Addressing Health Disparities Through Civil Rights Compliance and Enforcement September 19, 2012 Sarah Albrecht, J.D. HHS Office for Civil Rights

Your Role in Ensuring Civil Rights Compliance Recipients of Federal Financial Assistance (FFA) Agency Program Staff Grant Management Staff

HHS Office for Civil Rights (OCR) What We Do & How We Do It

Non-Discrimination on the Basis of Race, Color, or National Origin Title VI of the Civil Rights Act of 1964 Applies to all recipients of FFA Multiethnic Placement Act of 1994 (MEPA) Applies to recipients of FFA who administer foster care and adoption programs Hill-Burton Community Service Assurance Applies to recipients of Hill-Burton funds

Non-Discrimination on the Basis of Race, Color, or National Origin Avoiding National Origin Discrimination Under Title VI Must take reasonable steps to provide meaningful access to individuals who are limited English proficient (LEP) Failure to provide meaningful access to individuals who are LEP, such as through oral interpretation and written translation, may constitute national origin discrimination

Non-Discrimination on the Basis of National Origin Ensuring Compliance with Respect to LEP Persons

Non-Discrimination on the Basis of National Origin Ensuring Compliance with Respect to LEP Persons Strategies to ensure compliance: Maintain written policies and procedures on providing language assistance services Assess language needs of the service area Maintain data on the primary language of each LEP person served and the type of language assistance provided Notify LEP persons in the service area in their native languages of the right to language assistance at no cost Ensure competency, quality and accuracy of language services Offer language services even if a person brings a family member, friend, or child to interpret

Number of LEP persons likely to be served or affected Non-Discrimination on the Basis of National Origin Ensuring Compliance with Respect to LEP Persons Four factors to consider to determine the reasonable steps needed for meaningful access: Number of LEP persons likely to be served or affected Frequency of contact Nature and importance of the program Costs and resources

Non-Discrimination on the Basis of National Origin Immigration Status Inquiries

Applications and processes to determine a child’s eligibility: Non-Discrimination on the Basis of National Origin Ensuring Equal Access for All Children Applications and processes to determine a child’s eligibility: Should focus exclusively on the criteria to determine the child’s eligibility Should identify and differentiate between “applicants” and “non-applicants” early in the process to clarify which questions pertain to the applicant child

Non-Discrimination on the Basis of Race, Color, or National Origin MEPA Prohibits: Recipients of federal financial assistance (FFA) from using race, color, or national origin as a basis: to deny any person the opportunity to become an adoptive or foster parent, or to delay or deny any child’s adoptive or foster home placement

Non-Discrimination on the Basis of Race, Color, or National Origin

Race, Color, or National Origin Ensuring Compliance Develop and implement policies and procedures prohibiting: The use of race, color, or national origin in making adoption decisions The use of culture as a proxy for race or national origin The different treatment of families who are willing to adopt or foster a child of a different race, color, or national origin Do not collect and act on birth parents’ preferences concerning the race, color, or national origin of adoptive parents Document the reasons a family was considered more appropriate to adopt a child

Hill-Burton Community Service Assurance Non-Discrimination on the Basis of Race, Color, National Origin, Creed, and Other Bases Hill-Burton Community Service Assurance Prohibits facilities receiving federal financial assistance under Title VI or Title XVI of the Public Health Service Act from discriminating on the basis of: race, color, national origin, creed, or any basis unrelated to the need for the service or the facility’s ability to provide the service Distinct from the Hill-Burton uncompensated care provision

Non-Discrimination on the Basis of Race, Color, or National Origin Key Take Away Points: Race, Color, or National Origin Title VI Reasonable steps to provide meaningful access Discriminatory effects of questions about immigration status of non-applicants MEPA Applies to foster care and adoption Hill-Burton Community Service Assurance Applies to recipients of Hill-Burton funding

Non-Discrimination on the Basis of Disability Section 504 of the Rehabilitation Act of 1973 Applies to recipients of FFA Title II of the Americans with Disabilities Act (ADA) Applies to public entities, including those that do not receive FFA

Non-Discrimination on the Basis of Disability Discriminatory Prohibitions: Exclude or deny benefits based on an individual’s disability Provide separate or different benefits to individuals with disabilities, unless it is necessary to ensure that the benefits and services are equally effective Establish eligibility criteria that screen out, or tend to screen out, individuals with disabilities, unless the criteria are necessary to meet the program objectives

Non-Discrimination on the Basis of Disability Obligations: Ensure that programs are accessible Make reasonable modifications, unless it would result in a fundamental alteration in their program or activity Provide services and programs in the most integrated setting Provide auxiliary aids and services, at no cost, where necessary to ensure effective communication

Non-Discrimination on the Basis of Disability Equal Opportunity to Receive Services

Non-Discrimination on the Basis of Disability Equal Opportunity to Receive Services Definition of disability is broad and includes HIV status Prohibited actions include excluding participation in a program and denying services to an individual with a disability based on the disability

Non-Discrimination on the Basis of Disability Program Accessibility

Non-Discrimination on the Basis of Disability Program Accessibility Under Section 504 and Title II of the ADA: Must make programs accessible 2010 ADA Standards for Accessible Design Set minimum requirements for newly designed and constructed or altered state and local government facilities

Non-Discrimination on the Basis of Disability Live in the Most Integrated Setting

Under Section 504 and Title II of the ADA: Non-Discrimination on the Basis of Disability Live in the Most Integrated Setting Under Section 504 and Title II of the ADA: Make reasonable modifications unless it would result in a fundamental alteration Must provide services in the most integrated setting Enables interaction with nondisabled persons to the fullest extent possible Prevents unnecessary institutionalization

Non-Discrimination on the Basis of Disability Auxiliary Aids and Services

Under Section 504 and Title II of the ADA: Non-Discrimination on the Basis of Disability Auxiliary Aids and Services Under Section 504 and Title II of the ADA: Must provide auxiliary aids and services unless it would fundamentally alter the program or result in undue financial and administrative burden Considerations for Auxiliary Aids and Services: Make an individualized determination based on needs, circumstances, and preferences Provide at no cost Refrain from asking a family member, friend, or child to interpret

Non-Discrimination on the Basis of Disability Key Take Away Points: Section 504 and Title II of the ADA Definition of disability is broad Must not: Exclude or deny Provide different or separate programs Use eligibility criteria that screen out persons with disabilities Must: Make programs accessible Make reasonable modifications Provide services in the most integrated setting Provide auxiliary aids and services

Lack of Effective Communication Impacts Outcomes Effective communication is critical for safe, quality services. Consequences for Individuals: Denial of needed benefits Delay in delivery Wrong benefits or services Ineffective or less effective services Consequences for Providers: Inferior Quality Potential Liability Increased Costs and Inefficiencies

Non-Discrimination on the Basis of Age The Age Discrimination Act of 1975 Prohibits recipients of FFA from discriminating on the basis of age in their programs and activities Use of age must be necessary to normal program operations or to achieve a statutory objective

Non-Discrimination on the Basis of Age

Non-Discrimination on the Basis of Age

Non-Discrimination on the Basis of Sex Title IX of the Education Amendments of 1972 Prohibits recipients of FFA from discriminating on the basis of sex in education programs and activities Comprehensive Health Manpower Training Act and the Nurse Training Act Program-specific laws administered by HRSA Prohibit sex discrimination in health training schools and centers that receive FFA and operate academic or other training programs or activities

Non-Discrimination on the Basis of Sex

Non-Discrimination on the Basis of Sex Ensuring Compliance Strategies to ensure compliance: Use gender-neutral language in eligibility criteria Include a nondiscrimination policy in program materials Conduct outreach and recruitment in a manner that is accessible to all persons regardless of gender

Non-Discrimination on the Basis of Religious or Moral Objections Federal Health Care Provider Conscience Protection Statutes Church Amendments Section 245 of the Public Health Service Act Weldon Amendment

Non-Discrimination on the Basis of Religious or Moral Objections

Non-Discrimination Provisions In the Affordable Care Act (ACA) Section 1553 of the Affordable Care Act Prohibits discrimination against individuals or institutional health care entities that do not provide assisted suicide services Section 1557 of the Affordable Care Act Prohibits discrimination in federally assisted and some federally conducted health programs and activities and program and activities administered by entities created under Title I of the ACA

Non-Discrimination on Multiple Bases in Program-Specific Laws Some program laws prohibit discrimination on the basis of age, race, color, national origin, disability, sex, or religion Maternal and Child Health Services Block Grant (HRSA) Projects for Assistance in Transition from Homelessness (SAMHSA) Substance Abuse Prevention and Treatment Block Grant (SAMHSA) Community Mental Health Services Block Grant (SAMHSA) Preventive Health and Health Services Block Grant (CDC) Community Services Block Grant (ACF) Low-Income Home Energy Assistance Program (ACF) Family Violence Prevention and Services Act (ACF)

Ensuring Compliance with Civil Rights Laws Strategies for recipients of FFA: Maintain written policies and procedures on ensuring nondiscrimination and responding to complaints Identify a coordinator of the recipient’s compliance efforts Develop and post nondiscrimination policy. Ensure effective communication with persons who are LEP or have disabilities Notify LEP persons in the service area of the right to language assistance at no cost. Train supervisors and staff

Opportunities to Promote Civil Rights Compliance Agency Program Staff Incorporate civil rights in program oversight materials Identify when recipients need technical assistance Grant Management Staff Include civil rights information in: Funding announcements Materials on grant requirements Outreach materials on HHS grant opportunities

Technical Assistance OCR Regional Offices Provide technical assistance Receive reports of noncompliant programs or activities For more information, contact us: 1-800-368-1019, ocrmail@hhs.gov Visit http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html

Resources Are Available Useful Links and Documents HHS Office for Civil Rights information and tools, http://www.hhs.gov/ocr/ OCR Fact Sheets, http://www.hhs.gov/ocr/civilrights/resources/factsheets/index.html OCR Compliance Activities, http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/heccomplianceactivities.html HHS LEP Guidance (2003), http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/hhslepguidancepdf.pdf Tri-Agency Guidance, http://www.hhs.gov/ocr/civilrights/resources/specialtopics/origin/policyguidanceregardinginquiriesintocitizenshipimmigrationstatus.html ADA Standards for Accessible Design (2010), http://www.ada.gov/regs2010/2010ADAStandards/2010ADAstandards.htm#designconstruction DOJ Language Access Assessment and Planning Tool, http://www.lep.gov/resources/2011_Language_Access_Assessment_and_Planning_Tool.pdf Federal Interagency Working Group on LEP, http://www.lep.gov National Standards on Culturally and Linguistically Appropriate Services (CLAS), http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 DOJ Guidance: Accessibility of State and Local Government Websites to People with Disabilities, http://www.ada.gov/websites2.htm Web Content Accessibility Guidelines 2.0, http://www.w3.org/TR/WCAG/