What Is Health Equity? Tracing Equity Origins and Progress

Defining Health Equity

According to the Centers for Disease Control and Prevention (CDC), health equity is “the state in which everyone has a fair and just opportunity to attain their highest level of health.”

Health equity does not mean giving the same or equal type of healthcare to all patients; rather, it is giving patients the tailored tools they need to achieve an equal level of health and well-being, the Robert Wood Johnson Foundation says. Said otherwise, one size does not fit all when it comes to patient care.

“[Achieving health equity] requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care,” according to RWJF.

CDC states that achieving health equity requires addressing historical and contemporary injustices, like institutional racism; overcoming social determinants of health impeding healthcare; and eliminating preventable health disparities.

Right now, true health equity in America is elusive. In a June 2022 report, Massachusetts-based thinktank Lown Institute found that fewer than 2 percent of hospitals excel at health equity, which the researchers measured as having pay equity, inclusivity, and community benefits.

Promoting health equity at a hospital or organization level requires leadership buy-in and for those leaders and other stakeholders to have a deep understanding of the organization’s unique population health needs and resources.

Efforts to support staff diversity, promote culturally competent care, drive community engagement, address social determinants of health, improve data collection and analytics, and participate in policy advocacy may help organizations push for more health equity.

Health Equity’s Historical Roots

Although health equity may seem like a modern concept that gained momentum in response to the nation’s push for overall racial equity and civil rights, the concept dates back to the 19th century.

By 1946, the World Health Organization proclaimed within its constitution that “the highest standards of health should be within reach of all, without distinction of race, religion, political belief, economic or social condition.”

In the US, the 1895 establishment of the National Medical Association (NMA) highlights a formal start to a focus on health equity, although it is clear that minoritized populations had their own small-scale efforts for health equity.

NMA was founded when healthcare was still racially segregated, resulting in serious disparities in healthcare access and outcomes. One of NMA’s primary focuses was ensuring access to professional healthcare for all.

By 1912, NMA was focusing on how to increase the number of Black physicians and improve the well-being of the Black population. NMA was also active during the Civil Rights Movement of the mid-20th Century.

“Fueled by demonstrations occurring in other parts of the country, the NMA coordinated sit-ins, marches and picket lines to advocate civil rights. Active participation replaced passivity,” NMA says on its website. “The NMA lobbied to pass the Civil Rights Act of 1964 and supported Dr. Martin Luther King’s 1965 voter registration campaign in Selma, Alabama.”

On the federal level, momentum for health equity didn’t build until 1985 with HHS’ Heckler Report, or the Report on Black and Minority Health. HHS said that this report sparked the agency’s efforts to understand and address health disparities.

In 1986, HHS created its sub-agency, the Office of Minority Health, and in 1987, OMH established its resource center to publicize materials to learn more about minority health and health disparities.

HHS counts the Americans with Disabilities Act (ADA) as a key step toward achieving health equity. And in 2000, in its second iteration of the Healthy People initiative, HHS, for the first time, called for the elimination of health disparities. This call has been echoed in Healthy People 2010, 2020, and 2030.

Since then, HHS and related federal agencies have made small steps advocating for health equity, while healthcare organizations themselves have worked to better understand the health disparities and barriers impacting their individual populations.

However, health equity didn’t become a prominent topic until much later, in large part as a response to the COVID-19 pandemic and the nation’s overall push for social justice.

Impetus for Promoting Health Equity

Although the reasons for promoting health equity may be obvious—and the work to achieve health equity has been going on for decades—health equity has only been a kitchen table topic for a few years.

It started with the COVID-19 pandemic, which illuminated the deep racial health disparities that have existed for centuries. The pandemic sparked a nationwide movement to spread awareness and begin the work to dismantle those disparities.

Hospitals nationwide made pledges to promote racial equity in healthcare; the American Hospital Association’s Institute for Diversity and Health Equity even published a health equity pledge form. At the American Hospital Association, which admitted to a checkered past with racial equity in medicine, an organization-wide commitment to health equity has had a domino effect on the physician members of the organization. Some of the nation’s largest health systems pledged to promote health equity.

Again, this is not to say these were the first calls for health equity; today’s health advocacy builds on decades of grassroots movements in the US outlined above. However, the mix of the pandemic and the industry’s push toward value-based care helped move health equity to the forefront.

Policymaking continued to center health equity when, at the start of his term in 2021, President Joe Biden issued Executive Order 13985, which directs federal agencies to center racial equity and support for underserved communities.

“Our country faces converging economic, health, and climate crises that have exposed and exacerbated inequities, while a historic movement for justice has highlighted the unbearable human costs of systemic racism,” Biden wrote in the Executive Order.

“It is therefore the policy of my Administration that the Federal Government should pursue a comprehensive approach to advancing equity for all, including people of color and others who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.”

That mandate included marching orders for HHS, which quickly laid out its action plan to promote health equity through its federal rulings.

The agency said it would focus on civil rights protections to address care access barriers, acquisitions to bolster small businesses, integrating equity considerations into Notices of Funding Opportunities, incorporating equity into HHS policy and programming, and addressing racial health disparities in maternal and infant mortality.

To be clear, health equity refers to more than racial equity. Health equity encompasses a number of demographics, including race, ethnicity, language, sex, sexual orientation/gender identity, rural or urban geography, disability status, and a number of others.

Challenges to Achieving Health Equity

Like many aspects of medicine, health equity efforts are foremost stymied by data—or, rather, a lack thereof. When healthcare organizations don’t have adequate documented demographic data, they can’t determine where disparities exist. After all, you can’t improve what you don’t measure.

Right now, collection of demographic data is somewhat low. In 2020, a report from AHA’s Institute for Diversity and Health Equity (IFDHE) showed that only about six in 10 hospitals were collecting REL data, or race (61 percent), ethnicity (58 percent), and language (58 percent) data. Without that data, it can be difficult for a hospital to stratify outcomes and detect disparities.

For sexual orientation/gender identity (SOGI) data, the numbers are equally dismal. The AHA/IFDHE report showed that 57 percent of organizations collect sexual orientation data, and 59 percent collect gender identity data. A 2023 report published in JAMIA also showed that SOGI data is missing in 60 percent of adult EHRs.

Without demographic data, organizations cannot stratify outcomes by demographic and detect any potential disparities.

The healthcare industry is pushing to fill those gaps. In addition to the creation and promotion of data standards that will make it easier to share demographic data once it’s documented, stakeholders have also looked into linking healthcare databases with other federal databases. In April 2023, the US Census Bureau found that linking Census data with Medicaid databases helps bridge the gap in race data collection in healthcare.

Healthcare organizations themselves are also making concerted efforts to improve collection of demographic data. The “We Ask Because We Care” campaign, which has been adopted at health systems nationwide, seeks to make both healthcare professionals and patients more comfortable with the sharing of demographic information.

The campaign states that hospital staff members ask about demographic data so the organization can better understand its patient populations.

“We collect and use patient demographic information to ensure we are providing health care that does not vary in quality or safety because of personal characteristics such as preferred language, race, ethnicity or ethnic background,” Yale New Haven Health, a “We Ask Because We Care” campaign participant, says on its website. “By learning more about what makes our patients unique, it allows our team to verify that we are delivering the highest quality and safest health care to all our patients.”

Patients are free to decline to answer any or all demographic surveys or to fill them out via the patient portal, the campaign states.

These types of efforts have proven effective. In a case study detailed in the 2020 AHA/IFDHE report, Henry Ford Health System saw REL data collection increase to 90 percent.

Poor collection of REL and SOGI data can impede organization-level assessments of health equity, but even when they do have this information, the work of a health equity officer and members of their teams can often feel like an uphill battle.

In a 2023 article in Health Affairs, researchers recounted survey responses from health equity officers appointed by hospitals as organizations recognize their social responsibility. Although the health equity officers surveyed expressed growing support from organization leadership and staff themselves, they find themselves hamstrung by the legacy that racism has left on the fabric of the United States.

“White supremacy and the White supremacy culture is just embedded in any health care system…so trying to crawl our way out of that is going to be difficult,” one respondent noted.

Other obstacles include limited staff diversity (25 percent), racist beliefs by individuals in the hospital or health system (13 percent), and a lack of a standardized way to record SDOH data (27 percent).

These pitfalls notwithstanding, the medical industry has shown an energy around health equity work. In the Health Affairs article, health equity officers noted an impressive level of commitment from organization leaders.

As organizations continue on with this work, it will be essential to understand the roots of health equity in the Civil Rights Movement and the nation’s aspirations for liberty and justice for all. In doing so, payers, providers, and policymakers can avoid giving simple lip service to health equity and embark on meaningful work.