Context: The racial health equity implications of the Trump administration's response to the COVID-19 pandemic.

Methods: We focus on four key health care policy decisions made by the administration in response to the public health emergency: rejecting a special Marketplace enrollment period, failing to use its full powers to enhance state Medicaid emergency options, refusing to suspend the public charge rule, and failing to target provider relief funds to providers serving the uninsured.

Findings: In each case, the administration's policy choices intensified, rather than mitigated, racial health inequality. Its choices had a disproportionate adverse impact on minority populations and patients who are more likely to depend on public programs, be poor, experience pandemic-related job loss, lack insurance, rely on health care safety net providers, and be exposed to public charge sanctions.

Conclusions: Ending structural racism in health care and promoting racial health care equity demands an equity-mindful approach to the pursuit of policies that enhance—rather than undermine—health care accessibility and effectiveness and resources for the poorest communities and the providers that serve them.

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