President Biden’s Executive Order 13995 on COVID-19 and Health Equity: Seeking Justice in a Public Health Crisis

Introduction

In January 2021, President Biden signed Executive Order 13995, Ensuring an Equitable Pandemic Response and Recovery, to better serve communities of color. As part of the President’s “National Strategy for the COVID-19 Response and Pandemic Preparedness,” the Executive Order created a Presidential COVID-19 Health Equity Task Force to address the disproportionate impact of the pandemic on minority populations and to reduce racial and ethnic disparities of COVID-19 prevention, testing, and treatment.^{1, 2, 3} That Task Force issued and delivered the Presidential COVID-19 Health Equity Task Force Final Report and Recommendations to the White House on November 10, 2021.⁴ A substantial majority of those recommendations are directed at federal action; however, many of the COVID-19 policy recommendations can, and should be, adapted for implementation by local governments.

This article explores several health policy issues related to the President’s COVID-19 Executive Order, including health equity and justice, structural racism, health disparities, vaccine access, and vaccine acceptance in communities of color. This article also proposes several health equity policy considerations to local governments intended to supplement the Task Force recommendations. Health care attorneys can play a key role in achieving health equity by engaging with local officials and communities of color to adopt these local government health equity policy considerations.

COVID-19’s Effect on Communities of Color

It has been over two years since the COVID-19 pandemic began. Now, as of May 2022, with Alpha, Beta, Delta, and Omicron variants, including the BA.2 subvariant, fueling an enormous new surge of cases, COVID-19 has infected over 82 million people in the U.S. and almost 1 million have died.⁵ The COVID-19 crisis has killed Black, Brown, American Indian, Alaska Native, and other people of color at an alarming rate.^{6, 7} Because of health, social, and racial inequities, racial minorities have suffered a disproportionately severe impact from the COVID-19 crisis, resulting in higher rates of infection, hospitalizations, ICU admissions, and death.⁸ The cause, in large part, is structural inequity and racism. The effects and numerous policy challenges of this public health crisis are so wide-ranging that any successful policy responses will require collaboration among federal, state and local governments, and Tribal Nations, as well as engagement with communities of color, oppressed and marginalized populations, and underserved communities.⁹

President Biden’s Executive Order 13995

As a senator in 2020, Vice President Kamala Harris introduced legislation addressing racial and ethnic disparities in COVID-19 that provided a blueprint for the Presidential COVID-19 Health Equity Task Force.¹⁰ Rather than wait for Congress to act to address COVID-19 crisis health equity issues, in the first month of his presidency, President Biden signed at least ten Executive Orders and memoranda focused on addressing the COVID-19 pandemic, including Executive Order 13995: Ensuring an Equitable Pandemic Response and Recovery. These orders all took effect immediately. Executive Order 13995 was among several of his Executive Orders explicitly acknowledging systemic and structural racism’s role in perpetuating health and social inequities and seeking positive change.

The Presidential COVID-19 Health Equity Task Force was charged with implementing the President’s Executive Order. The Task Force’s mission was to ensure that the COVID-19 response, including the mass vaccination campaign, prioritized equity. To accomplish that mission, the Task Force was instructed to provide specific recommendations to the President to mitigate health inequities caused or exacerbated by the COVID-19 pandemic and to prevent such inequities in the future.¹¹ These included recommendations on the equitable allocation of COVID-19 resources and relief funds, effective outreach and communication to underserved and minority populations, and improving cultural proficiency within the federal government. In forming its recommendations, the Task Force was permitted to engage with, among others, state, local, Tribal, and territorial health officials.

The Task Force’s final report highlighted encouraging improvements in addressing inequities in the burden of COVID-19 on racial and ethnic groups, as well as disparities in vaccine access and immunization rates. The Task Force made 55 recommendations divided into five major actions. These include investing in local community-based efforts led by local leaders or organizations such as faith-based groups; putting more resources into collecting data on health-related concerns by race and ethnicity; and increasing representation of people of color in the health care system. The Task Force additionally recommended maintaining a health equity task force at the White House level to sustain the momentum of prioritizing equity when considering any pandemic response.

The Need for a Presidential COVID-19 Executive Order on Health Equity

Racial Justice, Structural Racism, and Health Equity

Racial justice is the systematic fair treatment of people of all races, resulting in equitable opportunities and outcomes for all. Achieving health racial justice has been historically challenging because longstanding racism, anti-Black and Brown discrimination, and other forms of racial injustice have contributed to dramatic health and safety disparities for Black, Brown, Indigenous communities, and other people of color.

There are systemic, pervasive, and structural health detriments associated with racism. The United States is experiencing an intense reckoning with structural racism because of the disparate health effects of COVID-19 on racial minorities, high-profile racial injustices, and extensive protests after the police killings of Ahmaud Arbery, George Floyd, Breonna Taylor, and others.¹² These protests have emphasized the ongoing and persistent problems of structural racism that go hand in hand with injustice and inequality.

Racism must be addressed through government policies and action. But racism is not simply a political or policy issue; it is a public health issue. The COVID-19 crisis has further exposed historical and contemporary structural racism—laws, policies, regulations, and institutions that lead to uneven distribution of health access, health quality, education, job opportunities, and criminal justice among races.

Health equity and justice are achieved when all members of society enjoy a fair and just opportunity to be as healthy as possible. Health inequities are a consequence of historic and ongoing racism, racial oppression, discrimination, and racist policies, and all of these have contributed to the COVID-19 crisis. Many of the effects of racism and resulting discrimination contribute to health disparities: poverty, chronic diseases, education, neighborhood, dense living conditions, and inadequate access to healthy food, clean water, and adequate housing. The COVID-19 pandemic has exacerbated longstanding underlying disparities already present in the health care system that adversely impact communities of color, including lower rates of health insurance coverage, increased barriers to accessing health care, and worse health outcomes compared to White people.

The Effects of Racism and Health Disparities on Communities of Color

There can be no doubt that health disparities are rampant. Front-page headlines in the New York Times, the Los Angeles Times, and other media have highlighted the issues of health disparities in the COVID-19 testing and vaccine rollout.¹³ Such disparities have been documented in testing, ICU admissions, and distribution of vaccines. People of color, the poor, and other vulnerable populations are more likely to be uninsured and to lack access to testing and vaccines. They are also less likely to have access to technology, the internet, and private transportation, making it difficult to get vaccinated.

Despite recent trends suggesting improving health equity in COVID-19 vaccination patterns and a recent narrowing in the gap between vaccination rates for White and Hispanic people, disparities persist. Those disparities persist even as minority groups have suffered much higher mortality rates from the pandemic than Whites and are at greater risk of infection as states have moved to reopen and lift mask mandates.¹⁴

Public health experts have offered a mix of explanations for these COVID-19 disparities.¹⁵ They include higher rates of preexisting health conditions that increase the risk of complications from COVID-19; social and economic factors that contribute to health risk; and long-standing inequities in health care access and outcomes for Black Americans compared with other racial and ethnic groups.

The existence of racial health disparities is a significant reason that communities of color have been more vulnerable to COVID-19, which takes a greater toll on people who already have poor health conditions. Racism—systemic and structural—is at the root of these health disparities.

Challenges in Vaccine Access and Vaccine Acceptance

There are many health equity factors that create challenges to vaccination access and acceptance, and that often affect racial and ethnic minority groups. Some of those factors include: 1) education, income, and household size, 2) job access and working conditions, 3) racism and other forms of discrimination, 4) gaps in health care access, 5) transportation and neighborhood conditions, 6) exposure to myths and misinformation, and 7) medical mistrust.¹⁶

Black, Brown, Indigenous and other people of color are more likely to be skeptical of vaccines, more likely to think the risks outweigh the benefits, and less likely to get vaccines. According to the Kaiser Family Foundation, nearly a quarter (22%) of African Americans were vaccine hesitant as of February 2021, taking a “wait and see” approach to the COVID-19 vaccines.¹⁷ When the presidents of two historically Black colleges and universities encouraged students, faculty, staff, and alumni to enroll in COVID-19 vaccine clinical trials, they were surprised at the strong negative feedback they received.¹⁸

Mistrust of government, public health institutions, and medical research in the United States is rooted in a history of unethical medical and public health experimentation and research practices involving people of color, as well as structural inequities in government institutions. This longstanding, but well-founded, mistrust resulting in vaccine hesitancy creates a significant barrier and challenge to the success of the Task Force’s effort to overcome racial inequities. In particular, Black adults are more hesitant to trust medical scientists, embrace the use of experimental medical treatments, and sign up for a potential vaccine to combat the illness.

The legacy of abuses by the health care system is long. For example, in the Tuskegee Syphilis Study conducted from 1932-1974, more than 600 African American men in Tuskegee, Alabama were made to believe that they were receiving free medical care—when they, in fact, were not receiving treatment. As a result, more than 100 men died from syphilis or its complications by the end of the study.¹⁹ Henrietta Lacks, a Black woman, also was an unwilling participant in medical experimentation. In 1951, without her knowledge or consent, her tissue cells began to be used in a long series of research projects.²⁰ These incidents and others complicate the responses of minorities when they are asked by the government to submit to treatments. Unless mistrust can be alleviated, vaccine hesitancy cannot be overcome.

Critical Health Equity Policy Considerations for Local Governments

The COVID-19 crisis offers an important opportunity to redesign local health care systems, laws, and society to meet the needs of its most vulnerable groups. Health and economic policy efforts to combat the COVID-19 pandemic by local governments must recognize and seek to eliminate health disparities endemic to the health care system. Although the Task Force final report and recommendations for federal government action have been submitted to the White House, local governments should also be committed to combating systemic racism in health care by forging health, economic, and racial justice policies and reforms to correct them. Critical local government and public health agency policy considerations should include:

1. Encouraging local municipal and public health leaders to declare through proclamations and ordinances that racism is a public health issue and act to address systemic health and racial inequities.
2. Instituting health equity community initiatives to address local structural and systemic changes to ensure equal access to health, economic and job opportunities; eliminate disparities; and advance racial equity.
3. Strengthening public health policy and public health infrastructure to better respond to surges of emerging COVID-19 virus variants and future public health crises.
4. Increasing engagement with communities of color to make sure that those most affected by COVID-19 are included in health policy and program decision-making.
5. Involving faith-based leaders and places of worship that play a key role in providing health and COVID-19 information and spiritual leadership among communities of color.
6. Increasing critical up-to-date COVID-19 vaccination and booster vaccination outreach, education, and funding to community-based organizations and local coalitions that often have diverse partnerships and collaborations with schools, local businesses, jails, and hospitals.
7. Addressing barriers that have restricted access to COVID-19 prevention, treatment, vaccinations, and other health services for communities of color.

Beyond these specific health equity policy considerations for local governments, any effort would be woefully incomplete if it did not also recognize and address longstanding racism, racial oppression, and anti-Black and Brown discrimination and the long, sometimes dark history of stress and trauma affecting the health of many Black and Indigenous people and communities of color.

Conclusion

Racism has been recognized as a public health issue. The COVID-19 crisis has highlighted and exacerbated preexisting inequities facing communities of color and other underserved populations. The history of racism in state and local government policies specifically impacting health care, public health, education, housing, employment, and justice has denied many communities of color the opportunity to be healthy and thrive. It is imperative that federal government agencies collaborate and engage with local governments and communities of color to enact health and economic policies and reforms to achieve health equity to most effectively use the opportunity presented by the Executive Order. It is also essential to rebuild trust in public health institutions and a belief in collective action in service of public health.

Although the Executive Order has resulted in a Task Force final report with significant and far-reaching recommendations, it is important to remember that it is merely the first step in achieving health equity policy and program changes at the local government level. It is impossible to predict how or to what extent the Task Force final report will be implemented at the local, state, federal, Tribal, and territorial levels. Federal and local government funding support for programs and initiatives could be problematic. To address many of the current challenges of COVID-19 inequities, and to be better prepared for inevitable outbreaks adversely affecting communities of color—including from new coronavirus variants— President Biden’s Executive Order 13995 is a step in the right direction. But, the path to ending health disparities and achieving COVID-19 health equity is a long one.

Author Profile

Darryl Crompton, JD, MPH has worked as an attorney, non-profit executive, and health equity advocate. He served as general counsel and vice president for legal affairs at Tuskegee University, where he was responsible for governmental affairs matters and for all legal matters, including Title IX compliance. Previously, he worked as a policy consultant to the Tuskegee University National Center for Bioethics in Research and Health Care. Before joining Tuskegee, Darryl held senior level positions at the United Negro College Fund Special Programs Corporation, the Catholic Health Association, and the Public Education Network. Earlier, Darryl was a tenured associate professor of health law and policy at the University of Alabama at Birmingham. He presently serves on the board of the Association of Yale Alumni in Public Health. He is a graduate of the University of California, Davis, School of Law, and holds a master’s degree in public health from Yale University, and a bachelor’s degree in political science from the University of California, Los Angeles. He currently resides in Maryland. Contact him via email at [email protected].