I was taught about the difference between health equity and health equality in college with a simple illustration. Imagine there are three people standing by a fence, one tall, one mid-height, and one short, all trying to look over the fence to see a baseball game. Equality would be to give each person one box to stand on to watch the game. In this scenario, the box was enough to allow the mid-height person to see the game, but not enough for the short person, and the tall person didn’t need the box to see the game at all. But in the illustration for equity, each person was given the amount of boxes they needed to see the game. The tall person didn’t need a box to see over the fence, the medium-height person only needed one, and the shortest person needed two boxes to be able to see. With an equitable distribution of boxes, all people were able to see the game from the same perspective, because the shortest person started with the greatest disadvantage.
The Harsh Reality of Health Inequity in the U.S.
What does health inequity in the United States look like? Health inequities are reflected in a variety of measures including the differences in quality of life and access to treatment, as well as rates of disease, disability, and death. Data shows that compared with white Americans, minorities have worse overall physical and mental health statuses, as well as substantially worse outcomes for a variety of health measures, with higher prevalence of chronic conditions. On average, Americans who are Black have a four year lower life expectancy than those who are white. The discrepancies in maternal and infant mortality rates between Black and white Americans are especially alarming, with infant mortality rates being over twice as high, and the likelihood of maternal mortality being over three times more likely for Black Americans.
Health inequities in the U.S. are tightly intertwined with social determinants of health (SDOH), with racial and ethnic minorities often having poorer SDOH compared with white Americans. SDOH are an individual’s inherent circumstances and environments that heavily impact a person’s quality of life and health outcomes. According to Healthy People 2030, social and community context, education access and quality, health care access and quality, neighborhood and built environment, and economic stability are considered SDOH. However, the dynamic and innovative nature of the U.S. healthcare system leads to rapid change, presenting new challenges for achieving equity and further growing the disparity gap.
Though disparities in individuals’ SDOH play a fundamental role in the growing gap of health inequity, rapid adoption of digital health technologies during the pandemic have shed light on a newer concept: digital determinants of health (DDOH). The digital divide is far from a new concept, but the rise of digital technologies in healthcare present novel challenges and opportunities to address inequities. Some examples of DDOH include:
- Access to digital resources
- Use of digital resources for health seeking or health avoidance
- Digital health literacy
- Beliefs about potential for digital health to be helpful or harmful
- Values and cultural norms/preferences for use of digital resources
- Integration of digital resources into community and health infrastructure
Telehealth revolutionized access to care during a time when it was unsafe to seek care in person, but did the people who have the greatest need for access to care also reap the benefits of telehealth? According to a study in the beginning of the pandemic, patients who are older, non-English-speaking, non-white and who have lower socioeconomic statuses were all less likely to access telemedicine services. One opportunity to optimize health equity in today’s digital health environment is the concept of mobile health, or “mHealth”. Only 66% of Black and 61% of Latinix adults report owning a computer, compared with 82% of white adults. However, roughly 80% of Black and Latinix adults own a smartphone and rely on their phone for medical information more compared with white adults.
Primary Care: A Vessel for Achieving Health Equity
It is no secret that having a primary care provider can improve the overall health of individuals and communities. Studies show that without access to a primary care provider, individuals are less likely to obtain preventive services, more likely to experience worse health outcomes, and are at a greater risk for hospitalization or emergency department treatment. And primary care can do the most good for vulnerable populations. Black women who have breast cancer are twice as likely to experience delayed diagnosis than white women, resulting in a 1.6 times increased odds of breast cancer mortality. Primary care providers play a fundamental role in preventative measures and early detection, ensuring women get timely mammograms which significantly improves outcomes for women with breast cancer.
Analyses find that higher ratios of primary care physicians to a population are associated with relatively greater health outcomes in areas with higher income inequality than in areas of low income inequality. Additionally, although the supply of primary care physicians reduces the total mortality rate in all populations, there is a greater positive impact on African American populations compared to white populations. Primary care physicians have the unique ability to build trust through long-term relationships with their patients, which is integral to minority and vulnerable populations who may have issues trusting healthcare providers or the system as a whole. Additionally, primary care practices (particularly independent practices) are often positioned in the heart of communities, allowing primary care providers to provide care within the valuable context of their patient populations’ distinct social determinants of health.
Though primary care is a determining factor in addressing health inequities, there are a number of systemic issues in the U.S. healthcare system that can and need to be addressed on the front end in order to make significant strides toward bridging the health inequity gap. One of which being increasing the diversity of medical school students and professionals. Research has found that patients who share the same ethnicity as their physician, or racial concordance, have more positive health impacts. For instance, Black men are more likely to take preventative health measures recommended by Black physicians. Many minorities have experienced some degree of implicit bias in healthcare encounters throughout their lifetime, which can explain why race/ethnic-concordant encounters lead to higher trust and better health outcomes. Developing intentional initiatives for increasing diversity in medical school recruitment and surfacing opportunities in the health profession early on for children and teens in minority communities are both pivotal steps to begin increasing diversity in healthcare professionals and ultimately achieving health equity.