The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program aimed to improve health care quality and reduce racial and ethnic disparities in 16 diverse communities in the United States from 2006 to 2015; yet most communities failed to make substantive progress toward advancing health care equity by the program's end. This qualitative analysis of key stakeholder interviews aims to identify the major contributors to success versus failure in addressing local health disparities during AF4Q and identified five major themes. Three themes highlight challenges related to collecting local data on racial and ethnic health disparities and transitioning from data collection to action. Two themes capture the critical contribution of stakeholder engagement and access to technical expertise to successful efforts. The challenges and facilitators experienced by these 16 AF4Q communities may help inform the disparities reduction efforts of other communities and guide state or federal policies to reduce health disparities.