背景:尽管在健康和健康结果的社会决定因素中越来越关注种族不平等,较少关注的是结构性障碍——嵌入在项目中并编入法律——如何塑造实现健康的机会。
方法:为了更好地了解美国联邦政策如何针对人口层面的机会和健康的结构性障碍,我们进行了一项法律审查,以确定具有里程碑意义的联邦政策,这些政策可能影响健康的关键社会决定因素。然后,使用佐治亚州和美国五个邻近州(阿拉巴马州,佛罗里达,北卡罗来纳州,南卡罗来纳州,和田纳西州),我们进行了一项观察性案例研究,以检查获得医疗保健的最新趋势,住房,和教育,因为它们都与旨在缓解长期结构性障碍造成的不平等现象的全面联邦立法相关,并且每个都被《健康人2030》确定为健康的关键社会决定因素。
结果:从2010年到2021年,健康保险费率在人口水平上有所改善,抵押和租金负担,和教育程度,格鲁吉亚的黑人和白人人口都有所改善,在东南地区,在美国全国。然而,在健康的社会决定因素中,黑人和白人之间看似有意义的差距在任何地理层面都没有消除。
结论:这项分析增加了越来越多的证据,表明历史上种族化的社会结构阻碍了黑人人口积累财富的机会,获得高质量的教育,在一个充满机会的社区拥有一个家,并获得医疗保健,与他们的白人同龄人相比。鉴于健康差距和不平等的根源在于健康的交叉点,卫生保健,经济学,教育,和其他社会制度,需要采取多部门的政策方法来解决这些系统性问题。虽然联邦法律确实为社会变革提供了近端利益的动力,在现代联邦制中,它们本身不足以解决所需的地方制度变革和非法律政策干预,在地方方案一级实施,可以作为补充机制来解决机会均等障碍的挥之不去的影响。
BACKGROUND: Despite increasing attention to racial inequities in social determinants of health and health outcomes, less attention has been focused on how structural barriers - embedded in programs and codified in laws - shape opportunities to achieve health.
METHODS: To better understand how U.S. federal policies targets structural barriers to opportunity and health at the population level, we conducted a legal review to identify landmark pieces of federal policy that held potential to impact key social determinants of health. Then, using publicly available data for Georgia and five neighboring U.S. states (Alabama, Florida, North Carolina, South Carolina, and Tennessee), we conducted an observational case
study to examine recent trends for access to health care, housing, and education because they were each associated with comprehensive federal legislation meant to alleviate inequities resulting from long-standing structural barriers and were each identified by Healthy People 2030 as key social determinants of health.
RESULTS: From 2010 to 2021, population-level improvements were seen in health insurance rates, mortgage and rental burden, and educational attainment, with improvements seen for both Black and White populations in Georgia, regionally in the Southeast region, and nationally in the United States. However, seemingly meaningful gaps between the Black and White populations across social determinants of health have not been eliminated at any geographical level.
CONCLUSIONS: This analysis adds to a growing body of evidence that historically racialized social structures hamper Black populations\' opportunities to build wealth, gain a quality education, own a home in a neighborhood of opportunity, and access health care, compared to their White peers. Given that the root causes of health disparities and inequities lie at the intersection of health, health care, economics, education, and other social systems, a multisectoral approach to policy is needed to address these systemic issues. While federal laws do provide momentum for proximal benefits for social change, in modern federalism they alone are insufficient to address needed local system change and nonlegal policy interventions, implemented at the local programmatic level, may serve as complementary mechanism to address the lingering effects of barriers to equal opportunity.