Issued following Executive Order 14281, “Restoring Equality of Opportunity and Meritocracy,” the rule aligns with similar actions by other federal agencies, including the Department of Justice (DOJ), Department of Education (DOE), and Department of Housing and Urban Development (HUD).
A Shift in Civil Rights Enforcement
The rule marks a significant change in the federal government’s approach to enforcing civil rights protections, which may have significant implications for its enforcement of civil rights law and health and health care disparities.
The changes narrow the scope for administrative enforcement of civil rights law. They may allow policies and practices leading to disparate outcomes in health and health care to remain, potentially worsening disparities. and may reduce proactive review of whether policies and practices have unintended disproportionate effects on certain racial or ethnic or other protected groups.
Title VI’s Historical Role in Combating Racial Discrimination
Enacted during the Civil Rights Movement, it addressed widespread racial discrimination by institutions receiving federal funds. These included hospitals that refused to treat Black patients, maintained segregated wards and waiting rooms, or provided unequal care.
Understanding Disparate Impact
Disparate impact refers to policies or practices disproportionately affecting people of a particular race, color, or national origin, even without evidence of intentional discrimination.
These regulations acknowledged that facially neutral policies can perpetuate or worsen inequities in access to programs, services, and benefits.
In health care, disparate impact can arise from inequities in institutional policies and practices, alongside persistent intentional discrimination.
For example, historical discriminatory policies like redlining have lasting effects today. They lead to residential segregation of Black and Hispanic people into urban neighborhoods with fewer resources and increased health risks.
Within medicine, disproven beliefs about biological differences by race persist and influence clinical decision-making and treatment. This includes their use in clinical algorithms, tools, and guidelines.
Language barriers can reduce care quality and increase adverse outcomes or medical errors. Studies show inadequate language assistance can delay access to timely care, contribute to suboptimal care and dissatisfaction, and lead to poor chronic disease management and worse health outcomes.
Disparate Impact’s Role in Federal Investigations and Resolutions
The federal government has used disparate-impact regulations for over 50 years to investigate and resolve policies and procedures of federal financial assistance recipients that negatively affect protected groups.
For instance, HHS’s Office for Civil Rights (OCR) investigated the proposed closure of University of Pittsburgh Medical Center (UPMC) Braddock. This hospital served a predominantly Black community in Pennsylvania.
The investigation assessed whether the closure would disproportionately affect Black residents’ access to care. It resulted in a voluntary resolution agreement requiring UPMC to implement measures reducing potential barriers to care.
These included expanded transportation services, enhanced primary care and behavioral health services, and ongoing monitoring of the closure’s impact on the community.
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Similarly, OCR entered into a voluntary resolution agreement with Mee Memorial Hospital (MMH) after investigating allegations that the hospital failed to provide meaningful language assistance to Triqui-speaking patients with limited English proficiency (LEP).
Although the hospital did not intentionally withhold services from Mexican indigenous patients, its lack of language assistance disproportionately prevented them from receiving effective care. The agreement required the hospital to strengthen language access policies, interpreter services, staff training, and monitoring.
In 2021, HHS’s OCR and the DOJ investigated the Alabama Department of Public Health (ADPH) over concerns that its wastewater and public health practices disproportionately burdened Black residents of Lowndes County.
The agencies reached an interim resolution agreement requiring ADPH to address the community’s longstanding exposure to raw sewage. This included improving access to functioning septic systems, suspending criminal enforcement against residents unable to afford compliant systems, and strengthening public health data collection and infrastructure planning.
In 2024, HHS and DOJ reported progress in implementing these reforms. However, in April 2025, the Trump Administration terminated the agreement, ending federal enforcement of the reforms.
Disparate Impact’s Influence on HHS Guidance and Standards
Disparate-impact standards have also shaped HHS guidance to recipients on designing and administering programs and policies.
This standard translated into expectations for providing meaningful access to care.
HHS’s Office of Minority Health (OMH) National Culturally and Linguistically Appropriate Services (CLAS) Standards also reflect principles underlying disparate-impact protections, particularly in language access standards.
The guidance identified examples of disparate-impact discrimination in COVID-19 vaccination programs. These included distributing vaccines solely through pharmacies or requiring online appointment scheduling, which could limit access in communities of color, even without discriminatory intent.
HHS advised vaccine providers to review policies for barriers, collect and analyze demographic data, address language and transportation barriers, and locate vaccination sites in historically underserved communities.
HHS also incorporated disparate-impact principles into a training curriculum for medical students. This included examples of facially neutral health care policies that could limit access for racial and ethnic communities and instructed participants to consider less discriminatory alternatives.
2026 Rule Change Eliminates Disparate Impact Enforcement
The final rule also clarifies that statistical evidence showing racial or ethnic disparities may still be considered as part of an investigation, but disparities alone are not sufficient to establish discrimination absent evidence of intentional discriminatory treatment.
For example, Section 1557 of the Affordable Care Act prohibits discrimination in covered health programs based on race, color, national origin, disability, age, and sex, and includes meaningful language access requirements.
