Top 10 Ways To Improve Health and Health Equity

From 2019 to 2020, life expectancy in the United States declined by 1.5 years, reaching its lowest level since 2003.¹ It fell yet again in 2021.² In fact, the health of Americans has been declining for decades, compared with citizens in other high-income countries:³ In 2020, life expectancy in the United States was nearly five years lower than it was in other industrialized countries, and it has only declined further as the country has faced the world’s largest total death toll from COVID-19.⁴ Unlike the United States, in 2021, many of its peer countries have started to see rebounds in life expectancy with the help of the COVID-19 vaccination.⁵

As health declines, it adversely affects not only quality of life but also the economy and national security, including workforce productivity, health care costs, and the fitness of military recruits.⁶ Yet these adverse health impacts are not felt equally across U.S. society. For example, the decline in life expectancy has been greater among Hispanic and non-Hispanic Black populations than among the non-Hispanic white population.⁷ To eliminate these disparities and those that exist in economic and social systems, an intentional focus on redressing structural and institutional racism is critical.⁸ Improving the health of the most vulnerable populations will not only boost overall health outcomes and social well-being, but also strengthen the economy and help to build a strong, equitable future.

Policies to strengthen the nation’s health must therefore ensure that individuals and all communities are healthy and thriving and that no one is left behind. This can be done through long-term, sustained investments to prevent disease, promote health, and prepare for and respond to continuous and urgent threats to health. Namely, by addressing social determinants of health—such as income, education, housing, employment, transportation, environmental conditions, and neighborhood conditions—policymakers can improve health,⁹ reduce racial disparities,¹⁰ and contribute to economic mobility.

Figure 1

This report outlines 10 priorities for improving the nation’s health, in no particular order:

1. Stop the spread of COVID-19.
2. Invest in public health infrastructure.
3. Address the opioid and substance use epidemic.
4. Mitigate climate change and invest in environmental justice.
5. Reduce poverty and improve economic stability.
6. Improve education access and quality.
7. Improve access to affordable, stable, inclusive, healthy, climate-resilient housing.
8. Improve health care access and quality.
9. Reinforce social connections and community safety.
10. Advance racial equity and inclusive policies.

As the COVID-19 pandemic winds down, the nation has an opportunity to focus attention on the critical opportunities and threats to the nation’s health. To improve and restore the health of Americans, policymakers should consider new policies that target these key drivers of health. Now is the time to capitalize on the investments that have been made through the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the American Rescue Plan (ARP), the Infrastructure Investment and Jobs Act, and the fiscal year 2022 omnibus appropriations package, along with future investments proposed in the reconciliation package being considered by Congress and the White House fiscal year 2023 budget proposal. Only then can we take meaningful steps toward improving the nation’s health.

COVID-19 has ranked among the top three leading causes of death in the United States throughout most of the pandemic.¹¹ In addition to lives lost, the pandemic has affected mental health, resulted in long-term illness and disability, and caused economic disruption—disproportionately affecting women, older adults, disabled individuals, residents of congregate care settings, and people of color.¹² Specifically, Black, Latino, and American Indian or Alaska Native populations have endured more severe health effects than white, non-Hispanic people as a result of COVID-19, including higher hospitalization and death rates.¹³ The pandemic has also led to a general increase in stress and anxiety, including a documented increase among young people.¹⁴

In early March 2022, a period of relatively low cases, COVID-19 was still killing slightly less than 700 people daily, about 10 times as many people per week than during a bad year of flu.¹⁵ Although the enduring impacts of COVID-19 are still being studied,¹⁶ recent research shows that COVID-19 may have long-term impacts on the brain.¹⁷ People who have had COVID-19 have experienced increased mental health issues, including brain fog, anxiety disorders, depression, and sleep disorders up to a year after their diagnosis.¹⁸ COVID-19 has also been found to increase the risk of heart problems for at least a year after diagnosis, even for those who have mild symptoms.¹⁹

From business closures to job losses, the financial and economic impact of COVID-19 has been nearly as significant. According to the U.S. Bureau of Labor Statistics, 2.3 percent of American workers were out sick in January—three times higher than in a typical month before the pandemic.²⁰ The effects were most extreme for households with less than $40,000 in income, who reported being more likely to miss work due to COVID-19-related sickness and less likely to have paid sick time.²¹ Notably, about 1.5 million additional women remain out of the labor force more than two years into the pandemic.²²

Despite the staggering impact of COVID-19 on health and the economy, there have been dramatic improvements lately. Since the peak of the omicron surge, case rates have fallen 95 percent,²³ and it is estimated that 94 percent of people now have some immunity, either from a vaccine or from previously contracting COVID-19.²⁴ Meanwhile, new COVID-19 cases, hospitalizations, and deaths continue to fall throughout the country; in fact, new case reports are at their lowest since summer 2021.²⁵

States and localities are removing COVID-19 precautions in response to these improvements.²⁶ Yet as these precautions unwind, it is critical to monitor trends and remain prepared to address any future surges, identifying early signals that point to the need for stronger prevention strategies.²⁷ Increases in cases in several Asian and European countries,²⁸ as well as rising U.S. test positivity rates in the second half of March, serve as reminders to maintain vigilance.²⁹

Public policy should reflect public health priorities. Specifically, in order to proactively protect the health of communities and populations, particularly those at high risk and disabled people, it is important to employ multiple layers of protection rather than a model focusing only on individual risk. While the country is not yet ready to move on from an emergency phase, a new “Roadmap for Living with COVID” by some of the nation’s leading public health experts builds a path forward to guide this effort,³⁰ calling for monitoring of key metrics and policies to center equity³¹ by addressing the health disparities exacerbated by the pandemic.³² In preparation for this new phase, the Biden administration’s National COVID-19 Preparedness Plan has outlined four key goals:³³ 1) continued availability of free high-quality masks and tests for the public; 2) steps to keep businesses and schools open; 3) stockpiling of supplies to improve systems’ ability to detect and respond to new variants; and 4) distribution of vaccines domestically and globally. As part of the plan, the administration also launched a new “test to treat” initiative to immediately provide patients who test positive at a pharmacy-based clinic or community health center with no-cost antiviral medications. Importantly, this initiative contains provisions to promote access for communities most affected by COVID-19.³⁴

Of the more than $370 billion that has been appropriated to the U.S. Department of Health and Human Services (HHS) for pandemic response in the past two years, most was targeted to health care providers, with about $140 billion set aside for testing, treatment, and vaccines.³⁵ Continued investment is critical to national and global response and readiness.³⁶ Yet federal inaction on a COVID-19 supplemental funding proposal leaves the country at risk, as it would be unable to continue ongoing surveillance; improvements in air ventilation and filtration; monoclonal antibody treatment; free testing, treatment, and vaccines for uninsured patients; oral antiviral pills and treatments for immunocompromised individuals; and other priorities.³⁷

Vaccination continues to be the most effective tool to reduce COVID-19 related severe disease and death.³⁸ Without additional resources, however, funding for vaccines will not be available beyond young children or fourth boosters for older adults. And vaccine supply may fall if the United States fails to pre-purchase doses, causing manufacturers to limit production.³⁹ Experts warn that antibody treatment shipments to states have already been cut and will run out.⁴⁰ With the Health Resources and Services Administration’s COVID-19 Uninsured Program no longer reimbursing for testing and treatment as of March 22, 2022, free testing sites are already closing, and claims for vaccine administration expired April 5, raising concerns about the possibility that COVID-19 adverse health impacts may rise among low-income and uninsured people, communities of color, and medically underserved areas.⁴¹

The public health system is vital to ensuring the health of the country. It is dedicated to disease prevention and health promotion through federal, state, and local agencies that track and predict emerging and persistent threats; respond to health risks and events; and promote health through education and policymaking, while also identifying and addressing health disparities. Yet the benefits of public health are less apparent because when interventions are successful, the system works as expected, and major misfortunes do not happen.

Despite spending more on health care than any other country, the health of Americans is declining.⁴² Meanwhile, health disparities continue to grow.⁴³ The research is clear: Public health interventions improve health and quality of life exponentially. Indeed, just moderate increases of 10 percent in public health spending have been linked to decreases in mortality rates of up to 7 percent.⁴⁴ Likewise, reductions in low birth weight, food-borne illnesses, and rates of sexually transmitted diseases have been linked directly to increased spending on public health interventions.⁴⁵ Notably, every $1 invested in public health yields up to $88 in benefits⁴⁶ and saves at least $5 on health spending for chronic conditions.⁴⁷

Yet most types of public health funding remained flat or declined in the decade prior to the COVID-19 pandemic.⁴⁸ Historically, investments in public health have largely come in response to major emergencies and tend to remain linked to those specific diseases or issues, as was the case with swine flu (the H1N1 virus), Ebola, and Zika.⁴⁹ Then, once the immediate threat subsides, public health funding is reduced.⁵⁰ This reactionary pattern of funding leaves little room for long-term system building and maintenance.

Because of such chronic underfunding, the public health system was both frail and fragmented going into the fight against COVID-19; experts had even warned about this lack of preparedness well before 2020.⁵¹ This proved costly: Delays and difficulties in implementing measures such as contact tracing, testing, supplying personal protective equipment, and distributing vaccines undermined the nation’s ability to reduce infection rates and save lives.⁵² On top of this, public health workers faced long hours, public and political hostility, and reduced authority as a result of the nation’s slow response to COVID-19, such that an already barebones workforce shrunk even more. In fact, an additional 100,000 workers are now needed to deliver core public health services to communities nationwide.⁵³ Even before the pandemic, challenges such as low compensation and limited opportunities for professional development plagued the public health workforce and limited its growth; those challenges continue today and have worsened.⁵⁴ Moreover, many public health departments and agencies still lack the sophisticated data systems to support basic public health functions such as real-time disease surveillance and disparities tracking, data sharing, and prediction of health threats.⁵⁵

The pandemic brought on a wave of significant increases in federal funding for public health, including $500 million through the CARES Act, $93 billion from the ARP,⁵⁶ and potential new funding for public health activities in a House-passed reconciliation package.⁵⁷ These temporary investments will help strengthen public health’s effort to control the impact of COVID-19 and target key infrastructure needs. Yet sustained, comprehensive funding is needed to ensure core public health services availability and preparedness for the next health threat.

Federal efforts, such as the bipartisan PREVENT Pandemics Act, can pave the path toward improving general funding for public health activities. The act includes support for medical preparedness and response coordination; public health communication and health security; biosurveillance and infectious disease data collection; recruitment and retention of the front-line public health workforce; and research and accountability, among other provisions.⁵⁸ The White House fiscal year 2023 budget proposal also includes roughly $10 billion for data modernization and disease surveillance at the Centers for Disease Control and Prevention (CDC) and public health departments, as well as another $5 billion for biomedical research at the newly formed Advanced Research Projects Agency for Health.⁵⁹ However, these efforts still fall short of the administration’s goals and the $4.5 billion in new and permanent annual funding that experts say is needed to ensure equitable and sustained foundational public health services for all.⁶⁰

States have started to take action to improve public health infrastructure within their own jurisdictions. For example, after advocacy efforts by the California Can’t Wait Coalition, in July 2021, California committed to spending an additional $300 million of its state budget annually on public health agencies.⁶¹ While such examples represent steps in the right direction, they do not make up for the gap in federal funding.

Importantly, health threats caused by extreme weather-related events, the opioid epidemic, and infectious diseases are emerging at an increasing rate. Without policy change to provide adequate, flexible, and sustained funding, supplemental investments made over the last two years are at risk of following the same pattern of previous public health investments—losing pandemic-era progress. It is critical to take advantage of the newfound public awareness of and support for public health in order to make lasting change in the nation’s approach to health.⁶²

Drug overdoses are the leading cause of rising mortality rates among young and middle-aged adults, and more Americans now die as a result of fatal drug overdoses than from car crashes and even gun violence. In April 2021, the number of fatal drug overdoses in the United States over a 12-month period surpassed 100,000 for the first time.⁶³ One of the primary drivers of this substance use epidemic is opioids. According to the 2020 National Survey on Drug Use and Health, more than 9.5 million Americans misused opioids in 2020.⁶⁴ As a result, more than 70 percent of overdose deaths in 2019 involved opioids, including prescription opioids, heroin, and synthetic opioids such as fentanyl, and the number of annual opioid deaths in 2020 was six times the number in 1999.⁶⁵

In December 2021, President Joe Biden declared the illicit drug trade a national emergency.⁶⁶ And later, in February 2022, the Commission on Combating Synthetic Opioid Trafficking deemed the overdose crisis to be one of the most pressing national security, law enforcement, and public health challenges in the United States, with an estimated cost of approximately $1 trillion to the U.S. economy annually, including health expenses, reduced productivity, and other losses.⁶⁷

Several factors contribute to the increase in overdoses: families struggling with stagnant wages and job insecurity, the growing prevalence of deadly fentanyl in the illicit drug supply, and the COVID-19 pandemic—which has led to social isolation and challenges for individuals needing in-person treatment or other support. Drug regulation and prescribing practices further compound the problem, as individuals who are prescribed opioids for pain may become addicted and transition to less expensive illicit drugs.⁶⁸

Yet opioid overdoses and deaths are preventable. Medication-assisted treatment, the use of medications in combination with counseling and behavioral therapies, can successfully treat these disorders and help sustain recovery for some people struggling with addiction,⁶⁹ thus helping to prevent or reduce opioid overdose.⁷⁰

Expanding access to evidence-based treatment is critical to addressing the opioid epidemic, including for individuals with opioid use disorder who are incarcerated. The Substance Abuse and Mental Health Services Administration distributed $3 billion in ARP funding through its mental health and substance use block grant programs, yet additional funding is needed to support research, prevention, treatment, and recovery support services, with targeted investments to support the most vulnerable populations.⁷¹ Specifically, widening disparities between overdose deaths in Black communities and other racial and ethnic groups point to the need to examine how structural racism and deep-seated inequalities affect conditions that influence drug use and services.⁷² Access to timely opioid-related overdose data, disaggregated by race and ethnicity, is critical to ensure evidence-based treatments and interventions are community-based and equitably distributed.⁷³

It is now clear that some methods for addressing the substance use epidemic are more successful than others. For instance, the criminalization of substance use disorder stemming from the war on drugs has proved ineffective and has also disproportionately affected people of color.⁷⁴ Policies and practices that lead to incarceration of individuals in possession of opioids for personal use should be discouraged given the public health risks and lack of public safety gains.⁷⁵

Instead, policymakers should focus on prevention, treatment, and recovery, such as the following actions:

• In October 2021, the HHS released a comprehensive Overdose Prevention Strategy, prioritizing four key target areas: primary prevention, harm reduction, evidence-based treatment, and recovery support.⁷⁶
• Increasing funding for the State Opioid Response program—by which the Substance Abuse and Mental Health Services Administration awards funding to states and territories in order to address the opioid crisis—would enable states to increase access to community-based treatment and recovery options, opioid prescription tracking, additional treatment beds, behavioral health and peer support workers, and prevention campaigns.⁷⁷
• According to a brief by the National Academy for State Health Policy, new Medicaid funding opportunities in the ARP present states with an “unprecedented opportunity to enhance and modernize their behavioral health crisis systems.”⁷⁸ Rhode Island, for example, established a 24/7 buprenorphine hotline to provide immediate telehealth access to treatment.⁷⁹

In fiscal year 2023, Congress needs to dedicate funding across agencies to combat the opioid crisis; stop the flow of drugs; expand access to evidence-based community treatment and recovery options, including naloxone; and address the root causes of addiction, such as systemic inequities, poverty, and the adverse effects of the criminal justice system.⁸⁰ Finally, this public health approach must be targeted to the communities most affected by dependence on opioids and other substances.

In 2021, more than 200 medical journals issued a joint statement describing climate change as the “greatest threat” to global public health.⁸¹ Indeed, extreme weather events, including hurricanes, flooding, tornadoes, drought, heat waves, wildfires, and winter storms, have increased in severity and frequency over the past four decades.⁸² Yet climate change not only affects the environment; it also leads to worsening health outcomes. Wildfire can inflame respiratory systems and aggravate conditions such as asthma.⁸³ Extreme heat can result in heat stroke, disability, and death.⁸⁴ Natural disasters and other weather-related events can flood roads or cause power outages, impeding access to, and quality of, emergency or other health-related care.⁸⁵

Meanwhile, climate change and environmental pollution have led to poorer air quality, more extreme weather, rising temperatures, and changes in insect behavior. These, in turn, have adverse impacts on health and well-being, including respiratory and allergy-related illness; heart disease and cancer; mental health complications; disease carried by insects, food, and water; and death.⁸⁶ Pollution also causes a variety of health conditions, from cancer to heart and respiratory disease.⁸⁷

Both climate change and localized pollution impact vulnerable populations and communities more severely,⁸⁸ including children,⁸⁹ older adults,⁹⁰ disabled people,⁹¹ low-income communities, and people of color. This disproportionate impact is in part due to a history of environmental racism, racial segregation, and racist housing policies that has also led to a disproportionate number of Black, Latino, and Indigenous communities in flood plains, heat islands, and other areas that leave them exposed to harmful chemicals.⁹² Moreover, economic inequity exacerbates the disproportionate impact of climate change on public health, which in turn has economic consequences for those at highest risk, including disease-related reduction in productivity and increases in health care costs to treat illness and disease worsened by climate impacts.⁹³

The health care systems designed to treat the medical conditions caused by climate and environmental hazards are also contributing to the problem. The health care sector is responsible for 10 percent of U.S. carbon emissions, prompting efforts to label health care pollution as a patient safety issue.⁹⁴ According to the Health Care Climate Council, reducing this carbon pollution 30 percent by 2030 would prevent an estimated “4,130 premature deaths, 85,000 asthma attacks, 4 million respiratory symptom events, 3,750 hospital visit incidents, and would save about $1.2 billion in medical costs.”⁹⁵

Investments that mitigate climate change and reduce pollution can improve health and save lives, while also protecting the planet and bolstering the economy. However, it is vital that any solutions center equity and justice.⁹⁶

Fortunately, the Biden administration has demonstrated a commitment to environmental justice. In March 2021, it established the White House Environmental Justice Advisory Council⁹⁷ and the Office of Climate Change and Health Equity at the HHS.⁹⁸ Moreover, in launching the Justice40 Initiative,⁹⁹ the administration committed to tackling environmental racism by directing 40 percent of the benefits of climate and energy investments to disadvantaged communities.¹⁰⁰

Over the past year, federal government investments in environmental justice and community health have significantly increased. According to Earthjustice, the ARP invested $12.7 billion in “energy and water bill assistance, environmental justice grants, air quality monitoring, and community health centers.”¹⁰¹ Meanwhile, the Infrastructure Investment and Jobs Act included almost $66 billion to advance environmental justice, including $5 billion for Superfund cleanup and brownfield redevelopment, more than $23 billion for clean drinking water, $15 billion to replace lead pipes, and $3.5 billion for the Weatherization Assistance Program, among other provisions.¹⁰² In addition, the Environmental Protection Agency provided $50 million in ARP funding for environmental justice initiatives to fund efforts by community groups and state, local, and tribal government agencies to focus on clean and healthy air, water, and energy infrastructure, as well as an additional $50 million to improve community air pollution monitoring in communities with high levels of pollution.¹⁰³ Governments at the state level have also taken bold climate action by adopting a whole-of-government approach—for example, Minnesota’s Climate Change Subcabinet and New York’s Interagency Climate Action Council.¹⁰⁴

These recent investments are a start, but additional transformative programs are critically needed to stabilize the climate, ensure global warming is limited to 1.5 degrees Celsius, and reduce and eliminate illness and death from pollution, especially in front-line communities. Such programs should incentivize the production of renewable energy and zero-emissions technologies;¹⁰⁵ enact coastal restoration and resilience projects; assist communities in preparing for and recovering from the harmful impacts of climate change and environmental injustice; ensure successful implementation of the Justice40 Initiative; invest in climate research and modeling, including the mental health implications of climate-related disasters; and develop and implement a national strategic action plan for the health system to prepare for and respond to the health impact of climate change.¹⁰⁶ These investments are both cost-effective and vital to improving health outcomes and protecting infrastructure, all while creating good jobs and a thriving economy.

Economic stability is critical to health, as people who are not steadily employed are more likely to have poor health outcomes.¹⁰⁷ Yet due to centuries of marginalization, certain populations suffer from economic instability more than others. In particular, disabled people, LGBT people,¹⁰⁸ and people of color are more likely to be unemployed and live in poverty.¹⁰⁹ Financial instability, unemployment, and low incomes are associated with not only poor health outcomes but also reduced health care access and shorter life expectancies.¹¹⁰ For instance, hospitals in low-income and/or rural communities are more likely to be underresourced or to close, further preventing access, lengthening times to emergency care, and putting lives at risk.¹¹¹ To help people achieve health and well-being, policymakers must assist them in meeting their basic needs and creating environments in which they can work, live, and thrive.

In early 2022, more than 22 million households reported food scarcity, including more than 10 million households with children.¹¹² Yet food insecurity is not felt equally across demographics. In 2020, people with disabilities, for instance, were twice as likely as nondisabled people to face food insecurity.¹¹³ And in 2021, transgender people were three times more likely than cisgender people to face food insecurity.¹¹⁴ In addition to stress, food insecurity is associated with poor children’s health and increased asthma risk, as well as limitations in activities of daily living among older adults.

The Supplemental Nutrition Assistance Program (SNAP) provides monthly grocery benefits to more than 37 million people with incomes below 130 percent of the federal poverty level, and 66 percent of households receiving SNAP benefits include children.¹¹⁵ Yet the program is set to expire September 30, 2023.¹¹⁶ Without congressional action to reauthorize the program before then, millions of people already struggling to make ends meet would face severe food insecurity, nutritional deficiencies, and poorer health outcomes.

Working parents need access to quality and affordable child care to find and keep a job.¹¹⁷ Yet the cost of child care is at least equal to the average mortgage payment and more than twice the average car payment per month.¹¹⁸ A shortage of licensed child care providers further compounds the issue: Indeed, the existing licensed child care workforce can only serve less than 1 in 4 infants and toddlers, according to CAP.¹¹⁹

Investing in children and families is key to families’ long-term health and well-being. For example, high-quality child care, nutritional programs, and early screenings are associated with better cardiovascular and metabolic health;¹²⁰ reductions in disease, depression, and substance use disorders;¹²¹ and improved recovery from adverse childhood experiences.¹²² These investments have downstream effects: Increasing the income of a family with a child under 5 years old by $3,000 can increase the child’s adult earnings by as much as 20 percent.¹²³ Since the stress associated with living in poverty and not having basic needs met leads to poor physical and mental health outcomes,¹²⁴ providing supports that help low-income families meet their basic needs, including nutritious food access, safe and affordable housing, and quality education, would greatly improve health for some of the most vulnerable individuals and families. Indeed, investments in employment-enabling activities such as child care, basic needs provisions, and direct workforce investments, would promote employment and potentially improve the quality of low-wage work.¹²⁵

As proposed in the House-passed budget reconciliation package, two years of universal preschool and a sliding scale limit on family costs would greatly improve access to child care services.¹²⁶ High-income families would pay a greater share of universal child care, but no family would spend more than 7 percent of their income on these costs.¹²⁷ According to analysis by CAP, “in 32 states, a typical family would save more than $100 per week on child care” under such a proposal, totaling $5,000 to $6,500 in annual savings in most states.¹²⁸

The ARP temporarily expanded the child and dependent care tax credit, which made up to $4,000 of child care costs refundable.¹²⁹ Permanently expanding the child tax credit and earned income tax credit would provide essential support for struggling families and give them the resources needed to achieve health and well-being. The previous design left out families with the lowest incomes and exacerbated racial disparities.¹³⁰ An expanded tax credit program, however, could support parents and children facing financial need and improve resilience to economic downturns and shocks. States have stepped in to fill these gaps: Nine states have introduced legislation for state child tax credits, and two have introduced legislation to expand their child tax credits.¹³¹

Whether through tax credits, supplemental programs, or improved economic conditions, increasing families’ earnings and reducing poverty have far-reaching impacts on health. To achieve widespread health and well-being, federal and state governments must create and maintain economic situations in which families can thrive.

To improve health, all people must be able to access quality, affordable education. Access to good education promotes child development and economic stability.¹³² However, in 22 states, more than half of residents live in areas with an insufficient supply of licensed child care, particularly in rural and minority communities,¹³³ and many schools, especially those in low-income areas, are severely underfunded.¹³⁴ In fact, half of American families struggle to find child care.¹³⁵

Early childhood education is one of the most critical components of healthy child development.¹³⁶ Indeed, early childhood development and education are key predictors of adult health and well-being, while poor educational attainment is tied to shorter lives, poorer health, greater risk factors, increased disability, reduced productivity, and higher health care costs.¹³⁷ The ARP included multiple funding streams to support families and stabilize the child care industry.¹³⁸ This historic investment provided states the resources to expand child care subsidies and give grants to child care providers that offset pandemic-related revenue losses and increased operating costs. Several states have taken care to stretch these investments to the communities who need them the most.¹³⁹

With limited funding, many schools in the United States have serious safety issues in their physical infrastructure, including lack of adequate drinking water, heating, ventilation, and air conditioning systems.¹⁴⁰ These infrastructure flaws were dangerous before the pandemic, but some elements, such as ventilation, pose additional risks for COVID-19 mitigation. Furthermore, many schools that were built to reduce costs, assuming a steady climate, face infrastructure challenges worsened by drastic changes to climate. Adequate funding could not only make schools safer environments but also allow for more environmentally friendly infrastructure, making buildings more resilient in the face of climate-induced extreme weather events.

It is also vital to address students’ mental health needs. The COVID-19 pandemic has left many students grappling with major changes to their lifestyles, grief, isolation, and confusion. Schools can serve as a tool for screening and caring for mental health needs. In addition to schoolwide programming to recognize and address growing mental health concerns, additional resources and counseling options can be integrated into the school system. For example, a meta-analysis of school-based mental health programs found a small to medium effect on reducing mental health problems, with higher rates of efficacy for more targeted and frequent service provision.¹⁴¹ As President Biden proposed in his 2022 State of the Union address, critical federal investments are needed to build school-based mental well-being resources.¹⁴²

Access to quality, affordable higher education is also key to improving economic stability and health. But unfortunately, 12.2 percent fewer high school seniors from the class of 2021 completed the Free Application for Federal Student Aid (FAFSA) compared with the previous academic year, which can affect college enrollment; the largest drops have been among students from low-income backgrounds and students of color.¹⁴³ Policymakers at the federal and state levels must reinvest in an accessible higher education system that will give students the resources to weather the effects of both the pandemic and centuries of systemic inequities.¹⁴⁴

The House-passed budget reconciliation package would make colleges more affordable for all students. The legislation includes funding for two years of free community college, investments in minority-serving institutions, an increase in the maximum Pell Grant award, and the establishment of a College Completion Fund to help colleges improve their retention and completion activities, particularly at community colleges and other institutions that serve high numbers of students from low-income backgrounds.

There is also the opportunity for progress at the state level. For example, Maryland used $480 million of its fiscal recovery funds to fund its groundbreaking blueprint for education reform.¹⁴⁵ This initiative was created before the pandemic and called for billions of dollars in new investments in education over several years. According to the Maryland State Department of Education, the “Blueprint’s future focus … will lift historically underserved communities, prepare the workforce of tomorrow through career and college readiness and enhance the State’s economic [competitiveness].”¹⁴⁶

Education access is critical for promoting healthy childhood development, improving financial stability, and achieving better health. Investments in public health must include education and reach children in early stages of life to better prepare them for a lifetime of healthy living.

Housing is a prerequisite and an essential building block for individuals and families to live with dignity, fulfill their potential, experience economic mobility, live safe and healthy lives, and participate in society. This is an issue that sits at the nexus of and that affects many policy areas—including employment opportunities, basic civil rights, access to nutritious food, public safety, environmental and climate justice, and public health and education.

Yet there is a dire housing crisis in the United States, where 1 in 4 Americans struggle with housing insecurity,¹⁴⁷ and more than half a million people experience homelessness.¹⁴⁸ Housing instability and homelessness disproportionately affect people of color, LGBTQ+ individuals,¹⁴⁹ disabled people,¹⁵⁰ and justice-involved individuals.¹⁵¹ And these challenges were only heightened by the pandemic, when quarantine orders highlighted the role of the home in keeping people safe and healthy.

Coordinating affordable housing, health care, and other social services through supportive housing interventions has proved effective in reducing housing insecurity and improving health for individuals transitioning from institutions, aging, or in recovery, as well as those who are disabled, have mental health issues, or struggle with chronic homelessness.¹⁵² However, at least 1.2 million more supportive housing units are needed to serve these populations.¹⁵³

The issue of housing is multidimensional, as there is not only a gap in the amount of affordable housing available but also in the quality of housing that already exists.¹⁵⁴ Because of decades of discriminatory policies and practices, along with underinvestment in infrastructure, communities of color, in particular, are more likely to live near and be exposed to the nation’s most toxic sources of pollution and are also more vulnerable to extreme weather, both of which have devastating health consequences.¹⁵⁵ In fact, the systemic inequities perpetuated by these discriminatory policy decisions persist today such that 45 million Americans in historically redlined communities are breathing dirtier air.¹⁵⁶ As a result, housing remains a major cost burden and driver of economic instability for many, while a major wealth-building tool for others.¹⁵⁷

Over the past two years, many protections—such as the federal moratorium on evictions¹⁵⁸—and investments made through pandemic relief bills at both the federal and state levels served as important tools in keeping people housed.¹⁵⁹ For example, Connecticut used some of its ARP funds to provide legal assistance to residents facing eviction.¹⁶⁰ Likewise, Washington state used $400 million of its funds to cover past-due rent for those facing eviction.¹⁶¹

However, long-standing investment is necessary to address the persistent issues in the housing crisis. For instance, housing choice vouchers, the largest federal rental assistance program, is an evidence-based tool that could be scaled up to help more people access affordable housing.¹⁶² Housing vouchers are highly effective at reducing homelessness, housing instability, and overcrowding and at improving other outcomes for families and children.¹⁶³ Notably, stable housing has cascading benefits that help low-income people, particularly children, in many ways. Specifically, by giving people greater choice about where they live, vouchers enable families to move to lower-poverty, better-resourced neighborhoods and schools.¹⁶⁴

The House-passed reconciliation package would expand the housing choice voucher program to serve 300,000 more low-income households,¹⁶⁵ while the fiscal year 2022 omnibus appropriations bill includes funding for an additional 25,000 new households under the program.¹⁶⁶ Additionally, the White House fiscal year 2023 budget proposal includes $32 billion to expand the voucher program by 200,000 vouchers.¹⁶⁷ The budget also includes $8.8 billion for the Public Housing Fund to support vital improvements to public housing; $1.1 billion to support climate resiliency improvements in public housing; $35 billion for a new Housing Supply Fund to build affordable housing options; $400 million to eliminate health hazards in homes; and other targeted resources to revitalize underserved neighborhoods, advance fair housing, and enhance homeownership opportunities.¹⁶⁸

All these efforts create more pathways to stable and affordable housing for the country’s most vulnerable populations and build the foundation for good health.

Health care access and affordability remains a major problem for many Americans, especially those with low incomes and historically marginalized groups. Policymakers have the opportunity to expand access to health coverage, lower costs for care and treatment, and improve the quality of health care services.

More than 2 million people are currently in the Medicaid coverage gap, meaning their incomes are too low to qualify for marketplace subsidies but too high to qualify for Medicaid coverage in their state, resulting in no affordable options for health coverage.¹⁶⁹ Thirty-eight states and Washington, D.C., have expanded Medicaid, an option enabled by the Affordable Care Act (ACA) for states to offer Medicaid coverage to a broader population. However, in the remaining 12 states, state officials have not expanded Medicaid, even though it could have resulted in an estimated 7,000 lives saved, 55,000 fewer evictions, and $2 billion in reduced medical debt.¹⁷⁰ In the absence of state-level expansion in those states, the federal government can and should step in to close the Medicaid coverage gap. The House-passed budget, for example, would federally extend marketplace subsidies such that those in the coverage gap would qualify for low- or no-cost coverage.¹⁷¹

Drug prices are another contributor to high health care spending. Eighty percent of Americans believe that prescription drug prices are unreasonable.¹⁷² These high drug prices can lead to dangerous drug rationing, in which people do not take medication as prescribed due to cost. For instance, in recent years, high insulin prices have led to insulin rationing, resulting in illness and death among people with diabetes.¹⁷³ As proposed in the Affordable Insulin Now Act of 2022 and the House-passed reconciliation package, if insulin prices were capped at $35 per month, people who depend on insulin would see greatly improved access.¹⁷⁴ Similarly, drug prices continue to rise faster than the rate of inflation—as much as 13 times the inflation rate.¹⁷⁵ Proposals to cap beneficiary drug spending and limit price increases would greatly improve access.

Access to resources that promote mental health is key to overall health and well-being. In recent years, the COVID-19 pandemic and reckoning with racial injustice has exacerbated an existing mental health crisis.¹⁷⁶ A recent JAMA Pediatrics study found that the number of children diagnosed with anxiety and depression grew by 29 percent and 27 percent, respectively, between 2016 and 2020.¹⁷⁷ Indeed, U.S. Surgeon General Dr. Vivek Murthy recently issued an advisory “to highlight the urgent need to address the nation’s youth mental health crisis,” which was reiterated by President Biden in his 2022 State of the Union address.¹⁷⁸ President Biden’s plan to address the mental health crisis includes banning excessive data collection from children to counter negative effects of social media and expanding in-school services.¹⁷⁹

Despite major strides made toward achieving mental health access and parity in the past few decades, access concerns persist. In fact, the U.S. Department of Labor, the HHS, and the U.S. Treasury conducted an audit of health plans and insurance companies and found they were falling short of meeting parity requirements.¹⁸⁰ The Mental Health Parity and Addiction Equity Act of 2008, a law that set national standards for mental health access, was an important step toward improving access to mental health care on par with physical and other health care.¹⁸¹ However, lack of enforcement and a nonoptimized workforce leave critical gaps in mental health access.¹⁸²

While insurers are required to cover mental health services under the ACA and be no more restrictive than other health services, insurance networks often limit access. Some states set additional parity standards to better ensure access to behavioral health services. For example, Illinois requires insurers to cover out-of-network services at the same rate as in-network services if the beneficiary made a “good faith effort” to access in-network services in order to support “timely and proximate access” to behavioral health services.¹⁸³

Meanwhile, payment rates for providers remain low, and demand outstrips the supply of practitioners.¹⁸⁴ Rather than accept low rates, mental health providers should be empowered to refrain from contracting with insurers and have their clients pay out-of-network rates. States such as California, Tennessee, and Nebraska already enforce network adequacy as parity by setting time and distance standards within which beneficiaries must be able to access care.¹⁸⁵ Similarly, policymakers can address the shortage of mental health providers by ensuring insurance coverage for and expanding scope-of-practice laws to permit the use of peer supports, licensed professional counselors, marriage and family therapists, and other paraprofessionals, as well as by enabling nurse practitioners and physician assistants to take on some psychiatric duties.¹⁸⁶

The relationships and interactions that exist where people live, learn, work, play, worship, and age meaningfully affect their health. Indeed, strong, positive social connections help protect against poor health and well-being.¹⁸⁷ Conversely, poor social connections and experiences are associated with more health risks.¹⁸⁸ For example, adverse childhood experiences such as exposure to violence and parental incarceration have been linked to chronic conditions, mental illness, and substance use in adulthood.¹⁸⁹ Additionally, living in environments where discrimination, prejudice, violence, and stigma are prevalent creates toxic stress that leads to negative health outcomes.¹⁹⁰

In neighborhoods that are not safe from violence, population health suffers. Every day, more than 100 people are killed with a gun, more than 200 people are nonfatally injured, and more than 1,000 people are threatened.¹⁹¹ As a result, firearm-related injuries are among the leading causes of death, with more than 45,000 deaths in 2020 alone.¹⁹² Notably, urban communities and communities of color are disproportionately burdened by gun violence, which further contributes to the health inequities that these communities face.¹⁹³

Another threat to safe communities is intimate partner violence (IPV), which is experienced by about 1 in 4 women and nearly 1 in 10 men in the United States¹⁹⁴—although these figures might underestimate IPV’s real prevalence given underreporting and fragmented data systems.¹⁹⁵ According to CDC data, the lifetime economic cost of IPV to society totals $3.6 trillion, including medical care, lost productivity, criminal justice, and other relevant costs.¹⁹⁶ Making matters worse, domestic violence, including IPV, has increased during the pandemic as economic and health stressors, coupled with stay-at-home orders, made those at risk more vulnerable.¹⁹⁷ Investing resources into both prevention and support for gun violence and IPV survivors would improve physical and mental health outcomes later in life.

One solution that has shown strong promise in reducing crime is community-based violence intervention programs, which are distinct from and outside of law enforcement systems.¹⁹⁸ For example, the establishment of a civilian-run Office of Neighborhood Safety in Richmond, California, was associated with a 55 percent reduction in gun homicides and hospitalizations and a 43 percent reduction in firearm-related crimes.¹⁹⁹ In another area of California, Oakland Ceasefire—a partnership among community members, social services, and law enforcement—worked to build trust, reduce violence, and target the needs of those at high risk of engaging in violence such that annual shootings and homicides have been cut by half since 2012.²⁰⁰ Additionally, the White House Community Violence Intervention Collaborative, established June 2021, builds partnerships across jurisdictions to share community-based violence prevention strategies such as those mentioned above.²⁰¹

Localities and states are also using their ARP funding to advance alternatives to policing in preventing violence.²⁰² For example, Illinois invested $52 million to support expanding violence interruption services.²⁰³ Other police reform priorities, such as increasing transparency and overhauling harmful policies and practices, such as chokeholds and the use of military weapons, can likewise help restore community trust and ensure public safety.²⁰⁴

Lastly, by declaring gun violence a public health crisis, policymakers can help prioritize supporting violence prevention efforts.²⁰⁵ CDC Director Dr. Rochelle Walensky has said that gun violence is a ”serious public health threat.”²⁰⁶ And after more than two decades without federal funding, Congress appropriated $25 million to the CDC and the National Institutes of Health in 2020 for gun violence prevention research and has since continued that funding through fiscal year 2022.²⁰⁷ Building on these investments, the White House fiscal year 2023 budget proposal includes funding for the CDC to invest in programs that address gun violence as a public health epidemic through research and community violence intervention, as well as $1 billion to support the Violence Against Women Act.²⁰⁸ Efforts to support addressing gun violence through a public health approach are both necessary and effective.

Systemic racism and discrimination also perpetuate health disparities and inequities in the social systems that affect health. The U.S. system of policing is riddled with inequities that largely affect communities of color and often increases violence within and toward those communities.²⁰⁹ Indeed, the number of fatal police shootings has increased in recent years, and the rate among Black Americans is higher than that of other racial and ethnic groups.²¹⁰ Research has shown that these fatal shootings and their proximity damage the mental health of Black Americans.²¹¹ To reduce violence, improve community relations with law enforcement, and improve the overall mental health of those communities most affected, police reform is necessary. Specifically, police should be less involved in situations better suited for community responders, health providers, and social services professionals.²¹²

In addition, predatory laws and practices threaten the voting rights of many low-income and minority communities, potentially disempowering these communities from effectuating change in the social systems around them.²¹³ The relationship between voting and health is a reciprocal one: Not only does voting serve as an avenue for people to have a voice in shaping the policies that affect their health, but having poor health can hinder voting participation.²¹⁴ Efforts to dismantle voting rights further marginalize groups already facing barriers to democratic engagement and therefore should be blocked. Instead, policymakers should pursue legislation that safeguards voting rights and access, such as the Freedom to Vote Act²¹⁵ and the John R. Lewis Voting Rights Advancement Act.²¹⁶

Disparities in health care and health outcomes have been well documented,²¹⁷ but they were brought to the forefront during the COVID-19 pandemic. In particular, disparities in coverage, access, and affordability within the health care system, as well as social, economic, and environmental factors, are key drivers of health inequities.²¹⁸ Systemic racism, discrimination, and structural barriers embedded within systems and policies contribute to preventable mental and physical health conditions and have led to racism being declared a serious public health threat.²¹⁹

Worse yet, these disparities are growing: Communities of color and other underserved populations have experienced disproportionate rates of infection, hospitalization, and death due to COVID-19 and related complications.²²⁰ The drop in life expectancy in 2020, which can be partly attributed to COVID-19, was highest among the Hispanic and non-Hispanic Black populations.²²¹

The economic burden of these health inequities is borne by individuals, communities, and society, including lost productivity, employment, and income, as well as increased disability and medical costs.²²² According to the Kaiser Family Foundation, these disparities cause $93 billion in excess medical care costs and $42 billion in lost productivity each year.²²³ They also widen the U.S. racial wealth gap, whereby Black households have $835,000 less wealth on average than white households, leaving Black households particularly vulnerable to the health and economic impact of the pandemic.²²⁴ As the population becomes increasingly diverse, without intervention, the economic cost of health inequities will only grow.

Fortunately, advancing racial equity throughout the federal government is a priority for the Biden administration.²²⁵ For example, the administration’s executive order on ensuring an equitable response to the pandemic was designed to address the disproportionate impact of COVID-19 on communities of color and other underserved populations and to advance racial equity in health.²²⁶ In addition to the Justice40 Initiative, which aims to tackle environmental racism, the Infrastructure Investment and Jobs Act includes funding to address lead exposure in drinking water and its adverse health implications, particularly in underserved communities.²²⁷ Meanwhile, the COVID-19 Health Equity Task Force, established under executive order, issued recommendations to ensure equitable allocation of COVID-19 resources and relief funds, fund organizations that work with communities of color and other underserved populations, standardize data collection, and conduct research to eliminate structural racism in health care systems. Finally, in administering fiscal recovery funds, the Treasury has explicitly encouraged states and localities to support those most affected by the pandemic and to address racial and economic inequities that predate, but were exacerbated by, the pandemic.²²⁸

Building on these efforts, the administration must continue to prioritize equity and inclusion in its second year and beyond. Gaps in addressing the social determinants of health have a disproportionately negative impact on people of color, those with disabilities, LGBTQI+ communities, and other marginalized groups. Prioritizing the most vulnerable and harmed communities when investing in the policy areas discussed in this report inherently furthers equity and can improve disparities. Indeed, to overcome years of disadvantage borne out of discriminatory policies and practices, state, local, and federal governments should commit to reducing racial and economic inequities that were only exacerbated by the pandemic. Such an agenda should include partnering with and centering the needs of affected communities and addressing the root causes of racism and inequity.

Some states have already taken action to incorporate equity in their approach to social and economic policy. For example, California was the first state to include health equity in decisions to reopen local economies during the pandemic: Reopening of county businesses and activities was contingent on proof that the COVID-19 test positivity rate in the most disadvantaged neighborhoods was not substantially higher than the overall positivity rate for the county—and that proportional investments were being made to address the needs of those populations.²²⁹

COVID-19 has raised awareness of public health infrastructure and other investments to address factors that influence health. Now, new policies must target all the drivers of health and recognize the intersectional nature of these issues, as they touch on everything from economic stability, housing, and education to climate change and access to COVID-19 resources and public health services. The failure to address any of these issues has ramifications for other areas, as seen by the increase in drug overdoses as public health departments shifted resources from traditional public health programs to respond to the COVID-19 pandemic.²³⁰

Moreover, systemic racism and discrimination drive disparities in many areas. Supporting underserved communities requires addressing structural racism and discrimination within the broader ecosystem of policymaking that has left communities behind. Therefore, it is critical to maintain an intentional focus on and provide dedicated funding for the social and structural determinants of health; structural and institutional racism; and access to high-quality health care and supportive services. Only then can the nation take a meaningful step toward improving health and health equity.²³¹

The authors would like to acknowledge Emily Gee and the Center for American Progress’ Domestic Climate, Criminal Justice Reform, Democracy Policy, Development, Disability Justice Initiative, Early Childhood Policy, Government Affairs, Gun Violence Prevention, Higher Education Policy, K-12 Education Policy, LGBTQI+ Research and Communications Project, Poverty to Prosperity, Racial Equity and Justice, and Women’s Initiative teams for their input and guidance.