Promoting Health Equity

IT’S A BUZZWORD that shows up everywhere in medicine these days: health equity, a somewhat ambiguous concept that is transforming the healthcare industry from the inside out. Health equity task forces are cropping up everywhere, advocating for equal outcomes and resources to be funneled to policies and procedures that promise to achieve them. Promoting health equity is even part of the Joint Commission’s national patient safety goals for 2024.¹ But what exactly is health equity, and how does it affect your practice? 

What Is Equity? 

A simple Internet search for “health equity” yields about 195 million hits, and yet the meaning of “equity” is easily confused with the meaning of “equality.” The two certainly overlap: Equality is the state of being the same in quality, nature or status for each member of a group, class or society; equity is justice according to natural law or right, specifically freedom from bias or favoritism.^2,3 

While equality refers to the state of being equal (something one is by virtue of being human), equity seems to refer to the quality of being equal (or one’s experience of equality). Health equality means treating patients in the same way; health equity means treating patients according to their needs. In other words, health equality seeks to treat all people the same regardless of demographics or background, while health equity seeks to treat people differently based on those exact premises. 

A Question of Fairness 

Equality is a good starting point in healthcare: All people, by virtue of their humanity, have a natural right to seek and receive medical care when they need it. But not every person needs the same thing or has the same resources to seek and receive medical attention when they need it. That’s where health equity comes in. 

The World Health Organization (WHO) describes “health equity” as a state in which everyone can attain their full potential for health and well-being regardless of who they are, where they come from, what they believe, etc.⁴ The Centers for Disease Control and Prevention says health equity is achieved “when all people have the opportunity to attain their full health potential.”⁵ Health equity aims to distribute resources according to need in an effort to make outcomes more fair. 

Traditionally, the idea of health equity recognizes that some people need more help than others do, and it is right and just to administer help where it is needed without favoritism or bias. On the other hand, an evolving, progressive idea of health equity argues that the healthcare system is inherently biased against some minority groups and asserts that things such as race, gender, sexual preference, age, ability and myriad other demographic details directly affect how equitably patients are treated. It ties health equity to diversity and inclusion, which inevitably ends up conferring favoritism to some populations — which is an inversion of true equity. In trying to eliminate bias or favoritism, this view promotes it in reverse. 

Health disparities — health differences linked to demographic differences — are real and they usually aren’t fair, but finding the best way to make them more so continues to be a problem, especially when trying to find common ground between the two competing ideologies. According to David A. Kindig, PhD, an emeritus professor of population health sciences and emeritus vice-chancellor for Health Sciences at the University of Wisconsin- Madison’s School of Medicine, fairness seems to be the shared ideal at the root of health equity, but finding the means of arriving at the elusive end is a challenge. 

“One major ideological difference in population health policy is the role of individual responsibility in producing and maintaining health. Although each of us must take personal responsibility for many of our health choices, we also know that making healthy choices is much harder for people with less education and/or fewer economic or social resources,” Dr. Kindig explains.⁶ “Many public and population health experts tend to approach this issue of common ground through a lens of social justice and principles of fairness. But many of our unhealthier communities are in more politically conservative areas of the nation, whose inhabitants have different assumptions about how social programs and population health have affected local, state and national policy for more than a century.”⁶ 

Opportunity vs. Outcome 

The traditional view of equity seeks equal opportunity. The question isn’t whether or not social determinants of health — the conditions in the environments where people are born, live, learn, work, play, worship and age — affect how easily people can access healthcare or pursue and maintain a healthy lifestyle.⁷ We know these things do indeed affect population health. The question is whether or not all people have the opportunity to overcome their own unique set of obstacles. Whether people utilize the opportunities available is a matter of personal choice. 

A more progressive view of equity seeks equal outcomes, and whether or not some populations achieve them is directly connected to social determinants of health and the discrimination and bias these populations face. According to WHO, “People’s living conditions are often made worse by discrimination, stereotyping and prejudice based on sex, gender, age, race, ethnicity or disability, among other factors.” To address this, WHO says “the right mix of government policies” ought to be put in place.⁴ However, this view often creates division by emphasizing differences while also taking away individuals’ control of their own health.⁶ It assumes some groups are unable to make healthcare decisions for themselves and gives bureaucrats the power to make choices for everyone. According to Dr. Kindig, that’s a problem, as many of the people whose social determinants of health that lead to health disparities, and ultimately health inequities, still value personal responsibility and decision-making.⁶ 

Could Agency Be the Answer? 

In a 2022 article discussing fairness in healthcare, Daniel H. Johnson Jr., MD, FACR, radiologist and former visiting fellow in health policy at The Heritage Foundation, and Robert E. Moffit, PhD, senior research fellow of the Center for Health and Welfare Policy, posited that the progressive idea of health equity is actually regressive. “This approach is problematic. It creates racial division. It also conflicts with the overarching goal of medicine, which is to provide the appropriate care in the appropriate setting at the appropriate time when a patient presents with illness or injury, with emphasis on preventing illness or injury whenever possible.”8 Dr. Johnson and Dr. Moffit argue that the population at large would be well-served by a patient-centered approach to medicine, one that gives patients agency and seeks to achieve true fairness by creating unity of purpose among healthcare providers and patients alike. 

In patient-centered care, a patient’s specific health needs and desired health outcomes are the driving force behind all healthcare decisions and quality measurements, according to an article in the New England Journal of Medicine Catalyst. “The main goal and benefit of patient-centered care is to improve individual health outcomes, not just population health outcomes, although population outcomes may also improve.”⁹ Patient-centered care emphasizes agency for single patients and entire populations: It assumes people are able to think for themselves and take action as they so choose. Ultimately, personal agency gives people the opportunity, tools and power to chart their own course in healthcare. 

Serve Individuals, Not Ideologies 

At its best, health equity aims to achieve equal opportunity for fair treatment and the pursuit of optimal health outcomes for everyone regardless of who they are or where they come from. It’s a high, hard calling. But focusing on patients — what they need and what health outcomes they want — could very well evade divisive ideology. People come from all sorts of backgrounds; life circumstances and stories vary from person to person; some populations need more help than others; and many people can’t easily change their situation. As Dr. Johnson and Dr. Moffit ask, “Why not just agree to concentrate on delivering the highest level of medical care to each patient, regardless of racial, ethnic or other characteristics?”⁸ True health equity that is right and just puts processes in place that make sure everyone gets the care they need regardless of who they are or where they come from.