare System Involvement: We understand that families in poverty and

those in Tribal and other communities are impacted by the child welfare system more than

others, in some cases largely because they lack sufficient access to economic resources and

community networks. Our efforts will be directed at connecting families in need to supports that

enable them to stay together and preventing discriminatory and other practices that make it

difficult for children, youth, and families to heal when child welfare is involved.

• Promoting Accessible and Welcoming Health Care: A lack of health insurance coverage and

social and geographic barriers to care mean that not everyone is receiving health care that

meets their needs within their communities. Our actions will promote access to comprehensive

insurance coverage and quality care designed to meet the diverse needs of Americans so

everyone can benefit from preventive care and effective treatments.

• Improving Maternal Health Outcomes: Too many women, particularly racial and ethnic minority

populations, and those in rural areas, are losing their lives or health during pregnancy or after

giving birth. Our actions will address gaps in insurance coverage and the birthing care

infrastructure to ensure better maternal health outcomes.

• Meeting Behavioral Health Needs: The impact of the COVID-19 pandemic increased mental

health and substance use challenges for all populations, but disproportionately exacerbated the

already existing behavioral health disparities among underserved racial, ethnic, and sexual

minority populations. The rising rates of suicide, depression, anxiety, and substance misuse

among youth and adults are impacted by a decreasing workforce, limited resources,

underinsurance, and lack of culturally competent care. Our actions will improve access to

behavioral health care coverage and ensure that prevention and treatment are accessible and

meet the needs of all populations.

• Advancing Clinical Innovation: To increase our understanding of what treatments are most

effective for which populations, we need to increase the diversity of our research and clinical

trials to inform that science. Our actions will engage a more diverse set of populations in

informing our efforts and participating in clinical research so that we can innovate to improve

health and well-being outcomes.

We have identified these action areas through visits to communities, listening sessions and roundtables

with people impacted by these issues, grantee and research community discussions, Tribal

HHS Equity Action Plan

consultations, formal written invitations for comment, and more. HHS will continue to engage the public

on these action areas, our progress, and next steps throughout the year and beyond.

Equity Progress Update and Accomplishments

202

2 Equity Action Plan Update and Accomplishments. Our initial 2022 equity action plan

focused on

five areas: civil rights protections and language access, acquisitions, grants, capacity building and

maternal mortality. HHS remains committed to continuing progress in these areas. Select

accomplishments include:

Civil R

ights Protections and Language Access:

• Published draft rules on language access in all health programs and activities funded by the

Department. On August 4, 2022, the Office for Civil Rights (OCR) published a Notice of Proposed

ulemaking (NPRM), proposing comprehensive updates revisions to the Department’s

regulations implementing Section 1557, t

he nondiscrimination provision of the Affordable Care

Act.

See proposed rule. The proposed rule restores and strengthens civil rights protections for

patients and consumers in certain federally funded health programs and affirms protections

against discrimination on the basis of race, color, national origin, sex, including sexual

orientation and gender identity, age, and disability.

• Cre

ated a c

omprehensive structure for implementing HHS’s action plan and practices for

language access. The Department relaunched the HHS Language Access Steering Committee

(LASC), which is comprised of representatives from every HHS agency. The LASC will facilitate

the sharing of effective practices and procedures for enhancing language access.

• Ensured state compliance with language access and effective communication obligations

during and after public health emergencies

. On April 5, 2023, OCR dispatched a letter to state

health officials reminding states of their language access and effective communication

obligations under federal civil rights laws to ensure that individuals and families continue to

have access to Medicaid and Children’s Health Insurance Program (CHIP) coverage upon the

expiration of the Families First Coronavirus Response Act continuous enrollment condition.

Maternal Mor

tality

• Awarded Equity in Postpartum Care Challenge grants to identify successful and promising

approaches to improving postpartum care and equity in maternal health outcomes.

• Th

e Centers for Medicare & Medicaid Services (CMS) has

approved 42 states, DC and the

Virgin Islands to provide 12 months of continuous postpartum coverage through Medicaid and

CHIP (as of December 2023). An estimated 540,000 Americans annually are eligible for essential

care for a full year after pregnancy. HHS secured this option for states permanently in the

Consolidated Appropriations Act of 2023 and CMS will continue to work with states on

continuous coverage.

• CMS established a "Birthing Friendly” hospital designation

– a publicly-reported, public-facing

hospital designation on the quality and safety of maternity care (to be launched Fall 2023). CMS

will award this designation to hospitals that report they participated in a national or statewide

quality collaborative and implemented all recommended interventions.

• HH

S established a Nat

ional Maternal Mental Health Hotline on Mother’s Day 2022, which

provides 24/7, free, confidential emotional support, resources, and referrals before, during, and

HHS Equity Action Plan

after pregnancy in English and Spanish and offers interpreter services in more than 60

languages. During the first year, hotline counselors responded to nearly 12,000 calls and texts.

Grant

• Established guidance for HHS programs to use plain language in funding opportunities. The

Office of Grants is formally tracking and reporting readability statistics for all Notice of Funding

Opportunities (NOFOs) and related public documents. These documents must be easy to read

and understand to reach as many potentially qualified applicants as possible.

• Published an NPRM clarifying nondiscrimination on the basis of sex in certain HHS grants. HHS

OCR and Assistant Secretary for Financial Resources published an NPRM which states that, in

statutes administered by HHS that prohibit discrimination on the basis of sex, the Department

interprets those provisions to prohibit discrimination on the basis of sexual orientation and

gender identity. This NPRM further builds on HHS’ efforts to ensure access to health and human

services in furtherance of President Biden’s Executive Orders on

reventing and Combating

Discrimination on the Basis of Gender Identity and Sexual Orientation and Advancing Equality

for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals.

Acquisi

tions:

• Successfully launched the small business customer experience procurement forecasting tool

and increased small business procurement opportunities. HHS established the Small Business

Customer Experience (SBCX) system as the department-wide procurement forecasting tool for

small businesses. It is designed to reduce barriers to entry for small businesses and increase

competition. Use of this tool has generated over 5000 procurement opportunities for FY23,

which is double from the previous year.

Capacit

y Building:

• Provided practical and hands-on guidance to HHS offices on identifying actions to ensure

opportunity for all. To ensure all staff and offices understand how to assess for opportunities to

deliver our services equitably, HHS created learning opportunities and tools for internal use.

These include resources for engaging communities and people with lived experience and

requirements and opportunities to improve access for people with disabilities. Our assessment

tools helped HHS surpass our 2022-2023 Agency Priority Goal on equity. Many tools are

available publicly, including resources on conducting

equity assessments and equity in research

and analysis.

Env

ironmental Justice Scorecard (pursuant to section 223 of EO 14008): The President’s Justice40

Initiative sets a goal that 40 percent of the overall benefits of certain federal investments should reach

disadvantaged communities that are marginalized and overburdened by pollution and underinvestment.

These federal investments address climate change, clean energy and energy efficiency, clean transit,

affordable and sustainable housing, training and workforce development, remediation and reduction of

legacy pollution, and the development of critical clean water and wastewater infrastructure.

The Phase One Environmental Justice Scorecard provides an update on initial progress made by HHS in

implementing the Justice40 Initiative. Metrics and highlights in Fiscal Year 2022 include:

• 13 Justice40 covered program(s)

• 18 funding announcement(s) covered under the Justice40 Initiative

• $4.7 billion in funding made available from Justice40 covered programs

HHS Equity Action Plan

See

HHS’s progress on advancing environmental justice

to achieve health equity for communities across

America.

Add

itional Efforts to Advance Equity: HHS continues to advance equity across the Department and

partner with other federal agencies. Select accomplishments include:

• Guidance on Nondiscrimination in Telehealth for people with disabilities and limited English

proficient persons: HHS and U.S. Department of Justice (DOJ) issued a joint guidance document

on the protections in federal nondiscrimination laws, including the Americans with Disabilities

Act, Section 504 of the Rehabilitation Act of 1973, Title VI of the Civil Rights Act of 1964, and

Section 1557 of the Patient Protection and Affordable Care Act, regarding access to telehealth

for people with disabilities and limited English proficient persons. This document reminded

healthcare providers that while telehealth expands healthcare opportunities for individuals who

would otherwise be unable to receive healthcare in person, it must be provided in a manner

that is accessible to individuals with disabilities.

• LGBTQ+ Behavioral Health Equity Center of Excellence: The C

enter of Excellence on LGBTQ+

Behavioral Health Equity (CoE LGBTQ+ BHE) mission is to bring information and resources to the

behavioral health field to enhance culturally responsive care and decrease disparities for this

population and does so by providing training and technical assistance opportunities for

behavioral health professionals.

• Established HBCU-Connect, a new initiative with Historically Black Colleges and Universities

(HBCUs). The National Institute of Environmental Health Sciences, an Institute within NIH,

developed the initiative to inspire the development of environmental health science leaders

from diverse backgrounds. HBCU-Connect is a multifaceted effort to strengthen ties between

the institute and faculty and students at academic institutions that are often underrepresented

in the sciences.

Advancing Equity Through Key Legislation: HHS has key responsibilities in implementing the Inflation

Reduction Act (IRA)’s provisions related to prescription drug costs. HHS is working to ensure that all

eligible individuals, particularly seniors and people with disabilities, can feel the benefits of the IRA’s

health care cost-saving provisions and will be engaging with communities on IRA implementation

. HHS

along with the Departments of Labor and Treasury, is implementing the

No Surprises Act provisions

which reduce surprise medical billing. HHS is conducting outreach to ensure that all consumers are

aware of their rights and protections under the Act, including making resources available in multiple

languages to reach all communities.

HHS Equity Action Plan

HHS Strategies to Advance Equity in FY 2024

Strategy #1: Prevent neglect and improve care to help children thrive in their families and

communities

Whole-

of-Government Equity Objective(s): Health Equity, Civil Rights

Barriers t

o Equity:

• Families who are experiencing poverty are more likely to be reported to child protective services

(CPS) for neglect compared to families with more resources. The strategy seeks to better

resource families so that CPS intervention and foster care, which destabilizes families, is not

necessary.

• Certain populations of children and families experience structural barriers to resources and

services that meets their unique well-being needs – namely Black families, American Indian and

Alaska Native (AI/AN) families, LGBTQI+ youth, children and parents with disabilities and parents

with limited English proficiency.

Evidence Base to Support Strategy:

• Families with lower income and those in historically underserved communities are

overrepresented in the population of people reported to CPS agencies for neglect.

• A si

gnificant body of research has documented the overrepresentation of certain groups,

particularly Black, Hispanic/Latino, and American Indian/Alaska Native children and families, in

the child welfare system relative to their representation in the general population.

• Rese

arch shows that even modest increases in resources provided through several mechanisms

such as earned income tax credits (EITC), Supplemental Nutrition Assistance Program (SNAP) or

Temporary Assistance for Needy Families (TANF) benefits, can reduce CPS involvement and the

incidence of neglect.

3,4,5

Interventions that provide economic supports and concrete services

have been shown to reduce child maltreatment reports and foster care entry.

• LGB

TQI+ youth are overrepresented in foster care, often due to family lack of acceptance, and

experience more trauma, disruption in placements and extended stays in foster care than non-

Child Welfare Information Gateway. (2023). Separating poverty from neglect in child welfare. U.S. Department of

Health and Human Services, Administration for Children and Families, Children’s Bureau.

https://www.childwelfare.gov/pubs/bulletins-povertyneglect

Child Welfare Information Gateway. (2021). Child welfare practice to address racial disproportionality and

disparity. U.S. Department of Health and Human Services, Administration for Children and Families,

Children's Bureau. https://www.childwelfare.gov/pubs/issue-briefs/racial-disproportionality/

Johnson-Motoyama M, Ginther DK, Oslund P, Jorgenson L, Chung Y, Phillips R, Beer OWJ, Davis S, Sattler PL.

Association Between State Supplemental Nutrition Assistance Program Policies, Child Protective Services

Involvement, and Foster Care in the US, 2004-2016. JAMA Netw Open. 2022 Jul 1;5(7):e2221509. doi:

10.1001/jamanetworkopen.2022.21509. PMID: 35816315; PMCID: PMC9280401.

Puls, H.T., Hall, M., Anderst, J.D., Gurley, T., Perrin, J., Chung, P.J. (2021). State Spending on Public Benefit

Programs and Child Maltreatment. Pediatrics, 148 (5): e2021050685. 10.1542/peds.2021-050685

Johnson-Motoyama M and Ginther DK. (2022). Associations Between State TANF Policies, Child Protective

Services Involvement, And Foster Care Placement, Health Affairs. 41:12, 1744-1753.

https://doi.org/10.1377/hlthaff.2022.00743

Weiner, D.A., Anderson, C., & Thomas, K. (2021). System transformation to support child and family well-being:

The central role of economic and concrete supports. Chicago, IL: Chapin Hall at the University of Chicago.

HHS Equity Action Plan

LGBTQI+ youth.

Child welfare agencies who actively identify and ensure access to foster homes

that provide stable, supportive, and safe families for LGBTQ+ youth can nurture positive

outcomes for such youth.

• HHS civil r

ights cases show a continuing trend of discrimination in complaints against child

welfare agencies brought by or on behalf of children and/or parents with disabilities, including

those with substance use disorders.

Actions to Achieve Equity: To address these barriers, HHS will:

• Increase evidence-based prevention programs, services and supports to children and families

leveraging the Family First Prevention Services Act to enable more children to be supported in

their own homes.

• Provide increased guidance to regulated agencies and enforce nondiscrimination provisions to

better educate agencies of their responsibilities and available resources to facilitate intact family

support and reunification for all families.

• Intensify technical assistance efforts and issuance of policy guidance to states on ways to

disentangle poverty from states’ considerations of child neglect to reduce unnecessary CPS

interventions and trauma allowing more children to stay safely within their own families and

communities.

• Provide policy options and practice expectations for child welfare agencies on how they can

ensure the most appropriate, stable, family-like and caring placements for children, including

appropriate placements for LGBTQI+ youth and kinship care, to protect their well-being in foster

care and expedite return to their families when feasible/appropriate.

Proposed Metrics (Outputs and Outcomes):

ear- to Medium-Term

• Increased number of states and Tribes with Title IV-E prevention plans with culturally relevant

interventions to reduce disparities in foster care for children

• Increased proportion of federal spending on Title IV-E Prevention Activities relative to Title IV-E

foster care

• Increased voluntary adoption by state child welfare agencies of practices to protect families and

children from discrimination

nger-Term

• Increased rate at which children who have a child-specific prevention plan enter out of home

care within 24 months of their prevention plan start date

• Reduced proportion of children who are removed from their home with associated factors of

neglect and housing instability

• Increased placement stability for children in foster care

• Increased proportion of exits from foster care to reunification with family and discharge to

relatives

Baams, Wilson, & Russell, 2019; Matarese et al., 2021; Sandfort, 2020; Huggins et al., 2019; Conron & Wilson,

2019; Wilson & Kastanis, 2015

Child Welfare Information Gateway. (2021). Supporting LGBTQ+ youth: A guide for foster parents. U.S.

Department of Health and Human Services, Administration for Children and Families, Children's Bureau.

https://www.childwelfare.gov/pubs/LGBTQyouth/

HHS Equity Action Plan

Public Participation and Community Engagement:

• The Administration for Children and Families (ACF) hosted nine cross-sector summits

in 2022 to

build knowledge among partners about the economic mobility challenges facing their

communities. All regions engaged their state leaderships in promoting intentional engagement

of parents and others with lived experience to inform their policies and practices.

• ACF and states will continue partnering to engage communities ongoingly about child welfare

through the Child and Family Service Reviews

. This process ensures meeting federal child

welfare requirements, determining what is happening to children and families as they are

engaged in child welfare services, and assists states in enhancing their capacity to help children

and families achieve positive outcomes. Through these reviews, states and ACF engage

impacted communities – including youth, parents, foster parents, Tribes, courts and child

welfare workers - to review data on performance and identify strengths and areas needing

improvement within their agencies and programs.

HHS Equity Action Plan

Strategy #2: Promote Accessible and Welcoming Health Services for All

Whol

e-of-Government Equity Objective(s): Health Equity, Civil Rights

Barriers

to Equity:

• Certain populations continue to face barriers to quality, affordable health services, including

those with low-incomes, rural communities, households with a primary language other than

English, immigrants, Tribes/Native Americans, racial and/or ethnic minority communities,

LGBTQI+ populations, and persons with disabilities.

• Certain populations experience biased treatment and care.

• The health care workforce needed to provide care in underserved areas needs additional

supports to facilitate improved health care access and quality for populations that historically

face barriers to care.

• There continues to be an unequal distribution of physicians coupled with a physician shortage,

especially for certain specialties including primary care, dental health, and mental health

practitioners.

Evidence Base to Support Strategy:

• Lack of health insurance coverage continues to be a large barrier to accessing health care

services, and unequal distribution of coverage contributes to health disparities.

9,10,11

Studies

show that having health insurance is associated with improved access to health services and

better health monitoring.

12,13,14

• Soc

ial, economic, cultural, and geographic barriers continue to affect access to care, especially

for rural and Tribal communities, Native Americans, racial and ethnic minority, and low-income

populations.

15,16

Institute of Medicine (U.S.) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health

Care (2003). Unequal treatment: Confronting racial and ethnic disparities in health care (B. D. Smedley, A. Y. Stith,

& A. R. Nelson, Eds.). National Academies Press.

Call, K. T., McAlpine, D. D., Garcia, C. M., Shippee, N., Beebe, T., Adeniyi, T. C., & Shippee, T. (2014). Barriers to

care in an ethnically diverse publicly insured population: Is health care reform enough? Medical Care, 52(8), 720–

727.

Tolbert J., Drake P., Damico, A. (2022). Key Facts about the Uninsured Population. Kaiser Family Foundation.

https://www.kff.org/uninsured/issue-brief

/key-facts-about-the-uninsured-

population/#:~:text=One%20in%20five%20uninsured%20adults,health%20conditions%20and%20chronic%20disea

ses.

Baicker, K., Taubman, S. L., Allen, H. L., Bernstein, M., Gruber, J. H., Newhouse, J. P., ... & Finkelstein, A. N.

(2013). The Oregon experiment — effects of Medicaid on clinical outcomes. New England Journal of Medicine,

368(18), 1713–1722.

McWilliams, J. M., Zaslavsky, A. M., Meara, E., & Ayanian, J. Z. (2003). Impact of Medicare coverage on basic

clinical services for previously uninsured adults. JAMA, 290(6), 757–764.

Buchmueller, T. C., Grumbach, K., Kronick, R., & Kahn, J. G. (2005). Book review: The effect of health insurance

on medical care utilization and implications for insurance expansion: A review of the literature. Medical Care

Research and Review, 62(1), 3–30.

Call, K. T., McAlpine, D. D., Garcia, C. M., Shippee, N., Beebe, T., Adeniyi, T. C., & Shippee, T. (2014). Barriers to

care in an ethnically diverse publicly insured population: Is health care reform enough? Medical Care, 52(8), 720–

727.

Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to health care access in

the rural USA. Public Health, 129(6), 611–620. doi: 10.1016/j.puhe.2015.04.001

HHS Equity Action Plan

• According to Health Resources and Services Administration (HRSA) data, in areas where a health

workforce shortage has been identified, the U.S. needs over 17,000 primary care practitioners

12,000 dental health practitioners, and 8,200 mental health practitioners to address Americans’

current health needs.

• Evide

nce indicates that a workforce diverse in its experiences, supports enhanced access to care

for underserved areas and populations, including with locating services in underserve

communities, patient acceptance of preventive care, patient to clinician trust, clinician and

patient communication, and provision of culturally relevant care.

18,19,20,21,22,23

• Implic

it racial/ethnic bias among health care professionals can lead to differences in the quality

of health care services received by certain racial/ethnic populations and perpetuate existing

health disparities.

24,25

• Women

face individual-level barriers to accessing reproductive health care including lack of

insurance, difficulty obtaining appointments or accessing a clinic, not having a regular physician,

and fear of lack of confidentiality of services.

26,27,28

HRSA. (2023). Health Workforce Shortage Areas.https://data.hrsa.gov/topics/health-workforce/shortage-areas

Kington R, Tisnado D, Carlisle DM. Increasing racial and ethnic diversity among physicians: an intervention to

address health disparities? In Smedley BD, Stith AY, Colburn L, Evans CH, (eds.). The Right Thing to Do, The Smart

Thing to Do: Enhancing Diversity in the Health Professions. Washington, DC: National Academy Press, 2001.

Alsan, Marcella, Owen Garrick, and Grant Graziani. 2019. "Does Diversity Matter for Health? Experimental

Evidence from Oakland." American Economic Review, 109 (12): 4071-4111.

DOI: 10.1257/aer.20181446

Street R.L., O’Malley, K., Cooper, L., & Haidet, P. (2008). Understanding Concordance in Patient-Physician

Relationships: Personal and Ethnic Dimensions of Shared Identity. The Annals of Family Medicine, 6 (3) 198-205;

DOI: 10.1370/afm.821

Gonzalez H.M., Vega W.A., and Tarraf W. (2010). Health Care Quality Perceptions among Foreign-Born Latinos

and the Importance of Speaking the Same Language. The Journal of the American Board of Family

Medicine, 23 (6) 745-752; DOI: 10.3122/jabfm.2010.06.090264

Hoffman KM, Trawalter S, Axt JR, Oliver MN. (2016). Racial bias in pain assessment and treatment

recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci,

113:4296-4301.

Goodfellow, Amelia; Ulloa, Jesus G. MD, MBA; Dowling, Patrick T. MD, MPH; Talamantes, Efrain MD, MBA,

MSHPM; Chheda, Somil; Bone, Curtis MD, MHS; Moreno, Gerardo MD, MSHS. (2016) Predictors of Primary Care

Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature

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26469668; PMCID: PMC4638275.

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critical juncture in the lifecourse. Curr Opin Obstet Gynecol. 2010;22(5):369-374.

doi:10.1097/GCO.0b013e32833d9661

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sexual and reproductive health services in California: a cross-sectional survey. BMC Health Serv Res.

2021;21(1):1263. doi:10.1186/s12913-021-07278-3

Grindlay K, Grossman D. Prescription birth control access among US women at risk of unintended pregnancy. J

Womens Health (Larchmt). 2016;25(3):249-254. doi:10.1089/jwh.2015.5312

HHS Equity Action Plan

• LGBTQI+ populations face challenges accessing health care services resulting in worse health

outcomes due to stigma, discrimination, inequality in the workplace, and other barriers.

Additionally, changes in laws and policies have made it more difficult to access services,

including gender affirming care, in certain parts of the country.

• Amer

ican Indian and Alaska Native Tribal communities face historical challenges in accessing

timely and quality health care services due to chronic underfunding and staffing for healthcare

services, discrimination, poor infrastructure including limited cellular and broadband access,

remote locations, and living in health-care deserts with long-standing structural and

socioeconomic inequities among other barriers.

• A var

iety of evidence shows that a diverse workforce supports access to care including with

preventive care, patient to clinician trust, clinician and patient communication and culturally

relevant care.

32,33,34,35,36

Actions to Achieve Equity: To address these barriers, HHS will:

• Reduce bias in health care and research settings and increase access to quality, respectful,

accessible, culturally relevant and linguistically appropriate care for underserved groups across

the life course.

• Develop more culturally and linguistically inclusive practices and support nondiscrimination in

health care services.

• Support a diverse health care, public health, and research workforce, especially in medically

underserved and impoverished areas, health professional shortage areas and for providers who

are most trusted by communities such as peer workers and those engaged in community-

initiated care.

National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+

Populations. Washington, DC: The National Academies Press. https://doi.org/10.17226/25877.

Dawson, L., Kates, J., Musumeci, MB. (2023). Youth Access to Gender Affirming Care: The Federal and State

Policy Landscape. Kaiser Family Foundation. https://www.kff.org/other/issue-

brief/youth-access-to-gender-

affirming-care-the-federal-and-state-policy-landscape/

Smith, M. (n.d.) Native Americans: A Crisis in Health Equity.

https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-

state-of-healthcare-

in-the-united-states/native-american-crisis-in-health-equity/

Smedley BD, Stith AY, Colburn L, et al.; Institute of Medicine (US). The Right Thing to Do, The Smart Thing to Do:

Enhancing Diversity in the Health Professions: Summary of the Symposium on Diversity in Health Professions in

Honor of Herbert W.Nickens, M.D.. Washington (DC): National Academies Press (US); 2001. Increasing Racial and

Ethnic Diversity Among Physicians: An Intervention to Address Health Disparities? Available from:

https://www.ncbi.nlm.nih.gov/books/NBK223632/

Alsan, Marcella, Owen Garrick, and Grant Graziani. 2019. "Does Diversity Matter for Health? Experimental

Evidence from Oakland." American Economic Review, 109 (12): 4071-4111.DOI: 10.1257/aer.20181446

Street RL Jr, O'Malley KJ, Cooper LA, Haidet P. Understanding concordance in patient-physician relationships:

personal and ethnic dimensions of shared identity. Ann Fam Med. 2008 May-Jun;6(3):198-205. doi:

10.1370/afm.821. PMID: 18474881; PMCID: PMC2384992.

González HM, Vega WA, Tarraf W. Health care quality perceptions among foreign-born Latinos and the

importance of speaking the same language. J Am Board Fam Med. 2010 Nov-Dec;23(6):745-52. doi:

10.3122/jabfm.2010.06.090264. PMID: 21057070; PMCID: PMC2995948.

Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations,

and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A 2016;113:4296-

4301

HHS Equity Action Plan

• Improve access and address barriers to care by engaging community health workers and trusted

partners in rural communities, Tribal Communities, and other underserved communities

• Support continuity of coverage during Medicaid unwinding by working with states and external

partners on renewals and connections to other forms of health coverage.

• Develop resources or programs to increase the number of culturally appropriate and informed

health care materials and information available in-language for providers and partners.

• Advance social determinants of health (SDOH) research and adverse childhood experiences

(ACEs) research to better identify and address structural barriers to healthcare access and

influence positive outcomes .

Proposed Metrics (Outputs and Outcomes):

Near- t

o Medium-Term

• Changes in demographics of health care professionals including their service locations as well as

the number of nurses and physicians who are members of, or have a history of service to,

underrepresented minority communities

• Changes in and patterns of services accessed by patients including medical, dental, mental

health, substance use disorder, vision, and enabling services

• Trends in demographic characteristics of total health center patients

• Trends related to health center patient income and insurance status

• Number and percentage of health center patients who are experiencing homelessness, are

agricultural workers or dependents, served at a health center located in or immediately

accessible to a public housing site

• Changes in health insurance and Medicaid coverage by state

• Changes in the development and use of culturally appropriate and informed health care

resources for providers and partners

Longer-Term

• Improved health outcomes for underserved populations and communities

• Increased equity in access to affordable, high quality, culturally appropriate health care

Public Participation and Community Engagement:

• The HHS Office for Civil Rights (OCR) has been holding a series of convenings across the country

on EO 14079 on Securing Access to Reproductive Health and Other Healthcare Services as part of

OCR’s continuing efforts to hold national and regional convenings with health care providers,

civil rights organizations, patient advocates, and provider associations to raise awareness of

Federal non-discrimination laws that protect individuals’ access to appropriate reproductive

health care.

• Subject matter experts are engaged in the development of HHS Office of Minority Health (OMH)

Think Cultural Health e-learning programs, aimed at building knowledge and skills in providing

culturally and linguistically appropriate services, to provide input on e-learning program

curricula and content.

• OMH held listening sessions with subject matter experts and community representatives, on

topics including community health worker sustainability and language access.

•

The NIH UNITE Initiative for Ending Structural Racism hosted 14 listening sessions with external

stakeholders who work and serve in diverse settings related to biomedical or behavioral

sciences. The insights shared provided valuable information on the full range of issues and

challenges facing diverse talent and will help develop UNITE priorities and an action plan.

HHS Equity Action Plan

Strategy #3: Improve Maternal Health Outcomes for Rural, Racial and Ethnic Minority

Communities

Whole-of-

Government Equity Objective(s): Health Equity

Barriers to

Equity:

• Maternal health outcomes vary by race, ethnicity, and rurality across the U.S. Key drivers of

poor maternal health outcomes include lack of provider and service availability, lack of tailored

interventions, cultural bias and relevant evidence on the safety and effectiveness of

technological innovations, data lags, and inadequate preventive and supportive care.

• Social and environmental determinants of health such as income, housing, nutrition climate-

related exposures such as extreme heat and air pollution, underlie many of the risk factors that

contribute to poor maternal health outcomes.

Evidence Base to Support Strategy:

• According to the CDC Pregnancy Mortality Surveillance System, women in rural areas are 60%

more likely to die during the perinatal period than women in urban areas.

• Pregna

ncy related death rates are three times higher among Black individuals and two times

higher among AI/AN individuals compared to White individuals.

• Although His

panics/Latinos have lower rates of maternal mortality, they have higher levels of

severe maternal morbidity than non-Hispanic White populations.

• Addit

ionally, although data are limited, Native Hawaiian and Other Pacific Islander (NHOPI)

populations also have higher rates of both maternal mortality and morbidity.

• Accordi

ng to the CDC- supported Maternal Mortality Review Committees data from 2017-2019,

more than 80% of maternal deaths are preventable, meaning that a “reasonable change to

patient, community, provider, facility or system factors” could have averted death.

• Enviro

nmental exposures related to climate change have a disproportionate effect on pregnant

women through influencing food and water security, civil conflicts, extreme weather events, and

the spread of disease.

Actio

ns to Achieve Equity: To address these barriers, HHS will:

CDC. (2023). Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternal-

mortality/pregnancy-mortality-surveillance-system.htm#urban-rural

CDC. (2022). Infographic: Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016.

https://www.cdc.gov

/reproductivehealth/maternal-mortality/disparities-pregnancy-related-

deaths/infographic.html

Howell EA, Egorova NN, Janevic T, Balbierz A, Zeitlin J, Hebert PL. Severe Maternal Morbidity Among Hispanic

Women in New York City: Investigation of Health Disparities. Obstet Gynecol. 2017 Feb;129(2):285-294. doi:

10.1097/AOG.0000000000001864. PMID: 28079772; PMCID: PMC5380443.

Maykin M, Tsai SP. Our Mothers Are Dying: The Current State of Maternal Mortality in Hawai'i and the United

States. Hawaii J Health Soc Welf. 2020 Oct 1;79(10):302-305. PMID: 33047104; PMCID: PMC7547177.

CDC. (2022). Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States,

2017–2019. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html

Veenema RJ, Hoepner LA, Geer LA. Climate Change-Related Environmental Exposures and Perinatal and

Maternal Health Outcomes in the U.S. Int J Environ Res Public Health. 2023 Jan 17;20(3):1662. doi:

10.3390/ijerph20031662. PMID: 36767030; PMCID: PMC9914610.

HHS Equity Action Plan

• Increase access and use of health care services by continuing to promote state implementation

of 12- month postpartum coverage extension in Medicaid and CHIP to improve health insurance

coverage for postpartum people, including the 40 percent of U.S. births covered by Medicaid

and CHIP.

• Increase screening for maternal depression and substance use disorder (SUD) during the

postpartum period to decrease maternal mortality.

• Address maternal/birthing care deserts and the maternity/birthing care safety net by

strengthening birthing care infrastructure, including a focus on obstetrics (OB) readiness,

especially in rural communities and Tribal communities.

• Build a competent and diverse workforce for maternal care pre- and post-birth, including

midwives, doulas, promotoras and other non-OB (non-stigmatizing) community-based settings.

• Establish a task force focused on maternal mental health and perinatal mental health.

• Increase funding for economic development and social mobility for Tribal communities and

families through grants and training and technical assistance.

Proposed Metrics (Outputs and Outcomes):

ar- to Medium-Term

• Changes in maternal mental health, mortality rates, and other health indicators

• Number of partnerships established in Tribal communities, rural communities, low-income and

low-resourced communities, and other high need areas

• Changes in access to primary care across the perinatal spectrum

• Number of states and territories that extend Medicaid coverage for a full 12 months

• Changes in impact and number of people who benefit from expanded Medicaid postpartum care

• Changes in number of hospitals with “birthing friendly” hospital designation

• Changes in number of conversations with the National Maternal Mental Health Hotline

counselors

• Changes in the number of health center obstetrician/gynecologist and certified nurse midwife

full-time equivalents and the number of clinic (in-person) and virtual visits to those providers

• Changes in prenatal care provided directly to health center patients or by referral

• Changes in the percentage of mothers enrolled in home visiting prenatally (or within 30 days

after delivery) who received a postpartum visit with a healthcare provider within 8 weeks of

delivery

• Changes in the percent of primary caregivers enrolled in home visiting who are screened for

depression within 3 months of enrollment or delivery

Longer-Term

• Improved maternal health outcomes for high-risk populations and communities

• Increased equity in access to affordable, high quality, culturally appropriate maternal health

care

Publi

c Participation and Community Engagement:

• CMS Center for Medicaid and CHIP Services seeks public comment annually regarding updates

to the Medicaid and CHIP Maternity Core Set. The public comments resulted in the addition of

Postpartum Depression Screening and Follow Up measure, as well as an Immunization in

HHS Equity Action Plan

Pregnancy Measure, to the Core Sets. These measures are used by CMS to measure and

evaluate progress toward improvement of maternal and perinatal health in Medicaid and CHIP.

• C

MS Center for Medicaid and CHIP Services (CMCS) engages, and consults states regularly as

part of the Quality Improvement Technical Assistance work through the Maternal and Infant

Health Initiative (MIHI). Group participants are encouraged to reach out to their beneficiaries to

determine barriers to improving quality on metrics, such as attendance at postpartum care or

infant well-child visits, transportation issues, or difficulty scheduling. These consultations help

inform states of barriers encountered by beneficiaries.

• HHS OMH and CMS CMCS held a listening session to gather consumer feedback regarding using

inclusive maternal language (especially as it relates to the word “maternal” and non-binary or

gender conforming people). Participants included professionals with direct clinical, research, or

system-level expertise on inclusive language or experience in providing affirming care for non-

binary and transgender patients. One key takeaway was that Inclusive language is important to

make people feel cared for by their providers.

• NIH sponsored the Connecting the Community for Maternal Health Challenge to encourage and

reward nonprofit community-based or advocacy organizations to develop research capabilities

and infrastructure to pursue maternal health research projects. The challenge offered

approximately $3 million in prizes, distributed across multiple phases of the competition to

organizations that successfully completed the objectives and requirements of each phase. Three

webinars introduced the challenge sponsors at NIH, provided general guidance on proposal

submission, and shared the opportunities that participation in this challenge provide. Ongoing

webinars are providing guidance to participants in building and sustaining their research

activities.

HHS Equity Action Plan

Strategy #4: Prioritize the Behavioral Health of Underserved Populations

Whole-

of-Government Equity Objective(s): Health Equity

Barriers t

o Equity:

• Some populations are at higher risk of experiencing behavioral health challenges and some also

face barriers to accessing mental and behavioral health care services, including racial and ethnic

minorities, American Indian and Alaska Natives, rural populations, persons with disabilities,

LGBTQI+ adults and youth, older adults, and other populations.

• There continues to be several workforce challenges among mental and behavioral healthcare

providers, including shortages, geographic maldistribution, lack of diversity, and burnout.

Evid

ence Base to Support Strategy:

• Youth behavioral health has worsened. In the past decade, the percentage of students across

every Tribal, racial and ethnic group feeling persistently sad or hopeless increased.

Female

students, LGBTQI+ students, and students who had any same-sex partners were more likely than

their peers to experience poor mental health and suicidal thoughts and behaviors.

• Behav

ioral health challenges are especially acute for the American Indian and Alaska Native

population. The percentage of AI/AN persons aged 12 or older in 2021 with a past year

substance use disorder (27.6%) was higher than among other racial or ethnic groups.

Percentage of AI/AN persons aged 18 or older in 2021 with any mental illness (26.6%) was

higher than among almost all other racial or ethnic groups.

• Accord

ing to the 2021 National Survey on Drug Use and Health, the percentage of adults with

any mental illness in the past year who received mental health services was lower among Asian

(25.4%), Hispanic or Latino (36.1%), or Black or African American adults (39.4%) than among

White (52.4%) adults.

• Adults wi

th disabilities, compared with those without disabilities, experience more mental

distress and are more likely to experience factors associated with a higher occurrence of mental

disorders, including poverty and limited health care access.

• Prev

enting adverse childhood experiences is key to reducing behavioral health challenges.

adverse child experiences and their social drivers are interdependent, comprehensive and

CDC. (2023). Youth Risk Behavior Survey Data Summary & Trends Report.

https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf

CDC. (2023). Youth Risk Behavior Survey Data Summary & Trends Report.

https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf

SAMHSA. (2022). Key Substance Use and Mental Health Indicators in the United States: Results from the 2021

National Survey on Drug Use and Health.

https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHFFRRev010323.pdf

SAMHSA. (2022). Key Substance Use and Mental Health Indicators in the United States: Results from the 2021

National Survey on Drug Use and Health.

https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHFFRRev010323.pdf

SAMHSA. (2022). Highlights by Race/Ethnicity for the 2021 National Survey on Drug Use and Health.

https://www.samhsa.gov/data/sites/default/files/2022-12/2021NSDUHFFRHighlightsRE123022.pdf

Cree RA, Okoro CA, Zack MM, Carbone E. Frequent Mental Distress Among Adults, by Disability Status, Disability

Type, and Selected Characteristics - United States, 2018. MMWR Morb Mortal Wkly Rep. 2020 Sep 11;69(36):1238-

1243. doi: 10.15585/mmwr.mm6936a2. PMID: 32914770; PMCID: PMC7499832.

Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and

Implications for Prevention — 25 States, 2015–2017

HHS Equity Action Plan

integrated approaches to support children and their families in their communities are

essential.

• Access

to care continues to be an issue. In 2021 fewer than half of people with a mental illness

were able to access timely care.

Rural areas and economically disadvantaged cities have less

behavioral health care providers serving the community,

52,

and many behavioral health

providers report burnout which can further challenge quality care.

Actions

to Achieve Equity: To address these barriers, HHS will:

• Support the development of an inclusive behavioral health workforce that may deliver quality

healthcare to diverse populations.

• Increase Behavioral Health Integration in clinical and non-clinical settings and continued

investments in school-based health services to improve access for underserved communities,

inclusive of emerging providers and trusted community facilitators.

• Focus on prevention and treatment for high-risk populations, including the mental health of

children, including infants and toddlers, and youth.

• Expand suicide prevention and crisis work for high-risk populations and underserved

communities to include culturally appropriate and in-language crisis services, as well as follow-

up and evaluation after delivery of crisis care.

• Work with the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Centers

of Excellence and relevant collaborators to address the behavioral health needs of specific

underserved communities.

• Work with the Departments of Labor and the Treasury to publish rules implementing new

Mental Health Parity and Addiction Equity Act (MHPAEA) requirements to ensure that private

insurance and self-funded, non-governmental plans provide their enrollees with access to

behavioral health care that is in parity with coverage of medical and surgical care

• Publish a report regarding the use of telehealth to address behavioral health service barriers and

increase access to behavioral health care, as well as provide resources to facilitate broader use

of telehealth for behavioral health care.

ASPE. (2022). HHS Behavioral Roadmap for Behavioral Health Integration.

https://aspe.hhs.gov/sites/d

efault/files/documents/4e2fff45d3f5706d35326b320ed842b3/roadmap-behavioral-

health-integration.pdf

SAMHSA. (2023). 2021 NSDUH Detailed Tables. https://www.samhsa.gov/data/report/2021-nsduh-detailed-

tables

University of Michigan Behavioral Health Workforce Research Center. Estimating the Distribution of the U.S.

Psychiatric Subspecialist Workforce. Ann Arbor, MI: UMSPH; 2018. https://behavioralhealthworkforce.org/wp-

content/uploads/2019/02/Y3-FA2-P2-Psych-Sub_Full-Report-FINAL2.19.2019.pdf

Mental Health Care Health Professional Shortage Areas (HPSAs). Kaiser Family Foundation.

https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-

hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Substance Abuse and Mental Health Services Administration (SAMHSA): Addressing Burnout in the Behavioral

Health Workforce Through Organizational Strategies. SAMHSA Publication No. PEP22-06-02-005. Rockville, MD:

National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services

Administration, 2022.

HHS Equity Action Plan

• Encourage states to implement an innovative service delivery system to facilitate successful

reentry transitions for Medicaid-eligible individuals leaving prisons and jails and returning to the

community.

Proposed Metrics (Outputs and Outcomes):

ar- to Medium-Term

• Changes in behavioral health outcomes for high-risk populations

• Changes in and patterns of services accessed by patients including medical, dental, mental

health, substance use, vision, and enabling services

• Number of partnerships with non-clinical and school settings and assess utilization of resources

• Degree of behavioral health integration into primary care

• Number of trainings and technical assistance activities conducted by SAMHSA Centers of

Excellence

• Utilization of the 988 Crisis Contact Centers available in English and Spanish text and chat

Longer-Term

• Improved mental and behavioral health outcomes for high-risk populations

• Increased equity in access to affordable, high quality, culturally appropriate behavioral health

care

• Overall reductions in the economic and social barriers that contribute to poor mental or

behavioral health outcomes

Publi

c Participation and Community Engagement:

• SAMHSA and the White House Initiative on Asian Americans, Native Hawaiians and Pacific

Islanders (AANHPI) convened a Summit on AANHPI Mental Health

in July 2023. Four key issues

emerged: Anti-AANHPI Hate, Language Justice, Behavioral Health Workforce, and Engaging with

988. Partners in this meeting made commitments to these Action Plans. SAMHSA hosted a

follow-up working meeting of AANHPI leaders from communities, advocates, practitioners,

researchers, national organizations, foundations, technology companies, and federal partners to

develop action plans on the four themes.

• SAMHSA sponsored a Behavioral Health Equity Challenge focused on innovative outreach and

eng

agement strategies that connect communities to behavioral health services in underserved

communities. From 426 entries, ten community -based organizations were selected as winners

of the challenge in August 2023. These winners presented and documented the impact of their

innovative strategies in mental health, substance use prevention, and substance use treatment

across historically underserved communities. Recognition will be given to these winners through

various presentations and showcases sponsored by SAMHSA.

• SAMHSA hosted a Policy Academy on Black Youth Suicide to develop a strategic plan to address

high rates of suicide among Black youth. Teams from 8 states (GA, IN, KY, LA, MD, OH, OR, PA)

convened to address their specific state’s needs, work with experts in suicide prevention, and

develop policy strategies to take back to their states. They will continue to receive technical

assistance sponsored by SAMHSA and report back.

• Since 2022, Secretary Becerra and HHS leaders have been traveling across the country

to hear

directly from Americans about the mental health challenges they're facing and engage with local

leaders to strengthen the mental health and crisis care system in our communities.

HHS Equity Action Plan

Strategy #5: Increase Clinical Research and Trial Diversity to Support Innovation

Whole-of-Government Equity Objective(s): Health Equity

Barriers to

Equity:

• Racial and ethnic minority populations, AI/ANs, older adults, women, pregnant and lactating

individuals, LGBTQI+ adults and youth, and persons with disabilities continue to be

underrepresented in clinical trials, stifling health care innovation, and hindering the

generalizability of effective treatments.

• Lack of diversity in clinical research has the potential to hinder innovation. Including populations

that have been underrepresented in clinical trials and medical studies can help researchers

better understand variation in the safety and effectiveness of interventions, identify new

biological processes, and lead to new discoveries that can benefit other populations.

• Eviden

ce from clinical studies help inform health recommendations, insurance coverage, and

reimbursement of healthcare services. Without representation of specific groups in trials and

studies, we may lack confidence about how new therapeutics will impact all populations. A lack

of representation in clinical studies can impede access to effective medical interventions for

underrepresented groups if they are not included to build the evidence base to begin with.

• Addit

ional barriers contributing to underrepresentation of racial and ethnic minority patients’

participation in clinical trials include mistrust or fear and stigma of participation, lack of comfort

with the clinical trial process, lack of information about clinical trials, time and resource

constraints associated with clinical trial participation, and lack of clinical trial awareness.

Evide

nce Base to Support Strategy:

• Currently, large swaths of the U.S. population, and those that often face the greatest health

challenges, are less able to benefit from clinical research discoveries because they are not

adequately represented in clinical research studies.

National Academies of Sciences, Engineering, and Medicine; Policy and Global Affairs; Committee on Women in

Science, Engineering, and Medicine; Committee on Improving the Representation of Women and

Underrepresented Minorities in Clinical Trials and Research; Bibbins-Domingo K, Helman A, editors. Improving

Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups.

Washington (DC): National Academies Press (US); 2022 May 17. 2, Why Diverse Representation in Clinical Research

Matters and the Current State of Representation within the Clinical Research Ecosystem. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK584396/

National Academies of Sciences, Engineering, and Medicine; Policy and Global Affairs; Committee on Women in

Science, Engineering, and Medicine; Committee on Improving the Representation of Women and

Underrepresented Minorities in Clinical Trials and Research; Bibbins-Domingo K, Helman A, editors. Improving

Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups.

Washington (DC): National Academies Press (US); 2022 May 17. 2, Why Diverse Representation in Clinical Research

Matters and the Current State of Representation within the Clinical Research Ecosystem. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK584396/

Clark, L.T., Watkins, L., Piña, I.L., Elmer, M., et al. (2019). Increasing Diversity in Clinical Trials: Overcoming Critical

Barriers, Current Problems in Cardiology, 44, (5),

148-172, 0146-2806.https://doi.org/10.1016/j.cpcardiol.2018.11.002

National Academies of Sciences, Engineering, and Medicine. 2022. Improving Representation in Clinical Trials

and Research: Building Research Equity for Women and Underrepresented Groups. Washington, DC: The National

Academies Press. https://doi.org/10.17226/26479

HHS Equity Action Plan

• Racial and ethnic minority populations and AI/ANs continue to be underrepresented in clinical

trials and clinical research. Older adults, women, children, pregnant and lactating individuals,

LGBTQI+ populations, and persons with disabilities remain underrepresented and may be

impacted by enrollment criteria that limit their ability to participate in research.

Acti

ons to Achieve Equity: To address these barriers, HHS will:

• Ensure people most affected by health challenges are represented in studies and clinical trials

and medical products/device testing to better reflect the full spectrum of populations who are

affected by the disease or condition for which a product/treatment is being developed, if

approved.

• Engage communities throughout the entirety of the research process and study design to build

trust and improve transparency and accountability.

• Engage Tribal communities throughout the research process to ensure honoring of tribal

sovereignty, data sovereignty, and to engender trust, transparency, and accountability.

• Advance engagement with diverse communities to build trust and improve representation in

clinical trials and studies by providing education, creating collaborative research opportunities,

and hosting public meetings and webinars.

• Engage a more diverse set of populations in informing our efforts and participating in clinical

research, respecting tribal sovereignty and data ownership, so that we can innovate to improve

health and well-being outcomes.

Proposed Metrics (Outputs and Outcomes):

Near- to

Medium-Term

• Trends in recruitment and report clinical trial demographics, including sex, age, race/ethnicity

and sexual orientation and gender identity data, compared to populations affected by the

disease or condition being studied

• Increase in the number of community group and research/medical center partnerships with

those who have experience working with the populations impacted by the disease or condition

being studied

• Increase in the number of clinical research studies with enrollment addresses of the populations

affected by the disease or condition being studied

• Increase in the number of engagements with communities, including Tribal communities,

throughout the research process to engender trust, transparency, and accountability

• Increase in the development and use of culturally and linguistically tailored materials and

information, patient navigators, and community health workers

Longer-Term

• Enhanced patient understanding of the importance of clinical trials and the clinical trials process

• Increased diversity of clinical trial participants

National Academies of Sciences, Engineering, and Medicine. 2022. Improving Representation in Clinical Trials

and Research: Building Research Equity for Women and Underrepresented Groups. Washington, DC: The National

Academies Press. https://doi.org/10.17226/26479

HHS Equity Action Plan

Public Participation and Community Engagement:

• The National Institute on Minority Health and Health Disparities (NIMHD), an Institute within

NIH, hosted the Inclusive Participation in Clinical Research Workshop to improve inclusive

participation and implementation of best practices in clinical research through discussion with

interested groups, including community-based organizations, academic institutions, federal

agencies, and pharmaceutical companies. Workshop participants learned about the multi-

faceted approach necessary to improve inclusion in clinical research, methods utilized to

overcome challenges, and lessons learned.

• The National Institute on Aging (NIA), an Institute within NIH, manages Alzheimer's & Dementia

Outreach, Recruitment & Engagement Resources (ADORE

), which offers a repository of

resources to support the recruitment and retention of participants into clinical trials and studies

on Alzheimer’s disease and related dementias. This includes resources developed through

community engagement and related to working with people living with Alzheimer's disease and

related dementias in clinical research.

•

The

National Institute of General Medical Sciences (NIGMS), an Institute within NIH, manages

the Institutional Development Award (IDeA) program, which is a congressionally mandated

program that builds research capacity in states that historically have had low levels of NIH

funding. It supports competitive basic, clinical, and translational research, faculty development,

and infrastructure improvements. Additionally, the

IDeA Clinical and Translational Research

Programs

focus on community engagement by building hubs for recruitment and relationship

development in communities in IDeA states.

• The Na

tional Institute of

Diabetes and Digestive and Kidney Diseases (NIDDK), an Institute within

NIH, hosted a workshop: “Optimizing Clinical Trials in Chronic Disease,” to discuss best practices

for planning, preparing, and implementing clinical trials, including recruiting and retaining a

representative study population. Workshop participants included patients, advocacy groups,

pharmaceutical companies, federal agencies, and academic/medical centers. Takeaways

included the importance of considering patient perspectives in planning and implementing

trials, barriers to participation and methods to address barriers, and the role of sponsors in

supporting efforts to create inclusive trials.