State Reported Efforts to Address Health Disparities: A 50 State Review

Summary Publicly Reported State Activities Strategic Priorities Community Engagement Cross-Sector Approaches Training and Diversifying the Health Workforce Data Equity Initiatives Internal Operations Lessons Learned Looking Ahead Methods

Summary

In recent years, there has been a growing focus on addressing health disparities and advancing health equity. This growth was spurred by incidents in 2020, including the COVID-19 pandemic, which highlighted the disproportionate impact of the virus on low-income people and people of color in the U.S. in addition to the police killings of George Floyd, Breonna Taylor, and others that increased attention to systemic racism that contributes to inequities such as health disparities. While the federal government can play a key role in addressing inequities, states also play a pivotal role, as they set policies, allocate resources, and administer many services and programs that are important for addressing the conditions that determine health both within and beyond the health care system. Moreover, states have varying demographics, population needs, and political leadership, which may shape efforts to address health disparities and promote health equity. Efforts at the federal level are expected to shift under the Trump Administration, given that, during his first term, he took executive action to prohibit federal agencies and contractors from providing training addressing racism and sexism and has proposed policies that may widen disparities in coverage and access to care. As such, understanding state actions in this area may be of increasing importance.

This analysis focuses on current state efforts, many of which were implemented during or after 2020, to address health disparities and advance health equity based on a review of publicly available materials from all 50 states and DC. In addition, case study interviews were conducted with 14 stakeholders in three states (California, North Dakota, and Michigan) to increase understanding of the factors contributing to success of these state initiatives, lessons learned, and potential implications for other states. The case study initiatives reflect some of the broad themes of state-level activities identified through the analysis of publicly available materials and include states with varied geography, racial and ethnic demographics, and political leadership (See Methods for more details.) Key takeaways from the review include the following:

• Nearly all states identify health equity and/or addressing health disparities as a strategic priority, and most have established infrastructure to lead this work. States vary in the level of governance they have established, how the positions or offices were created, and their scope and areas of responsibility. A few states do not have governance dedicated to addressing health disparities or health equity, although most of these states still have efforts focused on addressing health disparities. In contrast, a small number of states have passed legislation or instituted policies that prohibit activities related to diversity, equity, and inclusion (DEI) and/or that refer to structural racism. In addition to establishing infrastructure, some states describe shifts in their internal operations to address disparities and/or advance equity, including developing cross-agency collaboratives to embed equity into institutional practices and codifying these operational procedures into policy; mandating equity training for state staff; and stipulating equity-related requirements for budget, funding, and contracting decisions.
• Nearly all states include community engagement as part of their approach to addressing health disparities and/or equity. However, states vary in how they define community and the extent to which they share decision-making and resources with communities. Approaches range in the degree of engagement, as well as in the extent of power and resource sharing with communities, from soliciting input and feedback from communities; to having community representation on advisory councils, task forces, or similar groups to inform state planning and decision-making; to providing resources to support increased capacity of communities; to facilitating and funding community-defined and led strategies. States often are implementing multiple types of community engagement approaches, which may address different health or population needs and/or facilitate greater reach and impact.
• Many states describe cross-sector initiatives to address health disparities, recognizing the role social and economic factors play in determining health. States are incorporating a health equity focus across sectors in various ways. For example, several states have adopted place-based initiatives to address social determinants of health (SDOH) in specific geographic areas. Some states indicate that they employ a Health in All Policies (HiAP) approach and/or use Health Impact Assessments (HIAs) to incorporate health equity considerations into decision making across sectors beyond health. Many states also report using Medicaid managed care contracts to promote strategies to address SDOH.
• States also point to training and diversifying the health care workforce as part of efforts to address disparities and advance equity. These efforts include optional or mandated equity-related training for health care workers; efforts to increase diversity in the pipeline of health care workers; and recruitment, training, and support for community-based providers, including doulas and community health workers. Expanding access to and creating infrastructure to support doulas and community health workers are common areas of focus as part of state efforts to address disparities in maternal and infant health. A growing number of states are providing Medicaid reimbursement for doula services and/or providing funding and infrastructure to support doula training and credentialing and community health workers.
• States are implementing data collection, analysis, and reporting strategies aimed at addressing health disparities and/or equity. Most states are publicly reporting data to support efforts to address disparities, but there is wide variation in the timeliness, format, and scope of these data. A number of states have also developed or indicated that they are in the process of developing indices or datasets related to measuring equity and/or social vulnerability. Beyond increasing access to data through public reporting, some states also report changing data collection practices to support greater disaggregation of data and increased data sharing, including with communities.

This analysis shows that states with varying geography, demographics, and political leadership are pursuing work to address health disparities. However, states range in the level of commitment and resources focused on this work. While some states are taking more incremental steps, others have identified this work as a major cross-sector strategic priority, established dedicated infrastructure and resources to support this work, taken steps to empower and support impacted communities, and are working toward broader systems and policy changes to mitigate disparities.

As a result of these efforts, states have directed increased staff and resources to this work, established infrastructure and/or policies that facilitate community input to inform state decision-making and program implementation, increased funding to community-based organizations, and enhanced data available to identify and direct efforts to address disparities. In particular, the establishment of new infrastructure and policies to address disparities and advance equity may facilitate sustainability of this work amidst potential turnover in staff and leadership. Case study respondents highlighted factors that contributed to the success of initiatives and potential lessons for other states, including the presence of strong state leaders and champions, developing trusted and authentic relationships between the state and community, state leadership being open to innovative community-led approaches, and using evaluation data to support sustainability of initiatives over time.

This information may help inform state efforts to address health disparities and advance health equity by identifying potential strategies and approaches states may consider and factors that contribute to success. It is subject to limitations. While we sought to be comprehensive in our review, states may have activities underway that are not reflected in public-facing materials. It is also possible that new activities have begun, concluded, or been retracted after our data collection period. Moreover, while this analysis provides greater insight into the range of state-reported activities to address health disparities and/or equity, it does not give insight into the effectiveness or outcomes associated with these actions. Future work examining the impacts of these efforts on state operations and disparities in health care and health outcomes will be important to help guide ongoing efforts to address health disparities and advance greater health equity.
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Publicly Reported State Activities

State Infrastructure and Governance

Nearly all states have an office or division focused on health equity or disparities (Table 1). States vary in the level of governance they have established, how positions or offices were created, and in their scope. However, these offices are generally located within the states’ Departments of Health or Health and Human Services. While some are longstanding offices focused on minority health or disparities, others were more recently established or refocused in the wake of the disparate health impacts of the COVID-19 pandemic. As such, in a number of states the levels of staff and resources focused on addressing disparities and advancing equity have increased in recent years. The few states without an office or division dedicated to health disparities or health equity generally still have resources and initiatives aimed at addressing disparities or advancing equity. For example, although Vermont does not have a dedicated health equity office, health equity is a primary strategic goal, and it has an Office of Health Equity under development.

Some states also have equity branches or divisions within agencies or divisions of their Departments of Health or Health and Human Services, such as their Medicaid agencies and/or Behavioral Health agencies. Additionally, a number of states have health equity task forces, councils, or commissions, which vary in composition and roles. Some include membership from community members and experts outside the state to provide feedback and information to guide state efforts. Others bring together state employees across sectors to collaborate on equity efforts across the state and/or to coordinate regional or local activities. Some include a combination of external experts, community representatives, and state employees.

In contrast, a small number of states have passed legislation or instituted policies that prohibit activities related to diversity, equity, and inclusion (DEI), and/or refer to structural racism. In these states, health equity and disparities related activities and content do not exist in their public materials, are being scaled back, or have been eliminated. For example Texas‘ previous Center for Minority Health Statistics and Engagement was defunded in 2017, and a legislative proposal to establish a new Office of Health Equity failed due to Republican opposition. In 2022, Florida’s state health goals removed equity as a state priority. The new state health improvement plan did not reference equity and made no mention of race or ethnicity. In July 2024, the Utah legislature passed a bill prohibiting DEI training, hiring, and inclusion programs in higher education and government employment. In Arizona, SB1005 prohibits public institutions from spending funds on DEI programming and removes requirements for employees to engage in DEI programming or training.

Less than a third of states have an overarching equity office or position (not specific to health) that was identifiable through public-facing materials. Many of these were established in 2019 or later. In California, Governor Newsom established a Chief Equity Officer through an Executive Order, who is housed within the Government Operations Agency. Similarly, in Illinois, an Office of Equity within the Office of the Governor was established via Executive Order, and New Jersey has an Office of Diversity, Equity, Inclusion, and Belonging (Office of Equity) that was created by Executive Order. Vermont’s Office of Racial Equity was formed in 2019 through legislation and has since grown in scope. Washington State’s Office of Equity was established by legislation in 2020 in response to the growing diversity of the population, disparities in opportunities across groups, and the economic and social costs of inequities.

The scope of these offices varies across states. For example, in DC, the Office of Racial Equity, which was established in 2021, focuses on developing an infrastructure to ensure policy decisions and programs are evaluated through a racial equity lens and to implement the Racial Equity Achieves Results (REACH) Act. In New Jersey, the Office of Equity is charged with increasing the presence and participation of historically underrepresented groups in state government; developing equity frameworks to guide state policy decisions; directing diversity, equity, inclusion, and belonging efforts in the Governor’s Office; guiding and coordinating state agency initiatives to strengthen diversity, equity, inclusion, and belonging within the state workforce; and monitoring implementation of these measures. Other offices, such as the Office of Diversity, Opportunity, and Inclusion in Virginia and Division of Equity, Diversity, and Inclusion in Rhode Island, are primarily focused on promoting diversity and inclusion among the state workforces.

A number of states, particularly those that are home to larger populations of American Indian or Alaska Native (AIAN) people, have established positions, offices, or other organizational infrastructure focused on communicating and consulting with Tribes and/or addressing AIAN health. Some of these states have Tribal liaisons who serve as a link to exchange information between the state and Tribal nations and facilitate Tribal consultation processes. For example, in Arizona, the Department of Health Services Tribal Liaison serves as an “advocate, resource, and communication link between the Department and Arizona’s Native American health care community.” North Dakota has four Tribal health liaisons who facilitate community engagement with five Tribes throughout the state (Box 1.) The liaisons also serve as an internal resource to the state’s Indian Affairs Commission. Other states have established leadership positions or offices focused on AIAN health. For example, Montana has an American Indian Health Director who directs the Office of American Indian Health, which serves as a communication link between the state and American Indian communities. A few states have councils or commissions that serve similar roles. In Oklahoma, the Tribal Behavioral Health Coalition specifically focuses on providing guidance on mental health and substance abuse issues for Tribal nations co-located in the state. Beyond this infrastructure, some states have clearly outlined policies and processes for Tribal consultation. For example, in 2020, Michigan established a formal Tribal Consultation policy that was developed with feedback from Tribal representatives.

Many states have also established ancillary governance structures such as commissions, task forces, councils, and workgroups to support state efforts to address health disparities and/or equity. While some of these structures include state staff persons, they often facilitate engagement of non-governmental leaders, such as subject matter experts, advocates, health care practitioners, and community-based organizations, in the development and implementation of the state’s strategy. These structures can help inform an agency’s decision-making process and/or be responsive to specific information or advisory needs. In April 2020, for example, the Tennessee Department of Health’s Division of Health Disparities Elimination launched the Tennessee Health Disparities Advisory Group to address the disproportionate number of individuals in communities of color affected by COVID-19 by examining data, monitoring trends, and generating responsive solutions during the pandemic. In Minnesota, the Department of Health formed the Health Equity Advisory and Leadership Council to serve as a voice for communities impacted by health inequities throughout the state and provide guidance on policies, programs, performance metrics geared toward the promotion of \health equity. Similarly, the Oregon Health Policy Board established a Health Equity Committee to coordinate, develop, and recommend policy designed to eliminate health inequities.
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Strategic Priorities

Nearly all states have identified addressing health disparities and/or advancing health equity as a strategic priority, with most framing their goals around improving health for all residents. These include aims of advancing health equity, promoting optimal health for all residents, enabling all residents to achieve their full health potential, providing equitable opportunities for people to be healthy and have access to health services, and reducing or eliminating health disparities. While these goals typically encompass all residents, some states identify specific types of disparities or population groups that are of particular focus, including those that face inequities by demographic factors such as race and ethnicity, age, socioeconomic status, sexual orientation, gender, ability, immigration status, religion, and/or geographic location. State strategic goals commonly reference the role of SDOH and importance of engaging with the community as part of their efforts. A smaller number of states explicitly identify addressing racism and recognizing historical discrimination, disparities in behavioral and mental health, or environmental justice as components of this work. Some states also identify addressing internal capacity and workforce diversity as key components of these efforts.

Most states have a definition of health equity in their publicly posted materials, and about half have a publicly posted definition of health disparities. How states define health equity and health disparities may shape the directions and focus of their work in this area, as they vary in recognition of factors that drive disparities and potential mechanisms to advance equity. State definitions of health equity most commonly refer to or draw on definitions from the CDC, including the Healthy People 2030 definition, which recognize that achieving health equity requires addressing social and economic factors that contribute to disparities and historical and contemporary injustices. Some also reference or draw on definitions from the World Health Organization or the Robert Wood Johnson Foundation. Oregon’s definition of health equity is unique in that it identifies “equitable distribution or redistribution of resources and power” as a component for achieving health equity. State definitions of health disparities generally refer to or draw on definitions from Healthy People, the CDC, and the National Institutes of Health. These definitions all recognize that disparities impact groups of people who are socially disadvantaged or experience more obstacles to health. The Healthy People definition identifies health disparities as linked to social, economic, and environmental disparities, although states vary in the extent to which their definitions identify root causes of disparities and the role of social and economic factors. Minnesota’s definition specifies that disparities are not explained by genetic or biological factors and highlights that they are life-threatening and urgent to address. By contrast, Missouri identifies genetics as a contributing factor to disparities. Oklahoma’s definition highlights root causes of disparities as “poverty, racism, class and gender discrimination, and other factors.” California’s definition is unique in its inclusion of mental health disparities.

Areas of focus related to addressing health disparities spanned a wide array of health needs and conditions, with some areas of common focus, including maternal and infant health and chronic disease. For example, Michigan has prioritized addressing disparities in maternal and infant health through its 2024 strategic plan (Box 2). Ohio created the Eliminating Racial Disparities in Infant Mortality Task Force to work with local, state, and national leaders. Arizona’s AZ Health Start Program supports home visits for at-risk pregnant or postpartum women and its Tribal Maternal Task Force was established to develop a culturally relevant Tribal maternal health plan. The North Dakota Diabetes Prevention and Control Program (NDDPCP) established a collaborative between health systems, health centers, and pharmacies to increase point-of-care testing in community pharmacies. Some states also identified a focus on addressing disparities in behavioral health. The California Reducing Disparities Project is a statewide initiative designed to address disparities in behavioral and mental health among certain populations. Colorado established the Behavioral Health Administration, which focuses on addressing the social and structural determinants of behavioral health. Environmental health justice and addressing disparities in health-related environmental impacts is also an emerging focus area. For example, California developed Climate Change and Health Vulnerability indicators to identify people and places more susceptible to adverse health impacts associated with climate change. Wisconsin is developing an Environmental Equity Tool, which will help identify communities impacted by pollution, climate change, socioeconomic factors, and other environmental and health hazards.

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Community Engagement

Nearly all states are engaging with or have reported plans to engage with communities to address health disparities and/or equity, although they vary in how they identify community as well as in their approaches and the extent to which they share decision-making with communities. States varied in their references to community, with some defining community as local public health agencies or other local government partners, whereas others included community-based organizations. Some further sought to engage directly with individuals impacted by disparities. How states defined community informed their engagement approaches. State community engagement approaches range in level of engagement and sharing of power and resources, from more incremental efforts that solicit feedback to more comprehensive and deeper efforts that support the increased capacity of communities and community-defined and -led strategies to address disparities. States often implement multiple community engagement approaches, which may address different health or community needs. States engaged in efforts to share power and decision-making with communities tend to have more comprehensive and multi-pronged approaches (See Box 3).

States described gaining input from communities by hosting listening sessions or town halls, administering surveys and/or focus groups, or by requesting public comments. For example, when Michigan sought to improve how it collected race and ethnicity data for its health surveys, it posted its proposed changes on its website and requested feedback and held meetings with community groups across the state to raise awareness and garner feedback. Similarly, to inform the development of its Health in All Policies (HiAP) agenda, the New Jersey’s Department of Health worked with Rutgers University to conduct listening sessions with experts and community leaders across the state. To center the voices of Wisconsinites, the state conducted a series of community conversations to understand needs and resources in developing its state health improvement plan.

Beyond soliciting feedback, some states have included community-based organizations, Tribal members, local health departments, faith-based institutions, and other local organizations in strategic planning processes and on task forces, work groups, committees, advisory councils, and boards to inform decision-making. For example, in developing its strategic plan, Hawaii included contributions from universities, physicians, community-based organizations, and other local stakeholders. Oregon’s Healthier Together strategy was led by a community-based steering committee called the PartnerSHIP, which made final decisions about the plan’s priorities and strategies. Nevada’s Health Equity plan outlines efforts to form a data advisory committee to assess data needs and gaps and identify communities for inclusion  in efforts to identify, analyze and report data.

Many states also are providing resources and assets to support community-level efforts and increase the capacity of organizations serving the community. These efforts include strengthening community networks; utilizing community health workers; increasing local health services capacity; and providing training, technical assistance, and culturally tailored communications and resources to community-based organizations. South Carolina’s Cancer Alliance, for example, brings together a network of leaders, communities and organizations to coordinate, collaborate, and provide education and research on cancer disparities and solutions to communities in partnership with the state’s Department of Health and Environment Control. With its COVID Community Partnership (CCP), Utah deployed community health workers to connect under-resourced communities to provide credible health information and COVID-19 vaccines. Moreover, through its Embrace Project Study, it sought to build trust with the Native Hawaiian and Pacific Islander communities by having community health workers provide biometric screenings and health coaching sessions for diabetes and maternal mortality and morbidity prevention. Illinois has focused on increasing the capacity of local health services for behavioral health through its Recovery Oriented Systems of Care (ROSC). This statewide network program geographically distributes councils that assist communities with building local recovery systems of care, including local primary care, law enforcement, hospitals, prevention and recovery services, and a variety of community stakeholders.

Some states have demonstrated a deeper commitment to community engagement by sharing decision-making with the community and supporting community-led initiatives. In some cases, this is via government-to-government partnerships between states and Tribal nations and/or by having a dedicated state infrastructure to partner in Tribal affairs. For example, Alaska’s state health improvement plan (SHIP) is led by a state and Tribal partnership between the Alaska Native Tribal Health Consortium and the state’s Department of Public Health. In other cases, such as Minnesota’s Community Voices and Solutions infant mortality reduction initiative in Hennepin County and the Health Equity Zones in Pennsylvania, Rhode Island, and Washington, the states facilitate and fund initiatives. These initiatives are determined and led by the local communities themselves. In California, the California Reducing Disparities Project was developed specifically to support the design, implementation, and evaluation of community-led approaches to address behavioral and mental health disparities among certain populations (Box 4).

Some states have demonstrated a long-term commitment to community engagement through the establishment of staff, infrastructure, and/or strategic plans dedicated to leading and implementing community engagement initiatives. Louisiana’s community engagement strategy is guided by its Community Engagement Framework, which aims to build the health agency’s capacity to engage people and communities equitably. Colorado’s Community Action and Engagement Unit works to identify and support community organizations, healthcare entities, and public health agencies to promote health equity and address SDOH related to COVID-19. Similarly, North Dakota’s Community Engagement Unit is dedicated to community-engaged strategies and serves as a resource for addressing health disparities and advancing health equity.
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Cross-Sector Approaches

As part of efforts to address health disparities, many states are implementing initiatives that focus on broader social, economic, and environmental factors that influence health. For example, Connecticut’s Healthy Connecticut 2025 plan addresses SDOH through strategies focused on economic stability, healthy food and housing, and community resilience, while incorporating areas of structural racism, transportation, and education. In Washington State, the Governor’s Interagency Council on Health Disparities, which was created by legislative action, emphasizes equity and community engagement in addressing SDOH, including improving access to healthy food and educational opportunities and reducing environmental hazards. In North Dakota, the state is implementing a new Multi-Partner Health Collaborative, which includes state leaders across sectors and focuses on areas outlined in the State Health Improvement Plan (SHIP) (Box 5).

Several states have adopted place-based initiatives to address SDOH in specific geographic areas. Get Healthy Idaho’s place-based initiatives engage residents in local areas to identify priorities, challenges, and opportunities to ensure community voices guide the strategy development and implementation process. In Pennsylvania, North Philadelphia’s Health Enterprise Zones and Regional Accountable Health Councils collaborate using health and SDOH assessments to inform population health planning and develop long-term public health strategies, particularly for areas with high disease burden and health disparities. Rhode Island’s Health Equity Zones (HEZs) focus on addressing health inequities in geographic zones through community-led assessments and action plans, with a focus on integrated healthcare, community resilience, the physical environment, socioeconomics, and community trauma.

Some states indicate that they employ a HiAP approach and use Health Impact Assessments to incorporate health equity considerations into decision making across sectors. Nevada’s Health Equity Action Plan recommends adoption of an HiAP approach and utilization of tools like Health Impact Assessments, Racial Equity Impact Assessments, and the Office of Minority Health Equity’s Health Equity Lens to measure the effects of proposed policies, programs, and plans on health equity and community health. Additionally, Nevada promotes the use of health impact notes, similar to fiscal notes, to evaluate the potential health outcomes of proposed legislation across different sectors. In Washington, DC, the Office of Health Equity implements the Calling All Sectors Initiative, which is a multisector approach to operationalize health equity by using a HiAP approach and engaging stakeholders across sectors to promote health, wellness, and equity, recognizing the impacts of housing affordability, insecurity, and homelessness on maternal and infant health.

A growing number of states also are addressing health-related social needs (HRSNs) through their Medicaid programs. Most states that contract with managed care plans to deliver care to Medicaid enrollees report leveraging managed care organization (MCO) contracts to promote at least one strategy to address SDOH in FY 2024. These included requiring MCOs to screen enrollees for behavioral health needs, screen enrollees for social needs, provide referrals to social services, and partner with community-based organizations. States also report requiring MCOs to encourage or require providers to capture SDOH data, incorporate uniform SDOH questions within screening tools, employ community health workers, and track outcomes of referrals to social services. In addition to these MCO activities, as of October 2024, CMS approved ten states (Arizona, Arkansas, California, Illinois, Massachusetts, New Jersey, New Mexico, New York, Oregon, and Washington) under the new Health-Related Social Needs (HRSN) Section 1115 framework. These waivers authorize evidence-based housing and nutrition services for specific populations with unmet social needs. For example, Arizona’s AHCCCS Whole Person Care Initiative provides housing and other supports to individuals at risk of homelessness with health needs. States can also obtain “infrastructure” funding to support the implementation of HRSN waivers or build state or regional capacity to manage population health. For example, New York’s Health Equity Regional Organization is designed to develop regionally focused approaches to reduce health disparities, advance quality and health equity, and make recommendations to incorporate HRSN into value-based payments.
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Training and Diversifying the Health Workforce

A number of states identified health equity-related training initiatives for health care providers, although they varied in scope and implementation, with some optional and others required. For example, Alabama has an optional on demand web-based training for nurses, social workers, clinicians, health educators, and other healthcare professionals and administrators to better understand health equity and why it is important to their daily work. Other states have mandated equity-related training through executive action or legislation. For example, a 2019 law in California seeks to reduce Black maternal mortality by requiring all perinatal health care providers to undergo implicit bias training. Colorado passed legislation in 2022 requiring the Office of Health Equity and The Department of Public Health and Environment to create a culturally relevant and affirming health care training grant program aimed at increasing provider capacity to provide culturally responsive care. Maryland passed legislation requiring applicants for the renewal of a health occupations board license or certificate to attest to the completion of an approved implicit bias training program. Maryland also is in the process of creating a maternal health equity advisory group that will produce recommendations to educate non-obstetric providers of care to pregnant and postpartum patients on the topics of maternal morbidity, racial bias, and the importance of respecting the patient’s voice.

Some states reported efforts to increase the diversity of the health care workforce. For example, California’s Medicine Scholars Program, which was established, in part, through state funding, seeks to reduce barriers students of color face as they move through the pipeline to jobs in the medical workforce. Similarly, New York provides funding for student support programs designed to increase the diversity of providers in the state, including its longstanding diversity in medicine program.

Another area of focus for states is increasing access to and availability of community-based providers, including community health workers and doulas. Some states are seeking to increase access to these providers by providing patient education about these services, supporting training to increase the supply of these providers, and providing reimbursement for their services. For example, the intends to increase the number of Black birthing people who are informed about the benefits of doula care and offered the opportunity to work with doulas; improve the prenatal, labor, and delivery, and postpartum care of Black birthing people; and support the development of a culture of understanding and mutual respect between doulas and clinical staff. Other analysis shows, as of early February 2024, 12 states reimburse services provided by doulas under Medicaid , with two states, Louisiana and Rhode Island, also implementing private coverage of doula services. Additionally, states are funding grants or scholarships to support doula training and credentialing. Michigan launched a Doula Initiative that includes Medicaid reimbursement for doulas and efforts to increase and support doula providers, which is informed by a Doula Advisory Committee (Box 6). Other states identified efforts to enhance access to community health workers. For example, the Indiana Department of Health is using a place-based approach in which districts experiencing disparities are allocated community engagement funds to be used by community health workers to address the needs of underserved populations in the area. Montana is investing in the ongoing training for community health workers on issues related to health equity, cultural competencies, and SDOH.

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Data Equity Initiatives

Most states are publicly reporting data to support efforts to address disparities, but there is wide variation in the timeliness, format, and scope of these data. Many states have static reports with measures of health and, in some cases, health-related social and economic factors broken out by race and ethnicity and other demographic factors, which may be updated on a regular basis. For example, in California, the Office of Health Equity produces a biannual demographic report on health and behavioral and mental health inequities for the state legislature and residents. The scope of measures included in these reports, as well as the timeliness of the data included, varies across states. In some states, the latest publicly available reports have outdated data, while others are updated on a regular and timely basis. Beyond these static reports, a growing number of states are developing interactive data dashboards, data portals, or maps that allow users to explore a wide variety of measures, sometimes including social, economic, and/or environmental measures, by various demographic factors. For example, Washington’s Tracking Network was developed to make public health data more accessible by featuring a variety of data tools, including an Environmental Health Disparities map, which depicts where environmental health disparities are occurring to prioritize public investments. Similarly, in a partnership between the Division of Public Health, Delaware Racial Justice Collaborative, and United Way, Delaware’s Equity Counts Data Center provides multiple data points (i.e., indicators in health, education, criminal justice, and economics) that can be used to examine disparities by race, ethnicity, gender, and age across the state and at the zip code level.

Several states also have developed or indicated that they are in the process of developing indices or datasets related to measuring equity and/or social vulnerability. For example, the Get Healthy Idaho Index and Community Data tool measures and ranks neighborhoods’ health and well-being based on factors like access to healthy food, parks, clean air, and healthcare services, to provide a holistic view of community health. The index aims to guide policymakers and community leaders to improve the overall health of Idaho. Arizona indicates that it is adapting the CDC’s Social Vulnerability Index into an Arizona-specific index. Utah’s Health Improvement Index includes nine determinants of health including demographics, socioeconomic deprivation, economic inequality, resource availability, and opportunity structure. Michigan reports it is developing a health equity data set that will include indicators for social and economic conditions; environmental conditions; health status, behaviors, and healthcare; and priority health outcomes to monitor racial health disparities. In addition to SDOH, some states also are reporting measures related to environmental quality and conditions in their data dashboards or indices. For example, Rhode Island provides a map of extreme heat impacts in their Health Equity Zones.

Beyond efforts to increase accessibility of data through public reporting, some states also report changing data collection practices to support greater disaggregation of data. For example, through its REALD (race, ethnicity, language, and disability) and SOGI (sexual orientation and gender identity) efforts, Oregon is working to increase and standardize the collection of these data across health agencies. Utah’s Department of Health and Human Services has developed guidelines to promote a uniform set of data collection standards for race and ethnicity. Several other states have indicated plans to enhance their data collection and reporting practices. For example, North Dakota is examining how to improve data for multiracial people and incorporate race and ethnicity questions into its data collection practices. California also has pending legislation to use more detailed racial and ethnic categories. Michigan is prioritizing expanding the collection of race, ethnicity, and preferred language data. It is also working to implement reliable survey tools to collect data from smaller racial and ethnic groups and communities not represented in standard data collection systems.

Additionally, some states are working to increase data accessibility through data sharing. For example, some are putting data sharing agreements in place and/or improving the interoperability of datasets within and across state agencies, healthcare organizations, and with Tribes. Some states have also established data committees or advisory groups that oversee data coordination between agencies and sectors. For example, Connecticut is working to establish a cross-sector data committee that would act as a technical body to provide support to agencies across the department and advise the State Health Improvement Plan Advisory council.

Some states include a focus on equity as part of their Maternal Mortality Review Committees (MMRCs). Nearly all states have MMRCs, many of which are funded through the CDC, that review pregnancy-associated deaths and offer recommendations to prevent future deaths. However, state MMRCs vary in the extent to which they examine racial disparities, with some identifying and addressing disparities as a key focus. For example, in California, each death is examined through a health equity lens and considerations include how SDOH, discrimination, and racism may have contributed to the death. Similarly, Vermont amended the charge of its committee in 2020 to include considerations of disparities and SDOH, including race and ethnicity in perinatal death reviews. Rhode Island recently replaced its MMRC with the Pregnancy and Post-Partum Death Review Committee and noted that the name acknowledges the breadth of gender identity of individuals who may become pregnant. States also vary in the membership of their committees, with some having requirements related to Tribes and/or doulas or midwives. For example, Colorado’s MMRC includes experts with lived experience in the drivers of maternal mortality, including doulas, midwives, and patient advocates.
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Internal Operations

Some states have created cross-agency learning collaboratives to embed equity into their institutional practices among their state workforces. Through its Capitol Collaborative on Race and Equity, California established a 15-month learning cohort of 25 of the state’s departments, agencies, offices, commissions, and conservancies to embed racial equity into their respective institutional culture, policies, and practices with the aim that race will no longer be a factor in determining life outcomes or well-being for communities of color. The Minnesota Department of Health Equity Learning Community helped teams from local public health departments integrate health equity practices into their work. It identified several areas of suggested changes to existing practice, including data collection, analysis, and use; community engagement; organizational operations, like policies, budgets, and hiring; and policy work. Rhode Island’s Capacity Building for Policy Change Workshop Series is designed to support their Health Equity Zones in enhancing their capacity to engage in policy and systems change efforts that include making equity improvements to ordinances, state and local regulations, and agreements with municipal agencies and/or institutions like hospital systems.

States are also shifting internal operations by providing and, in some cases requiring, equity-related training for their staff. In Louisiana, Initiative 16 was developed to train and build the capacity of staff to have an understanding of systemic health equity, translate this to their daily work, and incorporate equity practice expectations into annual performance reviews. Maine’s Department of Health and Human Services developed a plan to increase DEI capacity within the department through a range of strategies, including publicly reporting staff demographics and providing staff training on best practices for hiring a diverse workforce and education about Equal Employment Opportunity and implicit bias in hiring. Some states are mandating training among the state workforce. For example, through executive order in Colorado, the Department of Personnel and Administration was tasked with developing and delivering required training for all state employees, with additional requirements and expectations for agency executives on DEI issues, including education on implicit bias, historical injustices and trauma, community engagement practices, and new assessment tools. Similarly, in Washington, the Secretary of Health’s directive mandates that leadership, management, and supervisors adhere to the recruitment policy and implement “hiring best practices” which include the requirement to complete implicit bias training and encourage ongoing training in the areas of diversity, inclusion, cultural humility, oppression, and equity.

In contrast, other states are moving to ban or restrict DEI-related activities. For example, under SB 266, public institutions in Florida are prohibited from funding or maintaining DEI programs. Similar legislation was passed in Texas under HB 5127, which bans DEI offices and diversity training for students and employees at public institutions as of January 1, 2024. Utah passed HB 261, which bans DEI offices and training requirements and prohibits race being considered in hiring practices for state board and government employees. In December of 2023, the Oklahoma governor signed an executive order banning DEI programs at state agencies; effective immediately, the order eliminated funding for all DEI positions. Some state medical boards have also been moving to limit DEI actions. A lawsuit against the Tennessee medical board challenges the legality of policies to ensure representation from minority groups through racial quotas. A similar lawsuit has been filed in Louisiana against the medical board for the use of racial quotas.

States are also stipulating requirements in operational procedures such as budgetary decisions, funding criteria, and contracting to support equity. For example, states like Minnesota, New York, Illinois, and Michigan dedicate specific budget lines to allocate funding for programs to reduce racial health disparities in areas including maternal health, HIV prevention, and mental health services. California established a Racial Equity Commission to develop tools for assessing how budget allocations impact communities of color, and Rhode Island is exploring incorporating community participatory budgeting practices. Some states are leveraging budgetary and funding requirements to expand state capacity to address disparities in social and environmental determinants of health. For example, Washington’s HEAL Act instructs covered agencies to incorporate environmental justice into funding and budgeting processes with the goal of directing 40% of funding for programs that create environmental benefits to go to “overburdened communities and vulnerable populations.” Other states stipulate requirements for contractors and procurement procedures that support equitable practices. Arizona’s Community Reinvestment policy, for example, requires contractors to designate and spend a minimum share of profits for community reinvestment activities (e.g., housing, non-medical transportation services, activities to combat social isolation or enhance social support, activities that reduce recidivism, employment or educational supportive activities, social programs that promote health and wellness and/or research activities that support a specific community activity that improves health outcomes).

Within Medicaid, many states leverage managed care contracts to promote reducing health disparities. As noted above, this includes adopting contract requirements related to addressing SDOH. Additionally, some state managed care organization (MCO) contracts incorporate requirements to advance health equity and/or tie MCO financial quality incentives to reducing health disparities. In a KFF survey, about one-third of responding MCO states reported at least one MCO financial incentive tied to reducing racial and ethnic disparities in place in FY 2024, including linking capitation withholds or pay-for- performance incentives to improving health disparities. Additionally, nearly all responding MCO states also reported at least one specified MCO requirement related to reducing disparities in FY2024, including requiring MCOs to have a health equity plan in place and train staff on health equity and/or implicit bias. Over half of states reported requiring MCOs to meet health equity reporting requirements and seek enrollee input or feedback to inform health equity initiatives. Fewer states reported requiring MCOs to achieve national accreditation standards or to have a health equity officer.
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Lessons Learned

In addition to the review of public materials, we conducted 14 case study interviews with stakeholders in three states to increase understanding of lessons learned from state efforts to address disparities. The case study initiatives reflect some of the broad themes of state activities identified through the analysis of publicly available materials and represent states with varied geography, racial and ethnic demographics, and political leadership. They include California’s Reducing Disparities Project (CRDP), which implements  community defined practices to reduce mental health disparities; North Dakota’s Community Engagement Unit, which prioritizes a community engagement approach to reducing disparities and includes a focus on Tribal relations; and Michigan’s efforts to narrow disparities in maternal and infant health through its Advancing Healthy Births equity plan and its Doula Initiative. (See Methods for more details.) Lessons learned from the case study interviews include the following.

Having strong leaders and champions within the state is important for success. Respondents noted that supportive leadership at the state executive level and within key state agencies has been key for facilitating the vision and funding necessary to support these initiatives. For example, in Michigan, respondents highlighted the importance of the Governor’s prioritization of maternal and infant health equity, which was backed by investment in the work. Respondents also referenced the importance of having champions within state legislature and at the local level, particularly in cases in which initiatives have required ongoing legislative funding. For example, respondents in California noted that having champions within the state legislature and county behavioral health offices was important for establishing the CRDP and maintaining it over multiple legislative funding cycles. Respondents further emphasized the importance of such leaders being supportive of addressing upstream drivers of disparities, including social and economic factors, and openness to systems change. At the same time, one respondent noted the importance of institutionalizing changes through policy or operations so that efforts are not contingent on specific leadership being in place and are more likely to continue amidst staff turnover or changes in leadership.

Authentic long-term trusted relationships between the state and community are an integral piece of this work. Respondents noted the importance of establishing authentic community engagement by meeting communities where they are, demonstrating responsiveness to their interests and needs, and maintaining ongoing, long-term conversations. For example, in North Dakota, the community engagement team travels to meet with communities, including Tribes, on an ongoing basis. This allows them to respond to issues raised by the community and deepen relationships over time. In Michigan, the state participates in regular meetings hosted by regional collaboratives in locations chosen by the community that are usually held in the evenings when families can attend. Families drive the conversation, and the state takes advisement and then reports back on issues raised in subsequent meetings. Respondents noted that authentic community engagement often involves a shift in dynamics from one in which communities used to have to come to the state to now the state traveling out to meet communities and from the state just taking data previously versus now sharing it back with the community.

Openness to innovation and community-led approaches facilitates development of new models and strategies.  Community defined and led approaches are core features across the initiatives being implemented in the case study states. Respondents highlighted the importance of state leadership being open to innovative models that do not fit within current systems and structures and supporting their implementation by allowing communities to design and lead efforts and providing funding to support these efforts. It was recognized that this sometimes requires being creative and finding ways to work within existing limits of system structures to implement new approaches. In California, the CRDP model recognizes that community-defined practices can be viable and valuable and that prevention and services do not need to adhere to a one-size-fits-all approach. This model recognizes that a particular approach may not work for everyone but can be effective at addressing the specific needs of the community being served. In North Dakota, respondents noted that the state is engaging with the community and key stakeholders to work toward the goals outlined in its SHIP. Respondents also pointed to the value of investing directly in the community. For example, in Michigan, the state increased funding directed to community-based organizations as part of its Advancing Healthy Births initiative. One respondent noted that the experts are the families and that solutions to challenges often can be found from the people you are serving.

Terminology used to describe this work can be important for garnering broad-based support amid opposition to DEI efforts and race-based interventions. Several respondents noted that describing initiatives as equity-focused can jeopardize broad support for this work amid the rising anti-DEI movement. They felt that implementing the work is more important than what it is called and noted that using terminology that is truthful to the work being done but intentional in avoiding potential opposition can be key for maintaining broad-based support. Some emphasized, for example, that health equity is not just about race, it is about working with a wide variety of populations, including rural and low-income populations, and about focusing on access to health care and addressing SDOH. Moreover, work to mitigate health disparities can elevate the entire system and benefit all residents of the state, not just populations of focus.

Having strong evaluation data can help maintain support for initiatives and facilitate their sustainability over time. Respondents highlighted the importance of having data to document the impacts and successes of initiatives, which can help counter potential opposition to equity-focused efforts and makes the case for sustaining the work. In California, each of the CRDP initiatives is being evaluated individually and as a whole, which helps demonstrate the impacts of the work and the value of community-designed approaches. Respondents also noted that having data can help guide programs to adapt and change over time by providing insight into what is working and what is not.

Establishing long-term funding strategies will be key to sustaining these initiatives over time. Much of the work under these initiatives in the case study states has been supported through limited funding streams, including time-limited appropriations and grants. Respondents recognized that to support long-term sustainability and increased scalability over time, it will be important to embed the efforts into systems and support them through reimbursement mechanisms. They identified challenges to integrating community practices into public health systems and suggested it will be important to consider how existing systems could adapt to integrate a broader array of models through a combination of cultural and systems change. For example, in Michigan, the Medicaid program has expanded to provide reimbursement for doulas and to create the doula registry. Respondents in California noted how identifying Medicaid and other reimbursement models could evolve to include community-designed approaches demonstrated through the CRDP will be important for long-term sustainability of these efforts.
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Looking Ahead

This analysis shows that states with varying geographies, demographics, and political leadership are pursuing work to address health disparities. However, states differ in the level of commitment and resources focused on this work. While some states are taking more incremental steps, others have identified this work as a major cross-sector strategic priority, establishing dedicated infrastructure and resources to support this work, taken steps to empower and support impacted communities, and are working toward broader systems and policy change to mitigate disparities. In these cases, case study respondents shared that certain facilitating factors have been vital to establishing and working toward sustaining health equity initiatives including having supportive leadership, building trust with communities, prioritizing community-driven innovations, considering the political context for messaging, demonstrating impact with data, and planning for sustainability.

As a result of these efforts, states have directed increased staff and resources to this work, established infrastructure or policies that facilitate community input to inform state decision-making and program implementation, directed increased financing to community-based organizations, and enhanced the data available to identify and direct efforts to address disparities. In particular, the establishment of new infrastructure and policies to address disparities and advance equity may facilitate the sustainability of this work amidst potential turnover in staff and leadership.

While this analysis provides greater insight into the range of state-reported activities to address health disparities and/or equity, it does not give insight into the effectiveness or outcomes associated with these actions. Future work examining the impacts of these efforts on both state operations and disparities in health care and health outcomes will be important to help guide continued efforts to address health disparities and advance greater health equity.
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Methods

The approach for this analysis consisted of two phases: a systematic review of publicly available materials and case studies in three states on efforts to address health disparities and advance health equity. The review was conducted for about a six-month period between September 13, 2023 and March 5, 2024. It began by compiling, reading, and synthesizing relevant literature including reports, blog posts, and journal articles to get grounded in the potential landscape of state-level issues on the topic. This informed an iterative process that started with piloting a draft protocol and inclusion criteria for reviewing public-facing webpages and content linked to webpages (e.g., PDFs of reports) for two states. The research team then created a data collection framework based on thematic categories (e.g., health equity infrastructure, strategic initiatives, data equity, etc.) that was piloted with two more states. Following, the protocol, inclusion criteria, and framework were refined over time through routine team discussions to reconcile divergent issues and by making adjustments for emergent themes for the remaining states. The team conducted the review using criteria that were intentionally inclusive, rather than exclusive, to allow for capture of a range of possible state activity that states identify as related to addressing health disparities and/or equity. Specifically, the team included a broad range of work identified by states related to health equity, health disparities/inequities, social determinants of health, health in all policies, and efforts to address the health needs of diverse populations. An expansive search approach was utilized by looking for information across a diverse set of state agencies, beyond those dedicated to health (e.g., justice, natural resources, education, etc.) and by including content where the state agency was a collaborating partner but not necessarily the lead. Relevant information that did not fit the established data collection framework was also included to facilitate the identification of atypical and innovative activities occurring in a small number of states. The states selected for the case studies were California, North Dakota, and Michigan. In selecting the case study states, the goal was to identify state efforts that reflect the broad themes of state activities identified through the analysis of publicly available materials, as well as to represent varied geography, racial and ethnic demographics, and political leadership. We also sought to avoid including state efforts that have already been highlighted in other national-level analyses. The team conducted five interviews for each state case study with the aim of understanding the impetus for the initiative, the accomplishments and lessons learned, and perspective on future directions for the work. Key stakeholders who were interviewed represented state employees that staffed the initiatives and their community partners allowing our team to gain insights of both the intentions of the initiative and the challenges that may come with program development and implementation. Each interview was tailored to the key stakeholder’s role, and the analysis to develop the case was conducted iteratively as each interview was conducted. This project is limited to being descriptive in nature during a specified period of time. It is possible that states may have had activity underway that was not reflected in their public-facing materials. In some cases, it was difficult to determine the current phase of strategy. For example, the presence of a strategic plan does not mean it has been funded and implemented as intended.