Advancing Racial Equity and Support for Underserved Communities Through the Federal Government (HHS Policy Initiatives)

Advancing Racial Equity and Support for Underserved Communities Through the Federal Government (HHS Policy Initiatives) is sponsored by U.S. Department of Health and Human Services (HHS). This initiative supports the development and implementation of new policies and innovative practices to address policies that may create or perpetuate health disparities and contribute to structural racism. It aligns with Executive Order (E.

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A service of the National Library of Medicine, National Institutes of Health. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of Federal Policies that Contribute to Racial and Ethnic Health Inequities; Geller AB, Polsky DE, Burke SP, editors. Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity.

Washington (DC): National Academies Press (US); 2023 Jul 27. Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity. Show details National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of Federal Policies that Contribute to Racial and Ethnic Health Inequities; Geller AB, Polsky DE, Burke SP, editors.

Washington (DC): National Academies Press (US) ; 2023 Jul 27. Hardcopy Version at National Academies Press 5 Health Care Access and Quality As described throughout this report, racial, ethnic, and tribal health inequities are created and sustained by factors both inside and outside of the health care system.

However, health is strongly tied to the health care system—a healthy population requires access to high-quality, comprehensive, affordable, timely, respectful, and culturally appropriate health care.

The health care system serves as an important setting for delivery of care and treatment, individual- and population-level prevention and health improvement interventions, and clinical research and as an important source of data needed to measure health outcomes and health inequities.

Some health inequities are created and sustained in the health care system—these are often referred to as “ health care inequities,” due to their direct tie to the health care system, as distinguished from “health inequities,” which describe the outcomes related to factors both in and outside the system.

This distinction becomes important when focusing on the federal health care policies that contribute to health and health care inequities to identify policy-level intervention points. This chapter summarizes the role of federal policy across the U.S. health care system, followed by an overview of health inequities within (created and propagated by) it.

It also reviews a selection of federal health care policies that either contribute to racial, ethnic, and tribal health inequities or advance equity; is organized around access, quality, and inclusion; and concludes with a section outlining impacts of the system on a few specific populations that were selected to provide a broadly illustrative, but not comprehensive or exhaustive, perspective on the interactions between populations and health care policies and systems.

Numerous policies could be reviewed along with their effects on every racially and ethnically minoritized population and in different geographic settings (e.g., urban, rural, U.S. territory); see Chapter 1 for an overview of the committee's process for selecting policies.

As it has done in other chapters, however, the committee identified a limited set of salient examples that contribute to or promote racial, ethnic, and tribal health inequities in a number of different areas (e.g., Medicaid and the Children's Health Insurance Program [CHIP] and policies and practices related to health literacy and language access, value-based payment, inclusion in clinical trials and the workforce, the Indian Health Service [IHS], and maternal, territorial, and immigrant health).

This approach does not mean that policies that were not reviewed, or not discussed in detail, are less important—rather, the goal of this and other chapters is to illustrate the different ways federal policies contribute to inequities and can further health equity. Federal policies drive all aspects of the U.S. health care system.

Congress legislates many aspects of health care finance, delivery, access, and quality; the Department of Health and Human Services (HHS) is the principal executive agency serving as the primary regulator/administrator of these laws, and it includes several subagencies responsible for specific policies and programs.

Due to the substantial role of the federal government in health care policy, HHS accounts for the largest percent of federal budget resources at nearly 25 percent, largely because of public health insurance programs ( CBPP, 2022 ).

HHS has agencies that finance and regulate public insurance programs (Centers for Medicare & Medicaid Services [CMS]), health care access (Health Resources and Services Administration [HRSA]), medical devices, pharmaceuticals, and clinical trials (Food and Drug Administration [FDA]), public health (Centers for Disease Control and Prevention [CDC]), research (National Institutes of Health [NIH] and Office for Human Research Protections), and the IHS, among others related to health and health care.

HHS also has the Office of Minority Health (OMH), which was created in 1986, following the Secretary's Task Force Report on Black and Minority Health (also known as the “Heckler report” ( Heckler, 1985 )), the first federal report to acknowledge racial and ethnic health disparities.

OMH is intended to “improve the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate health disparities” ( OMH, 2019 ).

In 2010, as part of the Patient Protection and Affordable Care Act (ACA) 1 , Offices of Minority Health were established in six agencies at HHS (Agency for Healthcare Research and Quality [AHRQ], CDC, CMS, FDA, HRSA, and Substance Abuse and Mental Health Services Administration), which, in partnership with the NIH National Institute on Minority Health and Health Disparities, are responsible for leading and coordinating activities across the agency.

However, as noted in the HHS Equity Action Plan, “HHS currently lacks the data and equity assessment capacity to consistently identify and address inequities in health and human services” ( HHS, 2022c , p. 12). HHS' lack of capacity, ability to coordinate, and limited authority contributes to racial and ethnic health inequities.

In the United States, access to health care is largely dependent on insurance coverage; federal policy drives that and many other aspects of health care, including how it is delivered, the data collected, the health care workforce, use of technology, and innovation; examples of such policies include the Emergency Medical Treatment and Active Labor Act, 2 the Health Information Technology for Economic and Clinical Health Act, 3 and FDA regulation of the process of developing, testing, and marketing pharmaceuticals.

Federal policies have created the health care safety net, designating medically underserved areas and health professional shortage areas, and authorizing federally qualified health centers, critical access hospitals, and other safety net settings in these areas, many of which serve a disproportionate share of racially and ethnically minoritized populations.

Mistrust in Health Care and Looking to the Future The federal government has had an active role in major events that created racial, ethnic, and tribal health inequities and severely harmed trust in the health system.

This includes, for example, the Tuskegee Syphilis Study, which the U.S. Public Health Service conducted from 1932 through 1972 and withheld available treatment from Black men with syphilis, and the involuntary sterilization of American Indian women by IHS in the 1970s, of Puerto Rican women through Law 116, and of Mexican women in California using federal funds through the 1970s ( Arce, 2021 ; Carpio, 2004 ; Krase, 1996 ; Lawrence, 2000 ; Reyes, 2016 ; Torpy, 2000 ).

These and many other examples of intentional harm to racially and ethnically minoritized people and communities have eroded trust in the federal government and the U.S. health care system generally (see Chapter 7 for more information on this and on trauma and healing).

The landmark study of how the behavior of Black men changed after the revelation of Tuskegee in 1972 found increases in medical mistrust and mortality and declining physician interactions with greater proximity to the victims ( Alsan and Wanamaker, 2018 ).

The closure of Black hospitals is also part of the landscape of medical mistrust—people lack access to health care institutions and providers who are from and center their communities. Before the Civil Rights Movement, hospitals outright refused to admit Black patients or treated them in segregated wards in undesirable locations, and Black doctors were excluded from working in many hospitals.

Black-run hospitals opened in the late 1890s, though many were underresourced ( Jordan, 2022 ; McBride, 2022 ). The Freedman's Hospital was the only federally funded health care facility for Black people when it was established in 1862 to provide care for formerly enslaved people ( Duke University Medical Center Library, 2022 ; Howard University Hospital, n. d.

). It is now Howard University Hospital, one of the few remaining traditional Black hospitals. Title VI 4 of the 1964 Civil Rights Act outlawed segregation and discrimination based on race, color, or national origin in any program or activity receiving federal funds or financial assistance.

Passed 1 year later, Medicare made hospital funding contingent on desegregation ( Duff-Brown, 2021 ; Yearby et al. , 2022 ). See the sections later in this chapter on implicit bias and racism and the health care workforce.

Federal policies related to health care are generally intended to improve health, with some explicitly meant to address health inequities. Yet racial and ethnic health inequities can be identified across most, if not all, federal health care programs. Federal policies continue to contribute to health and health care inequities but also serve as a powerful tool to mitigate and eliminate inequities and advance health equity.

Federal policies have also reduced inequities.

In recognition of the role the federal government plays in advancing health equity, HHS released the CMS Framework for Health Equity 2022–2032 , which outlines in five domains its strategy to advance health equity through CMS policy: improving data collection; identifying and adopting policies that can advance health equity; building appropriate health care organizations and workforce; advancing language access, health literacy, and cultural humility; and improving all forms of access regardless of ability ( CMS, 2022a ).

This document identifies health equity as a national priority and is broadly inclusive in defining underserved populations as identified in Executive Order 13985 5 Advancing Racial Equity and Support for Underserved Communities Through the Federal Government . Health care access and quality, one of the five broad categories of social determinants of health (SDOH), is directly tied to health outcomes ( AHRQ, 2022 ; HHS, n. d.

-b ; University of Wisconsin Population Health Institute, 2023 ). Understanding different domains of access and quality can help clarify the impact federal policies have on health care inequities and identify opportunities to reduce these. Health Insurance Coverage Health insurance coverage is critical for accessing health care in the United States; it is a combination of insurance segments, all of which are a result of federal policy.

Those with insurance have dramatically lower financial barriers to care, and providers are more likely to provide care to those with health insurance ( Glied et al. , 2020 ; Tolbert et al. , 2022 ).

Insurance is provided through private insurance markets and the public sector. The private sector includes employer-sponsored, individual, and other nongovernmental plans. Public-sector insurance includes Medicare, Medicaid, (CHIP), TRICARE, and several other programs, as detailed below.

According to the Census Bureau, employer-sponsored health insurance covered 54. 3 percent, Medicare 18. 4 percent, and Medicaid 18.

9 percent of the U.S. population in 2021 ( Keisler-Starkey and Bunch, 2022 ) (see Figure 5-1 ). The racial distribution for the under 65 population varies by insurance segment (see Figures 5-2 and 5-3 ).

About three-quarters of White and Asian nonelderly adults ages 19–64 have employer or other private coverage, as do about 60 percent of Native Hawaiian and Pacific Islander (NHPI) and Black people, but about half of Hispanic and 42 percent of American Indian and Alaska Native (AIAN) adults do ( Artiga et al. , 2022b ). Gaps in rates of public coverage and uninsured are reversed: they are relatively lower for White and Asian adults.

The gaps in uninsured are most consequential, with 25 percent of Hispanic and AIAN adults uninsured compared to 8 percent of White adults. Fourteen percent of Black adults and 12 percent of NHPI adults are uninsured ( Artiga et al. , 2022b ).

Similar trends by race and ethnicity are seen among children ages 0–18, but higher percentages in general have Medicaid and other public insurance and lower percentages are uninsured than adults. More than half of Black, AIAN, Hispanic, and NHPI children have Medicaid or other public insurance. Uninsured rates are highest among AIAN (13 percent), Hispanic (9 percent), and NHPI (7 percent) children ( Artiga et al.

, 2022b ). This system of insurance as the gateway to services is derived directly from employment status, age, income, and/or other social factors. This results in many individuals who are uninsured or underinsured and contributes to inequities in access that disproportionately affect Black, Latino, AIAN, NHPI, and other minoritized populations.

Percentage of people by type of health insurance coverage, 2021. NOTES: The estimates by type of coverage are not mutually exclusive; people can have more than one type during the year. Information on confidentiality protection, sampling error, nonsampling (more...)

Health care coverage of children by race and ethnicity, 2019 and 2021 (ages 0–18). NOTES: Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Totals may not sum to 100 (more...)

Health care coverage of nonelderly population by race and ethnicity, 2019 and 2021 (ages 19–64). NOTES: Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Totals may (more...)

Health insurance coverage is highly fragmented largely because the system was designed around private employer-sponsored health insurance with federal programs developed to address groups not covered by their employers.

Employer-sponsored health insurance is supported by a federal tax exclusion that has been in place since the 1940s ( Carpenter, 2019 ); these insured do not pay federal (or state) taxes for this part of their compensation. This policy creates tax inequity, as it benefits those with employment and provides greater subsidies to those with higher incomes ( CRS, 2011 ).

The fiscal year (FY) 2023 income tax expenditure for the exclusion of employer contributions for medical insurance premiums and care is estimated at more than $200 billion ( Department of the Treasury, 2023 ; Tax Policy Center, 2020 ). Nongroup insurance covers a relatively small segment of the population, and these individuals do not benefit from this tax exclusion.

ACA added subsidies scaled by income and regulations to make it easier for those outside of the employer-based system and other public programs to obtain insurance. This nongroup private market has expanded since 2014, when these rules went into effect.

In addition to creating subsidies for individuals and businesses to purchase private insurance market products, federal policy also regulates many other aspects of the private market, such as mandating coverage for certain types of services and regulating industry policies and practices.

For example, the Mental Health Parity and Addiction Equity Act 6 required private plans that cover treatment for behavioral health conditions to do so in the same way as for other medical conditions. The Employee Retirement Income Security Act 7 sets minimum standards for employer-sponsored private health insurance and retirement plans. ACA mandated that all public and private plans cover preventive services at no cost to the patient.

8 Government-sponsored health programs include Medicare, Medicaid and CHIP, military health programs, such as TRICARE and the Veterans Health Administration (VHA), IHS, and the Native Hawaiian Health Care Systems. Medicare has eligibility based on age (65 years and older), some disabilities and conditions, and other factors, with over 63 million enrolled in 2021 ( CMS, 2021a ).

Medicaid is the federal and state program for eligible low-income children, adults, pregnant people, elderly adults, and people with disabilities ( Medicaid. gov, n. d.

-b ). More than 86 million people were enrolled in Medicaid and CHIP in 2021, including 35. 9 percent of children ( Keisler-Starkey and Bunch, 2022 ; Medicaid.

gov, 2022 ; Mykyta et al. , 2022 ). The national health expenditures in 2021 were $900 billion for Medicare and $734 billion for Medicaid ($513 billion federal, $221 billion state and local) ( CMS, 2023d ).

The federal government pays for more than one-third of total national health expenditures through Medicare and Medicaid, providing insurance coverage to approximately one-third of the population ( CMS, 2023d ; Keisler-Starkey and Bunch, 2022 ). In 2014, through ACA, federal law allowed 9 states to expand their Medicaid eligibility criteria to cover all adults with incomes below 138 percent of the federal poverty level.

Medicaid and CHIP enrollment also increased after 2020 in part because of the continuous enrollment provision of the Families First Coronavirus Response Act 10 ( Tolbert and Ammula, 2023 ). TRICARE provides insurance for 9. 6 million active-duty and retired service members, members of the National Guard and Reserve, and eligible family; it costs about $50 billion annually ( DHA, 2022 ; Schaettle et al.

, 2021 ). VHA is the country's largest integrated health care system, serving 9 million veterans annually; Department of Veterans Affairs (VA) medical services receive about $120 billion in discretionary funding ( Shane, 2022 ; VA, 2022 ; The White House, 2023 ). IHS is the health care system for AIAN people from federally recognized tribes, serving around 2.

7 million persons, with a FY2022 budget of $6. 8 billion ( ASPE, 2022a ).

The Native Hawaiian Health Care Improvement Act 11 established Papa Ola Lōkahi and five Native Hawaiian Health Care Systems that serve Native Hawaiians in Hawaii and provide culturally responsive, community-based health promotion, disease prevention, and primary care services; the majority of funding is federal grant money from HRSA ( HRSA, 2023 ; Hui No Ke Ola Pono, n. d. ).

The program received $22 million in 2022 ( Hiraishi, 2022 ; Office of Senator Schatz, 2022 ). See sections later in this chapter for more information on Medicaid and IHS. Even with all of these programs, 27.

2 million people, or about 8 percent of the population, were uninsured in 2021; 5 percent of children were uninsured ( Keisler-Starkey and Bunch, 2022 ). Although disparities in rates of uninsured between racial and ethnic groups have declined as a result of ACA expansions, gaps remain ( Artiga et al. , 2022b ; Keisler-Starkey and Bunch, 2022 ; Lee et al.

, 2021 ). Racially and ethnically minoritized and low-income people, including children, continue to be more likely be uninsured. More specifically, individuals living in the 11 12 states that have not expanded Medicaid were two times more likely to be uninsured ( Artiga et al.

, 2022b ; KFF, 2023c ; Lee et al. , 2021 ; Tolbert et al. , 2022 ; Yearby et al.

, 2022 ). Yet it is not just a gap in federal and state policy; it is also a function of implementation, including availability and affordability of health insurance options, which affect an individual's decision to enroll. Approximately 63 percent of these 27 million uninsured individuals were eligible for some type of subsidized insurance coverage (see Figure 5-4 ).

Eligibility for subsidized insurance coverage among nonelderly uninsured, 2021. NOTES: The graph shows the share of uninsured Americans under age 65 who are already eligible for subsidized insurance via Medicaid or ACA tax credits to purchase coverage (more...) Access to Health Care Services In addition to inequities in health care coverage, access to health care services, including a regular primary care provider, is also inequitable.

Having a regular source of care is associated with better health outcomes, fewer disparities, and lower costs ( AHRQ, 2016 ). Health care quality and use can be affected by discrimination, bias, and racism in health care settings ( Bailey et al. , 2017 ; Williams et al.

, 2019 ). The landmark Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care , describes the solid evidence base indicating Black, Latino/a, AIAN, and other minoritized people receive lower-quality care compared to White people; this remains true after adjusting for income and insurance coverage ( AHRQ, 2022 ; IOM, 2003 ; Yearby et al. , 2022 ).

These populations are also more likely than White people to live in areas with shortages of primary care physicians, mental health professionals, and surgeons. Public and rural hospital closures contribute to this, in part because hospitals can be a base for some primary care physicians' practices ( Bailey et al. , 2017 ; Yearby et al.

, 2022 ). Rural communities with larger proportions of Black and AIAN residents are farther from many hospital services, such as emergency and trauma services, than those with a high proportion of White residents ( Eberth et al. , 2022 ).

One mechanism by which poor access to providers may affect health is suggested by the literature on the effects of lacking a regular primary care provider. It is associated with delayed or no consistent care ( HHS, n. d.

-c ). According to a Kaiser Family Foundation analysis, 34 percent of Hispanic adults reported not having a provider in 2021 ( Hill et al. , 2023 ).

Percentages for other racially and ethnically minoritized people were similarly higher than for White adults (16 percent): 24 percent of AIAN and 21 percent of NHPI people reported lacking a provider, as did 19 and 18 percent of Asian and Black people, respectively ( Hill et al. , 2023 ).

The same analysis found more Hispanic and Black children (9 and 7 percent, respectively) without a usual source of care than White children (4 percent) ( Hill et al. , 2023 ). Access to specialty care is also inequitable among racially and ethnically minoritized children ( Flores and The Committee on Pediatric Research, 2010 ).

The relationship between access to care and health also plays out in differential rates of early detection of disease that result from differential engagement in clinical preventive services can help prevent or slow disease progression. Based on 2018 data, differences among racial and ethnic groups exist for preventive care ( HHS, n. d.

-d ). For example, whereas 7. 8 percent of White adults ages 35 years or over report receiving appropriate clinical preventive services, only 5.

4 percent of Black and 4. 2 percent of Hispanic or Latino/a people did so ( HHS, n. d.

-d ). Given the high cost of health care, affordability is an important element of access, and health insurance is the primary policy lever.

The committee focused on Medicaid (including Medicaid structure, eligibility, enrollment and administrative burden, and innovation) because Medicaid is a major source of health care coverage for people with low income, racially and ethnically minoritized populations, people with disabilities, and other underserved groups.

Medicaid and CHIP are also critical sources of insurance for children; more than one-third of U.S. children are covered by Medicaid or CHIP ( Keisler-Starkey and Bunch, 2022 ; Mykyta et al. , 2022 ). Medicaid, enacted in 1965 alongside Medicare, was designed to provide health insurance for individuals with limited income; that focus makes it a key policy lever for addressing health equity.

An analysis by Kaiser Family Foundation found more than half of nonelderly enrollees identify as Black, Hispanic, Asian, or another minoritized race or ethnicity ( KFF, n. d. -e ).

As a more specific example, Medicaid paid for 41 percent of U.S. births in 2021, including 58 and 64 percent of births to Latina and Black women, respectively ( Osterman et al. , 2023 ). Medicaid is a critically important program and has improved health access and some health outcomes and reduced racial inequities, financial burden, and mortality rates ( Baicker et al.

, 2013 ; Flores et al. , 2017 ; Guth and Artiga, 2022 ; Lee et al. , 2021 ; Miller et al.

, 2021 ; NASEM, 2017b ). The Oregon Health Insurance Experiment was a significant study of the effect of expanding health insurance through a Medicaid lottery. Oregon initiated an experimental limited expansion of its Medicaid program in 2008 by filling spots on a waiting list with a lottery system.

About 90,000 adults signed up for the waiting list; approximately one-third of these names were drawn for 10,000 spots. The limited number of spots created a natural opportunity to randomize Medicaid coverage to understand its effects on health care use and outcomes, financial hardship, and well-being in the first 1–2 years of coverage ( NBER, n. d.

-a ). Research found that it resulted in significantly more outpatient and emergency department visits, hospitalizations, and prescriptions ( Baicker et al. , 2017 ; Finkelstein et al.

, 2016 ). It also reduced prevalence of depression but did not significantly change cardiovascular risk or cholesterol and blood pressure levels ( Baicker et al. , 2013 , 2018 ; NBER, n.

d. -b ). The likelihood of experiencing a catastrophic medical expenditure dramatically reduced and medical debt was significantly lowered ( Baicker et al.

, 2013 ; Finkelstein et al. , 2012 ; NBER, n. d.

-b ). Additionally, several studies have examined changes in health disparities resulting from the ACA Medicaid expansions that were not implemented in all states ( Donohue et al. , 2022 ).

Lee and colleagues (2021) found “Medicaid expansion was associated with significant decreases in uninsured rates and increases in Medicaid coverage among all racial and ethnic groups. ” Decreases in racial and ethnic disparities in delayed and unmet need for care were also observed. See Box 5-1 for information on the recent expansions of public health insurance and benefits to children.

Benefits of Recent Expansions in Children’s Health Insurance Coverage. However, Medicaid-relevant inequities remain. Within Medicaid, one cross-sectional study found Black enrollees generated lower spending and used fewer primary care and recommended care services than White enrollees but had more emergency department visits ( Wallace et al.

, 2022 ). This important study suggests that additional steps to ensure equity are needed within this critical program that reduces health inequity in important ways ( Wallace et al. , 2022 ).

The following sections highlight those program aspects that contribute to inequities and identify how improvements to Medicaid can further advance health equity. As Medicaid is a federal–state partnership, both governments are jointly responsible for its many aspects, including financing, eligibility, implementation, and delivery.

Medicaid is financed based on the federal medical assistance percentage (FMAP) formula (which considers each state's average per capita income relative to the national average) ( KFF, n. d. -b ).

The FMAP formula favors state investments—the more a state spends, the more it receives in matching federal funds. 13 FMAP ranges from 50. 0 percent in several states to 77.

3 percent in Mississippi in FY2024 ( KFF, n. d. -b ).

Furthermore, additional federal subsidies incentivize state participation, program requirements, and implementation policies and procedures. 14 This financing structure also provides states with financial flexibility to tailor programs to align with state budgetary priorities, political preferences, and population health needs. Federal policy offers states substantial flexibility to design and implement their Medicaid programs.

States can use waivers, innovation awards, and other program mechanisms to support innovations, provide services to specific populations, and test strategies for improving efficiency and effectiveness (see the Innovation section in this chapter). Many states have leveraged these flexibilities to focus on health equity, but these have also contributed to health inequities, as discussed later.

Medicaid and CHIP coverage in U.S. territories has some similarities and important differences compared to the 50 states and DC. The territories use different eligibility criteria, and Puerto Rico's CHIP program covers additional children who exceed the federal poverty level for Medicaid eligibility ( MACPAC, 2021b ).

Due to differences in economic status and determining eligibility, the five territories vary widely in the proportion of the population enrolled in Medicaid and CHIP, from 68. 4 percent in American Samoa to 21. 2 percent in Guam ( MACPAC, 2021b ).

Some of the requirement differences in the states and DC compared to the territories create inequities in health care coverage and access to health care for U.S. citizens (those born in the Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and U.S. Virgin Islands) and U.S. nationals (those born in American Samoa) residing in the territories.

The most high-profile example is that the territories' FMAP has been capped 15 at 55 percent (with occasional increases by Congress), and the territories have been responsible for costs beyond that federal match limit ( MACPAC, 2021b ).

In 2023, the Consolidated Appropriations Act 16 increased the FMAP to 83 percent for American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, and the U.S. Virgin Islands, along with a 5-year extension of the 76 percent FMAP for Puerto Rico ( McCoy and Wheatley, 2023 ).

In discussing the contributions of Medicaid to racial and ethnic health inequities, it is important to recognize the context and historical origins of its creation.

Medicaid and Medicare were adopted on the same day (July 30, 1965) in the same piece of legislation, yet researchers have attributed fundamental differences in the programs to the influence of racism and compromise tied to federalism (see Chapter 2 for more on federalism) ( Katznelson, 2013 ; Katznelson and Mulroy, 2012 ; Lieberman, 2001 ; Pearson, 2019 ; Skocpol, 1995 ).

In 1935, when President Franklin Roosevelt proposed a universal social security program, Southern White people feared disruption of the racial hierarchy and financial dependence of Southern Black people, resulting in a compromise that excluded domestic workers and agricultural laborers (both groups were predominantly Black) from the Social Security Act.

17 Medicare passed in 1965 as a program fully administered by the federal government, based generally on reaching age 65. However, because of the concurrent civil rights legislation (the Voting Rights Act 18 and Civil Rights Act 19 ) and immense changes it brought about, Southern states were generally resistant to federal involvement ( Nolen et al. , 2020 ; Pearson, 2019 ).

Therefore, unlike Medicare, Medicaid was determined to be a state-run program, as it limited federal involvement and allowed states to administer health programs for low-income