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State and local programs work independently to meet the specific needs of minority popula-tions in state, county, and municipal communities. At the same time, state programs often serve as models for federal initiatives. Two examples are Minnesota’s Eliminating Health Disparities Initiative and the California Department of Public Health Strategic Plan, both initiated in 2008. They serve large numbers of individuals, and their goals are closely aligned with the determinants of health in Healthy People 2020 (HHS 2010).Private InitiativesOne example of private endeavors to eliminate disparities is the Association of Schools of Public Health, which, with the support of the W. K. Kellogg Foundation, promotes health professional involvement in racial and ethnic health disparities research (Horowitz et al. 2000). Another example is the Building Healthy Communities Initiative launched in 2010 by the California Endowment (2018), which seeks to promote long-term improvements in health status in 14 communities with high rates of health disparities through broad investment in social, environmental, and medical interventions, with a primary focus on children and youth.THEUNINSUREDIn 2015, more than 9 percent of the US population lacked health insurance (Shi and Singh 2018). Studies show that people without health insurance face barriers to healthcare access, quality of care, and positive health outcomes (Akinlotan et al. 2017; Garfield and Damico 2012; Kenney et al. 2012; Moonesinghe, Zhu, and Truman 2011; Weissman et al. 2008). Advocates have long urged lawmakers to expand public insurance programs—such as Medi-care, Medicaid, and the Children’s Health Insurance Program (CHIP)—and have called for the improvement of the quality of care received through these programs.One primary goal of the Affordable Care Act (ACA) of 2010 was to reduce the number of uninsured Americans. Several provisions in the ACA sought to extend coverage to previously uninsured groups. Examples include the development of health insurance exchanges, which established insurance markets for individuals and small business owners, and the expansion of Medicaid to provide insurance coverage to all individuals and families with an income at or below 133 percent of the federal poverty level (Shi and Singh 2018). In 2013, the year before the major provisions of the ACA took effect, more than 44 million nonelderly people were uninsured, but by 2016, only 27.6 million were uninsured (Foutz et al. 2017). However, after the tax revisions led by President Donald Trump in 2017 eliminated the ACA requirement that all individuals have health insurance, the number of uninsured Americans began to rise again (Beaton 2018; Collins et al. 2018). By March
Chapter 6: Health Policy for Diverse Populations1 6 32018, 4 million fewer working people aged 19–64 had health insurance (Collins et al. 2018). Among lower-income adults in particular, the uninsured rate increased from 20.9 percent in 2016 to 25.7 percent in March 2018 (Collins et al. 2018). If the ACA were to be repealed entirely, as the Trump administration seeks to do—either without replacement or replaced