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What the American Rescue Plan Means for Health Equity

  • 1Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
  • 3Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
  • 4Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland

The primary goal of the $1.9 trillion American Rescue Plan Act of 2021 is to help the nation recover from economic, health, and social devastation of the COVID-19 pandemic. Yet the law will accomplish even more. Many of the provisions will have important implications for health equity among communities of color and other disadvantaged groups.

The Robert Wood Johnson Foundation has defined health equity as when “everyone has a fair and just opportunity to be as healthy as possible.” The pandemic has exposed the vast distance between this goal and reality in the US.

Profound disparities by race and ethnicity, as well as by social class, exist not only in outcomes that include life and death, but also in underlying conditions—such as poor access to affordable and nutritious food, safe housing, and health care—that undermine health. A disproportionate share of the people facing these health challenges are families with children.

The American Rescue Plan will advance health equity in 4 major ways: by reducing poverty among children and families, by closing gaps in access to medical care, by investing in community health, and by addressing social contributors to health.

Reducing Child Poverty

It is well established that poverty causes poor health outcomes, particularly for children.1 The new law takes unprecedented steps to address poverty among children and families. The Center on Poverty and Social Policy at Columbia University has estimated that unemployment, housing, and food provisions of the new law—combined with a new tax credit for families with children—will reduce child poverty by more than half from 13.5% to 5.9% of US children. The legislation will lift more than 5 million children out of poverty, a majority of whom are from communities of color—reducing, though still not eliminating, disparities in childhood poverty.

Closing Gaps in Medical Care

The inability to afford needed medical care contributes to many health disparities. The American Rescue Plan makes comprehensive health coverage more affordable and accessible for millions of people with low incomes, including many who lost coverage entirely due to unemployment. Specifically, the new law provides

  • Enhanced financial assistance on the federal and state exchanges. An estimated 3.6 million uninsured people will get financial assistance for the first time, 9.5 million uninsured people making between 100% and 400% of the poverty level will have access to more financial assistance than before, and 1.8 million uninsured people with incomes up to 150% of the poverty level will be eligible for a 100% premium subsidy.

  • Strong incentives for Medicaid expansion. Twelve states have yet to decide to expand Medicaid. If these states take advantage of additional incentives in the American Rescue Plan to do so, access will open for nearly 4 million uninsured low-income adults, including about 640 000 essential or frontline workers, approximately half of whom are people of color. These additional incentives include an extra federal match for state Medicaid expenditures for previously enrolled populations such as children and pregnant women. An additional provision creates an option for all states to extend postpartum coverage for women from 60 days to 12 months, which would facilitate access to needed medical care for new mothers2 across the US.

  • Special support for people who recently became unemployed. The legislation provides for a 100% COBRA subsidy for people who lose their health insurance because of involuntary job loss or reduction in hours between April 1 and September 30, 2021. Black and Latino workers have experienced greater job losses and rates of unemployment in the COVID-19 economy; this provision is a critical strategy to promote equity in health care access during this time.

Investing in Community Health

Access to preventive care and the ability to live in a safe environment help people stay as healthy as possible. The American Rescue Plan provides major funding at the community level to end the pandemic and promote health and well-being. Specifically, the new law provides

  • Substantial resources to fight COVID-19. These include more than $7.5 billion to support the distribution of vaccines and more than $47 billion to support disease control efforts, including testing and contact tracing. Many communities of color have had limited access to testing3 and vaccines throughout the pandemic. Many of these funds will reach state and local health departments, strengthening the public health infrastructure and reducing inequities.

  • New investments in the workforce. The legislation includes $7.6 billion for staff to strengthen the efforts of public health departments and community health centers, as well as $1 billion to expand the National Health Service Corps and the Nurse Corps.

  • Support for behavioral health. This includes grants to states of $1.5 billion for community mental health services and $1.5 billion for the prevention and treatment of substance use disorders. These resources will particularly assist communities of color struggling with disproportionate losses of life,4 stress related to violence and mistreatment by the police, and rising rates of hate crimes motivated by race and ethnicity.

Addressing Social Contributors to Health

A major reason for health disparities is inequity in access to food, safe housing, and other conditions required to support health. Public health scientists have called for a new kind of herd immunity to protect a sufficiently high proportion of the population—across race, ethnicity, and social class—from social contributors to poor health.5 To achieve this goal, the new law provides

  • Significant support to address hunger and food insecurity. Steps include extending benefits in the Supplemental Nutrition Assistance Program, providing more food assistance to school-aged children, expanding the Women Infants and Children nutrition program, and strengthening the food chain by protecting workers. Expanding these programs is likely to have important effects6 on reducing disparities, given the disproportionate number of women and children of color facing poverty.

  • Support for child care and early education. The legislation includes $39 billion that will help support nearly 500 000 childcare providers serving more than 7 million children, as well as $1 billion to allow the Head Start program to provide more assistance to children and families.

  • Emergency housing assistance. Access to safe, affordable, and healthy housing7 is a critical prerequisite for achieving optimal health. The American Rescue Plan includes more than $21 billion to prevent an epidemic of eviction and homelessness among renters, $5 billion to address homelessness, and more than $100 million for rural housing needs.

  • Transportation. Key provisions include more than $30 billion to save public transit agencies relied upon by millions of low-income persons and essential workers.

  • Environmental justice. The legislation includes $100 million to address air pollution and other toxic health threats in disadvantaged communities.

A point of reference for many in describing the American Rescue Plan is the New Deal, the 1930s-era set of policy changes that, among other major changes, kept millions of older adults out of poverty over the next century. Parts of the New Deal, however, also contributed to segregation and other harms that reduced opportunities for health for many in the US.

The American Rescue Plan has the potential to lead to a more just and sustained shift in health and social policy in the US. To succeed, however, many of the legislation’s time-limited provisions (many are only for 2 years) will need to be extended and expanded into areas such as climate change and employment policies. Furthermore, the lack of bipartisan support in Congress for the legislation may threaten its potential for sustainable effects on equity. Could broad understanding of this landmark legislation—as well as its effective implementation—inspire additional action and sustainable change? There is a great deal at stake for health equity in the answer.

Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Cooper LA et al. JAMA Health Forum.

Corresponding Author: Lisa A. Cooper, MD, MPH, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205 (lisa.cooper@jhmi.edu)

Conflict of Interest Disclosures: None reported.

References
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Williams  DR, Cooper  LA.  COVID-19 and health equity—a new kind of “herd immunity”.   JAMA. 2020;323(24):2478-2480. doi:10.1001/jama.2020.8051PubMedGoogle ScholarCrossref
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Thornton  RL, Glover  CM, Cené  CW, Glik  DC, Henderson  JA, Williams  DR.  Evaluating strategies for reducing health disparities by addressing the social determinants of health.   Health Aff (Millwood). 2016;35(8):1416-1423. doi:10.1377/hlthaff.2015.1357PubMedGoogle ScholarCrossref
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Bostic  RW, Thornton  RL, Rudd  EC, Sternthal  MJ.  Health in all policies: the role of the US Department of Housing and Urban Development and present and future challenges.   Health Aff (Millwood). 2012;31(9):2130-2137. doi:10.1377/hlthaff.2011.1014PubMedGoogle ScholarCrossref
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