1u.s. department of health and human services – office for civil rights addressing health...

1U.S. Department of Health and Human Services – Office for Civil Rights

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 ofRace, 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 AssuranceApplies to recipients of Hill-Burton funds



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 OriginEnsuring 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



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 OriginImmigration Status Inquiries


Non-Discrimination on the Basis of National OriginEnsuring 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



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


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


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



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 theBasis 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 DisabilityProgram 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


Non-Discrimination on the Basis of DisabilityLive 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 DisabilityAuxiliary Aids and Services


Non-Discrimination on the Basis of DisabilityAuxiliary 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 theBasis 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 CommunicationImpacts 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 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 SexEnsuring 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 ofReligious 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 ofReligious or Moral Objections


Non-Discrimination ProvisionsIn the Affordable Care Act (ACA)

Section 1553 of the Affordable Care ActProhibits discrimination against individuals or institutional health care entities that do not provide assisted suicide services

Section 1557 of the Affordable Care ActProhibits 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 inProgram-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 PromoteCivil Rights Compliance

Agency Program Staff• Incorporate civil rights in program oversight

materials• Identify when recipients need technical assistanceGrant Management StaffInclude civil rights information in:• Funding announcements• Materials on grant requirements• Outreach materials on HHS grant opportunities


Technical AssistanceOCR Regional Offices

• Provide technical assistance

• Receive reports of noncompliant programs or activities

For more information, contact us: 1-800-368-1019, [email protected] Visit http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html

mailto:[email protected]

http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html


Resources Are AvailableUseful 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/

http://www.hhs.gov/ocr/

http://www.hhs.gov/ocr/civilrights/resources/factsheets/index.html



http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/hhslepguidancepdf.pdf

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/origin/policyguidanceregardinginquiriesintocitizenshipimmigrationstatus.html

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/origin/policyguidanceregardinginquiriesintocitizenshipimmigrationstatus.html

http://www.ada.gov/regs2010/2010ADAStandards/2010ADAstandards.htm

http://www.lep.gov/resources/2011_Language_Access_Assessment_and_Planning_Tool.pdf

http://www.lep.gov/

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15

http://www.ada.gov/websites2.htm

http://www.w3.org/TR/WCAG/