essay about health equity

Health Equity Essay Example

Issues concerning health equity and accessibility continue to plague healthcare as we currently perceive it. Racial disparities and unequal access to healthcare are recurrent problems that exist in population health. To understand the current state of health disparities in the United States, it is prudent to recognize and acknowledge some of the root causes. Miceli (2020) defines health equity as fair opportunity for everyone to be as healthy as possible. This refers to fair opportunity for everyone in a community to receive the same health benefits, irrespective of factors such as socioeconomic status, education, ethnicity, race, identity, sexuality, gender, disability status, or other various factors. Health disparities take on many forms in the United States, and they involve an array of populations and groups. Racism is another recurrent issue that results in disadvantages for many minority groups, placing those communities at greater risk for poor health outcomes.

Achieving health equity means that every person has the fair opportunity to attain his/her full health potential without being disadvantaged because of social position or other socially determined circumstances (Ndugga & Artiga, 2021). Certain populations are socially disadvantaged, resulting in vast differences in health insurance coverage, access to care, and quality of care. Examples of these groups include minorities, low-income individuals and families, young single mothers, children/adolescents, people with special needs, the disabled, veterans, migrant workers, immigrants, and many others. Health inequity also extends beyond social factors such that there are observable differences in health care coverage and accessibility for individuals based on geographic regions, such as rural and inner-city areas. It is also important to recognize that these groups are not mutually exclusive, and they often intersect in various meaningful ways.

The introduction of the COVID-19 pandemic also launched a distinct set of challenges for many populations and subgroups. Prior to the pandemic, minority groups and many underserved populations were already facing deep-rooted health disparities. Despite the acknowledgement of disparities and documentation of overall improvements in population health, many disparities persist, and in some cases, widened the gap between equity and disparity (Ndugga & Artiga, 2021). Data before the COVID-19 pandemic suggested that people of color fared worse compared to their White counterparts, and people of low-income had worse health status than those with higher income (Ndugga & Artiga, 2021). The LGBTQ+ community also endured health care challenges linked to societal stigma and fear of seeking health care due to discrimination. As stated before, the challenges and disadvantages experienced by these populations or population subgroups often overlap, which may lead to greater health disparities. 

Identifying the barriers and facilitators for the issues surrounding health disparity is important to the recognition of the root causes, and it also helps realize the potential solutions as we move forward. According to Arespacochaga and Robinson (2020), the structural barriers to health equity among many communities are due to limited access to housing, food, and transportation. Inequities in education, employment, workforce diversity, and mistrust of the health care system further compound these disparities. Homelessness is one of the most prevalent barriers for veterans which contributes heavily to chronic conditions, poor veteran health, and limited access to quality health care (National Academy of Sciences, Engineering and Medicine, 2017). Veterans also require specialty services such as psychotherapy for traumatic events. The suicide rates for veterans is also another issue and health inequity is only going to worsen that problem. For rural communities, limited timely access to a health care provider, under-resourced hospitals, lack of sufficient health care providers and limited transportation are all barriers to health equity and access to care. The availability of food relative to income is also another huge barrier for many individuals and families. The affordability of nutritious food also concerns the health of many populations. Low-income families rely on affordable subpar food options for survival, most of which are linked to chronic diseases such as obesity, heart disease, and cancer. These barriers are identified as some of the root causes of health disparities in the U.S. Luckily, there are also facilitators in place that minimize the widening capacity of the barriers in relation to the gap between health equity and disparity.

Many partnerships and programs currently exist that help address some of the aforementioned barriers. For instance, the Veterans Sustainable Agricultural Training Program (VSAT) helps veteran students transition into the civilian workforce and potentially influence their health. A partnership between the American Heart Association (AHA) Institute for Diversity and Health Equity (IFDHE) and Blue Cross and Blue Shield of Illinois (BCBSIL) was developed to help more people achieve their best possible health (Arespacochaga & Robinson, 2020). Through this grant program, participating hospitals will receive money awards to support programs that target health disparities within their communities. These programs target areas such as diabetes, breast cancer, rural communities’ access to health care, pediatric, and maternal health. My suggestions for improvement as we move forward in time include the establishment of more government driven programs to support hospitals and health care organizations in supporting their communities, more agricultural funding, employment programs and basic housing for the homeless, and reforming policies involving universal health care. Also, diversity and health equity should be a major focus in the Healthy People 2030 initiative. The overall goal of health equity pertains to everyone, and we need to invest more in our communities and health care organizations to promote greater health equity and equal access to quality health care.

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Health Equity: What It Means and Why It Matters

BY KATHY KATELLA February 2, 2021

The pandemic has been relentless for everyone, but it’s hitting some of us harder. For instance, there is the man whose grocery store job puts him at higher risk for exposure to COVID-19 ; if he gets the virus, his diabetes could lead to complications. Working at home is not an option for him, and his family depends on his income. A pregnant woman is missing her prenatal visits because going to the doctor means taking two buses to the clinic and bringing along her two other children. She is worried that would mean exposing the whole family to COVID-19—especially concerning since she lives with and cares for her elderly mother, who has dementia.

There are many stories like this that illustrate why health equity matters. When it comes to health, many factors affect how the odds are stacked. If you’ve noticed that the phrase “health equity” is in the news much more of late, you’re right. It’s because the events of last year—not only COVID-19, but also issues around systemic racism and social justice—have highlighted the fact that some people face more struggles in life due to their background, culture, race, financial status, type of employment, whether or not they live with a disability, or other distinguishing factors.

As the topic of health equity gains traction in national conversations, Yale School of Medicine is emerging as a leader in the area. Marcella Nunez-Smith, MD, MHS , associate professor of internal medicine, public health, and management at Yale, has been an advisor to President Biden since the campaign, and she was then tapped to co-chair the Biden-Harris Transition COVID-19 Advisory Board to ensure that the response to (and treatment for) COVID-19 is distributed equitably.

In December, it was announced that she will serve as a senior advisor in the Biden-Harris White House as the inaugural chair of a federal COVID-19 Health Equity Task Force. Already a national leader in the field, Dr. Nunez-Smith occupies multiple roles at Yale, including serving as director of the Center for Community Engagement and Health Equity, the inaugural associate dean for Health Equity Research, and founding director of the Equity Research and Innovation Center (ERIC) , which will be incorporated as a center within a newly formed trans-institutional Office for Health Equity Research that aligns resources and programs focused on health equity across Yale School of Medicine.

In addition to her professional work, Dr. Nunez-Smith has shared some of her personal experiences with health inequities. In the U.S. Virgin Islands, where she grew up, “people too often died too young from preventable conditions,” she says. “My own father had his first stroke in his 40s and was left paralyzed. I learned there was a term for what we were: an underserved community, marginalized by place and by race.”

What is health equity?

As a term, health equity is broad. According to the Centers for Disease Control and Prevention (CDC), as a society we’ll achieve health equity “when everyone has the opportunity to be as healthy as possible.” Focusing on the pandemic, the CDC notes that “longstanding systemic health and social inequities have put many racial and ethnic minority groups at increased risk of getting sick and dying.” Black and Latinx Americans, for example, are roughly four times more likely to be hospitalized with complications from COVID-19 than non-Hispanic white people. In response, the CDC calls for addressing the situation by making sure everyone can maintain and manage physical and mental health, which requires easy access to information, affordable testing, and medical and mental health care.

“Sometimes, when we aggregate data, we fail to realize that it's not uniformly distributed, that some parts of the country face even greater disparities in health outcomes for racial and ethnic minorities.” Yale infectious diseases specialist Onyema Ogbuagu, MBBCh

Health equity is a complex challenge, says Kristen Nwanyanwu, MD, MBA, MHS , a Yale Medicine ophthalmologist and a member of ERIC. “It’s bigger than a roster of things to check off a to-do list,” she says. “It’s a good development that conversations are happening in many different settings on this topic, as simply raising awareness is a key step toward serving the needs of people who have traditionally been underserved.”

Health equity versus health equality

Onyema Ogbuagu, MBBCh , an infectious diseases specialist who is leading Yale’s clinical studies around COVID-19, says there is an important distinction between “equality” and “equity.” “Imagine there's a high fence, and the goal is to look over the fence,” he says. “A tall adult can see easily, a shorter adult may need a boost, and a child will need to be lifted up to see over it.”

If given three blocks of equal height to stand on, the shorter adult would still need to stretch to see, and the child wouldn’t see at all—each needs a block of the appropriate size, he says. “So, equity means that people have to get what they need to achieve the same results. It’s less about the quantity of what to do and more about the end result in outcomes.”

Which groups face the greatest pandemic challenges?

Health equity issues have hit Black and Latinx communities especially hard in the pandemic. Data from the CDC shows that, in the U.S., people in these two groups who contract COVID-19 are roughly three times more likely to die from it than non-Hispanic white people. Asian Americans and Native Americans are at higher risk as well.

This statistic for Black and Latinx Americans may reflect the broad pattern across the country, but in some places it’s even worse. “In some pockets of the U.S., it's four times greater mortality than for their white counterparts and in other parts, it’s less than one,” Dr. Ogbuagu says. “Sometimes, when we aggregate data, we fail to realize that it's not uniformly distributed, that some parts of the country face even greater disparities in health outcomes for racial and ethnic minorities.”

How does ‘structural marginalization’ play out in real life?

A phrase like “structurally marginalized” (sometimes referred to as “underserved” or “disadvantaged” or "vulnerable populations") refers directly to the connection between social and economic factors (such as education, employment, and housing) and health. It’s well-documented that many people in structurally marginalized situations have underlying health conditions that are influenced by their socioeconomic status, and that these conditions put them at a higher risk for complications from a number of diseases, including COVID-19. This explains why, as Dr. Ogbuagu points out, the death rate for Black Americans is generally higher than whites for heart disease, stroke , cancer, asthma , influenza , pneumonia , diabetes , and HIV/AIDS; Puerto Ricans suffer disproportionately from asthma and HIV/AIDS; and Mexican Americans from diabetes.

Marcella Nunez-Smith, MD, will serve as a senior advisor in the Biden-Harris White House as the inaugural chair of a federal COVID-19 Health Equity Task Force. “People too often died too young from preventable conditions,” she says. “My own father had his first stroke in his 40s and was left paralyzed. I learned there was a term for what we were: an underserved community, marginalized by place and by race.”

These figures are influenced by factors that, at first, might seem unrelated to health and medicine but, in fact, are closely intertwined. In the case of COVID-19, Dr. Nwanyanwu notes that many people of color live together with several generations of family members; when you live in a crowded house, isolation is difficult. “We’re always telling people they need to quarantine and what that should look like,” she says. “But if you have a family in a one-bedroom apartment in a city as opposed to a five-bedroom house in a suburban town, that might not be possible. If someone in your house gets COVID-19, everyone else could get it, because there is no place to quarantine.”

Other factors fueling the discrepancies in health outcomes include racial discrimination, difficulty accessing health care, and gaps in education and income. Workers whose jobs can’t be performed at home—such as those who work in factories, nursing homes, and grocery stores—are far likelier to be exposed to COVID-19 and other infectious diseases.  

These issues affect health in more ways than one might guess, including—for example—vision. As an ophthalmologist, Dr. Nwanyanwu sees this play out in her practice. Diabetic retinopathy, for instance, is preventable if diagnosed and treated early, but it remains the leading cause of blindness in adults. Here in the U.S., this condition affects more than one-third of Black and Mexican Americans, because, says Dr. Nwanyanwu, “we aren’t screening some patients at the appropriate time.”

Even those with loved ones who have lost their sight because of the disease haven’t seen an ophthalmologist, she says. To figure out why, she enlisted a team to go into the community and ask questions. Housing, transportation, and challenging life circumstances turned out to be major factors. “Health care lives among a list of one’s priorities. If there are barriers to health care in someone’s life, it is going to be more difficult to practice preventive care, like getting an eye exam for diabetes,” says Dr. Nwanyanwu. “These issues, compounded by systemic racism, become insurmountable for some of our community members.”

Telehealth, which should make it easier to see a doctor, turns out to be another roadblock for some people. Many don’t have the technology to access telehealth—or knowledge about how to use it, Dr. Nwanyanwu says. “If they had the proper technology, they could stay home, which is probably better for their safety, but instead they have to come into the office.”

And others can’t afford to pay for the care they need. For example, Dr. Nwanyanwu has learned to make sure patients get their eye drops on the day of surgery so they will avoid developing eye irritation when they go home. Even though insurance pays the majority of the cost for the drops, there is still an out-of-pocket cost barrier, she says. “It’s the difference between eye drops being given to a patient on the day of surgery—with the costs bundled into the procedure—and the barriers that come with having to get to the pharmacy and pay the co-pay necessary to purchase the medication,” says Dr. Nwanyanwu.          

Fear and mistrust play a role

Mistrust of the medical establishment is well-earned among people of color, given the extensive legacy of unfair treatment and abuse documented in the U.S. An example that is often cited is the Tuskegee syphilis study , a 40-year experiment carried out in Macon County, Alabama, from 1932 to 1972. Public Health Service officials followed 600 Black men (399 with syphilis and 201 who did not have it at the time) throughout their lives without giving them an accurate diagnosis of their disease (or information about the real purpose of the study). They also withheld treatment, even though it became available. Instead of receiving penicillin, which was established as the treatment of choice for syphilis in 1945, participants were given placebos, including aspirin and mineral supplements. Many of the men developed severe health complications of syphilis and died, and a number of their wives and children contracted the disease.

Dr. Nwanyanwu says she has seen patients who avoid seeking care for diabetic retinopathy partly because of stories like this. “Fear is an emotion that can affect people in different ways. Some don’t want to come for an exam because they are afraid we would find something,” she says. “But in marginalized communities, it can be hard to parse the effects of years of racism from general fear. I’ve heard people say, ‘I don’t want to be a guinea pig.’ They aren’t wrong. We have to address the legacy of racism in research and prove to historically abused communities that we are doing a better job.” 

Still others have different reasons for their attitudes toward medical advice. Early on during the pandemic, the message was to avoid the emergency room, if possible, Dr. Nwanyanwu says. “I have a patient who had a really bad eye problem, but he waited because he didn’t want to go to the ER,” she says. “So, we’re looking at rules, and how rules are followed by different communities. For his health, it would have been better if he went to the emergency room."

How can we move things forward?

All these stories give some insight into what Dr. Nunez-Smith will be addressing on a national level with the health equity task force, the doctors say. Work she has done at Yale may provide some clues about how she will do that.

For instance, ERIC, the organization she heads at Yale, promotes population health and health equity through research, much of which has been funded through National Institutes of Health (NIH) research grants. “ERIC is the true North that is really trying to use science to move our population to be healthier,” says Dr. Nwanyanwu.

Dr. Ogbuagu says that participating in clinical research helps ensure the needs of all kinds of people are met. “We are dying more, we are being affected more, and if we don't get the care we need—if we don’t participate in either research or in the outcomes of research—we will never truly know or experience the impact these opportunities can have in our communities,” he says.

For example, a study  published in the Journal of General Internal Medicine and cited on the ERIC website highlights the importance of including marginalized populations in health-related data. According to the study, only 28 states and New York City reported on race and ethnicity-stratified COVID-19 death rates. “The availability of high-quality and comprehensive race and ethnicity data is necessary to address factors contributing to inequity in COVID-19 mortality,” wrote the study’s authors, who include Yale Medicine internist Cary Gross, MD , as well as Dr. Nunez-Smith. 

Meanwhile, Dr. Ogbuagu highlights the work of a Yale Center for Clinical Investigation program in New Haven called Cultural Ambassadors . The group partners with the community-based organization Junta for Progressive Action  and the  African Methodist Episcopal Zion (AME Zion) Church  to encourage people to enroll in clinical trials so that diverse groups will be represented. “We worked together for our COVID-19 vaccine trial,” he says. Cultural Ambassadors helped develop recruitment materials and messaging within the communities, and participated in research themselves. “It's been an effective model,” Dr. Ogbuagu says. “And it's not just about COVID-19 research. They’ve used this model for cancer and other forms of research. That's at least one way to do this.”

But there is much more be done, he adds. A priority is to reassure people that decades of efforts have been directed toward ensuring that situations like Tuskegee never happen again. Clinical trials are now heavily monitored, the research is safe, and the risks are minimized. Unfortunately, “even in the backdrop of movements like Black Lives Matter, people of color feel that if something bad happens to them, no one will care as much as they would for the person who is not of color,” he says, noting that the result is that they won’t participate in a trial. “We had to work extra hard to be able to achieve minority recruitment goals with regard to the Pfizer vaccine.” 

Similar challenges are emerging now that the COVID-19 vaccination program is underway. In early December, 60% of all American adults said they would definitely or probably get the vaccine when it becomes available, while only 42% of Black adults said they would do the same, according to the PEW Research Center. The government is examining how to support minority acceptance of the vaccine, with efforts such as a special ad campaign to encourage people of color to take the vaccine.

What do people need to know?

In addition to the work taking place in the government and community, individuals can also help shape change by advocating among their friends and family members. Participating in clinical research helps ensure the needs of all kinds of people are met. “We are dying more, we are being affected more, and if we don't get the care we need—if we don’t participate in either research or in the outcomes of research—we will never truly know or experience the impact these opportunities can have in our communities,” Dr. Ogbuagu says.

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• Achieving Health Equity

Achieving Health Equity in the United States

• Policy Statements and Advocacy
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• Proposed Policy Statements
• Date: Nov 13 2018
• Policy Number: 20189

Key Words: Health Equity, Health Disparities, Social Determinants of Health

Abstract Decades of surveillance and research in the United States have documented health disparities in morbidity and mortality, particularly among racial/ethnic minority groups and those of lower socioeconomic status. Moreover, it is estimated that from 2003 to 2006 the combined costs of health inequities and premature deaths in the United States totaled $1.24 trillion and that elimination of health disparities among racial/ethnic minorities would have reduced these costs, including direct medical care, by $229.4 billion. In response to health inequities, national initiatives have been undertaken such as Healthy People 2020 and the National Partnership for Action to End Health Disparities. Despite Healthy People goals and objectives over several decades and modest reductions in health disparities in the United States, there are still persistent and pervasive disparities. Thus, more intentional, comprehensive, system-oriented, and coordinated strategies should be employed to achieve health equity in the United States. The action items presented in this policy statement call on national, state, and local governments, as well as nonprofit and philanthropic organizations and individuals, to implement policies, practices, surveillance, and research that include a health equity lens and framework across all sectors of society such that everyone can live a long life in optimal health.

Relationship to Existing APHA Policy Statements The following are some relevant APHA policies that are more narrowly focused on individual social determinants of health and health disparities.

• APHA Policy Statement 20179: Reducing Income Inequality to Advance Health
• APHA Policy Statement 20178: Housing and Homelessness a Public Health Issue
• APHA Policy Statement 201710: Protecting Children’s Environmental Health: A Comprehensive Framework
• APHA Policy Statement 20173: Public Health and Early Childhood Education: Support for Universal Preschool in the United States
• APHA Policy Statement 20101: Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities 
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
• APHA Policy Statement 20165: Addressing Social Determinants to Ensure On-Time Graduation
• APHA Policy Statement 20167: Improving Health by Increasing the Minimum Wage
• APHA Policy Statement 20091: Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities
• APHA Policy Statement 20073: Environmental Injustices: Research and Action to Reduce Obesity Disparities
• APHA Policy Statement 200311: Opposition to Eliminating or Compromising the Collection of Racial and Ethnic Data by State and Local Public Institutions
• APHA Policy Statement 20017: Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health
• APHA Policy Statement 20005: Effective Interventions for Reducing Racial and Ethnic Disparities in Health 
• APHA Policy Statement 9612: Threats to Affirmative Action Are Threats to Health
• APHA Policy Statement 8325: Access of Minority Medical Colleges to Public Hospitals
• APHA Policy Statement 7424: Racism in the Health Care Delivery System
• APHA Policy Statement 20062: Reducing Racial/Ethnic and Socioeconomic Disparities in Preterm and Low Birthweight Births

Problem Statement A major public health problem in the United States is that a baby born today is expected to have a shorter life span and live in poorer health than a baby born in other high-income countries.[1] Likely explanations for babies in the United States experiencing a poorer quality of life and dying earlier are that, relative to other high-income, democratic countries, the United States lacks organized and coordinated health and social systems and does not invest as many of its resources in social services. These circumstances translate to limited access to primary care, a larger uninsured population, increases in certain health risk behaviors (drug abuse and firearm violence), a greater population in poverty, less quality education of children, and less investment in safety net social programs. Furthermore, an  outcome of these circumstances for U.S. babies during their life spans is that their health status varies by race/ethnicity; gender; income; education; cognitive, sensory, or physical disability; sexual orientation or gender identity; and place of residence (geography).[2–4]

There have been efforts at the community, state, and national levels to address these “unnatural” health differences by population and place across the United States. National initiatives have created measurable goals and objectives for the nation to monitor health outcomes and determinants of health. Healthy People, a science-based, 10-year health agenda, has measured national health promotion and disease prevention progress since 1979, and more recently is measuring not only health outcomes and risk behaviors but also the social determinants of health for the decade from 2010 to 2020.  Currently, plans are under way for measuring health outcomes and determinants for 2020 to 2030.[2–4] Eliminating health disparities and achieving health equity such that everyone has optimal health (well-being) remains a foundational principle that guides the development of Healthy People 2030.[4]  The purpose of Healthy People 2020 is to engage communities and every sector of society to act in improving health across the United States. The vision of Healthy People is that its goals and objectives in communities across the nation will be applied through engaging multiple sectors to take action as described in the National Academy of Medicine’s report Communities in Action: Pathways to Health Equity.[5] This report highlights the role of communities in driving action, policy, programs, or laws to promote health equity in communities. Partnerships between governments at every level and nongovernmental organizations (including not-for-profit organizations, foundations, and the private sector) are also envisioned through active participation of the entire nation working locally to implement effective policies and programs across all sectors in society.

The goals of Healthy People 2020 include achievement of health equity and creation of social and physical environments that promote good health for all.[2,3] Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people.”[2,6,7] Moreover, “[a]chieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”[4,8] Other definitions of health equity, for example the definition offered by Dr. Camara Jones (APHA past president), posit that health equity is the assurance that conditions for optimal health are available for all people, based on the premise that all people are valued equally and injustice is both recognized and rectified.[9]

To assess health equity, a major measure is elimination of health disparities.[1] Healthy People 2020 defines health disparities as “a particular type of health difference that is closely linked with social, economic, and environmental disadvantage.”[1] As such, health disparities are rooted in sociopolitical and economic history. Health disparities adversely affect populations that have systematically experienced greater obstacles to health based on their race or ethnicity, religion, socioeconomic status, gender, age, mental health, disability status, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.[3]

Despite Healthy People goals and objectives over several decades,[7] and although there have been some health improvements, there are still persistent and pervasive health disparities in the United States. For example, pervasive disparities were reported in the 2015 midcourse review of national health progress toward Healthy People targets.[10] Only modest reductions were found in health disparities among the widespread health and social objectives examined.[10] Of the up to 492 trackable objectives by race/ethnicity, the Healthy People target was met or exceeded for 36.9% of non-Hispanic Whites, 27.2% of non-Hispanic African Americans, 34.8% of Hispanics, 26.6% of American Indians/Alaska Natives, 47.8% of Asians, and 43.9% of Native Hawaiians or other Pacific Islanders.[10]

Examples of persistent health disparities include infant mortality, all-cause mortality, and life expectancy. In fact, U.S. life expectancy in all populations dropped from 78.9 years in 2014 to 78.7 years in 2015 and 78.6 years in 2016.[11] It is well known that infant mortality, all-cause mortality, and life expectancy differ by race/ethnicity, and these disparities have been documented over the past three decades. Trends in infant mortality from the 1980s to 2016 show disparities for African American infants relative to White infants; infant mortality among African American infants, on average, continues to be twice as high as mortality among White infants.[12,13] These disparities have worsened over time despite declines in overall U.S. infant mortality,[12] and more recent adverse trends have been found among Puerto Rican, American Indian/Alaska Native, and Pacific Islander infants.[2] Likewise, disparities persist in all-cause mortality and life expectancy at birth for African Americans relative to Whites, even though there have been overall improvements in both indicators of health.[12]  Furthermore, despite overall declines in cardiovascular disease (CVD) mortality, marked population and geographical inequities persist. A recent study showed a widening of the rural-urban disparity in CVD mortality, with mortality continuing to be higher in rural than urban communities.[14] From 1969 to 2011, the decline in CVD mortality was largest in New England and the Mid-Atlantic region and smallest in the Southeast and Southwestern regions. In 1969, the mortality differential in the Southeast relative to New England was 9%, and this differential increased to 48% in 2011.[14]

Other health outcomes such as obesity and diabetes, which have increased by epidemic proportions over the past few decades, show marked adverse disparities among African American and Hispanic populations in comparison with the White population at all time points during the 1980s to 2000s.[12] In addition, the legacy of slavery, racism, current oppression, and violence has impacted the mental health of African American populations. Several studies show that there is a relationship between self-reported experiences of racial discrimination and poor mental health among African Americans (as an example), including increased risk of depression, anxiety, substance use, and psychological distress.[15–17] Although the proportion of individuals receiving mental health treatment has increased, racial/ethnic disparities with respect to access to mental health treatment still persist among both children and adults.[18] In fact, this circumstance leads to members of racial/ethnic minority groups being less likely to achieve symptom remission and more likely to be chronically impaired after a diagnosis of a mental health disorder.[19]

Healthy People 2020 findings of persistent disparities in health outcomes and behavioral risk factors by socioeconomic status and education suggest that solutions to improve health outcomes for racial/ethnic and other disadvantaged populations point to upstream social determinants of health, including health care access, utilization, and quality.[20,21] These social and economic conditions, which are the “causes of the causes” of health disparities, vary not only by population characteristics but also by geography.[20] As such, inequities in certain social determinants of health are also assessed in Healthy People 2020 to understand what gives rise to disparities and to identify effective interventions so that all people are given the opportunity to realize the benefits of optimal health. Because of the U.S. political economy (the driver), which structures opportunities (advantages) and disadvantages for individuals, social determinants have been often described by race/ethnicity and income, which are measures of racism and classism, major drivers of social conditions.[3,7,22

Racism is defined as “institutional and individual practices that create and reinforce oppressive systems of race relations whereby people and institutions engaging in discrimination adversely restrict, by judgement and action, the lives of those against whom they discriminate.”[23] Racism is a major social determinant of health disparities. According to Jones, racism occurs on three levels: institutional, personally mediated, and internalized. Institutional racism is defined as “differential access to goods, services and opportunities of society by race.”[24] Personally mediated racism is defined as “prejudice and discrimination where prejudice means differential assumptions about the abilities, motives and intentions of others by race and discrimination is the differential actions toward others according to their race.” An unfortunate consequence of these two forms of racism is internalized racism, which is the “acceptance by members of stigmatized races of negative messages about their own abilities and intrinsic worth.”[24] APHA has recently begun a campaign against racism initiated by Jones.

Disparities in poor health outcomes described by racial/ethnic populations (of which racism is a contributor) place a substantial health burden on the nation and its workforce and give rise to an extreme economic burden.[25] This economic burden, which concerns communities of color but also can spark concern throughout the entire nation, has been quantified and calculated.[26] It is estimated that between 2003 and 2006, eliminating health disparities among racial/ethnic minority populations would have reduced direct medical care expenditures by $230 billion and indirect costs to society (due to loss of productivity from illness and premature death) by more than $1 trillion.[26] This evidence illustrates the cost effectiveness of eliminating racial/ethnic health disparities.

Along with the important health, social, and economic burdens to society based on the existence of health inequities, government and private sectors have a number of legal obligations related to racial equity, disability accessibility, and avoidance of gender-based discrimination. In addition, there is a growing body of legislation designed to prohibit discrimination based on sexual orientation or gender identity.[1] Examples of legal obligations and extent of implementation are described below for housing and education.

Housing: To build healthy communities as outlined in the National Prevention Strategy, all people must have access to safe, affordable, and stable housing. Access to housing has a direct and tangible impact on people’s ability to access quality education as well as on other social determinants of health. Specifically, housing segregation has a direct connection with student poverty rates and inadequate school resources, among other indicators of poor academic outcomes.[27] The federal government passed the Civil Rights Act of 1968 to specifically respond to various ways that American life had been divided based on race. Title VIII of the Civil Rights Act, known as the Fair Housing Act, prohibits race-based discrimination in housing with the express goal of “replacing ghettos” and creating truly integrated neighborhoods.

More recently, potential renters have come up against a new iteration of housing discrimination in the form of online ads. Yet, section 3604(c) of the Fair Housing Act specifically targets media postings (e.g., Craigslist) and prohibits racial discrimination using media platforms. Even with these clear legal obligations prohibiting racial discrimination in renting and home buying, housing segregation persists. Moreover, this systematic grouping of resource-rich and resource-poor neighborhoods[28] has a ripple effect on the ability of certain communities to access stable housing and, in turn, on their access to quality services.

Education: Access to education is a crucial social determinant of health.[29] It has been shown that “[p]eople with less education have higher rates of illness, higher rates of disability, and shorter life expectancies.”[30] However, in the United States, even decades after the landmark civil rights decision by the U.S. Supreme Court in Brown v. Board of Education, education is largely segregated on the basis of race and socioeconomic status.[31] Furthermore, there is no federal or constitutional right to education, and communities must rely primarily on state constitutions and special education laws to ensure equitable access to educational opportunities. K–12 education access is tightly interwoven with access to housing, as in most places students are assigned to schools based on their residence and school districts are divided along the same racial and socioeconomic lines as housing. The Supreme Court has unfortunately held that interdistrict integration is an inappropriate remedy where there has been no finding that wealthier (usually suburban) districts directly contributed to the harm suffered in less affluent districts (Milliken v. Bradley, 1974). In addition to the harm caused by racially segregated school districts, students’ access to quality education is hampered by exclusionary discipline policies that unfairly remove students of color, students with disabilities, and LGBTQ (lesbian, gay, bisexual, transgender, and queer) and non-gender-conforming (GNC) students from the classroom.[32] However, students do have some protections through the Individuals with Disabilities in Education Act, a federal law requiring that students with disabilities receive a free appropriate public education and that parents have a private right of action to demand that their child’s school district develop an educational plan that will allow the student to make meaningful educational progress.

To ensure equitable access to public education, cities and states across the country must commit to redistributing school funding in ways that are equitable and that undo the past and present harm caused by racial housing segregation. Furthermore, communities and districts must commit to eliminating “zero-tolerance policies,” which have been shown to disproportionately exclude youths of color, youths with disabilities, and LGBTQ and GNC students. The American Academy of Pediatrics has released a policy statement detailing that students who have been suspended or expelled are more likely to drop out of high school and calling for a reduction in zero-tolerance policies and an increase of prevention efforts, including early intervention for preschool students and positive behavioral support and interventions within schools.[32] In addition, the American Bar Association’s Joint Task Force on Reversing the School-to-Prison Pipeline called for the removal of zero-tolerance policies from schools and for legislation designed to eliminate criminalization of students for behavior that does not harm others.[33]

Summary: Unfulfilled legal obligations and persistent and pervasive health inequities are major public health problems because inequities cause tremendous health, economic, and ethical burdens for U.S. society, and there is a need for enforcement of legal protections from discrimination. Elimination of health disparities is cost effective, and if nothing is done these societal burdens are projected to worsen as the U.S. population becomes more diverse and multicultural. By 2044, the United States is projected to become a majority-minority country.[34] Furthermore, racial/ethnic minority and low-income populations combined now represent nearly one half of the U.S. population.[34,35]

Evidence-Based Strategies to Address the Problem While there is not a comprehensive, coordinated strategy for the nation to achieve health equity, there are science- and evidence-based national strategies and initiatives that have demonstrated success in reducing or eliminating some health disparities at the local level and in communities because they have effectively addressed the social determinants of health, including racism and classism. Many are discussed in an Institute of Medicine report titled How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary.[36] Although national initiatives are emphasized as key opportunities, it is realized that their success involves multisector partnerships at every level of government and with nongovernmental, nonprofit organizations. These initiatives are discussed in the context of the Patient Protection and Affordable Care Act and include but are not limited to the following:  the dual vaccination strategy, the recommendations of the Community Preventive Services Task Force (CPSTF), Healthy People 2020 goals and objectives, the National Prevention Strategy (NPS),  the National Partnership for Action to End Health Disparities (NPA), the Environmental Justice Strategy and Implementation Plan, the Public Health Accreditation Board standards for public health agencies,  the Culture of Health initiative of the Robert Wood Johnson Foundation, Association of State and Territorial Health Officials (ASTHO) and National Association of County and City Health Officials (NACCHO) programs and initiatives to achieve health equity, and APHA efforts to achieve the healthiest nation in a generation.

The dual vaccination strategy includes multicomponent, evidence-based interventions designed to reach the general population of children in U.S. communities and targeted interventions designed to reach the most vulnerable children (e.g., those from underserved, low-income, and racial/ethnic minority populations) and high-risk communities (those at risk of vaccine-preventable illnesses because of low vaccination coverage).[37,38] Universal interventions include regular assessments of vaccination services for children at the local, state, and national levels and in health care practices.[37,38] At the health care practice level, the focus is on provision of high-quality vaccination services through practice standards, standing orders, and assessment of services.[39] Targeted interventions, based on the needs of the most vulnerable children, have enabled low-income and racial/ethnic minority children and high-risk communities to gain routine access to health care services via the Vaccines for Children Program. In addition, there is increased awareness of the need for and availability of vaccination services through strategic partnerships between public health agencies and community organizations at all levels of governmental public health, particularly faith-based organizations.[37,38] The Vaccines for Children program specifically provides free vaccines to uninsured and underinsured children.[40]

The evidence-based recommendations of the CPSTF represent examples of interventions proven to improve the quality of health care service delivery. Evidence-based recommendations also exist for communities in reducing risk behaviors for chronic diseases and injuries.[39] These recommendations, when applied to communities, have been proven to improve health.[39]

As mentioned, Healthy People 2020 provides achievable and measurable objectives for improving the health of all that are applicable at the national, state, and local levels.[2,3] Regular and routine monitoring of objectives requires assessments of the overall population at these levels as well as assessments of different groups by education, race/ethnicity, income, disability, and geographic location.[3] This strategy of monitoring the health objectives of individuals in communities, counties, states, and the nation reflects the adage “what gets measured, gets done.”[41]

The NPS, a key national initiative that includes targeted interventions as components, is designed to improve the resilience of all populations by addressing the social determinants of health.[42] The NPS goal is to increase the number of Americans who are healthy at every stage of life.[42] This goal is accomplished via four strategic directions: eliminating health disparities, building healthy and safe communities (e.g., through provision of clean air and water and affordable housing), integrating community and clinical preventive services and enhancing the quality of both, and empowering people to make healthy choices. Elimination of health disparities is applied across the other three directions and nine priority areas to reduce the burden of the leading causes of preventable deaths and major illnesses in the United States.[42] An example of integration of community and clinical preventive services is enabling access to clinical services by providing transportation, child care, and patient navigation interventions.[42] The nine priorities, which include tobacco-free living, prevention of drug abuse and excessive alcohol use, healthy eating, active living, and mental and emotional well-being, can reduce poor health outcomes.[42] Full implementation of the NPS in all communities, including those with substantial racial/ethnic minority and low-income populations, should improve community health.

While education and housing are important social determinants of health, racism (as mentioned) plays a dynamic role in shaping the health and well-being of individuals and populations alike. Throughout the nation, there are a number of efforts taking place at the state and local levels, particularly around building capacity to address racism. Training, webinars, and coalitions and committees formed by national and local organizations provide health departments, hospitals, businesses, and communities with tools and resources to recognize, address, and eliminate racism. Anti-racism training sessions, such as those taught by the Racial Equity Institute, the Center for Racial Justice Innovation, Clear Impact, and the Race Matters Institute, focus on creating racial equity and challenging the status quo.[43–46] These training sessions equip communities and the workforce with knowledge, skills, and resources regarding racial equity. Webinars such as those sponsored by APHA,[47] the Latino Medical Student Association,[48] and Human Impact Partners[49] offer an opportunity to examine the structural barriers that preserve racism while advancing racial and health equity. Coalitions and committees such as Organizing Against Racism, the Interfaith Coalition Against Racism, the United Nations Human Rights Committee on the Elimination of Racial Discrimination, and the International Justice Resource Center’s Committee on the Elimination of Racial Discrimination focus on disassembling racism while promoting justice.[50–53] In addition, organizations such as the National Collaborative for Health Equity, CommonHealth ACTION, the Aspen Institute, the W.K. Kellogg Foundation, and the Center for Ethical Leadership provide funding and resources to organizations in an effort to address the impact of racism.[54–56]

Interventions and initiatives targeting upstream social determinants of health are likely most effective in improving health equity. The NPA, a targeted umbrella initiative led by the Office of Minority Health of the U.S. Department of Health and Human Services (DHHS), is expected to mobilize a nationwide, comprehensive, community-driven, and sustained approach for combating health disparities and for moving the nation toward achieving health equity.[8] Systems-oriented, cross-sector, partnership-based, and community-driven approaches to eliminating health disparities include a national stakeholder strategy for achieving health equity. The goals of this strategy are to increase awareness of the impact of health disparities and actions needed for improving health among racial, ethnic, and underserved populations; to strengthen leadership in addressing health disparities; to improve health and health care outcomes for racial, ethnic, and underserved populations; to improve cultural and linguistic competency and the diversity of the health workforce; and to improve data, research, and diffusion of research and evaluation outcomes.[57] To accomplish the stakeholder plan, there are regional health councils in place. All public health agencies and the private sector could benefit from the guidance of the NPA regional health equity councils and state minority health directors, and they should engage in efforts with community health workers to educate and empower communities and individuals.[58,59] These councils and directors have established trusted partnerships in underserved and minority communities, and they can assist public health agencies in developing community improvement plans.

An example of such endeavors can be seen in the work accomplished by the National Indian Health Board and the National Partnership for Action. To build capacity and improve outcomes for tribal communities, these two organizations have collaborated in a joint effort sponsored by the Office of Minority Health.[60] This effort has provided resources to tribal public health departments surrounding public health accreditation and bolstered “use of the social determinants of health and health equity frameworks in programming and in community health needs assessments.

The 2012 DHHS Environmental Justice Strategy and Implementation Plan delineates actions to address environmental health disparities experienced by minority and low-income populations and American Indian tribes.[36] Environmental justice is defined as fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income in the development, implementation, and enforcement of environmental laws, regulations, and policies.[61] This definition was developed in response to a body of science and community advocacy indicating a disproportionate burden of environmental pollution among minority, low-income, and tribal populations in the United States.[61] The Environmental Justice Strategy and Implementation Plan builds on an earlier strategy from 1995 to protect the health and advance the economic potential of communities overburdened by pollution and other environmental hazards.[61] The four interrelated parts of the 2012 strategy are linked to climate change polices and directives such as policy development and dissemination; education and training; research and data collection, analysis, and utilization; and services.[61] The plan provides a roadmap for DHHS agencies to develop their own environmental justice strategies and plans, to enhance accountability, and to promote collaboration and meaningful community partnerships.

To strengthen the public health infrastructure and improve routine public health agency performance, the Public Health Accreditation Board offers an accreditation process for state, local, tribal, and territorial public health agencies.[62] As of August 2016, 150 local, tribal, and state agencies and one integrated state system of 67 local agencies were accredited.[62] An accredited public health agency meets national standards based on the 10 essential public health services. The accreditation standards drive public health agencies to develop and use documents such as community-driven health improvement plans, agency strategic plans, and emergency operations plans. With accreditation standards, there is strong attention to understanding emerging trends, using assessment data and identifying jurisdiction-specific needs and issues, and addressing health equity, cultural competency, and vulnerable populations. As such, the accreditation process and national standards are driving attention to important topics and actions, which could strengthen the preparedness and response of communities to the health impacts of climate change and improve efforts to address threats faced by vulnerable populations by more strongly motivating public health agencies to take actions required to address their needs. In addition to meeting overall standards, accredited agencies meet specific cultural competency standards.[62]

As mentioned in the problem statement, the health status of individuals in the United States is poor relative to those living in other high-income countries, and life expectancy is shorter. A major explanation for shorter life expectancy is that countries with the best health outcomes provide the strongest social services for their populations.[1] There is a need for social supports to improve health status and reduce health inequities in the United States.

The APHA goal is for the United States to become the healthiest nation in a generation by 2030. To accomplish this goal, APHA calls for the conduct of eight science-based key actions[63]:

• Build safe, healthy communities
• Help all young children graduate from high school
• Reverse growing income inequalities
• Remove barriers to good health for everyone
• Provide affordable, nutritious food for everyone
• Effectively prepare for and respond to the health impacts of climate change
• Provide quality health care to everyone
• Strengthen public health infrastructure

Furthermore, considerable literature exists denoting additional specific strategies in smaller localities that have led to improvements in health equity through addressing the social determinants of health. These strategies include, but are not limited to, research strategies (such as community-based participatory research), housing program and policy strategies (such as tenant-based rental assistance programs), and educational program and policy strategies (such as center-based early childhood education, full-day kindergarten programs, and high school completion programs).[64]

Also, critical state and local strategies to improve health equity are being led by nonprofit organizations. APHA has implemented case studies, as have NACCHO, ASTHO, and the Robert Wood Johnson Foundation.[9,65–67] In addition, a community of practice in North Carolina, which has the shortest life expectancies in the nation, has developed a health equity framework.[68,69] North Carolina has its own Office of Minority Health and Health Disparities, which generates health equity reports evaluating the state’s progress in eliminating health disparities.[68] The Chronic Disease and Injury Section of the North Carolina Department of Health and Human Services strives to decrease death and disability by way of education, policy change, and health services.[69] Within that section are communities of practice that aim to further the section’s work.[69] One community of practice developed a health equity framework that encompasses priorities, key activities, and terminologies surrounding health disparities, health inequities, and the social determinants of health. This framework offers an approach to advancing health equity while providing strategies and a common language that can be used to inform the policies of decision makers and increase funding for health equity in grant applications.[68,69]

In prioritizing multisectoral approaches to achieving health equity, the “health in all policies” approach provides an opportunity for multifaceted collaboration focusing on the social determinants of health.[70] This upstream approach also promotes the importance of considering health in developing every decision and throughout a wide range of sectors.[70] ASTHO asserts that “by taking a broader view of what creates health, we can better understand how policies related to transportation, housing, education, public safety or environmental protection can affect health outcomes.”[71]

Building safe communities also requires aggressive enforcement of existing civil rights protections and active work to undo the past harms caused by redlining, predatory lending, and other forms of discrimination in housing. Continued research and aggressive policy changes to hold financial institutions, landlords, and other actors accountable for fighting racial inequity in housing are absolutely necessary to combat inequity in housing.

In the journey toward achieving health equity in the United States, effective interventions to address the social determinants of health continue to be needed at the nonprofit and philanthropic organizational- levels.[5] It is estimated that 45% to 57% of the drivers of health determinants are outside of health care, supporting the need for intentional, collaborative, coordinated, and innovative efforts to address the social determinants of health.[72] Nongovernmental organizations play a critical role in stimulation of innovation; for example, the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation work through programs and grants to engage communities, policymakers, business leaders, and other stakeholders to set a standard for health equity in communities and to provide evidence for the business case for racial equity.[67,73] In addition, there are numerous other foundations that impact health, are thought leaders, and provide funding to impact decisions, policies, and programs that can address health equity, including the Henry J. Kaiser Family Foundation, Kaiser Permanente, the Ford Foundation, the California Healthcare Foundation, the Commonwealth Fund, and the California Endowment.

The Institute of Medicine’s report Communities in Action: Pathways to Health Equity further supports the notion that health is shaped by community context and is the product of multiple determinants.[5] This report provides examples of innovative evidence-based strategies and recommendations for closing equity gaps. In addition, the report acknowledges that both governmental and community actors are necessary but are independent of one another and are not sufficient for the advancement of equity. The community-driven initiatives included in the report illustrate several promising cross-cutting elements that promote equity, including creating a shared vision and building trust in the community, developing leadership, and building diverse partners through relationship building and mutual accountability.[5] By developing strategic partnerships/collaborations and building community capacity for equity, communities can successfully impact socioeconomic and political frameworks accounting for a range of factors such as employment, public safety, housing, transportation, and education.[5] It is evident through these examples that community-based organizations and subsequent partnerships are drivers of change and are a fundamental component in the implementation of effective strategies in pursuit of health equity. To further strengthen the success of this work, communities need evidence (from research), tools, supportive policies, resources, and political will that will nurture local efforts.[5]

Opposing Arguments/Evidence There are fundamental opposing arguments used against attaining health equity that are underlying values of decision makers and policymakers (e.g., capitalism, xenophobia, and sexism). These opposing arguments are as follows: (1) personal health choices are the responsibility of the individual and (2) the scarcity of resources leads to a need for a balance between health rationing and what is acceptable as redistribution of resources.[74]

Credence given to these fundamental opposing arguments, however, is difficult because during the public meetings for Healthy People 2010, when elimination of health disparities became a national health goal, the public expressed concern that differences in health status by race/ethnicity and income were unacceptable.[75] In addition, as previously mentioned, the cost effectiveness of eliminating health inequities[26] and the business case for racial equity[73,76] are strong economic arguments in support of achieving health equity.

Moral and ethical arguments have also been used to refute other opposing arguments. For example, Dr. Cynthia Jones has offered ethical arguments refuting specific prevailing opposing arguments against the elimination of health disparities.[77] She describes the following three prevailing opposing arguments to elimination of disparities: “The first opposing argument is that it is not necessarily wrong that some people are ‘less healthy’ than others. The second opposing argument holds that different cultural groups may exhibit cultural habits that perpetuate health disparities and the third opposing argument is that addressing health disparities is a waste of resources, as substantial resources have already been spent studying the problem of health disparities, yet the disparities persist.”[77] Jones then refutes these opposing arguments as follows.

• Refuting the first opposing argument: Even if individuals are responsible for their own health and, more important, the health disparities with which we are concerned are disparities that follow racial/ethnic lines and socioeconomic distinctions, it would be a strange leap to suppose that the members of a particular ethnic population are responsible for their lower health outcomes or that the poor are responsible for their lack of access to adequate medical care. Even if we assume, for the sake of argument, that this is indeed the case, we may still argue that the high rate of diabetes and heart disease in minority populations, for example, is a problem that should be addressed through education, even if the population as a whole exhibits habits that are unhealthy and are somewhat within their control. Public health programs designed to educate the public about the dangers of smoking are an example of this logic at work.[77] Furthermore, individuals’ choices are strongly influenced by options and opportunities in their environments, and in some communities, geographic areas, and socioeconomic groups individuals are limited by their access to making healthy choices.
• Refuting the second opposing argument: Cultural practices that result in significant health risks should be addressed, albeit as sensitively as possible. If a cultural practice results in harm to the individual or to others, then it would be morally problematic to ignore such harm. It may be that we can educate individuals about potential harm while presenting healthier alternatives that are not antithetical to a group’s ethnic and cultural practices.[77]
• Refuting the third opposing argument: We should not abandon efforts to address a problem because past efforts have been unsuccessful. Efforts to address diseases such as Alzheimer’s disease and breast cancer and social problems such as domestic violence and poverty should not be curtailed because these diseases and problems persist. There is also no clear evidence that the problem is indeed “unfixable.” At best, this objection points to the need to rethink approaches to addressing health disparities. Numerous factors, such as health literacy, housing, environmental toxins, mistrust of health care professionals, and lack of insurance, affect health and can perpetuate or increase health disparities. Clearly, a complex tangle of factors is at work to affect health and contribute to significant health disparities in the United States. We need to develop creative, broad-based approaches to address these inequities. Rather than pulling health disparities out of the social context in which they are entrenched and attempting to address them narrowly, researchers should find ways to address health disparities within the social context, which may require “fixing” more than just the health disparities. Perhaps increasing public awareness of health disparities as a moral issue can contribute to addressing this problem.[77]

Action Steps The action steps outlined below are based on the science- and evidence-based strategies described previously and are structured at the national, state, local, and nongovernmental levels, with ultimate impacts at the individual and community levels. It is recognized that nongovernmental partners also play a major role in fostering healthy communities.

National Level

• Congress should fund fully, and the federal government should implement fully, the Affordable Care Act, including (1) providing access to health services for everyone (through health insurance and promotion of Medicaid expansion by states on the path to universal access to health care), (2) implementing the recommendations of the U.S. Preventive Services Task Force and the CPSTF, (3) collecting required data, and (4) implementing value-based health care.
• Congress should fund fully the National Prevention Strategy and Implementation Plan and the National Partnership for Action to End Health Disparities, including implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
• Congress should continue to fund research on elimination of health inequities through the National Institute on Minority Health and Health Disparities as well as other institutes at the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), the Substance Abuse and Mental Health Services Administration, and the Patient-Centered Outcomes Research Institute (PCORI).
• The CDC, ASTHO, NAACHO, the Robert Wood Johnson Foundation, and other organizations should develop and implement evidence-based toolkits for communities to implement interventions that include the dual strategy approach of universal interventions and targeted interventions to reach society’s most vulnerable populations
• Congress should fund and implement fully social safety net services such as quality education, housing, jobs, and transportation.
• Congress should permanently reauthorize special provisions of the 1965 Voting Rights Act to prevent further reauthorizations.
• Federal, state, and local governments should enforce civil rights laws to achieve health equity.
• The CDC should continue to monitor progress on eliminating health disparities and health inequities and consider new methods to expand monitoring of health outcomes by socioeconomic status in addition to race/ethnicity.
• The CDC, NIH, AHRQ, and PCORI should continue and expand community research to identify models to reduce health disparities in communities across the United States.
• The CDC and the W.K. Kellogg Foundation should engage in efforts to reduce breastfeeding disparities across the United States.[78]

State/Local Level

• State governments should expand Medicaid to improve universal access to health care.
• State and local public health agencies should create broad coalitions with regional and state health equity councils and minority health directors to reach the most vulnerable populations (racial/ethnic minority and low-income populations) through health in all policies initiatives and other evidenced-based efforts to improve population health.
• State and local governments should fund state and local public health agency accreditation efforts.
• State and local governments should implement evidence-based interventions and identify practice-based interventions found to eliminate health disparities (e.g., communities of practice).
• State and local governments should support social policies to improve education, income, housing, jobs, and transportation.
• State and local governments should work with urban planners and health professionals to foster incorporation of health in planning, policy, and decision-making frameworks to create healthy communities.
• >State and local public health agencies should include the most vulnerable populations in developing, implementing, and evaluating community improvement plans and training.
• State and local governments should implement a dual strategy approach of public health programs and prevention programs.

Nongovernmental Organizations

• Nongovernmental organizations such as the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation should continue to introduce paradigm shifts such as the Culture of Health initiative and the business case for racial equity.
• Nongovernmental organizations should work with partners to create healthy communities.
• Nongovernmental organizations such as the Kellogg Foundation, the Satcher Institute, and the American Medical Students Association should enhance scholarship and fellowship programs seeking to develop public health leaders in academia and health policy who are focused on eliminating health disparities and advancing health equity.
• Academic institutions, in the major role of identifying effective interventions in communities to achieve health equity, should focus research particularly on the discovery of interventions that intervene on the social determinants of health in communities across the United States.
• Academic institutions should focus on training members of the public health workforce with the specific knowledge and skills they need to prepare them for leadership roles in developing, promoting, and implementing research and policies to advance health equity. Moreover, these institutions should enhance and develop centers and curriculums focused on advancing health equity, specifically providing graduates with the necessary training to work effectively with disadvantaged communities to develop sustainable programs and critically analyze issues, programs, and policies that impact health disparities and advance health equity.

Individuals/Communities

• Individuals and communities should advocate for political, social, and economic policies and programs that will improve health for the most vulnerable populations, families, and communities, as well as policies that support health advancement of multicultural populations.
• Individuals and communities should understand their legal rights and obligations to uphold civil rights laws and disability laws and advocate for enforcement of such laws.

Cross Cutting

• Federal, state, and local governments; professional organizations; and businesses should create a pipeline of public health and preventive medicine physicians and professionals made up of members of the most vulnerable populations in U.S. society.
• Federal, state, and local governments should adopt a “health in all polices approach” to ensure that health issues are addressed broadly, especially with respect to social policies that affect vulnerable populations.

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Developing a racial justice and leadership framework to promote racial equity, address structural racism, and heal racial and ethnic divisions in communities. Available at: http://leadershiplearning.org/system/files/Racial%20Equity%20and%20Leadership%20Scan.pdf. Accessed January 18, 2019. 57. U.S. Department of Health and Human Services. National Stakeholder Strategy for Achieving Health Equity. Available at: https://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286. Accessed 10 April 2017. Accessed January 18, 2019. 58. U.S. Department of Health and Human Services. Regional health equity councils. Available at: https://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=42. Accessed January 18, 2019. 59. Office of Minority Health. State minority health contacts. Available at: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=6. Accessed January 18, 2019. 60. Espinosa O, Coffee-Borden B, Bakos A, Nweke O. Implementation of the National Partnership for Action to End Health Disparities: a three-year retrospective. J Health Disparities Res Pract. 2016;9:6. 61. U.S. Department of Health and Human Services. 2012 Environmental Justice Strategy and Implementation Plan. Available at: http://www.hhs.gov/sites/default/files/environmentaljustice/strategy.pdf. Accessed January 18, 2019. 62. Public Health Accreditation Board. Accredited health departments. Available at: http://www.phaboard.org/news-room/accredited-health-departments/. Accessed January 18, 2019. 63. American Public Health Association. National Public Health Week 2016. Available at: http://www.publichealthnewswire.org/?p=14627. Accessed January 18, 2019. 64. Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health. 2010;100:S40–S46. 65. American Public Health Association. Health equity. 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Communities in Action: Pathways to Health Equity (2017)

Chapter: 1 the need to promote health equity, 1 the need to promote health equity, introduction.

In the United States, health equity and equal opportunity are inextricably linked, and the burdens of disease and poor health and the benefits of wellness and good health are inequitably distributed among groups of people.

Although biology, genetics, and individual behaviors play a role in these differences, many health outcomes are more substantially affected by social, economic, and environmental factors. Understanding the social determinants of health requires a shift toward a more “upstream” perspective—that is, the conditions that constitute the context in which an individual’s behaviors are shaped. To put this more simply, Keyes and Galea (2016) describe the relationship between an individual and the conditions in which one lives using the metaphor of a fishbowl. If the bowl in which a fish lives is dirty, or the glass is cracked and the water is leaking, the fish will never reach its full health potential, despite any individual effort. Although the life of a person is clearly more complex than that of a fish, this metaphor illustrates the futility of only addressing individual behaviors without considering the context. People inhabit environments shaped by policies, forces, and actions that influence their individual choices and behaviors over a lifetime and over generations. Community-wide and national problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, exposure to violence, and neighborhood deterioration (social or physical) are among the factors that shape people’s health, and they do so in unequal ways, thus contributing

to health inequities. The historic and ongoing interplay of structures, policies, norms, and demographic/geographic patterns shapes the life of every individual across the country. These factors are not intractable, and inequities in these factors can be mitigated by policies and community action in powerful ways (see Chapter 3 for a discussion of the evidence). Community assets can be built, leveraged, and modified to create a context to achieve health equity.

People are heavily influenced by the communities they work and live in, and the diverse actors that make up the community ecosystem can be powerful producers of health and well-being. Therefore, this report focuses on the promise of communities to create opportunities for their members to achieve their full health potential. By showcasing many creative, forward-looking, and bold community-led solutions for achieving health equity, this report aims to provide a new narrative about health in the United States. In addition to actors in communities, the report examines other elements that address the structures, policies, and norms needed to promote health equity.

DEFINING HEALTH EQUITY

This report makes frequent reference to a number of terms with meanings that vary depending on the context and the community of users. Such terms include “disparities,” “inequities,” “equity,” “racism,” and “bias,” and they are defined in the glossary of key terms and when first introduced in the report.

It is difficult to fully separate the concepts of equity and equality because they are intertwined. Different fields have used varying terminology in legal, public health, government, and other contexts. This report uses the term “health equity” by applying the term equity to the field of public health. Health equity is the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance. In this report promoting health equity means creating the conditions where individuals and communities have what they need to enjoy full, healthy lives. Health equity requires focused and sustained societal efforts to confront historical and contemporary injustices and eliminate health disparities ( Brennan Ramirez et al., 2008 ; HHS, n.d. ). Health disparities are differences that exist among specific population groups in the attainment of full health potential and in incidence, prevalence, mortality, and burden of disease and other adverse health conditions ( NIH, 2010 ), and they stem from systematic differences—that are preventable and unjust—among groups and communities occupying unequal positions in society ( Graham, 2004 ).

As discussed later in this chapter, studies of health inequities have focused largely on health disparities across racial and ethnic populations. Although such studies have uncovered patterns of discrimination and inequitable health outcomes, enlarging this work to assess the effects of poverty, unemployment, toxic stress, and the many secondary unintended consequences (e.g., drug use and violence) for minority and other disproportionately impacted populations is needed. It is well documented that low socioeconomic status (SES) hampers an individual’s ability to achieve optimal health by limiting access to health-preserving resources ( Williams and Purdie-Vaughns, 2015 ; Woolf and Braveman, 2011 ). However, SES does not fully explain health disparities based on race and ethnicity, sexual orientation and gender identity ( Williams and Purdie-Vaughns, 2015 ).

In the following sections, the nature and implications of disparities on three key health indicators and for health care are discussed. This discussion is followed by a brief introduction to the social determinants of health and the impacts of health inequities on society. Next, the changing social and environmental context and the role of communities in addressing health inequity are described. Finally, this chapter highlights the ongoing support for accelerating the progress to achieve health equity before providing an overview of the rest of the report.

DISPARITIES IN HEALTH OUTCOMES

The existence of racial and ethnic disparities in morbidity, mortality, and many indicators of health for African Americans, Native Americans, Hispanics, 1 and Asians/Pacific Islanders was first acknowledged by the federal government in the 1985 Report of the Secretary’s Task Force on Black and Minority Health ( Heckler, 1985 ). Since then, research has sought to identify additional disparities and explain the mechanisms by which these disparities occur.

Three indicators provide summary information about the overall health of a population or subpopulation: infant mortality , age-adjusted death rates , and life expectancy . The United States ranks lower than most peer nations on these indicators; moreover, racial and ethnic disparities exist in quality and length of life among U.S. residents. The failure to address growing income inequality, along with health inequities by race

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1 Hispanic/Latino identification with country of origin: Four decades after the U.S. government mandated the use of Hispanic or Latino for data collection (e.g., in the decennial census), most Americans with roots in Spanish-speaking countries prefer to be identified by their country (51 percent versus 24 percent who prefer a pan-ethnic term). Also, 69 percent respond that they believe there are multiple cultures, not one monolithic “Hispanic” or “Latino” culture ( Taylor et al., 2012 ).

and ethnicity, contributes to the United States’ low health ranking among peer nations ( Davis et al., 2014 ).

Infant mortality rates reflect the number of infants in a population who die before their first birthday per 1,000 live births. U.S. infant mortality rates have decreased since 2005 for the overall population and within each racial and ethnic group; however, sharp racial and ethnic disparities persist. In 2013, as in previous years, the infant mortality rate among African Americans (11.1 per 1,000 live births) was double the rate among whites (5.06 per 1,000 live births) ( Mathews et al., 2015 ). American Indians/Alaska Natives and Puerto Ricans also experienced higher infant mortality rates (of 7.61 and 5.93 per 1,000 live births, respectively) than whites ( Mathews et al., 2015 ). Infant mortality rates among Asians/Pacific Islanders and non-Puerto Rican Hispanics were lower than those of whites. If white America and black America were two separate nations, white America’s infant mortality rate would rank 49th in the world, while black America’s would be ranked 95th out of 224 nations listed by the U.S. Central Intelligence Agency’s World Factbook, following Botswana, Sri Lanka, the United Arab Emirates, and Turks and Caicos Islands ( WHO, 2015 ).

Life expectancy, the average number of years a person is expected to live based on current mortality rates (typically reported as life expectancy at birth or average number of years a newborn would be expected to live), captures the degree to which all of the individual-level socioeconomic, environmental, and health care–related resources in a society enable members of that society to achieve a long and healthy life. Better living conditions and better access to health care–related resources throughout the lifespan extend longevity. From 1980 to 2014, U.S. life expectancy (at birth) increased by approximately 6 years for males, reaching 76.4 years, and increased 3 years for females, reaching 81.2 years. Racial and ethnic disparities decreased, but they were not eliminated. In 2014, the life expectancy for African American males was 72.0 years, while that for white males was 76.5 years and that for Latino males was 79.2 years. In the same year, life expectancy was 78.1 years for African American females, 81.1 years for white females, and 84.0 years for Latina females ( Arias, 2016 ). Childhood obesity, which disproportionately affects Hispanic and African American youth ( Asieba, 2016 ; Taveras et al., 2013 ), has been projected to reduce the steady increase in overall life expectancy in this century ( Olshansky et al., 2005 ).

Age-adjusted mortality rates capture population deaths due to all causes, and especially those not due to old age. High death rates suggest that a population not only faces serious threats to health but also lacks the resources needed to address them. The 2012 to 2014 U.S. age-adjusted rates ranged considerably. By race and ethnicity, they ranged from 399.8

per 100,000 people among Asian/Pacific Islanders to 858.1 among African Americans. From 2007 to 2009, the rate was even higher (943.0 per 100,000) among American Indian/Alaska Natives ( IHS, 2016 ). Although the overall death rate among whites (729.1 per 100,000) was substantially lower than the rate among African Americans, it exceeded that of Asian/Pacific Islanders and American Indian/Alaska Natives ( NCHS, 2014 ) for causes including liver disease, suicide, and unintentional injury ( Kochanek et al., 2016 ). Looking at more distal causes, research indicates that age-adjusted death rates among whites are higher for those who live in rural settings ( Caldwell et al., 2016 ) and have lower incomes ( HRSA, 2015 ).

The patterns of health disparities among immigrants and their children that emerge from available data are not straightforward. More than half of U.S. citizens of Asian/Pacific Islander and Hispanic background come from families that emigrated to the United States since 1965. Considerable socioeconomic and cultural heterogeneity exists within these groups, and some subpopulations (e.g., the Hmong population of Asian descent) experience particularly severe health disparities ( Cho and Hummer, 2001 ; de Souza and Anand, 2014 ; Vang et al., 2015 ). However, recent immigrant status has also shown positive health impact in some populations ( Hummer et al., 2007 ; Lee et al., 2013 ; Markides and Coreil, 1986 ).

Along with race and ethnicity, sexual orientation and gender identity have emerged as important factors in the study of health disparities. Recent epidemiologic surveys have attempted to comprehensively assess the physical and mental health of lesbian, gay, bisexual, and transgender (LGBT) persons ( Hsieh and Ruther, 2016 ; IOM, 2011 ). The available evidence shows that the LGBT population does experience health disparities and that the disparities are exacerbated for those who hold multiple minority statuses: this “intersectional” perspective describes the recognition that when multiple identities intersect, they represent overlapping inequalities or types of disadvantage ( IOM, 2011 ). Thus, LGBT persons who are also racial/ethnic minorities have worse outcomes than do white LGBT individuals ( Hsieh and Ruther, 2016 ).

Health Care

It is becoming clearer that health insurance coverage alone will not address health disparities associated with race, ethnicity, SES, and geography ( Kenney and Huntress, 2012 ; Ubri and Artiga, 2016 ). The Patient Protection and Affordable Care Act (ACA), passed in 2010, has accelerated progress toward improved health equity by expanding health insurance coverage to about 20 million Americans ( Uberoi et al., 2016 ). However, challenges remain in fully addressing health care inequity, including policy hurdles affecting subgroups of the population (e.g., lack of coverage

for some immigrants and asylum seekers, or those subject to Deferred Action for Childhood Arrivals) ( HealthCare.gov, n.d. ); limited system capacity or competence to care for some populations, such as LGBT persons (e.g., newly covered partners of insured LGBT individuals); and the lack of health data to monitor the health needs of some populations (e.g., for American Indians, of whom approximately 20 percent live on rural reservations) ( Kruse et al., 2016 ).

Merely increasing the availability of health care services does not necessarily reduce health care disparities. Consider how the availability of effective antiretroviral therapies has not reduced the rate of acquired immune deficiency syndrome (AIDS) equally across groups. In the U.S. context, the progression to AIDS may signal a failure to access treatment in a timely and appropriate manner as indicated by racial and ethnic trends that have been followed since the beginning of the epidemic, as shown in Figure 1-1 .

Though AIDS diagnoses have decreased over time for all groups since the introduction of antiretroviral therapy, the proportion of diagnoses among whites has decreased substantially, while the percentage has increased for other groups, and most substantially for African Americans. Another striking example is found in the domain of clinical research,

where clinical trials of drugs and devices are not always carried out in diverse populations; therefore, the outcomes of trials may be biased toward the populations studied and fail to account for cultural or other factors that may influence effectiveness ( George et al., 2014 ).

From a policy standpoint, the ACA has achieved its primary goal: the proportion of people who lack health insurance is lower than it has ever been. In the 29 states that have to date elected to participate in the ACA, Medicaid expansion has resulted in more than 10 million low-income individuals now being insured; furthermore, the associated reduction of cost-shifting for uncompensated care has benefited hospital budgets, particularly for disproportionate share hospitals ( CMS, 2016 ; Cunningham et al., 2015 ). However, the costs of care for these patients are often greater than expected, and Medicaid’s reimbursement rates are a small fraction of the reimbursement rates from commercial payers; therefore, cost-shifting persists. The ACA has increased the availability of outpatient care for low-income persons through increased funding for the operation, expansion, and construction of community health centers.

Challenges remain, however. As noted above, access to insurance does not directly translate into health equity. The traditional fee-for-service system persists and influences utilization patterns more heavily than patient need or evidence-based practice guidelines ( The National Commission on Physician Payment Reform, 2013 ; Page, 2013 ; Robinson, 2001 ). Patients need only to receive the care they want and need. Also, there is still a subset of people without adequate insurance, and some commercial payers are leaving the exchanges, premiums are on the rise again, and pharmaceuticals and specialty drugs are increasing in complexity and pricing, untouched by the ACA.

A significant group of workers earn too much to qualify for Medicaid, but too little to afford health insurance. Also, the law does not address the needs of undocumented residents who are among the poorest people in the United States. Nearly one-third of all noncitizen immigrants lack insurance ( Barry-Jester and Casselman, 2015 ). Underutilization of health care services among subpopulations of Hispanic and Asian immigrants has been documented ( Alegria et al., 2006 ). The reasons for underutilization are complex and include an inability to speak the language, differences in the circumstances of immigration (e.g., refugees versus recruited professionals), and the fear of inadvertently outing family members who are in the country without documentation ( Ortega et al., 2015 ).

Because the law is still relatively new, researchers are investigating its outcomes, but there are concerns that some lower-income working class individuals remain underinsured but have had more cost of health care shifted to them ( Saloner et al., 2014 ), and the variations in use and cost persist.

SOCIAL DETERMINANTS OF HEALTH

Although most of the research being conducted at the time of the Heckler Report sought to explain how behavioral and other individual-level factors contribute to health and health care disparities, the evidence accrued since 1985 has led the field toward examining the social, environmental, economic, and cultural determinants of health. These determinants are the conditions in which one lives, learns, works, plays, worships, and ages, and these conditions are shaped by historical and contemporary policies, law, governance, investments, culture, and norms. Addressing the root causes of health inequities, such as the social determinants of health, is important in part to help enable sustainable interventions by engaging multiple sectors and addressing multiple health outcomes simultaneously. The solutions highlighted in this report recognize that national and state leadership are important to effect change in these determinants, but the report specifically addresses these interrelated determinants at the community level (see Chapter 3 for a detailed discussion of the root causes of health disparities, including the social determinants of health).

IMPACTS OF HEALTH INEQUITY IN THE UNITED STATES

Although moral arguments to promote health equity exist 2 advancing progress toward health equity could produce economic, national security, and other benefits for the nation. The premise that social mobility, opportunity to succeed with hard work, and opportunity to achieve prosperity exist is fundamental to the American Dream ( Carr and Wiemers, 2016 ). However, recent literature demonstrates that worsening social, economic, and environmental factors are affecting health in serious ways that compromise opportunity for all ( Chetty et al., 2016 ; Rudolph et al., 2015 ; Woolf et al., 2015 ). Health is more than life expectancy, infant health, and fitness and nutrition—it is the ability to lead a full and productive life. Additionally, an opportunity to achieve good health is crucial to U.S. democracy, national security, and economic vitality, as described below. The burden

2 For example, Jones and colleagues cite valuing all people equally as foundational to the concept of equity, noting that the equal worth of all people is at the core of the human rights principle that all human beings equally possess certain rights ( Jones, 2009 ). Braveman and colleagues point out that health differences adversely affecting socially disadvantaged groups are particularly unacceptable because ill health can be an obstacle to overcoming social disadvantage. They further note that this “consideration resonates with common sense notions of fairness, as well as with ethical concepts of justice” ( Braveman et al., 2011 ). Daniels argues for the moral importance of health by exploring the necessities for justice as it relates to health care and the social determinants of health ( Daniels, 2008 ).

of disparities lowers the nation’s overall health status and its ranking relative to other nations.

Political and Economic Impacts of Health Disparities

In addition to the dollar cost of health care, because health inequities contribute to overall poor health for the nation, health inequity has consequences for the U.S. economy, national security, business workforce, and public finances.

Consequences for the Next Generation

American children rank behind their peers in most Organisation for Economic Co-operation and Development (OECD) nations in health status and on key determinants of health, and they experience growing disparities on multiple measures of child well-being ( OECD, 2009 ; Seith and Isakson, 2011 ). Poverty, food insecurity, lack of stable housing, and lack of access to high-quality and developmentally optimal early childhood education are among the childhood factors that contribute to “chronic adult illnesses and to the intergenerational perpetuation of poverty and ill health found in many communities (e.g., obesity, diabetes, cardiovascular disease, poor educational outcomes, unemployment, poverty, early death)” ( AAP, 2010 , p. 839). Young children are most likely to live in poverty, and children from low-income and minority communities are most vulnerable ( Burd-Sharps and Lewis, 2015 ). The nation’s growing racial and ethnic diversity, coupled with the conditions that lead to serious early life disadvantage, have serious implications for health and health disparities in later life, leading to squandering human lives and their potential ( OECD, 2009 ).

Consequences for the Economy

The economic effects of health inequity are the result of both unsustainable and wasteful health care spending and diminished productivity in the business sector. Health care spending accounted for 17.5 percent of gross domestic product (GDP) in 2014, and health disparities contribute to a significant amount of financial waste in the health care system.

LaVeist and colleagues (2009) calculated that eliminating health disparities for minorities would have reduced indirect costs associated with illness and premature death by more than $1 trillion between 2003 and 2006. In 2009, the Urban Institute projected that from 2009 to 2018, racial disparities in health will cost U.S. health insurers approximately $337 billion in total ( Waidmann, 2009 ). Disparities in access to health care and

in the quality of care can be costly to individuals, health care providers, health insurers, and taxpayers. Obtaining care late in the course of disease (i.e., delayed care) and inadequate health care coverage may increase the cost of care exponentially due to the exacerbation of complications, the need for more expensive care (e.g., emergency department services), and the need for more extensive care; furthermore, such treatment can increase longer-term reliance on the health care system for the management of unintended consequences on one hand and preventable chronic diseases on the other ( IOM, 2009 ).

Consequences for National Security

For a nation that prizes military readiness, the effects of poor health status on entrance to military service and the readiness of the force matter. Military leaders reported that more than 75 percent of 17- to 24-year-olds—more than 26 million young adults—in the United States cannot qualify to serve in the armed forces because they have health problems ranging from obesity to dependencies on prescription and nonprescription drugs, are poorly educated, or are involved in crime ( Christeson et al., 2009 ). According to more than 500 retired admirals, generals, and other senior military leaders, the health of our nation’s youth represents a serious national security concern ( Christeson et al., 2009 , 2010 ). Individuals who are not healthy enough to participate in the workforce will not be afforded the same employment opportunities as their healthy counterparts. Rear Admiral Robert Besal (ret.) has asserted that young people who are physically unfit for “productive employment or military service represent a staggering loss of individual potential and collective strength for the nation as well” ( Council for a Strong America, 2016 ).

Consequences for Business

A healthy, productive workforce is a prerequisite to a thriving economy ( HERO, 2015 ; IOM, 2015 ). The impact of poor health on private businesses is significant. Research from the Urban Institute shows that those young adults with health problems who can find jobs in the mainstream economy are less productive and generate higher health care costs for businesses than those without health problems ( Woolf et al., 2015 ).

Consequences for Income Inequality

Research finds that people in counties with an inequitable distribution of opportunities for good health are more likely to die before the age of 75 than people in counties with more equitable opportunities for

health (health status), even if the average incomes are the same ( University of Wisconsin Population Health Institute, 2015 ). Political scientists at Princeton and Georgetown University are finding that crippling political polarization and gridlock are linked to income and wealth inequality ( Ferejohn, 2009 ; Voorheis et al., 2015 ). But income and wealth are not what worries Americans. Instead, it is what can be obtained with income and wealth that worries them most, and, of these, Gallup reports that health care is at the top of the list ( Swift, 2015 ). Health problems often reduce personal income in ways that worsen inequity, which in turn may lead to further inequity. For states, it is well understood that as health care spending through state Medicaid increases, the funds available to support state universities decrease ( Orszag and Kane, 2003 ).

CHANGING SOCIAL AND ENVIRONMENTAL CONTEXT

There are significant changes in the sociocultural (including demographic, economic, and political) and environmental landscapes affecting health disparities and the determinants of health.

The changing economic context is characterized by growing income inequality. According to an analysis performed by the Institute for Policy Studies, the income gap between higher- and lower-income individuals has increased substantially over the past 30 years, to the point that those with incomes in the top 10 percent average nine times the income of those in the bottom 90 percent, and those with incomes in the top 0.1 percent have incomes that are more than 184 times that of the bottom 90 percent ( Asante-Muhammad et al., 2016 ). This income inequality has a remarkable impact on individual health, as higher-income earners have longer life expectancies than lower-income earners in every region of the United States. There are significant economic changes that affect other social determinants as well. For instance, urban centers across the country are dealing with shifting demographics that can result in the displacement of long-term residents. The economic advantages of changing land value due to these shifts largely benefit those who are already in higher-income brackets. In contrast, dislocated low-income households face overwhelming challenges in efforts to find new housing with access to high-quality schools, jobs, and other essential social services that are vital to optimal health. The lasting effects of the 2008 recession and the resulting displacement of vulnerable populations exacerbated the impact on both their health and their economic well-being—resulting in greater income inequality and wealth inequality ( Smeeding, 2012 ).

Recent changes in U.S. demographics underscore the urgency of finding ways to attain health equity. For example, from 2000 to 2010 the African American population increased by 11 percent ( Rastogi et al., 2010 ),

and the Hispanic population increased by 43 percent ( Ennis et al., 2011 ), while the white population increased by only 1.2 percent ( Hixson et al., 2011 ). By 2040 the number of U.S. counties in which the majority of the population is comprised of people of color is expected to more than double; those counties will then represent about one-third of the United States ( Frey, 2015 ). Without significant and fundamental policy changes, these changes in the racial and ethnic composition of U.S. communities can be expected to further widen health inequities associated with race and class. Disparities in health, income, and education have also all been increasing over time (see Chapters 2 and 3 for more information).

Climate change will increasingly affect health. In 2015, at the United Nations Climate Change Conference—also known as COP 21—multiple nations, including the United States, came together to create an agreement to combat climate change and attempt to prevent the global temperature from rising more than 2 degrees Celsius. Health representatives played an integral role in the conference, as health is and will continue to be significantly affected by climate change. Climate change is happening in all areas, but its impacts are not distributed equally. It exacerbates vulnerabilities in communities that are already disproportionately affected by preexisting social, economic, and environmental factors. Extreme weather events are one of the many examples of the ways in which climate change will impact health. Hurricane Katrina was not necessarily the direct result of climate change. However, it offers many important lessons on mitigating risk and increasing resiliency in making plans to help the entire population, especially the most vulnerable. Although there is a risk that climate change could worsen health inequities, there is also great opportunity to integrate efforts to promote health into mitigation and adaptation efforts to support more resilient, healthy, and equitable communities ( Rudolph et al., 2015 ).

Finally, recent events involving race and law enforcement relations have elucidated systematically unequal treatment in the criminal justice system ( The President’s Task Force on 21st Century Policing, 2015 ). Moreover, there is a growing and bipartisan recognition that mass incarceration, which affects individuals of color disproportionately, plays a major role in the breakdown of families and communities, constitutes an unsustainable use of taxpayer dollars, and leads, in connection with the larger policy milieu in both the private and the public sector, to poor employment prospects and voter disenfranchisement ( Clear, 2008 ; NRC, 2014 ). These current realities serve as reminders that the vision of an equitable society will be challenging to reach, but community-driven solutions, such as those this report highlights, can help move in that direction on a local scale.

WHY COMMUNITIES?

Individuals and families are part of communities, and the role of communities is crucial to promoting health equity for several reasons. First, as discussed earlier, medical interventions are insufficient to address health equity, and behavioral health promotion continues to show little success in reducing disparities ( Baum and Fisher, 2014 ). Community-based and -driven efforts are needed to alter environmental, socioeconomic, and cultural conditions in ways that promote health equity. Community health refers to the overall well-being of a community at all levels (including the individuals within the community and the physical setting), which may involve multi-sector and multidisciplinary collaborative approaches to optimizing the health and quality of life of all persons who live, work, or are otherwise active in a defined community ( Goodman et al., 2014 ). A healthy community is the foundation for achieving all other goals, as it is essential for a productive society. (For example, a community with a healthy workforce has a good base upon which to build its economy, and healthier students are more equipped to learn and be successful academically.) Furthermore, communities differ in the local quality and availability of health care providers, the affordability and quality of housing, employment opportunities, transportation systems, the availability of parks, green space, and other aspects of the physical environment. Communities are uniquely positioned to drive solutions tailored to their needs that target the multiple determinants of health.

MOMENTUM FOR ACHIEVING HEALTH EQUITY

There is a clear urgency for the nation to fully address health inequity. An analysis of current trends provides evidence of persistent health inequity, but there are reasons for optimism. Turning the tide is not only possible, it is imperative; many organizations in the public and private sectors have recognized this, making health equity an explicit or implicit priority. These organizations span the sectors of finance, philanthropy, public health, community development, academia, and beyond. Local, regional, and state governments have also taken on issues essential to achieving health equity. For example, the Federal Reserve Bank and community development financial institutions are engaging in improving community development, employment, and housing—which drive health improvement—and they are making investments that expand access to healthy and affordable foods and neighborhoods with open space to promote physical activity and community safety ( Andrews and Erickson, 2012 ). Health equity is a guiding priority for the American Public Health Association in its initiative to make the United States the healthiest nation in a generation, with 2030 as a goalpost ( APHA, n.d. ). In

2016 the Association of State and Territorial Health Officials’ President’s Challenge is to “Advance health equity and optimal health for all,” and “Cultivating a culture of health equity” was the theme for the National Association of County and City Health Officials’ annual meeting. Numerous states, including California, Colorado, Massachusetts, Pennsylvania, and Wyoming, have created statewide offices of health equity that work in collaboration with other agencies and departments to inform policies that promote health equity. Health equity has become central to the goals of some of the nation’s largest philanthropic organizations, including The California Endowment, Ford Foundation, Kresge, and Kellogg. Advancing health equity is at the core of the Robert Wood Johnson Foundation’s (RWJF’s) new push for a culture of health ( RWJF, 2015 ). The federal government is investing heavily in health equity as well, and it recently established a National Institutes of Health research program to address health disparities in chronic disease as well as the National Partnership for Action to End Health Disparities. These investments seek to “transform lives and places for disinvested people” ( The Housing Fund, 2015 ), and at their core they are investments to create opportunity for all to achieve optimal health.

Conclusion 1-1: The persistent state of health disparities and health inequity in the United States has profound implications for the country’s overall health standing, economic vitality, and national security. Thus, addressing health inequities is a critical need that requires this issue to be among our nation’s foremost priorities.

ABOUT THIS REPORT

RWJF, as part of its Culture of Health Initiative, 3 asked the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to help delineate the causes of and the solutions to health inequities in the United States. The charge to the committee is provided below (see Box 1-1 for the full statement of task). To respond to the charge, the Committee on Community-Based Solutions to Promote Health Equity in the United States was formed.

The focus of this report is on what communities can do to promote health equity and on the broader policy context and contributions of stakeholders that can support communities. In addition to the root causes and structural barriers that need to be overcome, the committee also examined levers and policies to support change, some of which span

3 For more information, see http://www.rwjf.org/en/culture-of-health.html (accessed October 28, 2016).

national, state, regional, and other contexts for the work of communities. To address its charge, the committee reviewed examples of community efforts across the country and was inspired by how these communities are rising to the challenge to address the difficult challenges and barriers to health and well-being.

Culture of Health Lens

RWJF defines a culture of health broadly “as one in which good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities guides public and private decision making; and everyone has the opportunity to make choices that lead to healthy lifestyles” ( RWJF, n.d. ). RWJF also says that “the exact definition of a culture of health can look very different to different people. A national culture of health must embrace a wide variety of beliefs, customs and values. Ultimately it will be as diverse and multifaceted as the population it serves” ( RWJF, n.d. ). The culture of health framework was developed by the foundation in collaboration with RAND Corporation through a combination of literature review and structured discussions with stakeholders ( Chandra et al., 2016 ). The framework includes four action areas that are interdependent—none can be achieved alone ( Plough and Chandra, 2016 ). The four action areas are

• Making health a shared value
• Fostering cross-sector collaboration to improve well-being
• Creating healthier, more equitable communities
• Strengthening the integration of health systems and services

The committee used the framework as a guide for this report and adapted it to apply specifically to its statement of task and at the community level.

The committee also referred to the ecological model illustrated in the 2003 Institute of Medicine (IOM) 4 report The Future of the Public’s Health in the 21st Century. This figure shows the multiple determinants of health, beginning with an individual’s biology (and the biology of diseases) at the center, followed by individual behavior, and in the outermost layer, the highest level of social, economic, cultural, health, and environmental conditions and policy ( IOM, 2003 ). The committee was charged with examining community-based solutions, and it developed a simple model to show what it concluded are three important elements of community-based efforts to promote health equity. The community-based level of intervention is situated in the second and third outermost circles of Figure 1-2 (i.e., social, family, and community networks; living and working conditions). As Figure 1-2 clearly indicates, community effort is necessary, but it is not a sufficient contributor to population health and, by extension, health equity. The outermost ring—the broad milieu of social,

4 As of March 15, 2016, the Health and Medicine Division (HMD) carries out the work previously undertaken by the IOM.

economic, and environmental conditions and policies—is crucial to support community-level efforts.

Report Conceptual Model

Figure 1-3 is a conceptual model that grounds the committee’s report. The model adapts elements of the Culture of Health Action Framework

( RWJF, 2015 ) and the Prevention Institute’s Systems Framework to Achieve an Equitable Culture of Health ( Prevention Institute, 2016 ). The model applies the culture of health lens to the committee’s understanding of the underlying causes and conditions of health inequity in addition to the community-based solutions that promote health equity.

The model begins with the outer circle and background as the context in which health inequities and community-driven 5 solutions exist.

5 The committee chose the term “community-driven solutions” because the community will be the driving force behind the solutions in this report.

The “socioeconomic and political context” was adapted from the World Health Organization Conceptual Framework for Action on the Social Determinants of Health ( WHO, 2010 ) and encompasses policies, law, governance, and culture. In the report conceptual model, this socioeconomic and political context includes structural inequities and biases that are produced along the axes of race, gender, class, sexual orientation, and other social domains. These inequities are manifested in systematic disadvantages that lead to inequitable access to or experience of the determinants of health. The committee adapted the determinants of health identified by the Achieving Health Equity Team at the RWJF, separating the social and physical environments, and adding transportation. Although the framework incorporates transportation as part of the “physical and social environment,” transportation is vital to many areas of health (e.g., the ability to travel to health care facilities, community events, accessing jobs) and, alternatively, can have detrimental impacts on health (e.g., air pollution, unintentional injuries), and thus it has been highlighted in the model. (See Chapter 3 for a more detailed description of each determinant of health and the ways in which they affect health and well-being.)

The committee adapted two of the Culture of Health Action Framework Action Areas for community-level solutions: “Making health equity a shared vision and value” and “Fostering multi-sector collaboration.” Based on the committee’s information-gathering sessions, relevant literature, and committee deliberations, the committee also identified a third action area of importance for the framework when proposing solutions at the community level: “Increasing community capacity to shape outcomes.” This is a process that has emerged as essential for communities to have the power to address inequities and to sustain their efforts. (These three elements are discussed in more detail in Chapter 4 .) To align with its statement of task, the committee incorporated equity at the community level in its conceptual model. The Culture of Health action area “Creating healthier, more equitable communities” has been incorporated into the conceptual model as the outcome of the community-driven solutions in the center of the diagram.

The community examples featured in this report will highlight solutions that have been implemented at the community level to target one or more of the nine determinants of health using the processes identified in the conceptual model (see Chapter 5 ). By making health equity a shared vision and value, increasing community capacity to shape outcomes, and fostering multi-sector collaboration, these solutions foster equal opportunity for health, which is the foundation for a vibrant, healthy community.

Community Health

This report does not focus on interventions that target a single health condition, but on community-level changes and impacts on health through a holistic lens. The development of a community-based solution is a community-driven process that includes fair participation by the community in the decision-making process, in which all people have access to the information necessary to understand the matter and the process and which produces outcomes that the people accept as fair, equitable, and nondiscriminatory in the context of addressing health disparities. Therefore, the terms “community-driven solutions” and “community-based solutions” will be used interchangeably for the remainder of this report (see Box 1-2 for definitions). The importance of communities and their role and potential to promote health equity is discussed in Chapter 4 .

Overview of the Study Process

To address its charge, the committee gathered information through a variety of means. It held three information-gathering meetings that were open to the public and webcast live. The first, held in January 2016, focused on obtaining information on health disparities and their root causes, including an overview from the report sponsor. The second, held in March 2016, focused on many of the social determinants of health and

included presentations on how transportation, planning, environmental justice, and civil rights law affect health. The third meeting was held in April 2016, and presentation topics included faith-based community organizing, community-based participatory research, place-based factors and policy at the community level, and the economics of community development (meeting agendas are in Appendix C ). The committee met in executive sessions for deliberative discussion throughout the study process. The committee received public submissions of materials for its consideration at the meetings and by e-mail throughout the course of the study. 6 A website was created to provide information to the public about the committee’s work and to facilitate communication between the public and the committee. 7 The process used to identify the community examples highlighted is outlined in the Chapter 5 Annex .

Overview of Report

Chapter 2 begins with a description of the state of health disparities in the United States by geography, income, race and ethnicity, and other categories. Chapter 3 discusses how structural and institutional inequities have led to disparate health outcomes and highlights historical issues that continue to affect health outcomes today, as well as the ways in which current and emerging issues ultimately affect communities. This is followed by a discussion on the multiple determinants of health and how they affect health equity. Chapter 4 discusses the role and capacity of communities to promote health equity and explains the larger context in which communities are situated, as well as the types of evidence needed to support communities. Chapter 5 provides nine examples of communities that are tackling health inequity and the lessons learned from these efforts. Chapter 6 addresses the policies that ultimately affect communities and that could either hinder or promote solutions at the level of individual communities. Chapter 7 discusses the roles of various stakeholders and the actions that these actors could undertake in their communities, with an emphasis on multi-sector collaboration. Chapter 8 is geared toward communities and provides an array of strategies, tools, and activities available to communities to help them promote health equity. Chapter 9 provides brief summarizing thoughts.

6 Public access materials can be requested from http://www8.nationalacademies.org/cp/projectview.aspx?key=IOM-BPH-15-15 (accessed December 23, 2016).

7 See http://www.nationalacademies.org/hmd/Activities/PublicHealth/Culture-ofHealth.aspx (accessed December 23, 2016).

CONCLUDING OBSERVATIONS

There are systemic root causes of health inequities in this country that can be overwhelming and that will take considerable time to address. It will require system-level changes to eliminate structural racism, reduce poverty, improve income equality, increase educational opportunity, and fix the laws and policies that perpetuate structural inequities. Until these root causes are addressed nationally, health equity will not be fully realized. However, actors at the community level—policy makers, businesses, state and local governments, anchor institutions, and community residents—are agents of local change who have the power to change the narrative and take action that will promote health equity. The latter is what this report will focus on, although, where possible, it will provide promising strategies to address these hard-to-tackle root causes at higher levels.

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In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health.

Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways.

Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.

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Why Health Equity Matters in an Era of Health Care Transformation

Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

For more than 150 years, advocates have been waging campaigns for health equity in this country. Relying primarily on moral arguments, these campaigns have tackled inequities in racial and ethnic minority health, women’s health, mental health, children’s health, veterans’ health, rural health, and most recently LGBT health. While these various campaigns have faded in and out of the public’s focus for more than a century and a half, the health equity movement as a whole has become increasingly mainstream in recent years and is finally a national priority. The reason for this is simple: Equity has become more than just a moral issue. Today, it is a legal and an economic issue as well—supported by both Republicans and Democrats at federal and state levels.

In fact, it was 30 years ago under the Reagan administration that the federal government initiated efforts to prioritize, in law and policy, issues affecting the health of underserved populations and the disparities experienced by these groups. Every successive administration since then has continued to prioritize this issue by either enacting bills into law, establishing new programs, or including it in national strategies. In 2001, former U.S. Senate Majority Leader William H. Frist (R-Tenn.) pledged to prioritize health equity in the 108th Congress and “focus on the uninsured and those who suffer from health care disparities that we so inadequately addressed in the past.”

Health equity means giving patients the care they need when they need it. Or as the Institute of Medicine (IOM) report put it, health equity means “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”

“This increased federal focus on value-based care, combined with new data and metrics made available through EHRs, provides incredible opportunities for integrating care, improving quality, and achieving health care equity in every community.” Daniel Dawes, JD, Morehouse School of Medicine

Savvy academic medical centers, public policymakers, insurers, and clinicians have finally realized that health equity—or the lack thereof—increasingly affects the bottom line. It is no surprise that higher rates of chronic and costly conditions, combined with high rates of uninsured individuals among lower socioeconomic and minority populations, result in a greater reliance on emergency services, higher treatment costs, and, ultimately, a financial strain on providers and government programs. We know that preventive medicine and early interventions save money and lives.

In each administration since Reagan’s, our policymakers also have recognized the compelling governmental interest in elevating the health of all populations in the United States. In 2010, the Affordable Care Act (ACA) further prioritized equity as a legal requirement by including 62 provisions specifically designed to reduce and eliminate health disparities among racial and ethnic minorities and other vulnerable populations. Yet each year, approximately $300 billion and countless lives are lost because of health care disparities. With the elections now behind us and a new administration and Congress before us, there will be new challenges and opportunities to advance public laws and policies that prioritize health equity.

ACA provisions align with health equity

Under the ACA, insurers participating in the federal exchanges are required to reward health care providers for programs that reduce health disparities. The law also bolstered opportunities to engage community health workers in health systems across America, established grant programs aimed at eliminating health disparities, and required tax-exempt hospital providers to conduct meaningful community health needs assessments. In addition, the ACA established six new offices of minority health at federal agencies that are tasked with ensuring new federal regulations incorporate health equity measures, and elevated the National Center on Minority Health and Health Disparities to an institute at the National Institutes of Health. Other requirements expanded protections to both clinicians and consumers, especially to those who have experienced discrimination in health care, including women, minorities, people with disabilities, and the LGBT community.

The adoption of electronic health records (EHRs) under the American Recovery and Reinvestment Act as well as the ACA has strengthened data collection and reporting for race, ethnicity, sex, primary language, and disability status. This makes it easier to identify disparities in care and underperforming treatments among different populations. Additionally, there is also a push to include more minorities in clinical trials and strengthen comparative effectiveness research to ensure medical devices and drugs are inclusive of these populations so providers will be able to make more informed decisions about treatments for diverse patient populations.

Make no mistake: The changes brought forth by the health reform law are working. Since 2013, when the bulk of the ACA took effect, 3 million African Americans, 4 million Latinos, and nearly 9 million white adults got health insurance. During that same period, nearly 4 million young adults became insured. These historic gains in coverage have lowered the U.S. uninsured rate to 8.6 percent, down from 16 percent when the ACA passed in 2010. But the next step is equity in the quality of care, and Congress’ passage of the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 helped to accelerate that process.

MACRA reauthorized many of the ACA provisions that were expiring and repealed Medicare’s sustainable growth rate in favor of a new Quality Payment Program, which includes the Merit-Based Incentive Payment System to increase quality of care across the country. This federal focus on value-based care—rather than a volume-based payment system—increases the incredible opportunities for integrating care, improving quality, and achieving health care equity in every community.

Recognizing health equity as a value

Health systems are paying attention to disparities in the quality of their care and seeking remedies as health care costs rise and consumers demand action. They are doing so not just because it is the right thing to do, but because the financial incentives are increasingly aligning, the legal requirements are there, and their bottom lines benefit.

Those institutions and clinicians that do not recognize the importance of achieving health equity in their communities and reducing costs related to health inequity, will struggle more and more in the years ahead as our nation moves toward a health system that is more accessible, equitable, cost effective, and person centered.  While there is uncertainty about the fate of the ACA beyond the insurance coverage, health disparities cannot be ignored by the new administration and congress since they will continue to be a major contributing factor to health care costs and have major implications for our country in the future.

• Health Care
• Health Equity

Health Equity in Healthy People 2030

As Healthy People has evolved over the decades to reflect the most current science and address the latest public health priorities, it has strengthened its focus on health equity. This focus is reflected in one of the overarching goals of Healthy People 2030: “Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.”

Healthy People 2030’s emphasis on health equity is closely tied to its focus on health literacy and social determinants of health . Social determinants — like structural racism or systemic bias — can affect health literacy and contribute to health disparities. Taking steps to address these factors is key to achieving health equity.

In line with this focus, Healthy People 2030 provides tools for action to help individuals, organizations, and communities committed to improving health and well-being advance health equity.

Leveraging Healthy People to Advance Health Equity

Health equity is the attainment of the highest level of health for all people..

Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and social determinants of health — and to eliminate disparities in health and health care. 

Identify priorities by browsing Leading Health Indicators and other objectives

Compare population-level progress to national targets

Use Healthy People data  to track health disparities and inform program and policy development

Find inspiration by consulting evidence-based resources to use in your community

Review Healthy People in Action stories to learn how others are addressing health equity

Use the Healthy People 2030 framework as a model for program planning

Use the social determinants of health framework to build partnerships across sectors and communicate root causes of health disparities

Definitions

Use the definitions of health equity and health disparities to promote a shared understanding and identify areas for collaborative action to improve health for all

Download the graphic

Leveraging Healthy People to Advance Health Equity [JPG — 591.48 KB]

How Does Healthy People Define Health Equity and Health Disparities?

Defining health equity and health disparities promotes a shared understanding of these concepts and helps individuals, organizations, and communities nationwide align their resources and efforts — and identify areas for collaboration.

Similar to Healthy People 2020, Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”

Healthy People 2030 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

How Does Healthy People 2030 Address Health Disparities?

Measuring health disparities is essential to advancing health equity. That’s why Healthy People 2030 monitors differences across population groups as it tracks progress toward meeting objectives . Healthy People data tools summarize and display these health disparities to help identify priority populations.

Healthy People 2030 also features evidence-based resources focused on strategies that are proven to improve health. These resources include interventions to address public health issues among specific population groups and improve the health of all people.

In addition, Healthy People 2030 collects Healthy People in Action stories that highlight how states, communities, and organizations address health disparities, advance health equity, and improve health by:

• Using evidence-based interventions and strategies
• Evaluating interventions
• Forming multisector collaborations

Learn more about health equity and health disparities definitions and frameworks

The Health Equity and Health Disparities Environmental Scan explored how health equity and health disparities are defined and communicated within the field of public health.

Download the report [PDF – 3.53 MB]

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

You will be subject to the destination website's privacy policy when you follow the link.

Health Equity in an Interconnected World Essay

The problem of equity in health care is always urgent in the context of an ever-expanding cultural diversity, taking into account the process of globalization and international communication only superficially. Progress and technologization were supposed to equalize the world, improving it to an impeccable degree. But in the end, technologies and their development spectrum rather only alienated people from each other. One might even get the impression that the global model of world perception, which has been so popular over the past few decades, has been exhausted. The world situation is such that large states are increasingly moving away from close cooperation with each other throughout the 21st century, and the autonomy of major powers that are not in mutually beneficial communication is only growing. Consequently, these countries, which are engaged in competition in the sphere of economic and political influence, have less time and resources to solve the problems of the third world countries.

Against the background of economic rivalry, the life of an individual person gradually ceased to be perceived as a primary value. Thus, many third world countries may still receive less humanitarian aid. It should be noted that this problem often applies to marginalized segments of the population in the countries of the first world. The current tragic situation has a chance to be revised in the context of a global pandemic.

As a result of the shock experienced by the entire world community, it becomes obvious that nations are not able to completely separate and live autonomously and independently from each other. Many countries that are not economic giants have found themselves in situations of real economic pressure. It is clear that developing countries still face extreme challenges in the areas of health and social services. Scientists emphasize that the outlined widespread crisis economic processes and the following social inequality are only at risk of increasing. At the same time, in those countries where such social problems were previously unclear, the crisis situation inflicted an unexpected double blow on state and medical infrastructures. At the same time, it is not difficult to assume that the pandemic problem only aggravates the situation with massively widespread diseases already existing in many countries, while health systems are losing control over them.

The official position of the international powers in relation to the current global crisis was the declared tactics of solidarity. This term requires consideration in ethical criteria and in terms of its real relation to the provision of assistance internationally. The chosen policy is the principle of rational medical justice, that is, limited due to economic considerations. Theorists believe that strategies for achieving full balance are impossible, while the lack of global equality in receiving medical care is demonstrated by statistics. Looking at the big data, it should be mentioned that of the three hundred vaccine test launches, most are in the United States and China, while the smallest are in Africa (Johnson, 2020). Based on these measurements, it is clear that the principle of relative solidarity only emphasizes the existence of inequality on the global scale.

Moreover, speaking of large international organizations for the protection of health in recent years, only one of them has only one African country, South Africa (Johnson, 2020). This only emphasizes a problem of actual inequity in global healthcare system and calls for an immediate response. Global support during a pandemic is still not reaching those in need on a continent-wide scale. At the same time, the principle of rational solidarity at the moment practically excludes these countries from the dialogue on the international support system. The system of solidarity is thus demonstrated as extremely relative and proceeding primarily from the urgent needs of influential countries.

It follows from the article that European states are striving to unite in international organizations for the protection of health care, which cumulate the forces of doctors and the whole society in the fight against the pandemic. Also in 2020, several transnational funds were organized, the money received from which will go to help weaker health systems. This money is spent on training and improving the skills of doctors, as well as organizing communities that can counteract disease in any way possible. It is logical to assume that for the most part such measures are required if the health care system of a particular state is not able to ensure proper control over the disease. Thus, through such funds, the problem of inequality in health care around the world can be really addressed.

Countries can also team up with large companies and international organizations for a collaborative strategy to provide equal levels of assistance to all countries or sectors of society in need. The largest of these, the General Health Security Agenda, includes a community from 31 countries (Johnson, 2020). At the same time, they are in collaboration with large companies, thus complementing and enhancing financial mutual influence. Based on this, we can conclude that financial support and the concentration of such a large amount of energy may be enough to develop solutions that can truly help the maximum number of people. That being said, it is interesting to note the ethical delivery of the claims of such global organizations to provide assistance. The UNICEF statement calls on this support not to be seen as help, but as a true collaboration for the overall health of the world’s population (Johnson, 2020). It can be concluded that this statement implies that countries with fewer resources should, however, strive to adopt the proposed innovations as much as possible and cooperate in their implementation.

Speaking about assistance to states in crisis, it is important not only to distribute medical supplies and humanitarian aid, which is absolutely necessary. An extremely effective element in the fight against the epidemic is also awareness of it, the ability to maximally protect oneself and the loved ones. To truly move closer to overcoming today’s health problems requires a global network of scientists, legislators, governments.

It is true that the funding provided by transnational organizations and individual states is valuable at the moment. However, based on all of the above, one can conclude that states still need to reconsider many political priorities in order to unite in a more effective consolidation. Only in this way will the system of global connections really live up to its name, creating a situation in which the best minds in the world will not compete in creating a vaccine, but will cooperate with each other in its development. Thus, tackling the global inequality in health care delivery requires a concerted effort and scaling up of support, although at this time this seems to be disadvantageous or impossible.

Johnson, Stephanie B. (2020). Advancing global health equity in the COVID-19 response: Beyond solidarity. Journal of Bioethical Inquiry , vol. 17, no. 4, pp. 703-707. doi: 10.1007/s11673-020-10008-9

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IvyPanda . "Health Equity in an Interconnected World." February 13, 2023. https://ivypanda.com/essays/health-equity-in-an-interconnected-world/.

• Sibling Solidarity in a Polygamous Community in the USA
• Solidarity in The Waste Land and Angels in America
• Family Communication Comparison: Interconnected System
• Durkheim's Ideas on Social Solidarity
• The Late 19th and Early 20th Century to Build Solidarity
• Transnational IT Operations
• Growth of Urgent Care Centers
• Moving from an International to a Transnational Entity
• North American Environmental Transnational Activism
• Supranational and Transnational Structures' Effects
• Epidemiology for Public Health Practice
• COVID-19 Vaccine Production Facility Failures
• Electronic Health Records and the COVID-19 Pandemic
• The Online COVID-19 Health and Safety Program
• Features of Treatment and Diagnosis of Severe Diseases

Importance of Health Equity

A health care system is designed to provide individuals with sufficient service and improve their health outcomes. It is efficient if everyone who needs assistance receives adequate care, which is possible because of Health Equity. According to Minkler et al., this term denotes “removing obstacles to health such as poverty, discrimination and their consequences, including powerlessness, lack of access to good jobs with fair pay,” and others (11S). For me, Health Equity means that every person deserves adequate care irrespective of their race, gender, economic status, and background.

However, it is impossible to deny that health inequities are present in the current medical practice. A suitable example is when people cannot reach positive outcomes because they lack sufficient financial resources. On the one hand, it relates to developing countries where economies are weak in enhancing their health care systems. As a result, individuals do not have sufficient access to medical services, which results in shorter life expectancy and more diseases. On the other hand, citizens of developed countries can also suffer from this issue. It refers to low-income individuals who do not have money to visit a doctor. Consequently, this example of health inequality is topical for the whole world.

In addition to that, it is reasonable to consider some of the factors contributing to that inequity. Firstly, it relates to global economic forces that lead to unequal distribution of financial resources. Thus, developing countries cannot reckon that their health care systems will be equal to those of developed nations. Secondly, the inequity under consideration has appeared because medicine has turned into a business. Health care establishments cannot provide their service free of charge because they will suffer financial losses. Consequently, an economic situation influences the medical industry and leads to health inequities.

Minkler, Meredith, et al. “Growing-Equity and Health Equity in Perilous Times: Lessons from Community Organizers.” Health Education & Behavior, vol. 46, no. 1, 2019, pp. 9S-18S.

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OCR Health Equity Factsheet

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) implements statutes that are critical to health equity, including federal civil rights laws, conscience and religious freedom laws, the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules, and the Patient Safety Act and Rule, which together protect fundamental rights of non-discrimination, conscience, religious freedom, and health information privacy. OCR’s Strategic Plan provides a framework for how compliance work, partnerships, and operations can implement the Biden-Harris Administration’s commitment to advancing health equity, as described in President Biden’s Executive Orders 14076 , 13985 , 14091 and 14110 .

OCR adopts the definition of health equity articulated in Executive Order 14091 of consistent and systematic treatment of all individuals in a fair, just, and impartial manner, including individuals who belong to communities that often have been denied such treatment, such as Black, Latino, Indigenous and Native American, Asian American, Native Hawaiian, and Pacific Islander persons and other persons of color; members of religious minorities; women and girls; LGBTQI+ persons; persons with disabilities; persons who live in rural areas; persons who live in United States Territories; persons otherwise adversely affected by persistent poverty or inequality; and individuals who belong to multiple such communities.

OCR is working to advance health equity through its rulemaking and enforcement activities, both of which allow OCR to effectuate and enforce standards of the law to prevent non-discrimination and advance fair, just and equal treatment in Federally funded health care programs and activities.

Disability and Aging

Health Equity Goal: Ensure non-discrimination and increase access to services in the community for persons with disabilities who want to return to their communities from institutional settings or are at risk of institutionalization.

• Improve opportunity for people living with disabilities by resolving individual and systemic complaints alleging Olmstead violations and by increasing educational activities for the public that raise awareness of OCR’s enforcement authorities, including press releases on Olmstead resolutions, internal and external presentations, and website updates. Olmstead enforcement strategies include early complaint resolutions, systemic relief, technical assistance, guidance, and outreach. Impact: Ensures individuals who have been wrongfully institutionalized or are at risk of institutionalization are aware of their rights and receive the services to which they are legally entitled in their own homes and communities.

Health Equity Goal: Combat and prevent discrimination and advance opportunities for individuals with disabilities through rulemaking.

• Update and clarify critical regulatory provisions that help persons with disabilities accesshealth and human services and prohibit discrimination on the basis of disability under Section 504 of the Rehabilitation Act . The rule updates Section 504 to align with other disability non-discrimination laws and adds specifics to prevent and respond to discrimination on the basis of disability in health and human services. Impact: Will help protect the general health and wellbeing of individuals with disabilities by clarifying what counts as discriminatory medical treatment and improving patients’ ability to have meaningful access to necessary medical equipment and health and human service programs.
• Issued guidance on civil rights protections for people with disabilities that makes clear that civil rights protections remain in full force and effect during disasters or emergencies, including during the COVID-19 pandemic. Impact: Improves protections for people with disabilities during public health disasters and emergencies.
• Issued guidance on how disability non-discrimination laws apply to certain people - affected by COVID-19. The guidance provides clarity on “Long COVID” and disability rights under the ADA, section 504, and Section 1557. The guidance also provides resources for additional information and best practices. Impact: Helps educate the public on how disability rights laws apply to conditions related to the COVID-19 pandemic.

Non-discrimination in Health Care

Health Equity Goal: Ensure non-discriminatory access to health care services and supporting persons with disabilities seeking access to medication.

• Resolved complaints with national pharmacy chains to ensure timely access to medications for women and persons with disabilities, including access to prescriptions for individuals with disabilities. As a result, the pharmacies implemented new processes to promote access to medication by preventing potential delays. Impact: Improves access to medication so individuals with disabilities are able to get timely access to vital prescriptions.

Health Equity Goal: Advance non-discrimination in health and human services programs through rulemaking.

• Released proposed revisions to regulations implementing Section 1557 of the Affordable Care Act (ACA) that restores and strengthens non-discrimination civil rights protections for LGBTQI+ people, women, and individuals seeking care in Federally funded health programs and activities. The proposed rule affirms protections against discrimination on the basis of sex, including sexual orientation, gender identity, and pregnancy, in the provision of health services. Impact: Improves non-discrimination protections for marginalized communities, including gender diverse individuals, LGBTQI+ individuals, pregnant people, individuals with limited English proficiency, and individuals with disabilities. The proposed Section 1557 Rule would expand the applicability of non-discrimination standards in health care to health coverage, including limited-duration health plans, and to the Department’s activities related to health programs such as the Medicare and Medicaid programs and the Indian Health Service.  
• Released a proposed update to the HHS Grants Rule that prohibits sex discrimination in specific HHS grant programs by clarifying that the prohibition on discrimination on the basis of sex includes discrimination on the basis of sexual orientation and gender identity. Impact: Clarifies non-discrimination protections in specific HHS grant programs including services and grants that provide aid to refugees, assistance to people experiencing homelessness, substance use treatment and prevention, community mental health services, maternal and child health services, and community services. 

Operations and Outreach

Health Equity Goal: Provide outreach and technical assistance to the public to advance our health equity activities in civil rights and HIPAA.

• Ensured communications are available to the public by widely publicizing OCR’s dedicated email for inquiries and monitoring and responding to inquiries on a daily basis, with over 55,000 responses to public inquiries per year. Impact: OCR connects with the public by regularly responding to inquiries on subjects such as civil rights, religious conscience, and health information privacy through providing technical assistance, information on rulemaking, and, at times, speaking directly with staff.
• Translated the OCR Complaint Portal into 15 languages and updated the complaint   form to include gender inclusive language. Impact: Increase the accessibility of OCR services for people with different language access needs and gender identities.
• Updated OCR’s toll-free support line to provide the consumer with self-service options and provide OCR the ability to collect data on calls received to serve callers better. Impact: Improves ability to provide individuals information more efficiently, re-route their calls to other agencies, and start to identify trends from data received from callers. 

Language Access

Health Equity Goal: Advance meaningful access for individuals with limited English proficiency and effective communication for individuals with disabilities by issuing guidance to states and health care providers and by ensuring the Department delivers linguistically appropriate and accessible programs and services

• Relaunched the Language Access Steering Committee and released an HHS Language Action Plan setting forth practical guidance, best practices, and action steps Operating and Staff Divisions can use to develop their own, agency-specific language access plans. The plan also calls for agencies to collect data regarding their language access services. Impact: The Language Access Plan helps Departmental agencies ensure access to timely, quality language assistance services including translation and effective communication services that will have a disproportionately greater impact on individuals with disabilities and individuals with limited English proficiency. The data collection component of the Language Access Plan also helps agencies identify and address communication barriers to equal opportunity that underserved communities face.  
• Issued a letter reminding states of their obligations under federal civil rights laws to ensure that individuals and families continue to have access to effective communication in Medicaid and Children’s Health Insurance Program coverage as states return to normal processes to redetermine enrollees’ eligibility, (i.e., post COVID-19 public health emergency Medicaid and CHIP “unwinding”). Impact: Improves compliance with civil rights requirements by requiring states to meet individuals’ communication needs. This letter helped to improve states’ understanding of their responsibility to provide effective communication in the Medicaid Unwinding process and addresses communication needs for individuals identified in EO 14091, Further Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. OCR’s letter reminded states of their obligations to ensure non-discrimination on the basis of race, color, national origin, and disability, and anticipates that this work will bolster state efforts to retain children and families on Medicaid programs, reducing the medical and financial risks caused by coverage gaps.  
• Issued guidance on federal non-discrimination laws that require accessibility for people with disabilities and limited English proficiency in health care provided via telehealth. Impact: Helps health care providers better understand their non-discrimination obligations and helps patients better understand their rights under federal law.

Environmental Justice

Health Equity Goal: Address health disparities and reduce environmental risks for underserved communities by ensuring compliance with federal civil rights laws.

• Initiated the first-ever federal government environmental justice enforcement action over a lack of wastewater disposal systems in Lowndes County, Alabama, where the majority of residents are Black and low income. Entered a Settlement Agreement that requires the State of Alabama to take several actions to address the problem, including assessing need for wastewater disposal, developing a public health and infrastructure plan, seeking funding and technical assistance, and adopting a moratorium on enforcing criminal statutes and liens on properties that lack approved wastewater disposal systems. Impact: Helps residents of Lowndes County access clean water and public health resources. The Settlement Agreement requires the Alabama Department of Public Health to take a number of measures, including launching a public health campaign, providing educational materials on the impacts of sewage to health care providers, and creating a sustainable and equitable public health infrastructure improvement plan. This action also creates a model for future actions under Title VI and Section 1557.

Substance Use Disorder and Related Conditions

Health Equity Goal: Increase awareness of non-discrimination laws that protect individuals involved in child welfare who are in recovery from substance use disorder.

• Resolved a complaint that a county child welfare agency denied an individual the opportunity to apply to be a foster parent because she receives medication for the treatment of substance use disorder. The investigation and subsequent settlement identified systemic concerns regarding the state child welfare agency’s oversight of county child welfare agencies’ compliance with federal disability rights laws. Impact: Protects the civil rights of individuals with substance use disorders. OCR enforced its authorities through a voluntary resolution agreement that required the state welfare agency to take a number of corrective actions that adopt OCR non-discrimination standards for individuals living with a substance use disorder.

Health Equity Goal: Increase Health Care Coordination and Confidentiality for Patients with Substance Use Challenges

• Published a Final Rule on Confidentiality of Substance Use Disorder Patient Records to bring its requirements into closer alignment with HIPAA Rules. Impact: Increases coordination among providers in any setting, including those who treat individuals with substance use disorder and clarifies protections surrounding records disclosure to help address concerns that discrimination and fear of prosecution may deter individuals with substance use disorder from seeking health care. Such protections include civil enforcement and requiring reporting of breaches of substance use disorder treatment records.  
• Introduced a video series on federal disability rights protections that apply to some individuals in recovery from an opioid use disorder. The five-part series discusses   protections that apply to some individuals in recovery from an opioid use disorder and       provides an overview of medications for opioid use disorder (MOUD). Impact: Provides clear and accessible guidance on disability protections for individuals in recovery for opioid use disorder.

Health Information Privacy

Health Equity Goal:  Advance health equity and the attainment of the highest level of health for all people by supporting the privacy and security of individuals’ health information.

• Protected patient privacy and access to health care by issuing Guidance on the HIPAA Privacy Rule and Disclosures of Information Relating to Reproductive Health Care , which addresses when the HIPAA Privacy Rule permits disclosure of protected health information without an individual’s authorization and the limitations on these disclosures. Impact: Helps improve privacy protections for patients seeking reproductive health care. Infringements on reproductive health privacy are likely to have a disproportionate impact on women and communities that have been historically underserved.  
• Released guidance on Protecting the Privacy and Security of Your Health Information When Using Your Personal Cell Phone or Tablet , which explains that the HIPAA Rules do not apply to individuals’ health information when it is stored or accessed using a personal mobile device. This guidance also explains how to turn off location services on Apple and Android devices and identifies best practices for selecting apps, browsers, and search engines that are recognized as supporting increased privacy and security. Impact: Supports patients’ privacy rights and expectations and advances confidence in the confidentiality of patient communications with their health care provider and the privacy of their health records. The guidance will help provide accessible information on health information privacy, including to individuals who may be reliant on telehealth services and those who may have not been previously exposed to information on data privacy.  
• Support Patient Privacy in Reproductive Health Care Privacy by publishing a notice of proposed rulemaking on the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule , which would prohibit the use or disclosure of protected health information to investigate or prosecute patients, providers, and others involved in the provision of lawful reproductive health care. Impact: Advances trust in the patient-provider relationship and ensures that patients’ private medical records will not be disclosed and used against people for merely seeking, obtaining, providing, or facilitating lawful reproductive health care. Infringements on health information privacy related to reproductive health care are likely to have a disproportionately greater effect on women, individuals of reproductive age, and individuals from communities that have been historically underserved.

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Designing solutions to ensure equity in health care

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Growing up in the Boston suburbs, MIT senior Daisy Wang spent her spare time upside down underwater, dancing with her competitive artistic swimming team. 

“It feels like you and your teammates are one unit in the water, moving and working together, and there is an incredible amount of trust involved with all of the lifts and throws,” she said from her dorm room on campus. 

From synchronized swimming, Wang learned a valuable lesson about how people are deeply interconnected: One person’s challenge is everyone’s challenge. Many evenings, when Wang isn’t at MIT, she can be found pacing the deck of the very same pool at Cambridge Synchro, where she’s moved into a coaching role on the team. 

Wang is an aspiring physician, majoring in biological engineering and minoring in women’s and gender studies . She says what pulls her into both disciplines is a passion for engineering solutions for social problems that have the potential to effect systemic change. 

“I am a completely different person in my biological engineering classes and my women’s and gender studies courses,” Wang says. Biological engineering demands creative problem-solving and boundless iteration, while women’s and gender studies requires a different, equally critical skill set, she says.

“From my first WGS.101 class, we have never just read a static text. We apply the texts to our lives and share our personal experiences, looking at the real world through a gender framework,” she says. 

Finding ways to benefit society

In fall 2023, Wang’s two academic worlds unexpectedly collided in class 20.380 (Biological Engineering Design), a capstone course in which small groups of undergraduates integrate theoretical knowledge to design hypothetical new products to benefit society. 

She explains, “My team wanted to come up with a system that could automatically sense opioid overdose in drug users and administer an emergency treatment of Narcan (naloxone HCI).” 

The National Institute on Drug Abuse reported that in 2021, there were 80,411 opioid overdose deaths in the United States. Although Narcan, a drug that rapidly reverses overdose, is increasingly available at major drug stores like CVS, Wang and her colleagues noted that Narcan cannot be self-administered. 

Many overdoses take place when users are alone. Wang says, “Narcan works by binding to the opioid receptors and acts as an antagonist. Our idea was to develop a microneedle patch to detect and treat overdose.” 

As Wang learned more about the opioid epidemic, she realized that, “Ultimately, new technologies mean nothing if we can’t make them work for the people that need them.” 

In her work as an intern in the Health Equity Research Lab at Cambridge Health Alliance, she sees this firsthand in a local hospital system. With funding from the Priscilla King Gray Public Service Center  at MIT, Wang is helping a team analyze data regarding the implementation of a mental health survey tool used by clinicians to monitor patients’ symptoms. 

She says, “Right now, this is a digital survey tool — and that’s actually a big equity issue. For example, many patients don’t speak English, and some don’t have access to a phone with internet access, which is how the survey is administered.” Wang is digging deeply into both qualitative and quantitative data to make recommendations for improving this tool for the future.

The internship helped her determine that she wants to specialize in implementation science as a physician, studying how evidence-based solutions are translated into practice and made accessible to patient populations. 

“Passion breeds passion”

Back on campus, Wang is the operations chair of PLEASURE@MIT , a student-led group that sets out to increase positive relationships on campus through education and shifting cultural norms. She often facilitates peer-to-peer workshops and training on sensitive topics like safe sex, consent, self-love, and positive body image. 

This experience of facilitating difficult conversations, listening deeply, and helping to support a community translated into fieldwork in Oyugis, Kenya, this January as a student enrolled in EC.718/WGS. 277 (MIT D-Lab Gender and Development course). The class was co-taught by Sally Haslanger, the Ford Professor of Philosophy and Women's and Gender Studies, and D-Lab lecturer Libby McDonald. 

In the field, Wang and peers supported an ongoing D-Lab initiative in collaboration with an in-country community-based organization, the Society Empowerment Project. Together, they aimed to co-design solutions for educating youth on menstrual and reproductive health and ways to support teen parents. 

Her biggest takeaway was observing, “Passion breeds passion.” That was especially true among team members who gave up sleep each night of the trip to prepare slides for the following day’s workshop and motivated one another to care deeply about the community. She says, “This was also applicable to the participants who commuted from far away to partake in the workshop and reflect deeply on solutions.”

The experience in Kenya brought together Wang’s studies, research, internship, and even her biggest future goal of becoming a physician advocating for patients. 

She dove in with excitement, but just like in synchronized swimming, Wang says, “We did everything in true partnership with the team on the ground. While we provided support about the design cycle and logistics of ideation, imaging, prototyping, and testing, our partners were the ones thinking up their own program.” One move at a time. 

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

5 The Role of Nurses in Improving Health Equity

Being a nurse … in 2020 must mean being aware of social injustices and the systemic racism that exist in much of nursing … and having a personal and professional responsibility to challenge and help end them. —Calvin Moorley, RN, and colleagues, “Dismantling Structural Racism: Nursing Must Not Be Caught on the Wrong Side of History”

Health equity is achieved when everyone has a fair and just opportunity to be as healthy as possible. Nurses are well positioned to play a major role in addressing the underlying causes of poor health by understanding and recognizing the wide range of factors that influence how well and long people live, helping to create individual- and community-targeted solutions, and facilitating and working with interdisciplinary and multisector teams and partners to implement those solutions. Nurses have the potential to reshape the landscape of health equity over the next decade by expanding their roles, working in new settings and in new ways, and markedly expanding efforts to partner with communities and other sectors. But for the United States to make substantial progress in achieving health equity, it will need to devote resources and attention to the conditions that affect people’s health and make expanded investments in building nurse capacity. And nursing schools will need to shift education, training, and mindsets to support nurses’ new and expanded roles.

When this study was envisioned in 2019, it was clear that the future of nursing would look different by 2030; however, no one could predict how rapidly and dramatically circumstances would shift before the end of 2020. Over the coming decade, the nursing profession will continue to be shaped by the pressing health, social, and ethical challenges facing the nation today. Having illuminated many of the health and social inequities affecting communities across the nation, the COVID-19 pandemic, along with other health crises, such as the opioid epidemic ( Abellanoza et al., 2018 ), presents an opportunity to take a critical look at the nursing profession, and society at large, and work collaboratively to enable all individuals to have a fair and just opportunity for health and well-being, reflecting the concept of “social mission” described by Mullan (2017 , p. 122) as “making health not only better but fairer.” This chapter examines health equity and the role of nursing in its advancement in the United States.

As stated previously, health equity is defined as “the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance” ( NASEM, 2017a , p. 32). While access to equitable health care, discussed in Chapter 4 , is an important part of achieving health equity, it is not sufficient. Health is affected by a wide range of other factors, including housing, transportation, nutrition, physical activity, education, income, laws and policies, and discrimination. Chapter 2 presents the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) , in which upstream factors represent the social determinants of health (SDOH) that affect individuals and communities in a broad and, today, inequitable way. Low educational status and opportunity, income disparities, discrimination, and social marginalization are examples of upstream factors that impede good health outcomes. Midstream factors comprise social needs, or the individual factors that may affect a person’s health, such as homelessness, food insecurity, and trauma. Finally, downstream factors include disease treatment and chronic disease management.

Much of the focus on the education and training of nurses and the public perception of their role is on the treatment and management of disease. This chapter shifts that focus to nurses’ role in addressing SDOH and social needs, including their potential future roles and responsibilities in this regard, and describes existing exemplars. First, the chapter provides a brief overview of nurses’ role in addressing health equity. Next, it describes opportunities for nurses to improve health equity through four approaches: addressing social needs in clinical settings, addressing social needs and SDOH in the community, working across disciplines and sectors to meet multiple needs, and advocating for policy change. The chapter then details the opportunities and barriers associated with each of these approaches.

NURSES’ ROLE IN ADDRESSING HEALTH EQUITY

As described in Chapter 1 , the history of nursing is grounded in social justice and community health advocacy ( Donley and Flaherty, 2002 ; Pittman, 2019 ; Rafferty, 2015 ; Tyson et al., 2018 ), and as noted in Chapter 2 , the Code of Ethics for Nurses with Interpretive Statements, reiterated by American Nurses Association (ANA) President Ernest J. Grant in a public statement, “obligates nurses to be allies and to advocate and speak up against racism, discrimination, and injustice” ( ANA, 2020 ).

Addressing social needs across the health system can improve health equity from the individual to the system level. The report Integrating Social Care into the Delivery of Health Care identifies activities in five complementary areas that can facilitate the integration of social care into health care: adjustment, assistance, alignment, advocacy, and awareness ( NASEM, 2019 ) (see Figure 5-1 and Table 5-1 ). In the area of awareness, for example, clinical nurses in a hospital setting can identify the fall risks their patients might face upon discharge and the assets they can incorporate into their lives to improve their health. In the area of adjustment, telehealth and/or home health and home visiting nurses can alter clinical care to reduce the risk of falls by, for example, helping patients to adjust risks in their homes and learn to navigate their environment. And these activities can continue to the high level of system change through advocacy for health policies aimed at altering community infrastructure to help prevent falls.

Areas of activity that strengthen integration of social care into health care. SOURCE: NASEM, 2019.

Definitions of Areas of Activities That Strengthen Integration of Social Care into Health Care.

In short, improving population health entails challenging and changing the factors and institutions that give rise to health inequity through interventions and reforms that influence the institutions, social systems, and public policies that drive health ( Lantz, 2019 ). It is important to note, however, that there are shortcomings in how evaluations of health equity interventions are carried out (see Box 5-1 ).

Shortcomings of Evaluations of Health Equity Interventions.

• ADDRESSING SOCIAL NEEDS IN CLINICAL SETTINGS

Although the provision of clinical care is a downstream determinant of health, the clinical setting presents an opportunity for nurses to address midstream determinants, or social needs, as well. Screening for social needs and making referrals to social services is becoming more commonplace in clinical settings as part of efforts to provide holistic care ( Gottlieb et al., 2016 ; Makelarski et al., 2017 ; Thomas-Henkel and Schulman, 2017 ). Nurses may conduct screenings; review their results; create care plans based on social needs as indicated by those results; refer patients to appropriate professionals and social services; and coordinate care by interfacing with social workers, community health workers, and social services providers. Although the importance of screening people for social needs has led more providers to take on this role, it has yet to become a universal practice ( CMS, 2020 ; NASEM, 2016 ), as most physician practices and hospitals do not perform screenings for the five key domains of social need 1 : food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence ( CMS, 2020 ; Fraze et al., 2019 ). As trusted professionals that spend significant time with patients and families, nurses are well equipped to conduct these screenings ( AHA, 2019 ). Federally qualified health centers (FQHCs)—community-based health centers that receive funds from the Health Resources and Services Administration’s (HRSA’s) Health Center Program—often screen for social needs.

In many clinical settings, however, challenges arise with screening for social needs. Individuals may be hesitant to provide information about such issues as housing or food insecurity, and technology is required to collect social needs data and once obtained, to share these data across settings and incorporate them into nursing practice in a meaningful way. While nurses have an educational foundation for building the skills needed to expand their role from assessing health issues to conducting assessments and incorporating findings related to social needs into care plans, this focus needs to be supported by policies where nurses are employed. As the incorporation of social needs into clinical consideration expands, nurses’ education and training will need to ensure knowledge of the impact of social needs and SDOH on individual and population health (see Chapter 7 ). Communicating appropriately with people about social needs can be difficult, and training is required to ensure that people feel comfortable responding to personal questions related to such issues as housing instability, domestic violence, and financial insecurity ( Thomas-Henkel and Schulman, 2017 ). Finally, the utility of social needs screening depends on networks of agencies that offer services and resources in the community. Without the ability to connect with relevant services, screenings and care plans can have little impact. Consequently, it is important for health care organizations to dedicate resources to ensuring that people are connected to appropriate resources, and to follow up by tracking those connections and offering other options as needed ( Thomas-Henkel and Schulman, 2017 ).

• ADDRESSING SOCIAL NEEDS AND SOCIAL DETERMINANTS OF HEALTH IN THE COMMUNITY

While interest in and action to address social needs in the clinical setting is rapidly expanding, nurse engagement in these issues in community settings has been long-standing. Nurses serving in the community often work directly to address social needs at the individual and family levels, and often work as well to address SDOH at the community and population levels. Public health nurses in particular have broad knowledge of health issues and the associated SDOH, as well as needs and resources, at the community level. Embedded within the community, they also are well positioned to build trust and are respected among community leaders. Also playing important roles in addressing social needs within the community are home visiting nurses. At the individual and family levels, home visiting nurses often represent the first line of health care providers with sustained engagement in addressing social needs for many individuals. They recognize and act on the limitations associated with social needs, such as the inability to afford transportation, or may work with an interdisciplinary team at the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to address food issues and other social needs. By connecting with individuals in their neighborhoods and homes, public health and other community-based nurses promote health and well-being for families within communities and engage in this work with partners from across social, health, and other services.

At the population health level, public health nurses work to achieve health equity within communities through both health promotion and disease prevention and control. They often work in municipal and state health departments and apply nursing, social, epidemiology, and other public health sciences in their contributions to population health ( Bigbee and Issel, 2012 ; IOM, 2011 [see AARP, 2010 ]; Larsen et al., 2018 ). They offer a wide range of services to individuals and community members and are engaged in activities ranging from policy development and coalition building to health teaching and case management ( Minnesota Department of Health, n.d. ). Public health nurses serve populations that include those with complex health and social needs, frail elderly, homeless individuals, teenage mothers, and those at risk for a specific disease ( Kulbok et al., 2012 ). Their interventions may target specific health risks, such as substance use disorder, HIV, and tobacco use, or populations at risk for health problems, such as individuals with complex health and social needs. Specific knowledge and skills they bring to communities include the ability to perform assessments of individual, family, and community health needs; use data and knowledge of environmental factors to plan for and respond to public health issues in their community; provide community and health department input in the development of policies and programs designed to improve the health of the community; implement evidence-based public health programs; and develop and manage program budgets ( Minnesota Department of Health, n.d. ).

Public health nursing roles are characterized by collaboration and partnerships with communities to address SDOH ( Kulbok et al., 2012 ). Core to public health nursing is working across disciplines and sectors to advance the health of populations through community organizing, coalition building, policy analysis, involvement in local city and county meetings, collaboration with state health departments, and social marketing ( Canales et al., 2018 ; Keller et al., 2004 ). Yet, while the work of public health nurses is foundational to the health of communities, their work is rarely visible. Additionally, regarding measurable reductions in health disparities, little research is available that connects directly and explicitly to public health nursing roles ( Davies and Donovan, 2016 ; Schaffer et al., 2015 ; Swider et al., 2017 ).

Recent experiences with H1N1, Ebola, Zika, and COVID-19 underscore the importance of having strong, well-connected, well-resourced social services, public health, and health care systems, matched by an adequate supply of well-educated nurses. A 2017 report from the National Academies of Sciences, Engineering, and Medicine focused on global health notes that when infectious disease outbreaks occur, significant costs are often associated with fear and the worried-well seeking care ( NASEM, 2017b ). In their role as trusted professionals, and given their widespread presence in communities, incorporating public health nurses into community, state, and federal government strategies for health education and dissemination of information can help extend the reach and impact of messaging during infectious disease outbreaks and other public health emergencies. Nurses can serve as expert sources of information (e.g., on preventing infectious disease transmission within their communities) ( Audain and Maher, 2017 ). In the United States, for example, as Zika infections were identified and spreading, one of the strategies used by the U.S. Department of Health and Human Services (HHS) was to work through nursing associations to reach nurses and through them, help reach the public with factual information and minimize unnecessary resource use (Minnesota Department of Health, 2019 ). Given their expertise in community engagement and knowledge of local and state government health and social services assets, public health nurses are well positioned to link to and share health-related information with community partners to help reach underresourced populations, including homeless individuals, non-English-speaking families, and others.

• WORKING ACROSS DISCIPLINES AND SECTORS TO MEET MULTIPLE NEEDS

As nurses work in concert with other sectors and disciplines, interventions that address multiple and complex needs of individuals and communities can have far-reaching impacts on health outcomes and health care utilization. Through partnerships, community-based nurses work to address an array of health-related needs ranging from population-level diabetes management to community-based transportation to enable low-income families to access health care services.

Because multiple factors influence individual and population health, a multidisciplinary, multisectoral approach is necessary to improve health and reduce health inequity. While an approach focusing on only one SDOH may improve one dimension of health, such as food insecurity, intersectional approaches that simultaneously address complex, holistic needs of individuals, families, and communities are often required. Commonly found across underresourced communities are layers of intersecting challenges impacting health, ranging from adverse environmental exposures to food deserts. Health care systems, community-based organizations, government entitities, nurses, and others are increasingly working together to design interventions that reflect this complexity ( NASEM, 2017a , 2019 ). Creative alliances are being built with for-profit and not-for-profit organizations, community groups, federal programs, hospitals, lending institutions, technology companies, and others ( NASEM, 2019 ).

Work to prioritize and address health disparities and achieve health equity is predicated on meaningful, often multidimensional, assessments of community characteristics. One key opportunity to inform multisectoral efforts lies in community health needs assessments. The Patient Protection and Affordable Care Act requires nonprofit hospitals to conduct these assessments every 3 years, with input from local public health agencies. These assessments are then used to identify and prioritize significant health needs of the community served by the hospital while also identifying resources and plans for addressing these needs. Conducting a community health needs assessment is itself a multisectoral collaboration as it requires engaging community-based stakeholders ( Heath, 2018 ). The results of the assessment present opportunities for multiple sectors to work together. For example, a hospital may partner with public health and area food banks to address food insecurity. Or it may partner with a health technology company and a local school board to address digital literacy for underserved youth and their families, and also extend the reach of broadband to support health care access through telehealth technology and strengthen digital literacy. In assessing the community’s health needs, these hospitals are required to obtain and consider community-based input, including input from individuals or organizations with knowledge of or expertise in public health. The reports produced as part of this process are required to be publicly available ( IRS, 2020 ).

These and other community engagement efforts can involve nurses from a variety of clinical and community-based settings in any and all steps of the process, from design to implementation and evaluation of the assessments themselves or the processes and programs established to address identified priorities. For example, the Magnet recognition program of the American Nurses Credentialing Center requires participating hospitals to involve nurses in their community health needs assessments ( ANCC, 2017 ).

A variety of models feature nurses directly addressing health and social needs through multidisciplinary, multisectoral collaboration. Two illustrative programs are described below: the Camden Core Model and Edge Runner.

Camden Core Model

The Camden Coalition, based in Camden, New Jersey, is a multidisciplinary, nonprofit organization that works across sectors to address health and social needs. The Coalition’s formation was based on the recognition that the U.S. health care system far too often fails people with complex health and social needs. These individuals cycle repeatedly through multiple health care, social services, and other systems without realizing lasting improvements in their health or well-being. The Coalition employs multiple approaches that include using faith-based partnerships to deliver health services and encourage healthy choices; sharing data among the criminal justice, health care, and housing sectors to identify points of intervention; and building local and national coalitions to support and educate others interested in implementing this model ( Camden Coalition, n.d. ). One of the Coalition’s best-known programs is the Camden Core Model. This nationally recognized care management intervention is an example of a nurse-led care management program for people with complex medical and social needs. It applies the principles of trauma-informed care and harm reduction with the aim of empowering people with the skills and support they need to avoid preventable hospital use and improve their well-being ( Finkelstein et al., 2020 ; Gawande, 2011 ). The model uses real-time data on hospital admissions to identify “superutilizers,” people with complex health issues who frequently use emergency care. An interprofessional team of registered nurses (RNs) and licensed practical nurses (LPNs), social workers, and community health workers engage in person with these individuals to help them navigate their care by connecting them with medical care, government benefits, and social services ( Camden Coalition, n.d. ; Finkelstein et al., 2020 ). With federal funding, similar versions of the model have been extended to cities outside of Camden (AF4 Q, 2012 ; Crippen and Isasi, 2013 ; Mann, 2013 ).

Camden Coalition partnerships optimize the use of nurses in the community in several ways. An interprofessional team of nurses, social workers, and community health workers visits program participants, helps reconcile their medications, accompanies them to medical visits, and links them to social and legal services. Critical to the model’s success is recruiting nurses who are from the local community, capitalizing on their cultural and systems-level knowledge to facilitate and improve access to and utilization of local health and social services. The culture of the Camden Coalition model has been key to its success. The uniform commitment of nurses, staff, and leadership to addressing people’s complex needs has created a supportive work environment in which each team member’s role is optimized. Care Team members have accompanied people to their meetings and appointments for primary care, helped with applications for such public benefits as food stamps, provided referrals to social services and housing agencies, arranged for medication delivery in partnership with local pharmacies, and coordinated care among providers.

The Camden Coalition focuses on “authentic healing relationships,” defined as secure, genuine, and continuous partnerships between Care Team members and patients. This emphasis has evolved into a framework for patient engagement known as COACH, which stands for C onnect tasks with vision and priorities, O bserve the normal routine, A ssume a coaching style, C reate a backward plan, and H ighlight progress with data. An interprofessional team of nurses, social workers, and community health workers visits participants in the community. Team members are trained to problem solve with patients to achieve the program goals of helping them manage their chronic health conditions and reducing preventable hospital admissions.

Early evidence of the program’s effect in a small sample showed a 56 percent reduction in monthly hospital charges, a roughly 40 percent reduction in monthly visits to hospitals and emergency departments, and an approximately 52 percent increase in rates of reimbursement to care providers ( Green et al., 2010 ), although later evidence from a randomized controlled trial (RCT) indicated that the Camden Core Model did not reduce hospital readmissions ( Finkelstein et al., 2020 ). Other RCTs, conducted in Philadelphia and Chicago, showed that similar social care programs using case management and community health workers can reduce hospital admissions and save money in addition to improving health and quality of health care. Kangovi and colleagues (2018) conducted an RCT in Philadelphia to assess Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention addressing unmet social needs across three health systems ( Kangovi et al., 2018 ). After 6 months, patients in the intervention group compared with controls were more likely to report the highest quality of care and spent fewer total days in the hospital (reduced by about two-thirds), saving $2.47 for each dollar invested by Medicaid annually ( Kangovi et al., 2020 ). The RCT in Chicago assessed the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical conditions and found a 29 percent reduction in hospitalizations and a 24 percent reduction in emergency department visits ( Sadowski et al., 2009 ).

Edge Runner

The American Academy of Nurses’ Edge Runner initiative identifies and promotes nurse-designed models of care and interventions that can improve health, increase health care access and quality, and/or reduce costs ( AAN, n.d.a ). As of February 2020, 59 such programs had been evaluated against a set of criteria and designated as part of this initiative. Many Edge Runner programs are built around the needs of underserved communities and seek to improve health through holistic care that addresses social needs and SDOH, including a range of upstream, midstream, and downstream determinants. Mason and colleagues (2015) assessed 30 Edge Runner models identified as of 2012, finding four main commonalities that illustrate these programs’ broad and encompassing approach to health.

A holistic definition of health. Across the programs, health was defined broadly to include physical, psychological, social, spiritual, functional, quality-of-life, personal happiness, and well-being aspects. Additionally, the definition of health was based on the values of clients and shaped around their preferences. Typically, programs were grounded in SDOH to inform their design of individual- and community-level interventions.

Individual-, family-, and community-centric design. Most programs prioritized individual, family, and community goals over provider-defined goals through a “participant-led care environment” and “meeting people where they are.” Thus, interventions were tailored to the values and culture present at each of these three levels.

Relationship-based care. The programs reflected the importance of building trusting relationships with individuals, families, and communities to help them engage in ways to create and sustain their own health.

Ongoing group and public health approaches to improving the health of underserved populations. The nurses who designed the programs viewed serving underserved populations as a moral imperative. Through peer-to-peer education, support groups, and public health approaches, they sought to empower clients, give them a sense of control, build self-care agency, and increase resilience.

An in-depth study of three Edge Runner programs (the Centering Pregnancy model, INSIGHTS, and the Family Practice and Counseling Network) revealed particular lessons: the essential role of collaboration and leaders who can collaborate with a wide range of stakeholders, the need for plans for scalability and financial sustainability, and the importance of social support and empowerment to help people ( Martsolf et al., 2017 ). In these and other models, the capacity and knowledge associated with building meaningful, sustained partnerships across sectors is a key dimension of nursing practice that impacts health equity. The Edge Runner programs emphasize how, in the pursuit of improving care, lowering costs, and increasing satisfaction for people and families, nurses are actively working to achieve person-centered care that addresses social needs and SDOH and focusing on the needs of underserved populations to promote health equity ( Martsolf et al., 2016 , 2017 ; Mason et al., 2015 ). However, evidence directly linking the programs to decreases in disparities is generally not available. Two examples of Edge Runner programs are described in Box 5-2 .

Examples of Edge Runner Programs.

As models continue to evolve and be disseminated, it is critical to establish an evidence base that can help understand their impact on health and well-being and their contribution to achieving the broader aim of health equity. For care management programs incorporating social care, it is important to consider a broad array of both quantitative and qualitative measures beyond health care utilization ( Noonan, 2020 ). Although RCTs generate the most reliable evidence, this evidence can be limited in scope. For example, the RCTs cited above assessed neither the multidimensional nature of care management/social care models that might be reflected in such outcomes as client self-efficacy, satisfaction, or long-term health outcomes nor their potential social impacts. Also important to note is that care management models incorporating social care are limited by the availability of resources in the community, such as behavioral health services, addiction treatment, housing, and transportation. Programs that connect clients to health and social services are unlikely to work if relevant services are unavailable ( Noonan, 2020 ). Important to underscore in the context of this report is that multisector engagement, as well as health care teams that may involve social workers, community health workers, physicians, and others engaging alongside nurses, all are oriented to a shared agenda focused on improving health and advancing health equity.

• ADVOCATING FOR POLICY CHANGE

Public policies have a major influence on health care providers, systems, and the populations they serve. Accordingly, nurses can help promote health equity by bringing a health lens to bear on public policies and decision making at the community, state, and federal levels. Informing health-related public policy can involve communicating about health disparities and SDOH with the public, policy makers, and organizational leaders, focusing on both challenges and solutions for addressing health through actions targeted to achieving health equity.

When nurses engage with policy change as an upstream determinant of health, they can have a powerful and far-reaching impact on the health of populations. In the National Academy of Medicine’s Vital Directions series, Nancy Adler and colleagues (2016) note that “powerful drivers of health lie outside the conventional medical care delivery system…. Health policies need to expand to address factors outside the medical system that promote or damage health.” Because health inequities and SDOH are based in social structures and policies, efforts to address them upstream as the root of poor health among certain populations and communities need to focus on policy change ( NASEM, 2017a ). Nurses alone cannot solve the problems associated with upstream SDOH that exist outside of health care systems. However, by engaging in efforts aimed at changing local, state, or federal policy with a Health in All Policies approach, 2 they can address SDOH that underlie poor health ( IOM, 2011 ; NASEM, 2017a ; Williams et al., 2018 ). Whether nurses engage in policy making full time or work to inform policy part time as a professional responsibility, their attention to policies that either create or eliminate health inequities can improve the underlying conditions that frame people’s health. Nurses can bring a health and social justice lens to public policies and decision making at the community, state, and federal levels most effectively by serving in public- and private-sector leadership positions. Much of this work is discussed in Chapter 9 on nursing leadership, but it is noted in this chapter given the substantial influence that policy decisions have on health equity. Nurses can and should use their expertise to promote policies that support health equity.

For example, a nurse in Delaware was influential in getting the state’s legislature to pass legislation to implement a colorectal cancer screening program that has increased access to care and reduced disparities in morbidity and mortality from colorectal cancer (see Box 5-3 ). While individual nurses, often through their workplace and professional associations, engage in upstream efforts to impact health equity, there have been repeated calls from within the nursing community for more nurses to engage in informing public policy to improve health outcomes for individuals and populations.

Delaware Cancer Consortium.

• CONCLUSIONS

In the coming decade, the United States will make substantial progress in achieving health equity only if it devotes resources and attention to addressing the adverse effects of SDOH on the health of underresourced populations. As 2030 approaches, numerous initiatives to address health equity are likely to be launched at the local, state, and national levels. Many of these initiatives will focus on health care equity. Yet, while expanding access to quality care is critical to reducing disparities and improving health outcomes, such efforts need to be accompanied by additional efforts to identify and change the social institutions, dynamics, and systems underlying health inequities from the local to the national level. Nurses can contribute to reshaping the landscape of health equity over the coming decade by serving in expanded roles, working in new settings and new ways, and partnering with communities and other sectors beyond health care. Some nurses are already working in roles and settings that support health equity and are engaged in educating about and advocating for health equity through their professional associations. Nonetheless, broader engagement as a core activity of every nurse will help advance health equity nationwide. To achieve this aim will require

• support for and the willingness of the nursing workforce to take on new roles in new settings in the community;
• consistency in nurses’ preparation for engaging in downstream, midstream, and upstream strategies aimed at improving health equity by addressing issues that compromise health, such as geographic disparities, poverty, racism, homelessness, trauma, drug abuse, and behavioral health conditions;
• more experiential learning and opportunities to work in community settings throughout nursing education to ensure that nurses have skills and competencies to address individuals’ complex needs and promote efforts to improve the well-being of communities;
• nursing education that goes beyond teaching the principles of diversity, equity, and inclusion to provide sustained student engagement in hands-on community and clinical experiences with these issues;
• funding to support new models of care and functions that address SDOH, health equity, and population health; and
• evaluation of models to build the evidence needed to scale programs and the policies and resources necessary to sustain them.

These issues are discussed in the chapters that follow. Programs described in this chapter, such as the Camden Coalition and the Edge Runner initiatives, are exemplars of the kind of multidisciplinary, multisector efforts that will be necessary to address the complex needs of individuals and communities and make a lasting impact by eliminating health disparities, with the goal of achieving health equity. Central to these future efforts, however, are parallel efforts that evaluate and provide the evidence base on which to determine the effectiveness of models. One of the greatest challenges this committee faced was finding evidence directly linking the efforts of nurses to address social needs and SDOH to reductions in health disparities that would signal improved population health outcomes and health equity. Such evidence is essential to informing payment policy decisions that can ensure the sustainability of and nurse engagement in these models (discussed further in Chapter 6 ). Through evidence, the nursing profession can leverage its own potential, and the public, other professionals, and other sectors can understand the impact and value of such nursing engagement.

Conclusion 5-1: Nurses are in a position to improve outcomes for the underserved and can work to address the structural and institutional factors that produce health disparities in the first place. Conclusion 5-2: Nurses can use their unique expertise and perspective to help develop and advocate for policies and programs that promote health equity.

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These five domains of social needs are part of the Centers for Medicare & Medicaid Services’ Accountable Health Communities Model ( Fraze et al., 2019 ).

Health in All Policies (HiAP) is a collaborative approach that integrates health considerations into policy making across sectors. It recognizes that health is created by a multitude of factors beyond health care and in many cases, beyond the scope of traditional public health activities. In accordance with HiAP, for example, decision makers in the health care sector should consider transportation, education, housing, commerce, and other sectors impacting communities. HiAP stresses the need to work across government agencies and with private partners from these different sectors to achieve healthy and safe communities. It also encourages partnerships between the health care sector and community developers, for example ( CDC, 2016 ).

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 5, The Role of Nurses in Improving Health Equity.
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