Health equity definition and history.
A critical first step in granting everyone fair access to health care, regardless of factors like identity or income, is making health equity a common goal. Health equity advances when institutions and policymakers acknowledge barriers to access and directly apply solutions to health systems.
What is health equity?
Health equity is the act of granting everyone access to achieve their maximum state of physical and mental wellness, without interference from factors like gender, sex, race, ethnicity, economic status, and other individual characteristics. Health equity includes not just access to providers and health care resources, but also a culture in health care that is non-judgmental, receptive, and understanding.
Health equity is social justice.
Social determinants drive health disparities, such as environment, housing, education, insurance coverage, employment, food security, and transportation. There are barries to access these essentials because of socioeconomic inequities often based on discrimination, racism, and bias. Health disparities disproportionately affect people in the BIPOC, LGBQ, and TGNC communities. Even if someone is able to get their foot in the door to see a clinician, if the environment is not supportive of their identity or circumstances, the individual cannot fully access care. Inclusive care improves health outcomes by effectively meeting the social, cultural, and linguistic needs of patients.
The term “health equity” was first recorded in 1801, although it wasn’t until 1966 that the first peer-reviewed paper on health equity was published. In 2021, Violet became the first to standardize a framework that measures cultural competence. We have made health equity the core principle of our cultural congruency education, so that health care providers can measurably improve their understanding of diverse populations. We work with providers to transform health care by improving cultural competency, and by creating benchmarking systems to hold clinicians accountable.
The relationship between health equity & health disparity
Obstacles to health equity are signs of health disparity. But it’s not enough to say that health disparity is the absence of health equity, since that’s not actionable. Instead, we should consider specific instances of health disparity, then examine how to care for certain populations.
The US Department of Health and Human Services recognizes the goal of health equity and characterizes health disparity as follows:
"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."
It’s important to note that denying people equitable access to health care creates power dynamics that devalue and deprioritize underserved communities. From seemingly benign intake questions to overt value statements, such as “I refuse to treat transgender patients,” there are a wide range of health policies that create discrimination and neglect the care needs of certain communities. The lack of power that underserved communities hold in comparison to the health care industry puts the extraodinary responsibility on physicians, leadership, and other decision makers to mend trust and create equitable practices and infrastructure to make visible what was once overlooked.
To advance health equity is challenging. Successful intervention requires gradual, systemic changes to health care. And it starts with learning cultural congruency and listening to community members.
Naming and acknowledging people and their experiences is a powerful first step towards facilitating health equity. Many important milestones on the path to health equity are notable for calling out the existence of disparities impacting the care of different groups of people.
Modern evolution of health equity interventions
Who gets to define health equity and identify disparity? Identifying health disparities is still relatively new, and there is no single body that is formally recognized as the authority.
Though, there are several key moments on the path to health equity, including many individuals and groups paving the way. Each of the efforts below sought to either increase access to health care or enhance the quality and sensitivity of health care services so that individuals could better access them regardless of identity.
- 1973 - Roe v. Wade
The Supreme Court’s Roe v. Wade decision was a landmark case for the level of protection it offered birthing people. This ruling held that a birthing person’s right to choose to have an abortion was protected by the Constitution, specifically under the right to privacy noted in the 14th Amendment.
- 1985 - Heckler Report & rates of death based on racial identity
The product of a task force commissioned by the US Department of Health and Human Services (HHS), the Heckler Report was published in 1985. It documented higher death rates for minorities, noting far more deaths per year for Black people than any other racial group. This report also surveyed HHS agencies to see what programs they already had in place to improve the health of culturally diverse populations. As more data began to characterize health disparities, productive discussions could start about health equity.
- 1986 - Office of Minority Health
One major outcome of the previous year’s Heckler Report was the creation of the Office of Minority Health, striving to address the disproportionately high Black mortality rate, improve outcomes for racial and ethnic minorities, and eliminate disparities. Since its founding, the OMH has led initiatives targeting diseases, particularly prevalent in culturally diverse populations, gathering data to pinpoint next steps, and creating educational programming to promote awareness about disparities.
- 1990 - Americans with Disabilities Act (ADA) passes
The passage of the Americans With Disabilities Act (ADA) sought to guarantee equal opportunity to individuals with disabilities while also actively prohibiting discrimination. In doing so, it acknowledged and validated the problematic treatment and lack of support of Disabled Americans.
- 1992 - The Concepts and Principles of Equity in Health
Following on the heels of her publication The Health Divide in 1987, Margaret Whitehead published The Concepts and Principles of Equity in Health, and began her work leading organizations, like the World Health Organization (WHO), toward action for global health equity.
- 1995 - Center for Linguistic and Cultural Competence in Health Care (CLCCHC)
The founding of the CLCCHC was intended to address the needs of a growing population of non-English speakers who sought health care. It recognized both issues of language as well as cultural values that could interfere with effective communication in medical settings.
- 2000 - National Standards in Cultural and Linguistically Appropriate Services (CLAS)
The major federal organization acknowledged the positive impact that culturally competent health care has on patient outcomes. At the end of the year, the CLAS in Health Care was published by the HHS, aiming to prepare health care providers for “culturally sensitive” situations–and acknowledging that many do not have clear guidance or adequate preparation in doing so.
"… Federal health agencies, State policymakers, and national organizations have independently developed their own standards and practices. Some have developed definitions of cultural competence while others mandate providing language services to limited English proficient (LEP) speakers. Some specify collection of language, race, and ethnicity data. Many approaches attempt to be comprehensive, while others target only a specific issue, geographic area, or subfield of health care such as mental health. The result is a wide spectrum of ideas about what constitutes culturally appropriate health services, including significant differences with respect to target population, scope, and quality of services. Although limited in their jurisdiction, many excellent policies do exist, and the increasing numbers of model programs and practices demonstrate that culturally competent health services are viable, beneficial, and important to health care consumers." (2000 CLAS)
These standards were the first of their kind.
- 2003 - Unequal Treatment published by the Institute of Medicine
The Institute of Medicine published Unequal Treatment, where a panel of experts evaluated racial and ethnic disparities in health care: first through a literature review, then by evaluating the health care environment and points of disparity, followed by pointing out potential sources of disparities and room for intervention, monitoring, and further research. Combining both qualitative and quantitative data, this publication was action-oriented, pinpointing precise steps to take toward health equity and creating systems for monitoring progress and maintaining accountability.
- 2005 - California protects access to health care for all
In 2005, California became the first state to officially block health care plans from denying coverage to people based on their gender identity. This was formally reinforced nationwide for the first time in 2012 by the Department of Health and Human Services.
- 2007 - National Partnership for Action to End Health Disparities
The National Partnership for Action to End Health Disparities was created as a national movement to link the public and private sectors together with the common goal of health equity. The idea was to increase awareness about health disparities, take actions to improve care as well as cultural and linguistic competency, and then coordinate data collection to evaluate outcomes and take further action as needed.
- 2009 - AHRQ’s Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
The Agency for Healthcare Research and Quality (AHRQ) released its Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement publication to independently assess the signs of health disparities, define categorization and language needs, and enhance data collection within the healthcare system in order to evaluate progress towards health equity.
- 2010 - Affordable Care Act
The Affordable Care Act was the biggest overhaul of the US health care system since Medicare and Medicaid were enacted in 1965. One of its biggest changes was requiring insurers to accept applicants without charging based on preexisting conditions or demographics outside of age, as well as taxing the top 1% of income distribution enough in order to offer benefits to families in the lower 40% of income distribution. Both of these changes alone granted more people access to health care. Six years later, the uninsured portion of the US population was reduced by about 50%.
- 2013 - Enhanced CLAS Standards
The Office of Minority Health released the Enhanced CLAS Standards, effectively recognizing that cultural competence is evolving as social awareness and sensitivity evolves, too. One of the biggest updates to these standards was to expand sensitivity considerations beyond just race and ethnicity, to now include beliefs, values, language, and sociological characteristics. These enhanced standards introduced more detail in outlining points of patient contact within the health care system, getting more granular about opportunities for potential intervention towards health equity.
- 2017 - Federal ban on exclusion of gender-affirming care
The HHS’ Office of Civil Rights formally banned any federally-funded health insurance plans from excluding gender-affirming care coverage. Although the HHS cannot pass new legislation or create legal precedents, their policies can be the basis for lawsuits.
Violet’s mission is to build health equity and close gaps in care. We do this by standardizing and cultivating cultural competence in clinicians. If you would like to learn more, set up a call with our team today. Let’s build a better world together.