State Strategies for Overcoming Barriers to Advance Health Equity

Health Highlights

Editor’s Note: In a new issue brief for the Robert Wood Johnson Foundation’s State Health and Value Strategies program, summarized below, Manatt Health explores impediments and accelerants to advancing health equity as states are increasingly being called upon to drive change. Click here to download a free copy of the full brief.

The COVID-19 pandemic has highlighted long-standing health inequities which have resulted in an increased risk of sickness and death for people of color. The crisis has also propelled a nationwide focus on understanding and addressing health inequities. As compared to White, Non-Hispanic individuals, American Indians or Alaska Natives are over five times as likely to be hospitalized, and Black or African-American individuals are over twice as likely to die from COVID-19.

While COVID-19 and the reckoning on racial justice have mobilized some state officials working in Medicaid, public health, insurance departments and Marketplaces alike, states are at different places on their journeys to confront systemic racism and inequities in healthcare, and each faces unique and challenging barriers. As early as August of this year, over one third of states had launched task forces to take a closer look at health disparities (or differences in health based on population group) in response to the pandemic. These new task force efforts stand in contrast to decades of siloed and often poorly funded work to advance health equity by state offices of minority health or health equity. The new wave of state health equity activities aims to mitigate structural, institutional, political, financial and analytical barriers to ensure everyone has a fair opportunity to be as healthy as possible.

Barriers to Health Equity

Health inequities are deeply rooted in structural or systemic racism. Understanding that racial bias and racism (such as redlining) underlie health inequities, states are working to understand structural, institutional, political, financial and analytical barriers to health equity in order to identify and implement strategies to overcome them.

Strategies to Address Structural, Institutional and Political Barriers to Advancing Health Equity

States are implementing a range of initiatives to overcome barriers to advancing health equity. States that are newly engaging in this work may consider implementing the following strategies:

  • Establish diverse and accountable leadership to drive health equity efforts.
  • Develop common terminology and internal understanding.
  • Create an integrated state health equity plan and collaborate across agencies to implement.
  • Ensure health equity initiatives are community driven.
  • Develop creative strategies given institutional constraints, such as the federal executive order released on September 22, 2020, prohibiting the use of workplace trainings on “divisive concepts” and “race or sex scapegoating” for federal employees and contractors.


While states are taking unprecedented steps in the right direction, they are still grappling with the challenges of advancing health equity, which can at times feel insurmountable. Engaging in honest conversation, both internally with state leaders and staff as well as with communities impacted by inequities, is critical to identifying barriers to equity and taking concrete action steps to remove them. States can also take on the arduous and important work of culture change to put health equity at the forefront of decision making as they create new programs and make changes to existing initiatives across public health, Medicaid and the Marketplace. These steps are critical to beginning what, for many state health policymakers, will be a lifetime of work necessary to repair health inequities and eliminate disparities in our healthcare system.

1,2 Barriers to advancing health equity were informed by a review of the available literature and discussions with states.



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