Equity in Action: Operationalizing Processes in State Governance

Abstract

This article takes a birds-eye view of equity in action, showcasing efforts to embed an equity lens in legislated and non-legislated policies and practices in three states. Authors from California, Colorado, and Minnesota provide state-specific examples of how equity has been advanced and operationalized in state-level governance. The article describes progress and lessons learned and offers guidance to others.

Introduction

This article showcases efforts in California, Colorado, and Minnesota to embed an equity lens into the formulation and implementation of legislated and non-legislated policies and practices. State-specific examples show how equity is being operationalized and woven into the fabric of state governance. Although brief, this discussion highlights progress among states, offers lessons learned, and suggests guidance on sustaining efforts.

A social determinants of health (SDOH) framework is central to this work. The framework describes how social, economic, and built environments in which people live, learn, work, and play interact to create health—and inequities—across diverse communities. Applying the framework in state-level efforts to improve health outcomes among communities experiencing inequities requires government leaders and staff, and external partners, to effectively convey that community conditions (e.g., quality of and access to housing, transportation, healthcare, education, and healthy food) are not random or inevitable but, rather, are rooted in power and policy prioritization processes. A deep look at inequities reveals that the primary drivers of health are, in large part, created by human decision-making and, thus, are inherently political.

The following examples stress that comprehensive structural changes in state governmental processes and policies are essential and must be prioritized to eliminate persistent inequities in health outcomes that disproportionately affect communities of color, indigenous communities, and other disadvantaged communities. Increasingly, state governments are implementing innovative legislative and non-legislative strategies such as those described here.

Pioneering efforts of Three States

California

Created by an Executive Order¹ in 2010, the California Health in All Policies Task Force (Task Force) brings together 22 state departments to collaboratively promote healthy, equitable communities. The Task Force uses four approaches, often in combination, to operationalize health and equity throughout state government: administrative (e.g., grant program development, procurement policies), legislative (e.g., implementation or enforcement of legislation), facilitative (e.g., building and strengthening relationships with and between departments), and stakeholder engagement (e.g., convening meetings, disseminating input opportunities). For example, as described below, these approaches have been used to collectively support healthy, equitable transportation planning.

Regional Transportation Plans (RTPs) provide blueprints for regional transportation systems. Because RTPs are tied to state and federal funds, addressing health and equity in plans can have an enormous impact on health outcomes. For example, communities that include programs and policies like bicycle and pedestrian trails and Safe Routes to Schools (SRTS) in their RTPs may spur increased physical activity. The State produces RTP Guidelines (Guidelines), which are used by Metropolitan Planning Organizations (MPOs) in developing their RTPs (administrative). In 2010, several community-based organizations (e.g., California Pan-Ethnic Health Network, TransForm, California WALKS, Rails to Trails Conservancy, Safe Routes Partnership) advised Task Force staff that incorporating health and equity into the Guidelines and subsequent RTPs would support positive change in their communities (stakeholder engagement). This input, and support from the California Department of Transportation (Caltrans), led the Task Force to include a recommendation to add health and equity content into Caltrans future RTP Guidelines in their 2010 “Health in All Policies Task Force Report to the Strategic Growth Council.”²

California Pan-Ethnic Health Network led some of the same and other advocates in developing a proposal that resulted in Assembly Bill 441 (2012, Monning),³ which required the next update of the Guidelines to include a summary of policies, practices, or projects to serve as models for regional transportation planning processes promoting health and well-being (legislative). The legislation signed into law did not include a timeline to update the Guidelines. In the interim, a non-government partner, TransForm, developed a corollary guide to educate and mobilize public health advocates to engage in local RTP processes (stakeholder engagement). Four years later, when the California Transportation Commission (CTC), in partnership with Caltrans, began updating the Guidelines, CTC and Caltrans staff were thoughtful about health and equity due to the trusting relationship the Task Force had cultivated with them over the previous six years through collaboration and support of other transportation programs (facilitative). Beyond the requirements of AB 441, the CTC took additional steps that included creating a health and equity workgroup to ensure inclusion of comprehensive content (e.g., goals, policies, data, metrics, definitions) and asked Task Force staff to lead the workgroup (administrative). The CTC also asked Task Force staff to help develop new health and equity content and coordinate, facilitate, and engage input on the process (stakeholder engagement).

The resulting “2017 Regional Transportation Plan Guidelines for Metropolitan Planning Organizations” includes an appendix that highlights promising practices for policies, programs, projects, and tools MPOs can use to address health and equity through RTPs.⁴ For example, the RTP Guidelines highlight Complete Streets sample policies and a farmworkers vanpool program to promote safe, reliable transportation. The combined interaction between legislation, ongoing partnerships, administrative activities, and strong stakeholder engagement made a critical difference in advancing health and equity through transportation system planning.

Colorado

Colorado's Office of Health Equity (OHE), created by state statute in 2007, is charged with “promoting health equity in Colorado by implementing strategies tailored to address the complex causes of health disparities, including the economic, physical, and social environment.”⁵ Situated within the Department of Public Health and Environment (CDPHE), OHE spearheads efforts to remove structural barriers that create unequal opportunities for health using a cross-sector, systems-level approach that addresses SDOH by incorporating an equity lens into state government operations. OHE plays a key role in leading and coordinating equity efforts both across state government and with grassroots community partners.

OHE has used several strategies to facilitate cross-sector dialogue about equity. At the state agency level, OHE has supported organizational and cultural changes within CDPHE by developing policies on equity and community engagement and incorporating equity into staff training, procurement processes, and departmental performance metrics.⁶ In partnership with community organizations and other state agencies, OHE released a statewide Equity Action Guide⁷ in August 2018 that examines root causes of inequity such as institutional implicit bias, leverages cross-sector collaboration (e.g., housing, transportation and health), and promotes data-sharing across state agencies and with community partners for sustainable, community-informed decision-making. To follow up on this work and operationalize strategies to address systemic barriers, OHE established an Equity Alliance that includes representatives from 13 state agencies and 11 grassroots community organizations.⁸ The Alliance uses an equity lens and assessments, including a Checking Assumptions tool, to examine state government programming and policies and then transform their design.⁹ To build additional state-level capacity, OHE has developed and led workshops for state agency leaders addressing the concepts of power and shared decision-making with communities. OHE has also worked with state agencies to integrate equity into agency priorities and plans (e.g., the 2040 Statewide Transportation Plan).¹⁰

Under OHE's leadership, Colorado has embraced a broad definition of equity that encompasses multiple systems (i.e., education, criminal justice, and human services) and structural barriers (e.g., poverty and racial discrimination).¹¹ This wide lens—and vision of a state in which “everyone, regardless of who they are or where they come from has the opportunity to thrive”—has allowed Colorado to align its equity work with other statewide initiatives. Colorado found natural synergy with two-generation (2Gen) strategies, which address the cycle of intergenerational poverty by holistically and simultaneously meeting the needs of children and their adult caregivers. 2Gen approaches highlight challenges that low-income families face when trying to access services across systems and offer additional perspectives on how these barriers exacerbate economic, gender, and racial disparities. By explicitly linking equity with 2Gen and other initiatives focused on helping families and communities to thrive, Colorado has created opportunities — through programs, policies, and cross-agency initiatives — to further embed equity principles into state agency core functions.

Minnesota

In 2013, the Minnesota Legislature created the Cultural and Ethnic Communities Leadership Council (CECLC)¹² to provide equity-based recommendations to the Minnesota Department of Human Services (DHS) to eliminate racial, ethnic, linguistic, and tribal inequities. With community-based support and the statutory grant of purpose and power to offer guidance to DHS leadership, CECLC recommended adoption of an agency-wide equity policy, grounded in a health-in-all-policies framework, to achieve structural impact, urgent application, and political feasibility.

The resulting 2017 Policy on Equity¹³ permeates core functions of governance and distribution of human financial and political capital at DHS by applying an equity analysis to recruitment, hiring, contracting/procurement, evaluation, community engagement, and policy development. The policy includes adaptive elements that meet DHS's specific needs (e.g., direct human services, healthcare, food security) yet can be adapted for use by other state agencies and governmental bodies such as the Metropolitan Council, which serves the seven-county Minneapolis-St. Paul region (transit, parks, housing, community, clean water). Notably, after the policy was adopted by DHS, CECLC shared it — and a broader set of equity recommendations¹⁴ — with Minnesota Governor Mark Dayton, key state agencies, and legislative champions. DHS is now tackling early challenges in implementing the policy (e.g., focusing on gaps in financial investments, human resources, and conflict resolution). In this early phase, the DHS Policy on Equity exemplifies nascent cultural transformation in state governance and provides strategic precedence and pragmatic templates for use by other institutions in Minnesota and elsewhere.

The central goal of CECLC's recommendations is to embed equity in policy-making criteria and processes. In 2015, with favorable alignment of equity leaders in the Governor's office and Senate leadership, the powerful Minnesota Senate Finance Committee made history by creating a Subcommittee on Equity¹⁵ to advise it during that session. The Subcommittee made recommendations to the Finance Committee regarding funding proposals intended to explicitly advance racial and economic equity. For example, CECLC's Chair testified in support of a proposal to create a Good Food Access Program, designed to bring healthy, affordable, and culturally appropriate foods into low access areas. The legislature funded this program precisely because of its intended health equity impact. During the legislative session, the Subcommittee screened a myriad of equity-focused bills, leading to legislated, multi-sector funding of $35 million (e.g., for workforce development and higher education). Advocates succeeded in advancing equity-based policies and expanding public discourse because equity was built into the legislative process and the Governor's agenda.

Additionally, in 2016, Governor Dayton appointed Minnesota's first Chief Inclusion Officer¹⁶ to support equity, diversity, and inclusion across his administration. This braiding together of equity-rooted policy, politics, leadership, and community power suggests a durable formula for transformational change. Moreover, the results of the 2018 mid-term elections will increase the size of the legislature's People of Color & Indigenous (POCI) Caucus,¹⁷ invigorating equity leadership in the legislature and, by extension, across branches of government, and activating community advocates — priming Minnesota for a bold health equity agenda.

Guidance and Lessons Learned

The following guidance and lessons learned are drawn from the pioneering experiences of California, Colorado, and Minnesota:

Equity requires intentionality. Governments play key roles in creating and perpetuating inequities, sometimes by design, sometimes unwittingly. Addressing historical injustices and integrating equity into state government systems requires a long-term commitment, concerted direct action, leadership support and engagement, and, fundamentally, an understanding that an “equity lens” is often a new way of thinking that necessitates training for all on core concepts.

Trust is imperative. Grassroots community partners who have been mistreated by government entities can be, understandably, suspicious of government-initiated outreach efforts. State agencies may also struggle to engage with partners, within and outside of state government, due to the siloed nature of their work and priorities. Despite (or because of) these challenges, it is crucial that they take time to find authentic, meaningful ways to engage and build relationships between community and government partners.

Align with existing statewide initiatives. Partnering and collaborating with ongoing statewide equity initiatives that incorporate multiple strategies, similarly focused on ensuring that all residents are healthy, valued, and able to thrive, can help maximize resources and yield greater success.

Conclusion

Ultimately, achieving equity and eliminating disparities in health — changing hearts, minds, and systems — requires long-term, deeply committed state-level investments in strategies rooted in a SDOH framework. Integration of equity into governance effectively matches long-term solutions to the root causes of inequities. The tragedy and triumph of inequities is that humans make them and, thus, can eradicate them.

Footnotes

The authors have nothing to disclose.

Acknowledgement

We thank Tara Smith (Governor Hickenlooper's Office, Two Generation Programs), Vaishnavi Hariprasad (Colorado Department of Public Health and Environment, Office of Health Equity), and Meredith Lee (California Department of Public Health) for their assistance in writing this manuscript.

References

Executive Order S-04-10, off. Governor Cal., available at <http://sgc.ca.gov/programs/hiap/docs/20100401-Executive_Order_S_04_10.pdf> (last visited May 8, 2019).

California Health in All Policies Task Force, Health in All Policies Task Force Report to the Strategic Growth Council (December, 3, 2010), at 273, available at <http://sgc.ca.gov/programs/hiap/docs/2010-HiAP_Task_Force_Report-_Dec_2010.pdf> (last visited May 8, 2019).

A.B. 441, 2012 Cal. Assemb., Reg. Sess. (Cal. 2012)

California Transportation Commission, 2017 Regional Transportation Plan Guidelines for Metropolitan Planning Organizations (2017), available at <http://www.dot.ca.gov/hq/tpp/offices/orip/rtp/docs/2017RTPGuidelinesforMPOs.pdf> (last visited May 8, 2019).

C.R.S. 25-4-2205 (2007)

Colorado Office of Health Equity, CDPHE Policies, 2019, available at <https://www.colorado.gov/pacific/cdphe/health-equity-resources> (last visited May 8, 2019).

Hariprasad ,

Hernandez , and

Singh , An Equity Action Guide: Creating Thriving Communities in Colorado, 2018, available at <https://www.colorado.gov/pacific/cdphe/equity-action-guide> (last visited May 20, 2019).

Examples of such agencies include Colorado Departments of Higher Education; Public Safety; Natural Resources; Transportation; and Human Services. Community partners include agencies such as the Asian Pacific Development Center; One Colorado; Latino Community Foundation; and the Denver Indian Center.

Colorado Office of Health Equity, Checking Assumptions to Advance Equity, 2017, available at <https://www.colorado.gov/pacific/cdphe/suite-of-tools> (last visited May 8, 2019)

10.

Colorado Department of Transportation, information on Transportation Plans and Studies, available at <https://www.codot.gov/programs/planning/transportation-plans-and-studies> (last visited May 8, 2019).

11.

Colorado Office of Health Equity, definition of equity available at <https://www.colorado.gov/pacific/cdphe> (last visited May 8, 2019).

12.

2013 Minn. Laws ch. 107, art. 2 § 1, available at <https://www.revisor.mn.gov/laws/?id=107&year=2013&type=0> (last visited May 8, 2019).

13.

Cultural and Ethnic Communities Leadership Council (CECLC), Community Relations Division, Minn. Dep't of Human Servs., App. J (January, 2017), at 82, available at <https://www.leg.state.mn.us/docs/2017/mandated/170946.pdf> (last visited May 8, 2019)

14.

Cultural and Ethnic Communities Leadership Council (CECLC), Minn. Dep't of Human Servs., Equity Integration Recommendations for Governor Dayton (March 2, 2018), on file with author (SRW).

15.

Minn. Legis., Minn. S. Comms., 2015-2016 Biennium, Eighty-Ninth Legis., S. Fin. Comm., Subcomm. On Equity (2015), available at <https://www.senate.mn/committees/committee_bio.php?cmte_id=3084&ls=89> (last visited May 8, 2019).

16.

Sawyer

, “James Burroughs Named Minnesota's New Chief Inclusion Officer,” Star Tribune, April 9, 2016, available at <http://www.startribune.com/james-burroughs-named-minnesota-s-new-chief-inclusion-officer/375145781/> (last visited May 8, 2019).

17.

J. P.

Coolican

, “Lawmakers from Minority Communities Create New Caucus,” Star Tribune, April 5, 2017, available at <http://www.startribune.com/lawmakers-from-minority-communities-create-new-caucus/418412623/> (last visited May 8, 2019).