What is Health Equity?

While the term health equity is used widely, a common understanding of what it means is lacking.

What is health equity?

In a report designed to increase consensus around meaning of health equity, the Robert Wood Johnson Foundation (RWJF) provides the following definition: “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

The definitional concepts presented in the report are based on widely recognized ethical and human rights principles and supported by knowledge from health sciences.

Consensus around definitions for an issue such as health equity can help bridge divides and foster productive dialogue among diverse stakeholder groups. Conversely, a lack of clarity can lead to detours, and pose a barrier to effective engagement and action.

Also included in the report are examples of specific terms related to health equity that often arise in discussions around the concept.

Key Findings

Health equity surrounds and underpins RWJF’s vision of a society in which everyone has an equal opportunity to live the healthiest life possible. The authors, including RWJF staff members, put forth these four key steps to achieve health equity:

• Identify important health disparities. Many disparities in health are rooted in inequities in the opportunities and resources needed to be as healthy as possible. The determinants of health include living and working conditions, education, income, neighborhood characteristic, social inclusion, and medical care. An increase in opportunities to be healthier will benefit everyone but more focus should be placed on groups that have been excluded or marginalized in the past.
• Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be as healthy as possible. Eliminate the unfair individual and institutional social conditions that give rise to the inequities.
• Evaluate and monitor efforts using short- and long-term measures as it may take decades or generations to reduce some health disparities. In order not to underestimate the size of the gap between advantaged and disadvantaged, disadvantaged groups should not be compared to the general population but to advantaged groups.
• Reassess strategies in light of process and outcomes and plan next steps. Actively engage those most affected by disparities in the identification, design, implementation, and evaluation of promising solutions.

The authors note that equity is not the same as equality. To equalize opportunities, those with worse health and fewer resources need more efforts expended to improve their health.

How Can We Achieving Health Equity

Why health equity matters and what you can do to help give everyone a fair shot at being as healthy as they can be.

Why Equity Matters

Across the nation, gaps in health are large, persistent and increasing—many of them caused by barriers set up at all levels of our society. After all, it’s hard to be healthy without access to good jobs and schools and, safe, affordable homes. Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make.

Health Equity and COVID-19

The coronavirus response continues to highlight inequity as COVID-19 hits hardest those facing economic, housing, health insurance coverage, and food insecurity issues. COVID-19 has changed the way we look at our health in modern times. Together, we can continue to fight it.

Health inequities—defined by the World Health Organization as systematic differences in the health status of different population groups—have been in the national spotlight for years, which isn’t surprising given that the U.S. ranks last on measures of health equity compared to other industrialized countries.

Health inequity is a multiple-industry issue with significant impacts (health, social, economic, etc.) on people and communities. Racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018.

Healthcare organizations are increasingly making health equity a strategic priority, with varying degrees of success.

How can we tell if health equity has been achieved? “When everyone has the opportunity to attain full health potential, and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance,” according to a Robert Wood Johnson Foundation (RWJF)-commissioned Communities in Action: Pathways to Health Equity report (a year-long analysis by a 19-member committee of experts in national public health, healthcare, civil rights, social science, education, research, and business).

Many healthcare organizations, such as Care Republic Inc., have initiated efforts to improve health equity by making it a systemwide strategic priority and investing in the right resources, infrastructure, and programs, which we’ll outline in this article. Other systems, however, are still largely unaware of the inequities and disparities within their walls.

Healthcare has a long way to go to effectively address health inequity, but there are evidence-based approaches to start tackling—or continue the battle against—health inequities. This article explores approaches, both simple and complex, health systems can implement to work toward restoring health equity.

Health Inequities and Disparities: Understanding the Problem

Why are racial and ethnic minorities in the U.S. disproportionately affected by poor quality of healthcare? Why are African American infants 3.2 times as likely to die from complications related to low birthweight than non-Hispanic white infants? Why is there a 25-year difference in life expectancy for babies who live just a few miles apart from each other in New Orleans (Figure 1)?

We can start to answer these questions by understanding what causes health inequity, as described in RWJF’s Communities in Action report:

1. Intrapersonal, interpersonal, institutional, and systemic mechanisms (i.e., structural inequities) that organize the distribution of power and resources differently across lines of race, gender, class, sexual orientation, gender expression, and other dimensions of individual and group identify.
2. Unequal allocation of power and resources—including goods, services, and societal attention—which manifests itself in unequal social, economic, and environmental conditions (i.e., determinants of health).

Health inequities are the result of more than individual choice or random occurrence; they are the result of poverty, structural racism, and discrimination. Health systems are just one cog in the wheel of the health inequity issue, but the role they play in the problem is a big one.

Healthcare’s Role in Disparities

Looking at race- and ethnicity-related disparities, for example, differences in access to care, receipt of needed medical care, and receipt of life-saving technologies for certain populations “may be the result of system-level factors or may be due to individual physician behavior” according to an NCBI article. The article states that “patient race/ethnicity has been shown to influence physician interpretation of patients’ complaints and, ultimately, clinical decision making.”

The literature shows that clinicians have biases toward certain populations that impede their ability to provide effective care. Over time, these biases become institutionalized and harder to eliminate. Given that the perceived quality of healthcare (or lack thereof) can significantly impact health outcomes (e.g., adherence to medical advice, cancer screening recommendations, and medication regiments), many health systems find themselves in a self-perpetuating cycle of health inequities and poor health outcomes. Health systems exacerbate their health inequity problems when they don’t have the required data (e.g., socioeconomic) or healthcare delivery structure to discover and correct disparities.

Given that health disparities are shaped by multiple determinants of health (social, economic, environmental, structural, etc.), achieving health equity requires engagement from not just healthcare, but also education, transportation, housing, planning, public health, and many other industries and businesses. Achieving health equity is a communitywide effort.

How to Make Health Equity a Strategic Priority

IHI says “health care professionals can—and should—play a major role in seeking to improve health outcomes for disadvantaged populations.” Healthcare organizations committed to outcomes improvement must also be committed to health equity, and their first step is making it a systemwide, leadership-driven priority.

The Health Equity Must Be a Strategic Priority article outlines five ways health systems can make health equity a core strategy:

1. Make health equity a leader-driven priority (healthcare leaders must articulate, act on, and build the vision into all decisions).
2. Develop structures and processes that support equity (health systems must dedicate resources and establish a governance structure to oversee the health equity work).
3. Take specific actions that address the social determinants of health (health systems must identify their health disparities and the needs and assets of people who face disparities, and then act to close the gaps). Some patient populations need additional support to achieve the same health outcomes as other patient populations (e.g., they need someone to drive them to appointments, they need home visits, etc.).
4. Confront institutional racism within the organization (health systems must identify, address, and dismantle the structures, policies, and norms that perpetuate race-based advantage).
5. Partner with community organizations.

Making health equity a strategic priority is the first step. Next, healthcare organizations need to tackle the disparities with proven interventions designed for their disadvantaged populations. The RWJF outlines specific steps health systems can take to address disparities:

• Adopt new vital signs to screen for the nonmedical factors influencing health.
• Commit to helping low-income and non-English-speaking patients get the care they need.
• Guard against the potential for bias to influence medical care.
• Make sure elderly, women, and racial/ethnic minorities are adequately represented in clinical trials.
• Understand the effects of adverse childhood experiences and use trauma-informed care.

Address the Socioeconomic Determinants of Health

Let’s take a closer look at how health systems can incorporate nonmedical vital signs into their health assessment processes to paint a more detailed picture of their patients’ health. RWJF’s Time to Act: Investing in the Health of Our Children and Communities report states that adding nonmedical vital signs (employment, education, food insecurity, safe housing, exposure to discrimination or violence, etc.) to existing ones (heart rate, blood pressure, weight, etc.) can help clinicians make better-informed decisions about treatment and care.

The article notes that new vital signs should be objective, readily comparable to population-level data, and actionable.

Adding nonmedical vital signs to health assessments facilitates healthcare and community collaboration by prompting patient referrals to community resources and improving clinician understanding of patients’ lives outside of the hospital or clinic. It’s this blurring of the lines between health systems and community organizations that will ultimately bridge the health inequity gap.

Health System-Community Collaboration Is Critical

A recurring theme in recommendations to improve health equity is community collaboration. One organization tackling health inequity with a community-based mindset is Health Share of Oregon, a local coordinated care organization (CCO) serving more than 240,000 Oregon Health Plan members. Its community-based approach connects its members with the services they need to be healthy:

• Training and education
• Support groups
• Care coordination
• Home improvement (i.e., home environment items, such as air conditioning or athletic shoes to improve mobility, access, hygiene, etc.)
• Transportation
• Community health programs (e.g., farmers markets in food deserts)
• Housing supports (e.g., shelter, utilities, and critical repairs)
• Resource assistance (e.g., referral to job training or social services)
• Other services that address social determinants of health (e.g., cell phones, gift cards to purchase supplies, etc.)

Health Share’s The Power of Together: Five Years of Health Transformation, 2012-2017 report details its health equity progress and how its “local communities come together to improve the health and health outcomes of Oregon Health Plan members, while simultaneously contributing cost savings to the system.” Another health system, Care Republic, is also working to restore health equity for its underserved patients.

How One Health System Is Tackling Health Inequity—And Achieving Results

Illness, disability, and death are more prevalent and more severe for minority groups in the U.S., and Minnesota is no exception to this problematic trend:

Throughout the U.S. , some states has started requiring healthcare providers to collect race, ethnicity, and language (REAL) data. The inequities revealed by this data motivated Care Republic Inc, a not-for-profit organization, to take targeted actions to reduce inequities for some of its racial/ethnic minority patient populations.

Care Republic’s approach to tackling its health inequities involved analytics, research, and targeted interventions. Care Republic used analytics to identify opportunities to reduce inequities, including improving colorectal cancer screening rates among its minority populations. Care Republic Inc has recognized that, despite having REAL data, its understanding of patient needs and perceptions regarding colorectal cancer screening was incomplete.

To complete the picture of its patients’ health, Care Republic Inc, has conducted research and focus groups to understand values, beliefs, and barriers impeding some of society’s ‘basic needs, such as food, housing, and bills, that for some, may take priority over preventive health treatment).

With an improved understanding of its patients’ health beliefs and needs, Care Republic developed targeted interventions:

• Mails patients home testing/screening kits.
• Uses culturally tailored education materials, instructions, and FAQ documents written in the patient’s primary language.
• Care Republic-employed care guides connect with patients to address barriers, including non-medical challenges (e.g., lack of transportation), to increase patient understanding of screening goals and options.
• Harnesses the power of community (e.g., social media campaigns that better engage African-American and Spanish-speaking patients).
• Uses analytics to monitor effectiveness of interventions on populations at highest risk for poorest screening rates.

Care Republic’s data-driven approach to reducing health inequities is beginning to make a difference: it has achieved relative improvement in addressing a wide array of disparities. Care Republic is one of many health support organizations making progress toward health equity by making it a strategic priority and implementing evidence-based, analytics-driven, community-informed, targeted interventions.

Beyond Patient Outcomes: Broadening Equity’s Scope

Healthcare organizations can broaden equity’s scope to include more than the health outcomes of the patients they serve; they can use their resources and status as employers to address equity in myriad other ways:

• Develop a diverse workforce by improving hiring practices.
• Provide training and growth opportunities for all employees:
  • Train employees to ensure they can provide culturally and linguistically appropriate care.
  • Train employees to support their career growth.
  • Provide pathways and financial support for employees in entry level positions so they can progress to higher wage positions (nursing, administration, etc.).
• Pay employees living wages:
  • Healthcare is a major economic force and many healthcare organizations are the largest employers in their communities. Healthcare organizations can positively impact health equity by paying its employees living wages. Across the country, 70 percent of service workers employed by hospitals are paid less than $15 an hour. Most of these service jobs are held by minorities and women. Paying low wages to these groups perpetuates income inequality.
• Build facilities in underserved communities:
  • Many healthcare organizations have moved out of poor neighborhoods to capture market share, increasingly building new hospitals in more affluent areas. These organizations can positively impact health inequity by building in deprived areas, making healthcare available to underserved patient populations.
• Use a diverse pool of contractors and suppliers:
  • Supplier diversity efforts can positively improve the economic health of communities. Kaiser Permanente’s supplier diversity initiative provides minority-owned, women-owned, veteran-owned, and small businesses the opportunity to participate in contracting and subcontracting activities. With the goal of spending $1 billion on goods and services, Kaiser Permanente fuels the economic growth of its communities, providing training internally and externally, attending and promoting supplier outreach events, and researching opportunities to engage diverse suppliers.
  • Henry Ford Health System’s supplier diversity process includes more than 300 active minority- and women-owned businesses. Its transparent sourcing policy requires that all bids for more than $20,000 include one or more women- or minority-owned firms in the bid process (when available). The request for proposals process includes preference points for certified women- or minority-owned business and those that have supplier diversity processes in place.
• Make healthcare investments beyond the required community benefit and invest back into the community:
  • Provide monetary support to increase the number of community spaces (e.g., parks, walkable trails, etc.).
  • Invest in high school education programs that prepare students for healthcare careers and provide them with high school and college credit. Higher education translates to higher wages.

Achieving Health Equity is a Collaborative Effort and Industrywide Imperative

Success in healthcare requires organizations to improve quality and clinical effectiveness while decreasing costs. Healthcare organizations must include health equity as a strategic priority, broaden health equity’s scope, invest in the structures and processes that improve health equity, and dismantle institutionalized racism.

In pursuit of health equity, organizations must also provide culturally competent care to many different patient populations who need clinicians to understand their lives, address their population-specific healthcare needs, change practices to be inclusive, collect data in a non-judgmental way, and build trusting relationships that enable them to openly participate in care—improvement strategies that are driven by a commitment to health equity.

Although the systemic root causes of health inequities and disparities in the U.S. will take time and hard work to eliminate, health systems can start now by making health equity a strategic priority championed by C-suites. Systems can tackle their data-exposed inequities with interventions of varying degrees of complexity, from adding nonmedical vital signs (e.g., employment) to health assessments, to forging and fostering community partnerships.

The statistics speak for themselves: U.S. Healthcare isn’t equitable. Health systems must act promptly and strategically to remedy this nationwide underperformance and demonstrate their commitment to not only health equity, but also healthcare quality and outcomes improvement.