Health equity: The finish line

Repairing multiple layers within systems is fundamental in changing policy and involves advocacy at the individual level and at the professional society level.

Health equity is the ultimate destination for the medical profession. The World Health Organization defines it as “the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality.”

Although racial and ethnic groups are most commonly highlighted in the U.S. when referring to health equity, health equity includes other demographics with a wide range of intersectionality, such as economic disadvantage, gender, sexual orientation, mobility or self-care disabilities, age, immigration status, and rural location, to name a few.

In the past three years, health equity has been an elevated priority in health care, as the global COVID-19 pandemic exposed the deficiencies of the U.S. health care system. However, health equity is not a new concept. The first U.S. report on health disparities by the Secretary Task Force (known as the Heckler Report) was published in 1985.

Obviously, this preceded the COVID-19 pandemic by nearly four decades, but no substantial changes have been made in advancing or transforming policy since then. There is recent opinion that health equity should be added as a fifth component of health care improvement and termed the quintuple aim.

Racism has contributed to social determinants of health, which subsequently widened the disparities gap leading to worse outcomes among historically disadvantaged populations. Most social determinants are rooted in political and economic policy that goes beyond the examination room. Yet, it can be very difficult for physicians to provide the most optimal care for a patient's health when structural systems and resources are not designed to support physicians in their work beyond the clinical setting. Because this is such a structural problem, repairing multiple layers within systems is fundamental in changing policy and involves advocacy at the individual level and at the professional society level.

This is one reason why ACP's Health and Public Policy Committee took the lead to compose a compendium of papers published in 2021. “A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care” was published in Annals of Internal Medicine, and other position papers discussed disparities as they relate to education and the physician workforce, law enforcement and criminal justice, and health care of persons and populations at highest risk.

As the authors of the comprehensive policy framework so eloquently stated, “If we accept that no one element of society is solely responsible for creating disparities, then any strategy to eliminate disparities that addresses any element independently of the others will fail to accomplish its goal.”

Without robust policy on issues that affect health outcomes, the College cannot adequately advocate on behalf of our patients, given that most health inequities are rooted in governmental systems, legislation, and public policy. ACP policies are rigorously composed of substantial evidence, which allows us to confidently speak out on behalf of our patients regarding the relationship between these social determinants and health outcomes. I am constantly reminded of the mantra that “health is not just the absence of illness.”

Although health equity is broad and has multiple layers outside of the health care system, there are layers within the health care system that can be improved. First, we must improve the physician workforce so that it is representative of the population that it serves. There is evidence to indicate that racial and ethnic concordance improves the patient experience, adherence, and clinical outcomes. In addition, we need to deviate from aspiring to be culturally competent to a concept of cultural humility, which is a lifelong commitment and process, rather than education and programming that have a designated endpoint. Finally, improving the medical education experience to one that is not race-based, but more race-conscious, will ultimately lead to a reduction in health care disparities and further close the equity gap.

There have been numerous examples to show the positive benefits of creative societal programming to address social determinants of health across the United States, which are clearly outlined in the Robert Wood Johnson Foundation's report “What Is Health Equity?”, published in May 2017.

However, as a society we have lacked the ability to scale these best practices more broadly across the country to positively impact more communities. In addition to these intentional community best practices, there remains much that needs to be done to further advance health equity: endorsing equity measurement, financially investing resources for those with greater need, incentivizing programs for showing progress in advancing equity, improving the public health infrastructure to better connect community resources with health care access points, changing the financial paradigm to a value-based system with prospective payments for practice transformation designated for a community's local needs, mobilizing health care to disinvested communities, and improving voting policies to eliminate barriers so citizens can have a voice in policy that will impact their community and health.

In order to truly advance health equity, effective change must occur at various levels from federal, state, and local governments: health insurance companies, health care systems, medical education institutions, the pharmaceutical industry, and even at the individual level. Given that this is my final column as ACP's President, I would like to declare a call to action. At the individual level, we must challenge ourselves and impart our humanity to close the empathy gap in manifesting a better understanding of the social factors that affect our patients' health. Once we understand, we each need to participate, navigate, mitigate, and ultimately eliminate the inequities that affect clinical outcomes of patients that we have committed to serve. Health equity is the ultimate destination, but commitment, investment, and a team approach are required to achieve this goal. Only then, when we are all working toward this common desire, can we cross the finish line.