A person’s understanding of health equity and how to achieve it can differ based on their identity and relationship to the health ecosystem. A policymaker might think of how to amend or propose new laws to promote access to health services for all people, while a public health professional might be concerned about how to ensure programs and systems don’t advantage the health of one group over that of another group. Providers may emphasize practicing cultural humility in their interactions with patients, while individuals are more often concerned about what behaviors they should practice and which providers they should use to enhance their level of well-being.
As public health researchers, we’re often asked to conduct work in service of equity. To do so, it helps to have a shared understanding of what health equity means. This is challenging, given the variety of lenses just mentioned; in addition, the pursuit of health equity is further complicated by historical and societal conditions that contribute to differences in individual and community health. These include the history of racism in health and social systems, trauma caused by negative interactions with health care providers, and systematic marginalization of disinvested communities by more privileged ones.
It is helpful to think about the advancing of equity as a process of achieving change along a clear pathway that requires focus at multiple levels. We visualize this pathway through a framework of key concepts represented by a tree, beginning at its roots (root causes) and ending with it bearing fruit (health and well-being). Each part of the tree presents different opportunities to influence health and well-being; we can conceptualize our health equity work along the change pathway based on how it impacts various drivers of health. For example, our work may reduce disparities in the quality and use of services or address social and structural determinants of health.
Levels at which we can work to advance health equity
Structural determinants of health refer to social and economic policies that determine whether and how power and resources are distributed. Though they are often invisible, they are the most fundamental and influential factors shaping the circumstances and conditions in which people live. We therefore visualize them as the roots of our tree. Changing these circumstances and conditions means dismantling policies and systems that favor one group over another and reallocating social resources to those who are historically disadvantaged. Practically, this means applying an equity lens to understand if policies were originally designed to and continue to distribute power and resources unequally to specific groups. If this is the case, those policies and systems must be changed to redistribute power and resources. It is also critical to acknowledge and restitute impacted communities for historical harm.
Structural determinant: Roots of Medicaid policy
Racism shaped welfare policy from its inception in 1935. Many Black Americans who were discriminated against and denied entrance into the formal workforce worked “side gigs” or were paid “off the books,” making them ineligible for unemployment insurance. This policy perpetuated inequities for decades that still exist; Black and Brown communities are still more often excluded from unemployment insurance due to the type of employment available to them. Until the welfare reform efforts of the late 90s, Medicaid eligibility was routinely linked to welfare eligibility; the delinking of eligibility for these programs in 1996 generally served to exacerbate inequities by enabling some states to avoid expanding Medicaid eligibility to communities at the margins of wealth.
Social determinants of health are created by the root policies and systems that determine the circumstances under which people are born, grow, live, age, and die. These social determinants of health represent the trunk and branches of the tree from which we grow. Throughout the course of life, these circumstances affect an individual’s level of access to health care, nutrition, safe shelter, education, emotional support, and other needed resources.
Social determinants of health: Social networks determining heart health
Having access to health care delivered in a hospital or doctor’s office only plays a small role in one’s level of health. In fact, social and economic, behavioral, and environmental factors account for at least 80 percent of any health outcome. A study demonstrated that people living in socioeconomically disadvantaged neighborhoods were two to three times more likely to develop heart disease, regardless of income, education, and occupation. Many other studies since that time have documented the influence of social determinants of health on well-being.
The quality and level of use of health services, assuming they are available, will further influence the ability of individuals to achieve and maintain optimal health. People that can access the larger and well-nourished leaves of the social system, represented by higher quality services—services that are safe, effective, patient-centered, timely, efficient, and consistent—are more likely to reach and maintain optimal health. Ideally, all leaves would be equally nourished and supportive, having received sufficient nutrition from the roots (structural determinants of health) through the trunk and branches (social determinants of health).
Quality and use of services: Disparities in the quality of the US health system
Compared with other developed nations, the U.S. ranks high in measures of the availability of preventive, safe, coordinated, and patient-centered care. However, high quality care is not universally provided to everyone. In a 2016 article, Ashish Jha says, “If you’re having a heart attack, there are very standardized protocols. If you’re African-American, you’re less likely to get those, even with the same health insurance, even with the same presentation.” The article also estimates that low quality care leads to 260 premature deaths among Black people daily, translating to 94,990 premature deaths annually. This means that about 27 percent of all deaths in the Black population might have been prevented with better quality care.
The fruit borne by our tree represent individuals’ health and well-being. These factors increase in magnitude as they are nourished by policies, systems, and quality services. If policies and systems are equitable and of high quality, then optimal health and well-being—and thus health equity—is achieved. In this state, policies and systems ensure the equitable distribution of power and resources, and people live in safe neighborhoods with ample access to high quality health and social services. All people can meet their full health potential regardless of visible and invisible characteristics, such as race, gender, age, religion, political beliefs, and any other economic or socially constructed identity.
The tree framework helps illuminate the pathway to achieving health equity. It highlights and helps us assess the multi-faceted approaches and interventions that can help us achieve that goal. And it helps us to better visualize and understand the intertwined roles of policy-related, systemic, community, and individual factors in driving health and wellness. Too often, decisionmakers design policies and programs to address health equity at just one level and fail to focus on the root causes or drivers of inequity. For example, a focus on measuring and assessing quality of care in health systems alone won’t substantively move the needle in achieving health equity. Actions to strengthen health system operations and provider practices must be complemented by policy that addresses issues such as food insecurity and the availability of affordable, safe housing and educational opportunities; such policy helps create the conditions in which people are more likely to engage in healthy behaviors and take steps to optimize their health. To advance health equity, we must acknowledge the legacy of health inequity and understand the mechanisms by which that inequity was created. In so doing, we can ensure that we avoid the mistakes of the past and gain insight into the level of intervention and types of innovations necessary to achieve a more equitable future.