The Long Road to Health Equity

Today, healthcare institutions acknowledge forces like structural racism as drivers of negative health outcomes—but effectively addressing racism inside of those institutions still has a long way to go.

Last month, health policymakers, funders, and executives gathered at the Urban Institute to discuss the 20-year anniversary of the report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Published in 2003 by the National Academies Press, the document stood out as one of the first official statements recognizing healthcare inequities in BIPOC communities.

Two decades later, attendees asked: Are we making progress toward addressing those inequities? What policies are further perpetuating inequities? And what new strategies are needed to ensure communities can hold decision makers accountable for health equity?

Uneven Progress in Addressing Health Inequity

During event keynotes, health funders echoed the need to tackle the past in order to move forward. When the report was published, it was relatively rare to explicitly name structural and systemic injustices as a cause of health inequities.

“We recognize that [institutions] shy away from centering racism [in discussions], and when we do that, we will not succeed in truly achieving a Culture of Health,” explained Rich Besser, President and CEO of the Robert Wood Johnson Foundation.

Joe Betancourt, President of the Commonwealth Fund, echoed this sentiment as he described the field’s evolution across five phases over the past 20 years:

• 2003–2010: Early adopters utilized the report to hold conversations on the presence of healthcare inequities, as well as explore how measurements could help expose them.
• 2010–2016: The Affordable Care Act dominated national dialogues, centering the role of healthcare access as a driver of inequities, but distracting from other structural barriers such as racism.
• 2016–2020: Crucial recognition of the impact of social determinants on health outcomes—such as housing or food insecurity—increased. However, healthcare institutions pointed to these outside factors as a rationale for stepping back from examining their own institutional roles in perpetuating inequities.
• 2020–2022: The COVID-19 pandemic and national reckoning on race drove greater institutional introspection and kicked off a new wave of dedication to health equity.

Given this renewed commitment, Betancourt pointed out that there is a unique opportunity to ensure institutions translate their statements on addressing health inequities into action.

As several speakers asserted throughout the event, health outcomes for marginalized groups have not seen significant improvement over the past 20 years. However, achieving those improvements is possible as healthcare institutions go from viewing health equity as a “nice to have” to making it an integral part of their organizational mandates.

Policies Perpetuating Health Inequity 

Presenters agreed that institutional efforts to address equity are not enough: it is also necessary to deploy advocacy, litigation, and regulatory change.

Another feature of the current moment highlighted by several speakers was the use of policies and laws tools to hinder health equity efforts. Tom Saenz, President and General Counsel of the Mexican American Legal Defense and Educational Fund, pointed out that this takes place even in contexts where policies are “colorblind.” Proxies like language or assumed immigration status, for example, are often used to continue healthcare discrimination against the Latinx community.

Margaret Moss, Director of the First Nations House of Learning, pointed to the country’s official policies of forced assimilation, genocide, and sterilization for Native peoples over centuries. “We are highly regulated,” she shared. “Our life expectancy… is the worst in the Western hemisphere. But do you see this on CNN, Fox, MSNBC, anywhere?”

Additional practices include state policies that seek to ban equity and inclusion language or that codify discrimination against LGBTQ+, immigrant, and other marginalized populations. Presenters agreed that institutional efforts to address equity are not enough: it is also necessary to deploy advocacy, litigation, and regulatory change.

New Strategies for Accountability

“In order to have a strong social contract, you have to have social solidarity between groups,” Tony Iton, Senior Vice President for Healthy Communities at The California Endowment, said during a session on a new social contract for health. “You have to be able to see other people’s needs as your needs.” In California, Iton explained, there are efforts underway to build power to shape state policy.

For example, one of the projects of the Endowment’s Building Healthy Communities initiative—a 10-year effort to support 14 low-income communities in their power-building efforts—started as a resident-led organizing effort to secure park and green space availability in Fresno. Over nearly a decade of intensive political advocacy, story gathering, and community mobilization, organizers secured funding for a comprehensive parks plan. In 2018, city agencies sought to block a small sales tax increase that would support the park’s effort. Residents organized a lawsuit that went to the California Supreme Court. The court sided with the residents; the tax revenue will raise more than $2 billion for parks in Fresno over the next 30 years.

Oxiris Barbot, President and CEO of the United Hospital Fund, echoed the concept of building public power to shift our social contract. In a closing keynote, she noted the importance of “voting as a social determinant of health,” as a way for the public to hold institutions and legislators accountable for strategies that actually address health inequities.

“The US didn’t reimagine the way it provides care to people,” Barbot noted about the country’s missed opportunity to overhaul healthcare as a result of the pandemic. Voting, however, has the power to enact change through collective societal decisions. Building civic power, particularly in communities of color, can ensure that both policymakers and institutional leaders are answering to those they claim to serve.

Twenty years after the publication of Unequal Treatment, as illuminated by this anniversary event, the path to addressing health inequities remains long. But grappling with history, utilizing diverse policy change levers, and exploring a new social contract on health could be effective catalysts. Communities and funders who deploy these tools can hold decision makers accountable and ensure that the next 20 years yield significantly greater improvements in health equity.