The Case for Health Equity: A Framework for the OCMH Medical Expert Panel

Presentation by Deena J. Chisolm, PhD

Brief by Jude Luke, Center for Closing the Health Gap

Healthcare disparity is an issue that has been prevalent within distinct communities for
many years now. ‘Disparity’ has become a buzzword of sorts for highlighting some of the key
social, economic, and environmental differences that exist between neighborhoods that leads to
variation in health outcomes. However, one scope of healthcare that has not been adequately
viewed is the concept of health equity. In this brief, a distinction between disparity and equity
will be made and the claims supporting an ‘equity approach’ to health care will be stated

In review, health disparity is defined as the differences in health outcomes amongst

varying populations that are often attributed to social determinants of health. These determinants
include but are not limited to disadvantages in areas of society, economy, and environment. A
related term, healthcare disparities, refers to institutional differences in access to healthcare
facilities and services. Health/Healthcare disparity is an important issue because of the broad
range of often marginalized populations that it affects. These populations include: racial/ethnic
minorities, low-income groups, LGBTQ+ populations, rural populations, cultural/language
minorities, and the special-needs community.

Disparity is an important topic because it highlights the pillars upon which unfair
differences often rely upon. However, when it comes to attaining equal health outcomes for all
people, it is important that we rather focus on the more holistic approach of health equity.
Health equity is defined by Health People 2020 as the “attainment of the highest level of health
for all people”. The attainment of health equity is dependent on the elimination of
health/healthcare disparities, but it also accounts for a few other factors. Among the factors
equity is dependent on are the belief that all individuals are equal, a focused effort to address
societal inequalities, and a drive to address historical/contemporary injustices that often
disproportionately affect populations affected by disparity.

When the lens through which healthcare is viewed shifts from an approach regarding
disparity to one regarding equity, individuals are better equipped to address inequities at the root-
level. As a result, issues in healthcare are able to have more thorough, long-reaching resolutions
that cause meaningful change in a community. When the lens of healthcare shifts, everyone,
regardless of race, social status, or culture, is provided the equal, fair opportunity to live a long,
healthy life free from many obstacles. However, in order to attain equity, a distinction needs to
be made between equality and equity. At birth, some populations of individuals are inherently
privileged with opportunities and access in a manner that other populations cannot match. This
inherent advantage creates a certain level on inequality that creates an immediate sense of
disadvantage in marginalized populations. An analogy for this is to think about three sisters, one
tall, one of medium height, and one short. As these three sisters reach their hand up to pick an
apple off a tree, the tallest sister has an inherent advantage that allows her to reach plenty of
apples. The middle sister may be able to reach the lowest apple, while the short sister cannot
reach any apples. Equality would dictate that each sister be given one box to stand upon. While
the tall and middle sister will be able to reach a few apples, the short sister may still not be able
to reach any apples. Equity on the other hand, would dictate that the boxes be distributed in a
manner that lets all three sisters reach their hand to the same height. Through equity, all three
sisters are happily able to reach the same number of apples. Through equality, only the sisters
who had some inherent advantage in height are able to reach the apples and the short sister
cannot.

Health equity certainly seems like the rational approach to healthcare, and this claim is
substantiated by data as disparity continues to grow. According to the Health Policy Institute
of Ohio, when looking at the top ten healthcare metrics with the largest level of
disparity/inequality in 2017, issues like second-hand smoke, childhood poverty, adverse
childhood experiences, and adult depression continue to be major issues. The impact surrounding
the elimination of disparity in these metrics is estimated to affect hundreds of thousands of Ohio
children and adults. The need to further pursue health equity is substantiated through the primary
drivers of population health, like social/economic factors and health behavior, which intertwine
so closely with disparity and injustice.

Further studies on health care access and quality disparity by the Agency for Healthcare
Research and Quality suggest that the differences between groups is only getting worse. Over
60% of poor individuals and black individuals reported a worse quality of care when compared
with wealthy and white populations, respectively. Similar trends were observed in poor/minority
groups when comparing access to care with wealthy/white populations. While a few disparities
were getting smaller, most were not changing or getting worse. An example of a disparity that
has worsened is the rate of breast cancer diagnosis in an advanced stage in women over the age
of 40. On the flip side, an example of a disparity that has been eliminated is the number of
children between the ages of 19-35 months, who received at least 1 dose of measles-mumps-
rubella vaccine. Unfortunately however, more often than not, minority groups are often
devastatingly affected by disparity, and these trends persist today in issues like hospital
admission for diabetes, and access to care in emergency situations as a result of insurance
conditions.

Unfortunately, these clinical metrics do not even begin to account for the hidden costs of
disparity, both economic and emotional, that take a toll on marginalized populations. Among
these are the cost of transportation, stress due to cultural biases, frequent hospital visits due to the
increased likelihood of living in a smoking household near the highway, and other social
determinants.

In truth, the road to achieve health equity is not one that can be paved by one outsider
alone. Change begins at the community level with the alleviation of social/environmental stress.
It continues through [self] identification of social factors and stressors that affect individuals and
families and addressing those issues with comprehensive solutions. These two steps are coupled
together to finally improve healthcare access and delivery with a goal to reduce healthcare
disparity. Most important through this entire process is the belief that genuine, sustainable
change that has deep implications in a community comes from population empowerment and
advocacy. By lending power and support to disadvantaged communities, we can take joy in the
equity they are able to attain and the improvements in healthcare they are able to achieve.