Health, Equity, and the Law: A Conversation with Professor Carmel Shachar

Professor Carmel Shachar is currently an Assistant Clinical Professor of Law and Faculty Director of the Health Law and Policy Clinic at the Center for Health Law and Policy Innovation at Harvard Law School. Her work focuses on some of the most pressing issues in healthcare today - from expanding access to care for vulnerable and underserved populations to leveraging telehealth and digital health tools to improve patient outcomes. She also studies the application of public health ethics to real-world challenges.

Professor Shachar has also played a large role regarding the implementation of the Affordable Care Act by making complex health policy issues understandable and actionable to various audiences. Her commitment to improving the healthcare system and making an active change makes her a valuable perspective in today’s healthcare field.

The interview below was conducted in Spring 2025. It has been edited for clarity.

Harvard Undergraduate Law Review (HULR): The first thing that I'm interested in is a little bit about your background. What drew you to the intersection of healthcare and law, and how was your understanding of what health equity is developed throughout your career?

Carmel Shachar: I came to health, law, and policy because I was very interested in questions around who gets access to care, who gets access to good quality care, and how we decide that. Some of that was informed by an experience in my family- my grandmother had breast cancer, and the treatment was mismanaged - and some of it came from an early internship that I had at an organization in New York City that conducted seminars for people living with HIV. We would go out to the community and meet them consistently. The seminar that we gave was always the most emotional. People were most passionate about how you interact with your physician and the health care system. How do you advocate for your health care needs? And so I would say that access to care and health equity has always been at the root of why I got into this field.

HULR: That definitely makes sense. I think, for a lot of people who start exploring health or are pre med, it usually comes from a personal experience. So when you started this work whether it was your personal experience or the internship, how did you think about health equity and how has that idea developed since you’ve done more research and met more colleagues?

CS: So I have been doing this work for a couple decades now. I think certainly it has shifted a lot like I think one very big thing is just the creation and implementation of the Affordable Care Act really changed the American health care landscape. Thinking back to a lot of the conversations that we had pre ACA, it does feel very night and day in terms of expectation that people will have pathways to access health care coverage. Beforehand, there wasn't any sort of that race opposition.

HULR: That definitely makes sense. Do you think there was a turning point, challenge, or experience that shaped how you thought about ACA policy reform or advocacy for these underprivileged communities?

CS: I think for me, something that was very formative in seeing the value of these programs is my role for the second half of the Obama administration, working with people living with HIV and hepatitis C in southern states regarding the ACA rollout. I was working on Medicaid expansion for these populations in states that had expansion, working on marketplace rollout, and learning about what programs are and aren’t working for this population. Then I would lift it back up to state and federal regulators and say “hey, you need to fix this” as well as explain to the communities what the government is doing. I would also explain how to take advantage of what is being built.

HULR: To confirm, you were working in Southern states for an informative role?

CS: Yes, an informative and advocacy role.

HULR: That definitely makes sense. What made you interested in law? Have you ever thought about working in healthcare or being pre-med?

CS: I get that question a lot if I thought about going to medical school and the answer was no, never. I think it's really important to be a provider who meets the needs of their patients, and the work they do is amazing, but I wasn't interested in being the person providing the care. I was interested in being the person working on the broader questions of, how do we get people access to care? Because I wanted to work on the macro level as opposed to the individual level, law school was a really good fit for me.

HULR: And just to confirm, you went to Harvard right?

CS: Yes, I went to Harvard, and I did the JD Masters of Public Health joint degree program.

HULR: That's exciting! How was your experience doing the joint program?

CS: I loved doing the joint program. It's a pretty small joint degree program as things go, but I really got what I wanted out of my graduate school training - which was both to better understand the healthcare system as well as understand the levers for how do you create change in the healthcare system?

HULR: That’s great! So in our government today, especially over the past few months, we've been seeing a lot of health policy changes or possibilities of health policy changes. In your opinion, what do you think is the most urgent policy change that the US healthcare system needs today?

CS: I think that we are really at an interesting inflection point. I think it's very clear that the ACA really helped improve our healthcare system, but there's a need for further health reform that we need to think about. What does the next chapter of health care reform look like when you think about the high cost to people? When you think about the challenge in accessing providers? When you think about the challenge in getting coverage? I think we are also at the point where there's a lot of questioning in the federal government about what programs do we continue when you look at the reorganization of the CDC, for example, as well as broader trends at Health and Human Services. I think the question is: is health policy going to be focused on dismantling a lot of the federal health care apparatus, or is it going to be focused on saying “what's proactively the next agenda”?

HULR: Got it. In terms of certain federal government healthcare programs, what do you think are the ones that you've seen that have had the most impact that are decreasing now or what do you think has been the best?

CS: I think best is not necessarily the right term there. Because how do you define best? If your child is at risk for measles, then you might say that all of the programs helping deliver vaccinations to communities were really important. That's the best. If you're somebody with an aging parent, you might say the expansion of Medicaid, which allows for my parents to get caregiver services, has been the best because that's really important to you. I think that's a really important thing in health policy to understand - that people have such different needs and experiences, but fundamentally, at the end of the day, what they want is that if they are sick, or their baby is sick, or their parent is sick, that they can get the care that they need.

HULR: That definitely makes sense. Healthcare is a really personal topic. When you were in this advocacy role working with those in Southern states, how were you able to form relationships and prove to people that you truly care about them?

CS: I think a lot of it is just showing up and doing the work. There are a lot of communities that are rightfully suspicious of people coming in, doing a little bit of something to make themselves feel good, and then not having the long standing commitment. For me, I’m going to show up and I wasn’t going to drive the agenda. I said, “I’m going to listen to you”. One thing I’ve come to really appreciate about lawyering is that it is fundamentally a service industry If you go to a law firm, your client may say, “Yes, I will pay your law firm rate, but I want you to do XYZ for me”. But, it’s also true that in public interest work, you’re telling a community, “here’s what I think you should care about”. If they say that that isn’t actually important and you don’t listen to that, you’re not going to develop the kind of relationships that you need, and you're not going to be able to do very successful work.

HULR: Yeah, that is definitely important. I’ve learned about your 2020 JAMA Article about prevention of bias and discrimination in clinical practices. You discuss the risk of having bias algorithms, especially in health care and with increasing technology. What steps do you think certain institutions or the government can take to identify and then also mitigate this bias when it comes to decision making and other clinical tools?

CS: I think it really has to be a multifactorial approach, in part because there's a lot of players that are involved. It might look like figuring out how you can push developers to be more thoughtful about avoiding bias and identifying bias in their product. That could mean working with the FDA on some sort of bias review on the front end. It could be like what OMC did during the last administration and saying they want to see effective data nutrition labels and where you are getting your data from. The next question is: how can you influence the users such as physicians and hospitals. In this case, you might need to find a way to evaluate the products that you are taking on. However, I think if we were to give a list of approved products, that would stifle innovation. And then you want to have some sort of post market surveillance to see how the algorithm is impacting people.

HULR: Got it. It’s definitely a big question in AI how to eliminate bias but increase efficiency. With that, what are some legal or ethical challenges that you foresee with the rise of digital health technologies and telemedicine?

CS: Digital health technologies is pretty broad, but I think with telemedicine, one challenge, for example, is the question of payment parity. Part of what people enjoy about telehealth is that you don’t need as much infrastructure to deliver it because the provider can do it from home. They don’t need to pay for an office so it is cheaper to deliver and therefore, we should be paying less for it as a system. It’s a huge cost savings which is a good thing. However, on the flip side, you might also have providers saying that they can’t survive on telehealth rates because fundamentally, they do still need to have office space. They need to see people in person and if they reimburse with lower rates, they won’t want to do it. It’s a really complicated question we haven’t come to an answer to.

HULR: Recently, we've seen some changes that are happening with funding to research and labs especially in various educational systems. How do you think that these recent fiscal policy changes are going to impact not just patient care, but specifically underprivileged populations?

CS: Yeah, so I think certainly there's a lot at stake with the question of federal funding of biomedical research, whether it's grants being frozen at quite a few universities now, or whether it's the issue of the indirect rates that will be allowed to be charged, or whether it's questioning if the NIH will be able to go forward to fund certain types of research. I think all of those can have a really concerning impact on patient care and our medical innovation. Some of it, for example, is that we're still learning so much about the human body and about people, such as in the field of cancer screenings. Here, this is so important because you want to screen people and catch diseases as early as possible, but you also don't want to waste people's time, or the medical system's time. You might accidentally catch something and force people to get treatment they don’t really need. And so we have to refine that and see who is the person who needs a mammogram or who needs colorectal cancer screenings. That’s a good example because for colon cancer, we’ve had colonoscopies which are very involved. We tend to set them at a certain age, and people put them off because they’re expensive and they don’t like it. But there are startups that are saying that through a fecal sample, they can screen you at home at a lower cost. Doing research like that and innovation like that is so important because it can literally save lives.

HULR: Yeah, for sure. I understand because limiting funding limits the amount of innovation possible. I also read your article that was talking about regulatory changes during the pandemic that allowed physicians to use telehealth across state lines and in broader locations. What do you think are some changes that could happen to our legal system or any policy changes that can help us preserve this and ensure that physicians are still able to contact their patients even if it’s across state lines.

CS: We are really working on that. I think that goes to show how law can have such an impact on people's lives. You know the difference between law and hard science is like in hard science, gravity is gravity. It doesn't matter what your thoughts are and what gravity is, because gravity doesn't care. In law, there aren't really these kinds of immutable truths. Telehealth is a good example where we have decided that for legal purposes, telehealth happens in this state or the where the patient is located. But there's no gravity behind that. We could easily say, actually, we think it's a better policy choice to have the location be the location of the position and shift there. Law is about figuring out what that best choice is and how to make it feasible. A lot of my work is saying the best choice has to be the choice that facilitates access to care for the greatest number of people

HULR: Do you have any projects or something you are researching right now that you are excited about?

CS: I’m working with a team from John Hopkins to host conversations in DC about what a path forward for facilitating interstate telehealth for certain patient groups would be. We are looking at patients who are involved in clinical trials, patients who have rare diseases, patients who are in palliative care, and it's been very exciting to build with them. It’s been interesting to look at the federal pathways leading to facilitating access to care for these patient groups using telehealth.

HULR: That sounds exciting! My last question for you is that as part of the Undergraduate Law Review, we have a lot of people who are deciding what sector of law they want to go into. What do you think is the best way to start meaningfully engaging with law and policy before law school, as an undergraduate.

CS: I think some of it is topical - understanding what areas are you really interested in. For example, are you interested in labor law, healthcare, or biomedical innovation? Some of it is a little harder to get undergrad such as what type of legal practice you want to do and what it looks like being in court. Does it look like a regulatory and compliance practice? I am generally a big proponent of taking at least a year or two off and working for a bit. I think you should not be in a heartache to go to law school. You should only go to law school when you can say, I need a law degree in order to have the kind of career I want.

HULR: Yeah, that definitely makes sense and is great advice. I think those are all of my questions! I really appreciate you taking the time to speak with me about your research and experiences.

CS: This has been a lovely conversation!