For more than 225 years, the United States has struggled with aligning the constitutional notions of equal protection and general welfare to our health laws and policies, which resulted in a chasm between researchers and the patients who need their discoveries, and a chasm between clinicians and the communities that have been locked out of the health care system. Despite this struggle, there have been lawmakers and advocates who have worked assiduously throughout the years to uphold the integrity of scientific research and build longer and stronger bridges to ensure that the discoveries made in a lab, a clinical setting or in the field translated positively to all communities, including those that have historically been marginalized and underserved such as racial and ethnic minorities, women, children, veterans, rural individuals, and most recently LGBTQ individuals.

Today's struggle to increase access to health care for our most vulnerable populations parallels the struggle 150 years ago when abolitionists worked tirelessly to increase access to care for poor whites and newly freed slaves and mental health champions labored assiduously to increase access to and improve behavioral health services in the United States for people with mental illness or substance use disorders.^{Reference Dawes1} In 1865, the federal government attempted to address the social determinants of health by enacting the first comprehensive health law, An Act to establish a Bureau for the Relief of Freedmen and Refugees,² giving these vulnerable population groups who were displaced by the Civil War, access to food, education, employment, housing, and health care.

However, after seven years, that effort to address the social determinants of health, reduce health disparities, and advance health equity³ was terminated by lawmakers.⁴ It would take more than one hundred years before there was another coordinated federal effort to enact a law to address the disparities in health status among racial and ethnic minorities and lower socioeconomic status individuals.⁵ Thanks in part to a landmark report by the Institute of Medicine, Health Care in a Context of Civil Rights,⁶ which highlighted the latest evidence concerning minority health and health disparities, the Reagan administration through Secretary of Health and Human Services Margaret Heckler, recognized that while the overall health of the nation had been improving the health of African Americans and other racial and ethnic minorities was alarming.

As a result, the Reagan administration convened a task force to more closely examine this issue. It was the first federal attempt to examine racial and ethnic health disparities in order to more fully understand why they had resulted, what the impact was, and what policies and programs should be authorized to address and rectify the problem. This effort led to the development and passage of two piecemeal, but significant statutes: the Disadvantaged Minority Health Improvement Act during the George H.W. Bush administration in 1990, and the Minority Health and Health Disparities Research and Education Act during the Bill Clinton Administration in 2000. Collectively, these two federal policies resulted in increased attention to and investments in studying and developing solutions to the issues impacting minority health and health disparities. From there, further research ensued and led to the publication of over 6,000 scholarly articles, which informed later public laws and policy, including the Patient Protection and Affordable Care Act, the most comprehensive and inclusive health law ever produced and passed by the U.S. Congress intended to advance health equity among all population groups.⁷ The Patient Protection and Affordable Care Act is a law that in many respects mirrors the Freedmen's Bureau Act and its protections were intentionally designed to stretch across geographic, socioeconomic, racial, gender, and age groups, all of whom have benefited from passage of the law.

Today, our understanding of health disparities demonstrates that it is not one factor that has driven the inequities in healthcare and health status, but multiple intersecting determinants, driven in large part by law and policy. This affords researchers, lawmakers and the legal community an opportunity to address not only the negative outcomes of health disparities, but also the imbalance of inputs resulting from laws and policies which fail to employ an equity lens, as the United States strives for a more healthy and equitable society. Addressing this complex issue is even more critical today considering the fact that in 25 years, racial and ethnic minorities are expected to comprise a majority of the United States population.^{Reference Colby and Ortman8} The problem will only become more pronounced with the rising incidence of obesity and chronic diseases, including mental illness and substance use disorders, the increasingly vulnerable aging population, and the disproportionalities experienced by certain groups in health status and healthcare. Hopefully, policy makers will recognize the shortsightedness of taking a reactionary approach to health policies as has been the case during our nation's history primarily when a direct threat, outbreak or other national security reason arises. Instead law makers should continue to take a proactive approach to public policy by addressing the social determinants of health and bolstering minority health efforts in the United States.

From a health equity perspective, the implications of the 2016 election were clear: the United States would, once again, wrestle with whether and how to advance universal health coverage and prioritize health equity as lawmakers engaged in contentious debates over repealing and replacing the Affordable Care Act. The 2018 election marked a critical juncture for the health law and the United States — one that will determine whether the country embraces a more accessible, equitable, and inclusive health system or reverse course toward a system of increasing health disparities.

The big question is whether opponents of the Affordable Care Act will be able to follow through and successfully repeal the longest surviving health reform law in America prioritizing health equity, which provided the greatest expansion of mental health reforms, health insurance protections, and prevention and public health programs. Or will proponents of the Affordable Care Act be able to beat back its repeal unlike advocates of the Freedmen's Bureau Act. Although the Affordable Care Act has survived 11 brushes with death, eighteen successful legislative efforts that repealed or modified certain provisions, including the zeroing out of the penalty associated with the law's individual mandate, and several administrative attempts to undermine the law, it remains to be seen whether those actions have collectively struck at the heart and guts of the law to a degree that will lead to its unraveling.

No other health law has extended mental health parity protections and expanded civil rights protections, required greater attention to diversity in comparative effectiveness research, ensured that critical benefits such as maternity, behavioral health, rehabilitative and habilitative coverage were included as essential health benefits, authorized the largest investment in public health to tackle the most pressing chronic diseases in communities, especially those disparately impacted, promoted the integration of behavioral health and primary care, included preventive services at no cost to the consumer, and provided other opportunities for health equity-related outreach and education campaigns like the Affordable Care Act has. In the face of strong evidence showing that repealing the ACA would jeopardize health care access and protections for millions of Americans, roll back health equity gains, and exacerbate health care costs, Democrats and Republicans should continue their efforts to repair the ACA to help stabilize the markets, ease the financial burden on Americans, and advance health equity nationally. As Francis Bacon once stated, “He that will not apply new remedies must expect new evils.”^{Reference Bacon9} If this does not bear truth in the debate around “ObamaCare,” we might still be fighting the battle for a more accessible, equitable, and inclusive health system 150 years from now.